Electronic Health Records

ehrThere is a lot of talk these days in healthcare about Electronic Health Records. Seems we are starting to move in that direction more and more. The American Recovery and Reinvestment Act (ARRA), was signed into law on February 17, 2009 by President Obama. Continue reading…

Nancy Drew, Girl Detective

Some of you may already know this about me … others maybe not. At one time, I was just like you, believe it or not. I always knew that one day I go back to school and finish my education. Early on I thought I really wanted to be a nurse, even started nursing school. However, life did get in the way and I needed to drop out for a while. I had a problem pregnancy and lost a child. Eventually, I found my way back to school. By that time, I decided I no longer wanted to be a nurse. I had spent many years taking care of others so I wanted something new. I knew I wanted to stay in healthcare but what could I do that would let me help people? I discovered the world of Health Information Management … coding to be exact! It was a like a dream come true! I could become the girl detective I always wanted to be growing up. My heroine years ago was Nancy Drew. I wanted to be like her. Remember the “Secret of the Old Clock?” Well, that was me!! As a young girl, I thrived on those books and becoming my own girl detective. I made my own secret code, used invisible ink, and spied on my brothers and their friends! Oh, how they hated that! You get the picture, I am sure! Well, I found medical coding is a lot like that except someone else made up the secret code! You must learn a brand new language, the language of the medical field, and transfer that language into codes! You must dig deep sometimes in the patient’s medical record to determine the patient’s diagnoses and procedures the physician carried out in treating the patient! It is a lot of fun! It can be frustrating when you don’t find the right code or information. Once you do though there is a feeling of Eureka! I found it! I did it! So tell me what you are discovering? What your thoughts? <<COMMENTS FOR THIS POST HAVE BEEN CLOSED>>

Did You Know that Billing and Coding Specialists are Health Information Management professionals?

So who are health information professionals? We are credentialed professionals who manage individual health records as well as aggregate data. We carry expertise in health care databases, medical classification systems, flow of clinical information, medico-legal issues, uses of health information, and data security systems. Our common purpose is to provide reliable and valid information that drives the healthcare industry. We are specialists in administrating information systems, managing medical records, coding information for reimbursement and research. We are uniquely qualified to:
  • Provide expertise on compliance issues and the integration of clinical documentation and coding with the billing process.
  • Provide assistance and function as a key resource/project manager for the development, transition, and maintenance of an electronic health record
  • Assist with implementation and function as a key resource on the Health Insurance Portability and Accountability Act (HIPAA) including information system security issues and privacy.
  • Develop, implement and monitor health information department policy and procedures and job descriptions.
  • Provide training and orientation to health information personnel on functions of the department and facility staff on documentation.
  • Develop and maintain health information systems and processes that meet regulatory requirements (both state and federal), professional practice standards, legal standards, and management/corporate policy.
  • Establish a process for systematically reviewing documentation on an ongoing basis for both quality and quantity of documentation.
  • Complete documentation/medical record audits and monitoring with an ability to assess the quality of documentation.
  • Recommend corrective actions for findings on medical record audits/monitoring.
  • Initiate clinical record systems and indexes.
  • Assist with forms development and forms analysis/flow.
  • Support compliance process of facility/organization.
  • Support quality assurance/quality improvement process of the facility/organization.
  • Train staff on quality assurance/quality improvement process related to health information management and appropriate methods for the collection of data.
  • Provide resources to the facility on health information, documentation, regulations, standards of practice, etc.
Not only do we have diverse roles we work throughout the continuum of care. So if you are thinking of an exciting new career this is the place to come!