Chapter 7 Computers in HIM Part #1

Admitting diagnosis Principal diagnosis Secondary diagnoses Principle procedure Secondary procedures Age of patient (or date of birth) Discharge disposition Gender Patient name Medical record number Account number

Common data elements in an encoder or grouper are:

(special credential -certified tumor registrar), diabetes, trauma (certified trauma registrar), etc.

Registries keep track of conditions such as cancer

Automated codebook encoder

is an encoder that lists diagnoses and procedures in alphabetic order much like the alphabetic index located in (ICD-10-CM) and CPT.

TNM Staging System

is based on the extent of the tumor (T), the extent of spread to the lymph nodes (N), and the presence of metastasis (M).

ROI system

is designed to manage the processing of requests for protected health information (PHI) received and processed by the HIM department.

Encoder

A computerized system designed to help assign the proper code is a(n):

Disclosure information

HIPAA requires accounting of ________ to be available to the patient for three years, so that would be the minimum amount of time for the requests to be maintained.

Three years

HIPAA requires accounting of disclosure information to be available to the patient for ______, so that would be the minimum of time for the requests to be maintained.

TNM Stage TNM classification system

It is the most commonly used staging system by medical professionals around the world. The ______ was developed as a tool for doctors to stage different types of cancer based on certain, standardized criteria.

Prompts

One of the biggest advantages in the use of an encoder or grouper is

MS-DRG grouper

The most common grouper is the

Release of information

The system used to notify requesters of invalid authorization is called a(n):

Rules-based/automated codebook encoder

There are two types of encoders

Medicare Code Editor, National Correct Coding Initiative, and other edits.

These assigned codes must be validated through

Site of injury Type of injury How injury occurred Date of injury Time of injury Work-related ICD-10-CM and ICD-10-PCS Safety requirement Register number Autopsy performed Emergency department arrival time

Trauma registry data elements:

The encoder and grouper

What is linked to the hospital's financial information system so that the codes can be automatically transferred to that system for billing?

Automated codebook encoder

Which of the following is the type of encoder that mimics a codebook?

Grouper

Which of the following systems should one use to assign the diagnosis and procedure codes?

Release of Information

Which system would you use to print out a report of people who have not paid for the copies of records sent to them?

Grouper

assigns the codes entered into the encoder into the appropriate Medicare severity diagnosis-related groups (MS-DRG) or other diagnosis-related group (DRG).

Encoder

is used by coders to select the appropriate code for the diagnosis(es) and procedure(s) supported by the medical record.

Disclosure management software system

may also track requests for amendments to PHI as well as restrictions to disclosures.

Rules-based encoders

require the user to type in the name or portion of the name of the diagnosis or procedure.

Cancer Registry Information System

tracks information about the patient's cancer from the time of diagnosis to the patient death.

Trauma registry software

tracks patients with traumatic injuries from initial trauma treatment to death.

Disclosure management system

tracks the disclosures made throughout the healthcare organization for reporting.