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ISBN 10: 1285871715
ISBN 13: 9781285871714
Author: Ann Peden
COMPARATIVE HEALTH INFORMATION MANAGEMENT, 4e immerses students in the growing field of HIM and its many career paths. Chapters explore traditional and clinical settings, including hospitals, ambulatory clinics and medical offices, veterinary practices, home health, long-term care, and correctional facilities, as well as emerging practice areas such as consulting and cancer registry. Focused on the challenges of managing and protecting the flow of information across sites, this updated text starts with an induction to the health care system, then progresses through care settings and associated HIM roles, infusing discussions with key terms, self-test questions, web links, and illustrations that add meaning to concepts. Special features include case studies for problem-solving practice, and new “Professional Spotlight” vignettes that highlight actual professionals in their HIM careers.
Comparative Health Information Management 4thTable of contents:
Section 1. The Health Care System
Chapter 1. Introduction to Health Care Systems
Twentieth-Century Health Care in America
Payment Issues Affecting Health Care Delivery
Other Regulatory and Accreditation Issues Affecting Health Care
Other Issues Affecting the Delivery of Health Care
Impact on the Role of the Health Information Manager
Summary
Review Questions
Web Activity
Case Study
References and Suggested Readings
Key Resources
Section 2. Acute, Ambulatory, and Managed Care
Chapter 2. Hospital-Based Care
Introduction to Settings
Types of Settings
Types of Patients
Types of Caregivers
Regulatory Issues
Licensure
Federal Regulations
Accreditation
Documentation
Joint Commission Documentation Requirements
Other Factors in Hospital Documentation
Reimbursement
Hospital Chargemaster or Charge Description Master (CDM)
Medicare
Other Payers
Billing
Information Management
Coding and Classification
Data and Information Flow
Electronic Health Records and Computer Systems
Data Sets
Quality and Utilization Management
Quality Assessment and Performance Improvement (QAPI)
Utilization Management (UM)
Risk Management and Legal Issues
Role of the Health Information Management Professional
Health Information Services
Compliance Officer
Revenue Cycle
Other Roles
Trends
Summary
Review Questions
Web Activity
Case Study
References and Suggested Readings
Key Resources
Chapter 3. Freestanding Ambulatory Care
Introduction to Setting
Types of Patients
Types of Caregivers
Regulatory Issues
Licensure
Medicare Certification
Accreditation
Other Regulations: Compliance
Documentation
Registration/Demographic Information
History and Physical
Laboratory and Radiograph Reports
Progress Notes
Encounter Form
Copies of Hospital Records
Problem List
Special Requirements
Record Format
Patient Identifier/Filing Methods
Reimbursement
Fee for Service
Medicare Physician Fee Schedule
Ambulatory Surgery Center Reimbursement
Capitation
Medicaid—Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Service
Reimbursement Resources
Information Management
Coding and Classification
Data and Information Flow
Record Linkage to Other Sites/Facilities
Computer Systems
Data Sets
Quality Improvement and Utilization Management
Quality Assessment and Performance Improvement
Utilization Management
Risk Management and Legal Issues
Role of the Health Information Management Professional
Trends
Summary
Review Questions
Web Activity
Case Study
References and Suggested Readings
Key Resources
Chapter 4. Managed Care
Introduction to Settings and Plans
Types of Managed Care Organizations
Consumer-Directed Health Plans
Types of Patients
Types of Caregivers
Regulatory Issues
Governmental Regulation
Voluntary Accreditation
URAC
Revenue Generation
Managed Care Organization Revenue
Reimbursement to the Provider of Care
Coordination of Benefits
Information Management
Coding and Classification Systems
Data and Information Flow
Electronic Information Systems
Basic System Requirements
Data Sets
Quality Improvement and Utilization Management
Quality Improvement
Utilization Management
Risk Management and Legal Issues
Identifying Unusual Events
Informed Consent for Procedures
Credentialing
Contract Management
Role of the Health Information Management Professional
Developing and Implementing Information Plan Based on Organizational Needs
Specialized Functions
Trends
Integrated Delivery Systems/Networks
The Changing Role of the PCP
Federal Programs
Accountable Care Organizations (ACOs)
Summary
Review Questions
Web Activity
Case Study
References and Suggested Readings
Key Resources
Chapter 5. Dialysis
Introduction to Setting
Types of Patients
Types of Caregivers
Regulatory Issues
Surveys
Federal Regulations
ESRD Networks
Documentation
Patient Assessment and Plan of Care
Reimbursement
Facility Reimbursement
Physician Reimbursement
Information Management
Coding and Classification
Data and Information Flow
Electronic Health Record (EHR) and Information Systems
Data Sets
Quality Assessment, Performance Improvement, and Utilization Management
Quality Improvement
