...diagnoses and procedure codes are taken from medical record documentation, such as transcription of medical notes, laboratory and radiologic results, etc. 2. What coding systems are used in the United States? The International Classification of Diseases (ICD) and the Current Procedural Terminology (CPT). According to the World Health Organization (WHO), 70% of the world's health care expenditures are allocated using ICD. ICD codes are alphanumeric designations given to every diagnosis, description of symptoms and cause of death attributed to human beings. 3. How did changes to the ICD-9 over the years reflect events? ICD-9-CM is based on the official version of the World Health Organization's 9th Revision of the International Classification of Diseases (ICD-9). In 1977, the steering committee was formed by the National Center for Health Statistics (NCHS) to clinically modify ICD-9 for use in the United States. The term "Clinical" meant that the United States needed a useful tool to report diagnoses, to classify morbidity data...
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...Week 6 – Course Project Dinae C. Davison, RHIT HIM 435 Professor Paula Arceneaux April 14, 2013 Introduction to ICD-10-CM/PCS The World Health Organization (WHO) is the entity that owns and publishes the International Classification of Diseases (ICD) system (The World Health Organization (WHO), 2013). The United States made modifications to this classification system and in 1979 implemented the use of ICD-9-CM. Since that time healthcare worldwide has evolved and the need to collect more detailed information regarding the diseases and conditions that effect world’s population has become a high priority. Due to this evolution, the ICD-9-CM system has become outdated and can no longer accommodate our needs. Effective October 1, 2014 the United States will implement ICD-10-CM/PCS for use across the nation. Initially we will cover ICD-10-CM and then address ICD-10-PCS. ICD-10-CM is the classification system to be utilized to record diagnoses identified and treated in both the acute care setting as well as the ambulatory setting. There are various differences between ICD-9-CM and ICD-10-CM and we will highlight several of those differences today. One difference between the two coding classification systems is the number of chapters. ICD-10-CM consists of twenty-one chapters as compared to the seventeen chapters in ICD-9-CM. There are approximately 68,000 diagnostic codes in ICD-10-CM as opposed to the 14,000 in ICD-9-CM (DeVault, Barta, & Endicott...
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...Introduction: There are a lot of abbreviations used in the United States health care delivery systems. A list of some of these abbreviations that are used by physician’s offices, hospitals, nursing homes, and other ambulatory care services are listed in this paper. 1. AMR - The definition of an Automated Medical Record, otherwise known as an electronic medical record, has been set forth by the 2003 IOM Patient Safety Report as the: • "collection of electronic health information for and about persons" • "provision of knowledge and decision-support systems [for] support for efficient processes for health care delivery" • "electronic access to person-and population-level information by authorized users" ("Definition Of Automated Medical Record", 2012). 2. CMR – According to "Mortality Frequency Measures" (2012), Crude Mortality Rate. The Crude Mortality Rate is the mortality rate from all causes of death for a population during a specified time period. • Mortality rates measure the frequency of occurrence of death in a defined population during a specified interval. • There are several specific kinds of mortality rates, but we will focus only on the ones that are used most often in infectious disease epidemiology. • To calculate a simple mortality rate, we need to know the number of deaths in a given population during a specified time period, and the size of the population in which the deaths occurred...
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...transportation company. AMR employs 19,800 employees. "AMR’s national headquarters is located in Greenwood Village, Colo. AMR provides services to more than 2,100 communities across the nation. From Miami to Seattle and hundreds of communities in between, AMR is ready to care for people and communities in need" (AMR, 2013, para. 4). * CMR: CMR is a state of the art emergency department information system (EDIS). This method increases office workflow and more accurate documentation. Health care facilities find that CMRs are user-friendly and provide understandable chart layouts. The browser increases communication among health care professionals. * CMS: Centers for Medicare and Medicaid Services. Federal agency that provides Medicare and Medicaid services. The CMS also administers specific standards for the Health Insurance Portability and Accountability Act of 1996 (HIPAA) The CMS provides health care to over 100 million recipients CMS, 2013). * CMS-1500: The CMS-1500 is a health insurance claim form. The CMS-1500 is the standard health claim form used by the National Uniform Claim Committee (NUCC). Any data provided on the CMS-1500 must be disclosed to a central state agency that examines the health information. The federal government adopted this particular form for any noninstitutional provider claim. Example includes a physicians services (Wager, Lee, Glaser, & Burns, 2009). * CPT: (Current Procedural Terminology), published by the American Medical Association...
