HTH 1304 Health Information Technology and Systems PowerPoint Assignment

HTH 1304 Health Information Technology and Systems PowerPoint Assignment

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Description/Paper Instructions

HTH 1304 Health Information Technology and Systems PowerPoint Assignment

Develop a PowerPoint presentation about standards/code sets and the government regulations regarding each of the sets, and include a slide for each topic outlined below:

Introduction

Slide 2: ICD-10-CM Overview

Slide 3: Describe ICD-10-PCS.

Slide 4: Describe how the coding guidelines are used.

Slide 5: Describe HCPCS/CPT.

Slide 6: Describe SNOMED-CT Code.

Slide 7: Describe a code set not mentioned in the textbook (use an outside source).

Slide 8: Describe NDC.

Slide 9: Describe CDT.

Slide 10: Discuss the how code sets are important to the interoperability between health care institutions.

Slide 11: Provide a summary slide.

Slide 12: Provide a reference slide with at least one outside source, not counting the textbook, in APA format.

Each code set should include an example of its character structure as well as sufficient detail on its purpose and function in a health care setting. Make sure you are taking advantage of the entire slide, and do not be afraid to be creative in the design layout.

Course Learning Outcomes for Unit III Upon completion of this unit, students should be able to:

4. Differentiate various health information standards in terms of their ability to support the requirements of a health care enterprise. 4.1 Explain specific health care coding sets used in the nomenclature and classification of medical

diagnoses. 4.2 Outline government regulations regarding health care coding sets.

5. Identify health information technologies necessary for effective data storage and use in health care

organizations. 5.1 Describe the interoperability required in the transmission of diagnostic information.

Course/Unit Learning Outcomes

Learning Activity

4.1 Unit Lesson Chapter 5 Unit III PowerPoint Presentation

4.2 Unit Lesson Chapter 5 Unit III PowerPoint Presentation

5.1 Unit Lesson Chapter 5 Unit III PowerPoint Presentation

Required Unit Resources Chapter 5: Coded Data

Unit Lesson Medical coding is an essential piece of the patient discharge process as it completes one stage of the health care delivery process and gets the ball rolling into the next stage. Coding is defined as the assignment of character values that are grouped in certain ways to identify specific diagnoses and procedures (Davis & LaCour, 2017).

While the primary use for medical coding is medical billing, including payment and reimbursement, this coding data can also be used for a multitude of other reasons. Coded information can be used to determine trends in diagnoses that, in turn, help with forecasting and planning. Having this type of information at their disposal, health professionals can strategically prepare to fight off an epidemic or even prevent one from occurring.

Not only can medically coding data be used for research, but it can also be used in other nonclinical ways such as measuring outcomes for audit or assessment purposes, reporting required information to accrediting bodies, and/or determining productivity baselines. The American Health Information Management Association (AHIMA) has been a pioneer, not only in the HIM arena but also in medical coding practices.

Evidence of this initiative comes in the form of the Standards of Ethical Coding published by the organization in an effort to guide professional coders in the right direction when it comes to correct coding. The Health Insurance Portability and Accountability Act (HIPAA) is also a governing body when it comes to code sets. HIPAA’s Standards for Code Sets puts forth guidelines as to how clinical coded data is transmitted from one entity to another entity.

Code set transmissions must be secure, and information must only be assessed by those who will be using the data for meaningful purposes. HIPAA has implemented these regulations to further advance the coding field as well as to ensure that patient’s information is safeguarded and protected as it flows from one institution to the next.

Code sets come in two types: nomenclature and classification. Nomenclature medical coding is basically a system of naming health care activities or procedures in order to stay consistent in electronic communication (Davis & LaCour, 2017). Examples of nomenclature code sets would be the Healthcare Common Procedure Coding System (HCPCS) and Current Procedural Terminology (CPT).

In each of these coding sets, the selected code is related to a specific definition, and no other code will be related to that definition. We will go over a few examples later to show how the coding is unrelated to other codes in that coding set. Classification medical coding would be the opposite of nomenclature as the coding is interrelated and may build on other codes. The task of classification coding is to categorize codes, hence creating a relationship between them.

Unlike nomenclature coding, classification code sets have related subcategories and sub-terms which create a sequence that helps coders code more specifically. The International Classification of Diseases (ICD) may be one of the more important coding classification systems that we use in the United States.

