HUTCHINSON COMMUNITY COLLEGE HEALTH INFORMATION MANAGEMENT PROGRAM STUDENT HANDBOOK

Transcription

1 HUTCHINSON COMMUNITY COLLEGE HEALTH INFORMATION MANAGEMENT PROGRAM STUDENT HANDBOOK Revised December,

2 TABLE OF CONTENTS Content Page No. Welcome/Accreditation 5 Mission, Vision, Philosophy 7 Important Telephone Numbers 8 HIM Advisory Committee 8 The Health Information Technician 9 The Healthcare Coding Specialist 9 The Healthcare Documentation and Transcription Specialist 10 Curriculum Competencies 11 Selection Criteria 15 Admission Procedure 15 Readmission procedure 15 Course Requirements 16 2

3 Graduation Requirements 16 Fees and Financial Aid 16 Scholarships 16 Curriculum 18 Course Descriptions 22 Professional Practice Experience 27 Confidentiality 28 Job Placement 29 Academic Honesty 29 Alcohol and Drug Free Environment 29 Attendance 29 Student Responsibilities 30 Evaluations Assignments 30 Examinations 31 Quizzes 31 3

4 Final Examinations 31 Review Session 31 Grading System 32 Professional Associations 32 AHIMA Code of Ethics 33 AHIMA Vision, Mission and Core Values 35 Appendices Readmission form Appendix 1 Health Forms Appendix 2 Goals and Standards Appendix 3 4

5 HUTCHINSON COMMUNITY COLLEGE STUDENT HANDBOOK WELCOME Hutchinson Community College is pleased to provide you with information regarding the Health Information Management Program. This handbook is designed to serve as a guide to information concerning the associate degree in Health Information Management and certificates in Healthcare Documentation and Transcription Specialist and Healthcare Coding Specialist and to student policies that are particular to these courses of study (hereafter known as the Program ). The requirements given in this handbook apply to all students enrolled in the Program. The student should become familiar with and make plans to comply with these guidelines. Please feel free to discuss any questions or concerns with the instructors in the Program. Be sure to read through the entire handbook. This Handbook is available online at the HCCHIM website. All HIM students are subject to the policies in this Handbook. ***************************************************** ACCREDITATION Hutchinson Community College is accredited by the North Central Association of Colleges and Schools. The HIM Program is accredited by the Commission on Accreditation for Health Informatics and Information Management Education (CAHIIM). CAHIIM is the accrediting organization for degree-granting programs in health informatics and information management. CAHIIM serves the public interest by 5

6 establishing quality standards for the educational preparation of future health information management professionals. When a program is accredited by CAHIIM, it means that it has voluntarily undergone a rigorous review process and has been determined to meet or exceed the Standards set by the Board of Commissioners and curricula by the sponsoring professional organization the American Health Information Management Association (AHIMA). 6

7 MISSION The Health Information Management Program at Hutchinson Community College offers a student-centered, quality educational experience from an accredited Health Information Management program. VISION Develop tomorrow's leaders in Health Information Management. PHILOSOPHY The Health Information Management Program at Hutchinson Community College provides instruction and professional practice experiences to assist students in developing the HIM Associate Degree Entry-Level Competencies Domains, Subdomains and Tasks of a health information technician. These are developed by the Board of Commissioners of the Commission on Accreditation for Health Informatics and Information Management Education and are included in this Handbook. The program also provides instruction and professional practice experiences for the certificates in Healthcare Documentation and Transcription Specialist and Healthcare Coding Specialist. The Health Information Management Program staff is committed to providing the best possible learning environment for the student. Every effort will be made to meet the individual needs of the student within the framework of the college requirements and professional standards. Each student is expected to accept responsibility for his/her own education and to make full use of the learning opportunities offered by the College. Hutchinson Community College does not discriminate on the basis of race, color, religion, national origin, sex, age, or disability in admission or access to, or treatment or employment in, its programs and activities. Any person having inquiries concerning the college's compliance with the regulations implementing Title VI, Title IX, or Section 504 is directed to contact the Affirmative Action Officer on the main campus. Any person may also contact the Assistant Secretary for Civil Rights, U.S. Department of Education, regarding the institution's compliance with the regulations implementing Title VI, Title IX, or Section 504. Any student who has a documented learning and/or physical disability and wishes to access academic accommodations (per the 1973 Rehabilitation Act and the Americans with Disability Act) must contact the HCC Coordinator of Disability Services, at , or Guidance and Counseling Office, Parker Student Union. The student must have appropriate documentation on file before accommodations can be provided. 7

