Health information is the data related to a person's medical history, including symptoms, diagnoses, procedures, and outcomes. Health information records include patient histories, lab results, x-rays, clinical information, and notes. A patient's health information can be viewed individually, to see how a patient's health has changed; it can also be viewed as a part of a larger data set to understand how a population's health has changed and how medical interventions can change health outcomes.

Health information management (HIM) is the practice of acquiring, analyzing, and protecting digital and traditional medical information vital to providing quality patient care. It is a combination of business, science, and information technology.

The Clinical Documentation Improvement Specialist (CDIS) will be responsible for demonstrating competency in coordinating and performing day to day operations, providing concurrent/retrospective review, and improving documentation of all conditions, treatments, and care plans to ensure highest quality care is provided to the patient. In addition, CDIS should be able to educate clinical staff in appropriate documentation criteria. The CDIS will ensure that documentation reflects Medicare Severity Diagnosis Related Groups (MS-DRG), case mix index, severity of illness, risk of mortality, physician profiling, hospital profiling, and reimbursement rules. Monitoring changes in laws, rules, regulations, and code assignments that impact documentation and reimbursement is implicit. Knowledge and skills on Microsoft Access database management and ability to present information effectively and clearly is essential.

Medical coders for hospitals spend their days reviewing medical records to assign inpatient and ambulatory surgery codes and ensure that the health care providers they work for are properly reimbursed for their services. Coding accurately is not easy. The coder must carefully read the doctor's and nurse's notes to determine exactly what services the patient received. If a service is overlooked, the provider will not receive payment for it. The coder must also understand private payer policies and government regulations for accurate coding and billing. If the coder chooses the wrong code, the provider may have to return any excess payment or face legal charges for overbilling. Codes change constantly, so coders must keep abreast of new rules and interpretations. A solid understanding of medical terminology, including anatomy, is also required.

Compile, process, and maintain medical records of hospital and clinic patients in a manner consistent with medical, administrative, ethical, legal, and regulatory requirements of the health care system. Process, maintain, compile, and report patient information for health requirements and standards in a manner consistent with the healthcare industry's numerical coding system.

Coding professionals use coding conventions and guidelines to abstract, analyze, and accurately assign International Classification of Diseases, Current Procedural Terminology, and other classification systems, as well as principal and secondary diagnostic and procedural codes to inpatient, ambulatory, and outpatient medical records. Coding professionals also query physicians when diagnosis is unclear, audit records, and perform peer reviews. These professionals use encoder, grouper, and other Health Information Management software, including electronic health records. Job requirements include a current credential, such as Registered Health Information Administrator, Registered Health Information Technician, Certified Coding Associate, or other designated credential from a nationally recognized organization.

Coding professionals assign clinical classification codes for medical services. They also use abstracting databases, internal and external audit results, Quality Improvement Organization reports, and revenue cycle edit and denial information, and they are a resource to the clinical team. This position requires effective interaction with coding staff, clinical staff, and different levels of management throughout the health care system.

Work Process Schedule PDF