This classification system can be used to diagnose diseases as well as document and report procedures performed by health care providers. The International Classification of Diseases, Tenth Revision—Clinical Modification (ICD- 10CM) and the International Classification of Diseases, Tenth Revision, Procedural Coding System (ICD- 10PCS) are the two systems used to perform these tasks (Davis & LaCour, 2017).

Nomenclature and classification systems have greatly improved the ability of stakeholders to communicate more effectively with each other. This “language” allows for professionals in the health care field to create even more specific code sets regarding certain areas of medicine. An example of that would be the International Classification of Diseases for Oncology (ICD-O) which particularly deals with neoplasms.

Hundreds of these coding systems have been developed throughout the world, and the attribute of uniformity is the catalyst. The Healthcare Common Procedure Coding System (HCPCS) is a vital nomenclature coding system used by health care providers and doctors. The task of HCPCS is to code for services, products, and equipment provided by health care institutions to patients for billing and reimbursement purposes.

HCPCS is used in outpatient settings such as emergency rooms, rehabilitation clinics, and outpatient surgery centers. This coding system is split into two levels with Level I being the fourth revision of the Current Procedural Terminology (CPT-4). CPT-4, or Level I, uses codes to identify common medical services such as radiology imaging or basic laboratory tests ordered by a physician.

CPT-4 coding would also include services or procedures rendered on doctor’s office visits or for any drugs that may be administered. While Level I codes consist of five numerical characters, Level II codes are alphanumeric, consisting of a mix of numbers and letters. Level II, or simply HCPCS codes, are used to report products, supplies, and services not included in CPT (Davis & LaCour, 2017).

For example, ambulance transportation for a patient would be an example of coding that does not use CPT-4 but rather would be coded using Level II. The Centers for Medicare and Medicaid Services jointly maintains the HCPCS coding system with the goal of creating a uniform and standardized code set that will ensure interoperability to all who use the system.

HCPCS/CPT-4 is updated regularly, usually on a quarterly basis, and communicated through means such as the Federal Register (Centers for Medicare & Medicaid Services, n.d.). The International Classification of Diseases, Tenth Revision—Clinical Modification (ICD-10-CM) is used worldwide, and it is tasked with reporting medical diagnoses and documenting reasons behind patient medical encounters (Davis & LaCour, 2017).

ICD-10-CM consists of a three-seven-character system that is alphanumeric, which is helpful if the system needs to be expanded or coding needs to be added. ICD-10-CM is a classification code set, so there are many categories and sub-terms that help physicians and coders be as specific as they can be while diagnosing illnesses and diseases. For example, the ICD-10-CM code for a glaucoma diagnosis is H40.

A sub-term that can be used to create a more specified code would be H40.1211 which is the code for a mild stage of low-tension glaucoma in a patient’s right eye. The latter code is much more detailed, which creates better statistical data as well clearer billing and reimbursement.

The International Classification of Diseases, Tenth Revision, Procedural Coding System (ICD-10-PCS) is used in inpatient settings to code medical procedures (Davis & LaCour, 2017). ICD-10-PCS is a seven- character coding system using both letters and numbers to classify items. There are 17 sections of ICD-10- PCS, each one a procedural category.

For example, the radiology section deals with imaging such as X-rays, while the obstetrics and laboratory sections deal with all thing’s pregnancy-related and test-related, respectively. The Systemized Nomenclature of Medicine—Clinical Terms (SNOMED-CT) is a European nomenclature coding system with the goal of assisting in the exchange of electronic health record (EHR) information (Davis & LaCour, 2017).

This system contains millions of medical terms which include procedures and diagnostic information that can be directly translated to other coding systems such as ICD-10 or HCPCS. The chart below outlining the diagnostic coding and treatment and/or procedural coding for kidney stones shows how useful SNOMED-CT can be in linking medical terminology:

CODE SET CODE MEANING/DEFINITION

As you can see, the SNOMED-CT coding for kidney stones can be directly related to the ICD-10 and HCPCS coding systems. We can link the ICD-10-CM coding for the calculus of a kidney, which is N20, directly to the SNOMED-CT code for the general medical term for kidney stones, 95570007. Even further, the CPT-4 procedural code for the removal of a kidney stone is 50060, which can be directly linked to the SNOMED-CT code for nephrolithotomy which is 6722002.