8 IMPORTANT TELEPHONE NUMBERS Name Title Telephone Number Dr. Edward Berger President of the College (ext 3506) Dr. Cindy Hoss Vice President of Academic Affairs (ext 3507) Randy Myers Vice President of Student Services (ext.3579) Christopher Lau Affirmative Action Officer/ Title IX (ext Contact Loretta Horton Co-Chair, Allied Health Dept (ext.2455) Coordinator, HIM Program Becky Hageman Instructor, HIM Program (ext.2440) Cathy Diggs Clinical Coordinator, HIM Program (ext.2456) Diana Twineham Secretary, HIM Program (ext.2456) HCC s long distance number is with the extension above. HEALTH INFORMATION MANAGEMENT PROGRAM ADVISORY COMMITTEE The Health Information Management Program maintains a group of health information and academic program professionals who serve as advisors to the program. These individuals are responsible for providing advice to the HIM program on current health information trends and needs of the community. They maintain a liaison function between the program and the health information professionals in the community. This group meets a minimum of twice per year. For a complete listing of current members, please inquire to one of your health information instructors. 8

9 THE HEALTH INFORMATION TECHNICIAN The Health Information Management Program is designed for persons interested in pursuing a career that combines skills in the following areas: information systems; interpreting/analyzing medical information; handling responses regarding consent for treatment and release of information; privacy and security of health information; managing data; and, maintaining the components of health record systems and the personnel required for systems to function. Health information professionals are responsible for maintaining components of health information computer systems, protecting patient privacy and providing information security, ensuring health information is complete and available to legitimate users, coding and classifying data for reimbursement, analyzing information necessary for decision support, complying with standards and regulations regarding health information, preparing health data for accreditation and licensing surveys, and analyzing clinical data for research and public policy. In all types of facilities, and in various locations within a facility, the health information technician possesses the technical knowledge and skills necessary to process, maintain, compile, and report health information data for reimbursement, facility planning, marketing, risk management, utilization management, quality improvement and research. The health information technician may be responsible for functional supervision of the various components of the health information system. This program provides instruction and professional practice experience to assist students in developing the technical skills necessary to become Health Information Technicians. Graduates receive the Associate in Applied Science degree from the college and are eligible to write the AHIMA national qualifying examination to become a Registered Health Information Technician (RHIT). Our courses transfer to four year colleges and universities offering a Bachelor s degree in Health Information Management. If you decide to continue your education to pursue a Bachelor s degree in Health Information Management, the four-year institution should be contacted to assure a smooth transfer of credit. THE HEALTHCARE CODING SPECIALIST Medical coders assign codes to diagnoses and procedures in order to receive proper reimbursement from third party payers. Medical coders use the International Classification of Diseases and Current Procedural Terminology coding system in order to assign accurate codes for compliance with federal regulations and insurance requirements. Coded information is used to prepare statistical reports for research and 9

10 public policy. Coders require a solid background in medical terminology, anatomy and physiology, pathophysiology and pharmacology. Graduates receive the Healthcare Coding Specialist Certificate from the college and are eligible to write the AHIMA national qualifying examination to become a Certified Coding Associate. THE HEALTHCARE DOCUMENTATION AND TRANSCRIPTION SPECIALIST Healthcare documentation and transcription specialists accurately and rapidly transcribe medical reports dictated by physicians and other healthcare professionals. These reports include history and physical reports, clinic notes, office notes, operative reports, consultation notes, discharge summaries, letters, psychiatric evaluations, laboratory reports, x-ray reports and pathology reports. This may involve receiving medical dictation by tape, digital system or voice file, and using ear phones, a foot pedal, a computer and a word processing program. Healthcare documentation and transcription specialists require good listening and language skills, hand, eye and foot coordination, computer skills and an exceptional knowledge of medical terms. Graduates receive the Certificate in Healthcare Documentation and Transcription Specialist and are eligible to write the Registered Healthcare Documentation Specialist exam from the Association for Healthcare Documentation Integrity. 10