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...Disease Classification Structures Health care information systems cover a wide range of issues dealing with the supervision and use of biomedical information. Health information systems are central support tools in the administration of health care services. An acceptable health information system is important not only for evaluating the health needs of populations but also for preparation and for application of health interventions. It is equally imperative in the assessment of programs. The goal of information systems is to create an appropriate working environment. This is done by providing initial and going training, allocating resources, and by managing unintended consequences (Wager, Lee & Glaser, 2009). This summary will examine disease classification information structures necessary for reimbursement and epidemiological data collection. Discussions will describe disease classification, analyze reasons why it was selected, and explain how it is applicable to work, review the benefits of the systems and also discuss the negative draw backs of the system. To begin discussions will focus on defining disease classification structures. Disease Classification Structures Disease classification structures are essential to health care. The International Classification of Disease Ninth Revision (ICD-9) is a classification system developed by the World Health Organization (WHO) to categorize diseases. ICD-9 collects data on disease and in the United States the ICD-9...
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...Kirkendol Definition of Terms People working with health information technology (HIT) systems must familiarize themselves with key terms to help them perform their assigned work tasks. The terms below help health care organizations to operate more accurately and efficiently. By applying these tools and resources, health care organizations and professionals provide better services and a continuum of care to their patients. Key terms include acronyms, such as AMR, CMR, CMS, CMS-1500, CPT, DRG, EPR, HL7, ICD-9, and UB-92. The following excerpt will translate and define these acronyms and describe the most important aspect of these key terms. Translation and Definition of Key Health Information Technology Terms SearchHealthIT (2011) describes an ambulatory medical record (AMR) as “an electronically stored file of a patient’s outpatient medical records, which includes all surgeries and care that do not involve being admitted to a hospital” (para. 1). Physicians and other medical professionals have access to a patient’s complete medical history. The article states the most important aspect of an AMR lies in the fact they only apply to medical procedures, which require an overnight or longer stay in the hospital. Ambulatory medical records only exist in non-hospital environments, such as physicians’ offices, urgent care clinics, and at-home medical care settings. A computerized medical record (CMR) stores health information and data about a patient in a computer....
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...System Structures Overview HCS/533 Health Information Systems Name Date Professor I have aforementioned that I was previously employed with hospice within the health care industry for several years. Within that experience, I have had the pleasure of using a few information systems. I have also had the pleasure of gaining insight and a better understanding of these systems and how and why they were implemented within the industry as well as how beneficial they have been throughout the years. If I may, I would like to report on a system that was not discussed during Week 2 of this course but is very imperative within the hospice industry which is Disease Classification Structure. Disease Classification Structures are very essential for compensation. The data system is one that classifies and provides diagnostic codes that help classify diseases. The ICD-9 (international classification of disease) was actually elected in the United States and the purpose was to “classify disease and health conditions on health care claims and is the basis for prospective payment to hospitals, other health care facilities and health care providers. (Overview of ICD-9, p.1). Every decade, the World Health Organization revises to include morbid and mortal conditions. The DRG (diagnosis related group) was put into motion in the early eighties with the intent of creating a classification system that identified the products that the patient received. (Medicare, 2013). Since that period of time...
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...Artra Thomas The International Classification of Diseases Have you ever heard of the Classification of Diseases? Well neither had I until back in the early 1990’s. I was taking a course in medical assisting, where I got my first introduction into healthcare. Initially, I wasn’t really sure of what it as but after my instructor explained it I had a better understanding. Have you ever been to the doctor and once your appointment was over you received a paper with a lot of different codes on it? Then were you asked to give it to the front desk on your departure? Well this is where the ICD comes into play. These codes are used to tell the insurance company what procedures or test were performed on you during this visit. The International Classification of Diseases 10th Revision (ICD-10) is a major change in how healthcare information will ultimately be used in documenting and collecting information both, worldwide and in the United States. Many countries have used the ICD-10 for many years now. The ICD-10 plays an essential part in everything related to the practice of medicine, from quality measures, research and claims that are processed. From the beginning there were concerns that are associated with managing and implementing the ICD-10 code set, preparing and realizing that getting through this transition would be the first of many. For me knowing that the classification of diseases will make doing paperwork easier, I can truly appreciate the ICD-10. With the constant changes...