Think about how helpful this could be for two entities that need to effectively communicate this type of information but have to overcome a language barrier to do so. SNOMEDCT would be critical in this situation as it can make the connection between the two. Two of the more specialized code sets in the health care industry are the National Drug Codes (NDCs) and Current Dental Terminology (CDT) (Davis & LaCour, 2017).

NDCs are used to identify drugs used for human consumption in the United States. These codes are updated bimonthly, and they aid in the tracking, distribution, and dispensing of pharmaceutical drugs. These codes are helpful if there is ever a recall on a specific drug.

With thousands of drugs in circulation, both generic and non-generic, this is a very important code set for safety in the medication industry. Code on Dental Procedures and Nomenclature or Current Dental Terminology (CDT) defines terms for dental procedures and treatments. The American Dental Association manages these codes, and they are updated biannually.

The common thread in each of these code sets is the focus of improving and advancing communication within the health care field. Each of the code sets discussed above, whether a nomenclature system or a classification system, were developed for uniformity and increased interoperability across systems.

Interoperability is defined as the ability for multiple systems to transmit electronic health information to each other without the user being involved in the translation (Office of the National Coordinator for Health Information Technology, n.d.). Information is automatically converted so that it can be used in the recipient system, increasing efficiency and saving time and effort on the part of the user.

There have been many initiatives led by the Office of the National Coordinator for Health Information Technology (ONC) that have improved health information, specifically the adoption of EHRs and the ability for more users to access them. As of today, those efforts have led to roughly 41% of hospitals having access to clinical information from outside entities, but there is still room for improvement (Office of the National Coordinator for Health Information Technology, n.d.).

To help continue the development and advancement of interoperability between health data systems, the ONC introduced an interoperability roadmap. This roadmap contains administrative and technical milestones with the goal of strategically planning the future of interoperability with the cooperation of all stakeholders involved.

Coded information provides a tremendous benefit to the health information field. We can exchange information faster and more efficiently than ever before, and health care providers now have more access to patient information. As technology continues to increase so will the ability to transmit, manage, and utilize health data, not only for the betterment of the patient but also for the betterment of society as a whole.

References Centers for Medicare & Medicaid Services. (n.d.). HCPCS – General information.

https://www.cms.gov/Medicare/Coding/MedHCPCSGenInfo/index.html Davis, N., & LaCour, M. (2017). Foundations of health information management (4th ed.). Elsevier. Office of the National Coordinator for Health Information Technology. (n.d.). Connecting health and care for

the nation: A shared nationwide interoperability roadmap. HealthIT. https://www.healthit.gov/sites/default/files/hie-interoperability/nationwide-interoperability-roadmap- final-version-1.0.pdf

Suggested Unit Resources In order to access the following resources, click the links below. The National Correct Coding Initiative (NCCI) was developed by the Centers for Medicaid and Medicare Services with the task of improving and maintaining accurate coding policies. The NCCI is updated annually. The overall purpose of NCCI is to prevent improper coding that will affect payment and reimbursement. Centers for Medicare & Medicaid Services. (2018). National correct coding initiative edits.

https://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/index.html The Office of the National Coordinator for Health Information Technology (ONC) created an interoperability roadmap that outlines the coordination needed between stakeholders in the exchange of health information. The Office of the National Coordinator for Health Information Technology. (n.d.). Connecting health and care

for the nation: A shared nationwide interoperability roadmap. Health IT. https://www.healthit.gov/sites/default/files/hie-interoperability/nationwide-interoperability-roadmap- final-version-1.0.pdf