Utilization Management (UM)
Risk Management, Legal, and Ethical Issues
Role of the Health Information Management Professional
Summary
Review Questions
Web Activity
Case Study
References and Suggested Readings
Key Resources
Chapter 6. Correctional Facilities
Introduction to Setting
State Departments of Correction
Operation by State Versus Contracted Firms
Prisons
Jails
Juvenile Facilities
On-Site versus Off-Site
Types of Patients
Types of Caregivers and Services
Regulatory Issues
National Commission on Correctional Health Care (NCCHC)
American Correctional Association (ACA)
The Joint Commission
American Public Health Association
Documentation
The Correctional Health Record
Administrative Information
Reimbursement and Funding
Information Management
Data and Information Flow
Coding and Classification
Electronic Information Systems
Hipaa
Quality Management, Performance Improvement, and Utilization Management
Quality Management and Performance Improvement
Utilization Management
Risk Management and Legal Issues
Risk Management
Common Legal Issues
Other Areas of Risk
Role of the Health Information Management Professional
Trends
Summary
Review Questions
Web Activity
Case Study
References and Suggested Readings
Key Resources
Section 3. Behavioral Health Care
Chapter 7. Mental Health: Long-Term and Acute Services
Introduction to Setting
Types of Clients
Types of Caregivers
Regulatory Issues
Documentation
Assessment
Treatment Plan
Progress Notes
Special Procedures
Discharge Summary and Aftercare Plans
Reimbursement and Funding
Information Management
Data and Information Flow
Coding and Classification
Data Sets
Quality Improvement and Utilization Management
Risk Management and Legal Issues
Confidentiality
Court-Ordered Treatment
Role of the Health Information Management Professional
Trends
Summary
Review Questions
Web Activity
Case Study
References and Suggested Readings
Key Resources
Chapter 8. Substance Abuse
Introduction to Setting
Care Settings
Types of Clients
Types of Caregivers
Regulatory Issues
Documentation
Legal/Administrative Documentation
Clinical Documentation
Reimbursement and Funding
Information Management
Data and Information Flow
Coding and Classification
Data Sets
Electronic Information Systems
Quality Improvement and Utilization Management
Quality Assessment and Improvement
Utilization Management
Risk Management and Legal Issues
Confidentiality and Release of Information
Court-Ordered Treatment
Involuntary Commitments
Role of the Health Information Management Professional
Trends
Summary
Review Questions
Web Activity
Case Study
References and Suggested Readings
Key Resources
Chapter 9. Facilities for Individuals with Intellectual Disabilities
Introduction to Setting
Types of Individuals Served
Types of Caregivers
Types of Settings
Regulatory Issues
Documentation
Reimbursement and Funding
Information Management
Data and Information Flow
Coding and Classification
Electronic Information Systems
Data Sets
Quality Improvement and Utilization Management
Quality Improvement
Utilization Management
Risk Management and Legal Issues
Risk Management
Legal Issues
Role of the Health Information Management Professional
Trends
Summary
Review Questions
Web Activity
Case Study
References and Suggested Readings
Key Resources
Section 4. Post-Acute Care
Chapter 10. Long-Term Care
Introduction to Setting
Types of Patients
Types of Caregivers
Regulatory Issues
State Licensure
Joint Commission Accreditation
Documentation
Federal Requirements
State Licensure Requirements
Joint Commission Long-Term Care Accreditation Requirements
Reimbursement and Funding
Medicaid per Diem Based on Overall Facility Costs
Medicare Part a Skilled Nursing Facility (SNF) Benefit
Medicaid per Diem Based on Level of Care
Resource Utilization Groups in Medicaid Reimbursement
Commercial Insurance
Managed Care Payers
Private Pay
Information Management
Coding and Classification
Data and Information Flow
Electronic Information Systems
Data Sets
Quality Improvement and Utilization Management
Quality Improvement
Utilization Management
Risk Management and Legal Issues
Role of the Health Information Management Professional
Auditing
External Consultant versus Fulltime Employee
Trends
Summary
Review Questions
Web Activity
Case Study
References and Suggested Readings
Key Resources
Chapter 11. Rehabilitation
Introduction to Setting
Types of Rehabilitation Settings
Types of Caregivers
Types of Patients
Durable Medical Equipment Commonly Used
Regulatory Issues
The Joint Commission
CARF International
Centers for Medicare & Medicaid Services (CMS)
Documentation
Reimbursement and Funding
Information Management
Information Flow
Coding
Electronic Information Systems
National Databases
Classification and Rating Systems Used in Rehabilitation
Quality Improvement and Utilization Management
Quality Improvement and Program Evaluation Systems
Utilization Management
Risk Management and Legal Issues
Avoiding and Managing Risk
Third-Party Litigation
Role of the Health Information Manager
Trends
Acute Rehabilitation, Skilled Nursing, and Other Post-acute Care Providers
Outpatient Rehabilitation