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...Creating an effective plan for the management and treatment of female offenders There are nearly 2.1 million violent female offenders annually in the United States (Greenbelt et al. 2000). Three out of four female violent offenders commit simple assaults, and three out of four female violent offenders attack other women. The incarceration rate for women is increasing at nearly twice the rate of men (Gater, 2005). Some risk factors contributing to the increase in criminal behavior among women include spousal abuse, substance abuse, and mental illness. The treatment of female offenders is becoming an increasingly important issue. Female offenders are often incarcerated in facilities designed for male treatment and rehabilitation needs. In the past, it was considered that male and female inmates had similar treatment needs, but as correctional administrators become aware of the increasing numbers and the differing needs of female offenders, they must re-evaluate the available treatment programs and begin to implement revisions to the management of program plans. It is now clear that differences in treatment between women and men within the judicial and correctional systems often have harmed rather than helped women (Harris 1998). In addition, Harris (1998) adds that evidence continues to grow of ways in which women’s experiences have been tied to their race and class, as well as the part of the country in which they lived and other personal characteristics. Research...
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...Application ORIGINAL XXX 1541-5147 ARTICLES International of Orem’s Self-Care Deficit Theory and Standardized Nursing Languages in a Case Study of a Woman With Diabetes IJNT Malden, USAJournal Inc Blackwell Publishing of Nursing Terminologies and Classifications Application of Orem’s Self-Care Deficit Theory and Standardized Nursing Languages in a Case Study of a Woman with Diabetes This paper aims to illustrate the process Coleen P. Kumar, RN, MSN, CNS, is Assistant Professor of Nursing, Kingsborough Community College, Brooklyn, New York. Introduction As the average lifespan is extended, more individuals are coping with chronic illnesses such as diabetes, which has reached epidemic proportions with more than 20 million people in the United States having this diagnosis (Gordois, Scuffham, Shearer, Oglesby, & Tobian, 2003). The American Diabetes Association (ADA) estimates that a million people will be diagnosed of diabetes every year (2004). Long-term complications of diabetes are costly to both the individual and the healthcare system. Over the past decade, diabetes research has focused on pharmacological approaches and lifestyle interventions to the illness (Odegard, Setter, & Iltz, 2006). Recent evidence in the forum of diabetes care revealed a need for healthcare professionals to assess and empower individuals in the self-management of this illness. For the purposes of this case study, health assessment by nurses was defined by Fuller and Schaller-Ayers (2000) as a process...
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...it threatens the values of society. The cause and the solutions are responsibilities of the society Affected Population The meaning of being homeless in the United States helps define who is able to receive shelter and assistance from health and social service providers. In order to live a normal life requires having a home to live in. Yet people with no home and unable to afford anything can be found in all countries. The main reason is the individual cannot get the housing loans or welfare accessible to others. The causes of homelessness can be caused by family altercations or tragedy (or prison), or even a natural disaster. The larger proportions of homeless parents who are separated from their children in the US and the larger number of families in the homeless population are both likely because of the US social policy. Higher levels of inequality and lower levels of social benefits are associated with higher rates of homelessness. The Stewart McKinney Homeless Assistance Act of 1987 describes a homeless person as any place not meant for regular sleeping accommodation by humans. In 2005, an estimated 744,313 men, women, and children were homeless in the United States (National Alliance to End Homelessness, 2007). Adults that are homeless are poor and have high rates and they don’t qualify for health care. There are also a large number of former veterans who become homeless. It is estimated that between 23 percent and 40 percent of homeless adults are veterans (National...