11 DOMAIN I: Health Data Management Curriculum Competencies A. Subdomain: Health Data Structure, Content and Standards 1. Collect and maintain health data (such as data elements, data sets, and databases). 2. Conduct analysis to ensure documentation in the health record supports the diagnosis and reflects the patient s progress, clinical findings and discharge status. 3. Apply policies and procedures to ensure the accuracy of health data. 4. Verify timeliness, completeness, accuracy, and appropriateness of data and data sources for patient care, management, billing reports, registries, and/or databases. B. Subdomain: Healthcare Information Requirements and Standards 1. Monitor and apply organization-wide health record documentation guidelines. 2. Apply policies and procedures to ensure organizational compliance with regulations and standards. 3. Maintain the accuracy and completeness of the patient record as defined by organizational policy and external regulations and standards. 4. Assist in preparing the organization for accreditation, licensing, and/or certification surveys. C. Subdomain: Clinical Classification Systems 1. Use and maintain electronic applications and work processes to support clinical classification and coding. 2. Apply diagnosis/procedure codes according to current nomenclature. 3. Ensure accuracy of diagnostic/procedural groupings such as DRG, MSDRG, APC, and so on. 4. Adhere to current regulations and established guidelines in code assignment. 5. Validate coding accuracy using clinical information found in the health record. 6. Use and maintain applications and processes to support other clinical classification and nomenclature systems (e.g. DSM IV, SNOMED-CT). 11

12 7. Resolve discrepancies between coded data and supporting documentation. D. Subdomain: Reimbursement Methodologies 1. Apply policies and procedures for the use of clinical data required in reimbursement and prospective payment systems (PPS) in healthcare delivery. 2. Apply policies and procedures to comply with the changing regulations among various payment systems for healthcare services such as Medicare, Medicaid, managed care and so forth. 3. Support accurate billing through coding, chargemaster, claims management, and bill reconciliation processes. 4. Use established guidelines to comply with reimbursement and reporting requirements such as the National Correct Coding Initiative. 5. Compile patient data and perform data quality reviews to validate code assignment and compliance with reporting requirements such as outpatient prospective payment systems. 6. Ensure accuracy of diagnostic/procedural groupings such as DRG, APC and so on. DOMAIN II: Health Statistics, Biomedical Research, and Quality Management A. Subdomain: Healthcare Statistics and Research 1. Collect, maintain, and report data for clinical indices / databases/registries to meet specific organization needs such as medical research and disease registries. 2. Collect, organize, and present data for quality management, utilization management, risk management, and other related studies. 3. Comprehend basic descriptive, institutional, and healthcare vital statistics. B. Subdomain: Quality Management and Performance Improvement 1. Abstract and report data for facility-wide quality management and performance improvement programs. 2. Analyze clinical data to identify trends that demonstrate quality, safety, and effectiveness of healthcare. DOMAIN III: Healthcare Services Organization and Delivery A. Subdomain: Healthcare Delivery Systems 12

13 1. Apply current laws, accreditation, licensure, and certification standards related to health information initiatives from the national, state, local and facility levels. 2. Differentiate the roles of various providers and disciplines throughout the continuum of healthcare and respond to their information needs. B. Subdomain: Healthcare Privacy, Confidentiality, Legal and Ethical Issues 1. Adhere to the legal and regulatory requirements related to the health information infrastructure. 2. Apply policies and procedures for access and disclosure of personal health information. 3. Release patient-specific data to authorized users. 4. Maintain user access logs/systems to track access to and disclosure of identifiable patient data. 5. Apply and promote ethical standards of practice. DOMAIN IV: Information Technology and Systems A. Subdomain: Information and Communication Technologies 1. Use technology, including hardware and software, to ensure data collection, storage, analysis, and reporting of information. 2. Use common software applications such as spreadsheets, databases, word processing, graphics, presentation, , and so on in the execution of work processes. 3. Use specialized software in the completion of HIM processes such as record tracking, release of information, coding, grouping, registries, billing, quality improvement, and imaging. 4. Apply policies and procedures to the use of networks, including intranet and internet applications to facilitate the electronic health record (EHR), personal health record (PHR), public health, and other administrative applications. 5. Participate in the planning, design, selection, implementation, integration, testing, evaluation and support for EHRs. B. Subdomain: Data, Information and File Structures 1. Apply knowledge of data base architecture and design (such as data dictionary) to meet departmental needs. C. Subdomain: Data Storage and Retrieval 13