HTH 1304 Health Information Technology and Systems PowerPoint Assignment

RUBRIC QUALITY OF RESPONSE NO RESPONSE POOR / UNSATISFACTORY SATISFACTORY GOOD EXCELLENT Content (worth a maximum of 50% of the total points) Zero points:  Student failed to submit the final paper. 20 points out of 50:  The essay illustrates poor understanding of the relevant material by failing to address or incorrectly addressing the relevant content; failing to identify or inaccurately explaining/defining key concepts/ideas; ignoring or incorrectly explaining key points/claims and the reasoning behind them; and/or incorrectly or inappropriately using terminology; and elements of the response are lacking. 30 points out of 50:  The essay illustrates a rudimentary understanding of the relevant material by mentioning but not full explaining the relevant content; identifying some of the key concepts/ideas though failing to fully or accurately explain many of them; using terminology, though sometimes inaccurately or inappropriately; and/or incorporating some key claims/points but failing to explain the reasoning behind them or doing so inaccurately.  Elements of the required response may also be lacking. 40 points out of 50:  The essay illustrates solid understanding of the relevant material by correctly addressing most of the relevant content; identifying and explaining most of the key concepts/ideas; using correct terminology; explaining the reasoning behind most of the key points/claims; and/or where necessary or useful, substantiating some points with accurate examples.  The answer is complete. 50 points:  The essay illustrates exemplary understanding of the relevant material by thoroughly and correctly addressing the relevant content; identifying and explaining all of the key concepts/ideas; using correct terminology explaining the reasoning behind key points/claims and substantiating, as necessary/useful, points with several accurate and illuminating examples.  No aspects of the required answer are missing. Use of Sources (worth a maximum of 20% of the total points). Zero points:  Student failed to include citations and/or references. Or the student failed to submit a final paper. 5 out 20 points:  Sources are seldom cited to support statements and/or format of citations are not recognizable as APA 6th Edition format. There are major errors in the formation of the references and citations. And/or there is a major reliance on highly questionable. The Student fails to provide an adequate synthesis of research collected for the paper. 10 out 20 points:  References to scholarly sources are occasionally given; many statements seem unsubstantiated.  Frequent errors in APA 6th Edition format, leaving the reader confused about the source of the information. There are significant errors of the formation in the references and citations. And/or there is a significant use of highly questionable sources. 15 out 20 points:  Credible Scholarly sources are used effectively support claims and are, for the most part, clear and fairly represented.  APA 6th Edition is used with only a few minor errors.  There are minor errors in reference and/or citations. And/or there is some use of questionable sources. 20 points:  Credible scholarly sources are used to give compelling evidence to support claims and are clearly and fairly represented.  APA 6th Edition format is used accurately and consistently. The student uses above the maximum required references in the development of the assignment. Grammar (worth maximum of 20% of total points) Zero points:  Student failed to submit the final paper. 5 points out of 20:  The paper does not communicate ideas/points clearly due to inappropriate use of terminology and vague language; thoughts and sentences are disjointed or incomprehensible; organization lacking; and/or numerous grammatical, spelling/punctuation errors  10 points out 20:  The paper is often unclear and difficult to follow due to some inappropriate terminology and/or vague language; ideas may be fragmented, wandering and/or repetitive; poor organization; and/or some grammatical, spelling, punctuation errors 15 points out of 20:  The paper is mostly clear as a result of appropriate use of terminology and minimal vagueness; no tangents and no repetition; fairly good organization; almost perfect grammar, spelling, punctuation, and word usage. 20 points:  The paper is clear, concise, and a pleasure to read as a result of appropriate and precise use of terminology; total coherence of thoughts and presentation and logical organization; and the essay is error free. Structure of the Paper (worth 10% of total points) Zero points:  Student failed to submit the final paper. 3 points out of 10: Student needs to develop better formatting skills. The paper omits significant structural elements required for and APA 6th edition paper. Formatting of the paper has major flaws. The paper does not conform to APA 6th edition requirements whatsoever. 5 points out of 10: Appearance of final paper demonstrates the student’s limited ability to format the paper. There are significant errors in formatting and/or the total omission of major components of an APA 6th edition paper. They can include the omission of the cover page, abstract, and page numbers. Additionally the page has major formatting issues with spacing or paragraph formation. Font size might not conform to size requirements.  The student also significantly writes too large or too short of and paper 7 points out of 10: Research paper presents an above-average use of formatting skills. The paper has slight errors within the paper. This can include small errors or omissions with the cover page, abstract, page number, and headers. There could be also slight formatting issues with the document spacing or the font Additionally the paper might slightly exceed or undershoot the specific number of required written pages for the assignment. 10 points: Student provides a high-caliber, formatted paper. This includes an APA 6th edition cover page, abstract, page number, headers and is double spaced in 12’ Times Roman Font. Additionally, the paper conforms to the specific number of required written pages and neither goes over or under the specified length of the paper.
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