Independent Living
Technology
Summary
Review Questions
Web Activity
Case Study
References and Suggested Readings
Key Resources
Chapter 12. Home Health Care
Introduction to Setting
Types of Patients
Types of Caregivers
Specialty Services
Regulatory Issues
Medicare/Medicaid
The Joint Commission
Community Health Accreditation Program
Accreditation Commission for Health Care (ACHC)
Documentation
Outcome and Assessment Information Set-C1 (OASIS-C1)
Reimbursement and Funding
Medicare Prospective Payment System (PPS)
Payer Mix
Financial Stability
Information Management
Coding and Classification
Data and Information Flow
Electronic Information Systems
Data Sets
Quality Improvement and Utilization Management
Quality Improvement
Utilization Management
Risk Management and Legal Issues
Risk Management
Satisfaction Committee/Monitoring
Legal Issues
Policies and Procedures
Role of the Health Information Management Professional
Trends
Summary
Review Questions
Web Activity
Case Study
References and Suggested Readings
Key Resources
Chapter 13. Hospice
Introduction to Setting
Types of Patients
Types of Caregivers
Regulatory Issues
Licensure and Accreditation
Hospice Medicare Benefit and Regulations
Documentation
Certification Requirements
Assessment, Interdisciplinary Plan of Care, and Associated Documentation
Volunteer Documentation
Inpatient Documentation
Documentation at the Close of Care
Reimbursement and Funding
Information Management
Data and Information Flow
Coding and Classification
Electronic Information Systems
Data Sets
Quality Assessment/Performance Improvement and Utilization Management
Quality Assessment/Performance Improvement (QAPI)
Utilization Management
Risk Management and Legal Issues
Role of the Health Information Management Professional
Trends
Summary
Review Questions
Web Activities
Case Study
References and Suggested Readings
Key Resources
Section 5. Other Specialized Care Settings
Chapter 14. Dental Care Settings
Introduction to Care Settings
Care Settings
Types of Patients
Types of Providers
Regulatory Issues
State Licensure
Drug Enforcement Agency (DEA) Regulations
Reporting of Adverse Effects of Medications and Dental Materials
Other Reporting Requirements
Treatment Documentation
Patient Information
Health and Dental History
Head, Neck, and Intraoral Examination
Dental Examination and Charting
Periodontal Examination
Dental Radiography and Intraoral Photography
Treatment Plan
Treatment Notes
Patient Education
Diet Evaluation
Reimbursement
Dental Insurance
Self-Pay Patients
HMO Plans
Centers for Medicare & Medicaid Services
TRICARE Dental Program
Veterans Affairs
Information Management
Treatment Coding and Classification
Electronic Information Systems in Dentistry
Quality Improvement and Utilization Management
Risk Management and Legal Issues
Injuries to Caregivers and Patients
Malpractice and Negligence
Adverse Reactions to Medications and Dental Materials
Dental Records for Identification of Individuals
Role of the Health Information Management Professional
Trends
Dental Services
Dental Treatment
Technology in Dentistry
Dental Informatics
Summary
Review Questions
Web Activity
Case Study
References and Suggested Readings
Key Resources
Chapter 15. Veterinary Settings
Introduction to Setting
Types of Patients
Types of Caregivers and Staff
Regulatory Issues
Purpose of Accreditation
Documentation
Standards
Format
Forms of Documentation
Reimbursement
Out of Pocket
Mortality Insurance
Pet Health Insurance
Information Management
Coding and Classification
Data Sets
Electronic Information Systems
Quality Improvement and Utilization Management
Risk Management and Legal Issues
Risk Management
Legal Issues
Role of the Health Information Management Professional
Trends
Summary
Review Questions
Web Activities
Case Study
References and Suggested Readings
Key Resources
Chapter 16. Consulting
Introduction to Setting
Working as a Team Member
Examples of Consulting Projects
Regulatory Issues
Documentation
Reimbursement and Compliance
Role of the Health Information Management Professional
Leadership Ability
HIM Consulting Fees
Seeking Clients
Working at Home
Office Equipment
Negotiating Contracts
Trends
Summary
Review Questions
Web Activity
Case Study
References and Suggested Readings
Key Resources
Chapter 17. Cancer Registry
Introduction to the Setting
Types of Cancer Registries
Types of Professionals Working in the Cancer Registry
Regulatory Issues
Commission on Cancer
The Surveillance, Epidemiology, and End Result Program (SEER)
National Cancer Registrars Association
North American Association of Central Cancer Registries
National Program of Cancer Registries
Documentation
Patient Information
Cancer Information
Stage of Disease at Diagnosis
Treatment
Outcomes
Case Administration
Text Documentation
Suspense Cases
Additional Documentation
Revenue Generation
Information Management
Coding and Classification
Data Information and Flow
Electronic Systems
Data Sets
Quality Improvement and Utilization Management
Legal and Ethical Issues
Role of the Health Information Management Professional
Trends
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