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...Definition of terms Chinedu HCS/533 Health Information Systems AUGUST 25, 2014. Definition of terms This presentation will translate and define the following abbreviations: AMR, CMR, CMS, CMS-1500, CPT, DRG, EPR, HL7, ICD-9, and UB-92. Technology today has revolutionized the health care system, as technology evolves, so does the environment promoting quality care for those in need of it. AMR- An ambulatory medical record (AMR) is an electronically stored file of a patient’s outpatient medical records, which includes all surgeries and care that do not involve being admitted to a hospital. An AMR is similar to an electronic medical record (EMR), but while EMR’s keep track of inpatient care (surgeries and care that require spending overnight or longer in a hospital), AMRs only apply to medical procedures and cares that do not result in an overnight stay in a hospital or that are given in non-hospital settings such as urgent care clinics, physicians’ offices and at home medical care. AMRs are stored in electronic databases called ambulatory medical record systems that are accessible by doctors and other medical professionals. CMR- Computerized medical record is an electronic information system and keeps records of each individual patient’s health. Computerized medical records (CMR) provide a viable mechanism for implementing clinical governance. Computers are involved in all aspects of the clinical interaction-from consulting room to system-level use of large systems...
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...Of Medical Coding and Billing John F. McMahon BU480, Central Methodist University Abstract Medical coding and billing affects everyone during their lifetime and yet the regulations of medical coding and billing are extremely complex. Examining the history, evaluation, and effect of new regulations and their cost shed light on an already complex industry. We will review government regulations, technological advancements, and requirements that providers will face in the near future. We will examine our current systems and how they evolved through time and what they may be in the future. We have reviewed articles from the Medical Billing and Coding Association, the Department of Human and Health Services as well as the Office of the Inspector General. We will review the different types of insurance, how they each affect the process of medical coding and billing and then see what the future will be. Finally we will review what steps we have taken that has allowed a government to be so involved in our healthcare decisions. Thesis Statement Medical Coding and Billing has evolved to a point that it affects everyone at one time or another during their lifetime and has only led to complex rules and regulations that you almost need a degree to understand. From times that Physicians bartered for their services to the government telling them what to charge and insurance companies negotiating the...
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...Nurse practitioner From Wikipedia, the free encyclopedia In the United States, nurse practitioners have a national board certification. Nurse Practitioners can be educated and nationally certified in areas of Family Health (FNP), Pediatrics, including Pediatric Acute/Chronic Care, Pediatric Critical Care, Pediatric Oncology and general Pediatrics (PNP), Neonatology (NNP), Gerontology (GNP), Women's Health (WHNP), Psychiatry & Mental Health (PMHNP), Acute Care (ACNP), Adult Health (ANP), Oncology (FNP, ACNP, ANP, PNP or ANP) Emergency (as FNP or ACNP), Occupational Health (as ANP or FNP), etc. In Canada, NPs are licensed by the province or territory in which they practice. The advanced practice nursing role began to take shape in the mid-20th century United States. Nurse anesthetists and nurse midwives were established in the 1940s, followed by psychiatric nursing in 1954. The present day concept of the APN as a primary care provider was created in the mid-1960s, spurred on by a shortage of doctors. The first official training program for NPs in the United States was created in 1965, with a vision to help balance rising health care costs, increase the number of health care providers, and correct the inefficient distribution of health resources. There was some confusion about the varying titles and abilities of advanced practice nurses as the role was developed, which has persisted as the authority and responsibilities of the NP have evolved over time. ...
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...Technology, and the definitions of health care information, and health care acronyms and remittance terms Jesse Davis Jr. University of Phoenix MBA 533/ Health Information Systems December, 2014 Professor Aimee Kirkendol Health information related acronyms, their translation, and elucidation The field of healthcare is primarily concerned with the care of people requiring preventive and medical care. However healthcare is a business. The business of health care generates trillions of dollars for the national and international health care communities. Health care as a right in the United States precludes the fact that capitalism rules every aspect of citizen life, especially health care. The factors primarily affecting health care include new technologies. The medical technology industry is a 150 to 200 billion industry. Prescription drugs, government regulation, malpractice liability and the aging of the largest generation birthed in the U.S., the Baby Boomers (78 million). Every day in the U.S., 10,000 Baby Boomers reach age 60, putting greater demands on medical services. Chronic diseases, many preventable (diabetes, cancers of the lung and cardio vascular disorders) also contribute to escalating cost of health care. Acronyms reduce the amount of...
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