14 1. Use appropriate electronic or imaging technology for data/record storage. 2. Query and generate reports to facilitate information retrieval using appropriate software. 3. Apply retention and destruction policies for health information. D. Subdomain: Data Security 1. Apply confidentiality and security measures to protect electronic health information. 2. Protect data integrity and validity using software or hardware technology. 3. Apply departmental and organizational data and information system security policies. 4. Use and summarize data compiled from audit trail and data quality monitoring programs. DOMAIN V: Organizational Resources A. Subdomain: Human Resources 1. Apply the fundamentals of team leadership. 2. Participate in and work in teams and committees. 3. Conduct new staff orientation and training programs. 4. Conduct continuing education programs. 5. Monitor and report staffing levels and productivity standards for health information functions. 6. Use tools and techniques to monitor, report and improve processes. 7. Comply with local, state, and federal labor regulations. B. Subdomain: Financial and Resource Management 1. Make recommendations for items to include in budgets and contracts. 2. Monitor and order supplies needed for work processes. 3. Monitor coding and revenue cycle processes. 4. Recommend cost-saving and efficient means of achieving work processes and goals. 5. Contribute to work plans, policies, procedures, and resource requisitions in relation to job functions. 14

15 SELECTION CRITERIA ASSOCIATE DEGREE In order to promote student success in the Health Information Management Program and in the health record profession, the following criteria is established: 1. a. High school graduation with a minimum cumulative grade point average of 2.0 on a 4.0 scale for the last two years of high school, or b. Minimum cumulative grade point average of 2.0 on a 4.0 scale for a minimum of twelve semester hours of college, or c. Satisfactory performance on the GED. Consideration will be given to applicants who do not meet the selection criteria at the time of application. Students may be considered for provisional admission; however, the grade point requirement must be met by successful completion (grade point average of 2.0 on a 4.0 scale) of the first college semester (minimum 12 hours). Provisional admission of any student is considered on an individual basis. Please refer to the College website for information about the admission process at ADMISSION PROCEDURE 1. Submission of application to HCC and required official transcripts from high school and all colleges previously attended Submission of application to the Health Information Management program It is the responsibility of the applicant to ensure that the documentation is complete. 4. No applicant will be considered until all required documentation has been submitted. There are no selection criteria for the Healthcare Documentation and Transcription Specialist or Healthcare Coding Specialist Certificate Programs. Readmission procedures: A student must reapply to the HIM program if: He/she has previously been admitted to the HIM program and there is a lapse in continuous enrollment for one fall or spring semester. He/she has been dismissed from the HIM program. 15

16 The student should submit the readmission form found in Appendix 1 and the HIM application found at Final decision for readmission is made by the selection committee of the Health Information Management Program Advisory Committee. (Appendix 1) COURSE REQUIREMENTS All health information core courses in all programs must be completed with a grade of "C" or better in order to progress to the next course and/or successfully complete any of the programs. Core courses include all classes designated with an "HR" at the beginning of the course number. GRADUATION REQUIREMENTS The specific course requirements for the Associate in Applied Science degree in Health Information Management and the certificates in Healthcare Documentation and Transcription Specialist and Healthcare Coding Specialist are listed under Curriculum in this Handbook. Please review these with your advisor to make certain you have met all the requirements for graduation. Students are encouraged to view the degree audit in their DragonZone accounts to track graduation requirements. Please refer to the College website at to ensure that you are ready for graduation. FEES Please refer to the college catalog on the website at for a current listing of tuition and fees. FINANCIAL AID Students with financial aid concerns are encouraged to talk with the Financial Aid Office and visit the website at SCHOLARSHIPS The Health Information Management Program participates in the scholarships program of the College. Speak with your advisor or visit the Financial Aid website at for more information. Other scholarships are available from the AHIMA Foundation ( the Kansas Health Information Management Association ( and some healthcare facilities. Other state health information management associations 16

17 offer scholarships for students. You are encouraged to consult your state association. Healthcare organizations often offer scholarships to current employees. Consult the Program Coordinator or your health information contact at your facility for further information, and be sure to check with your facility s Human Resources office. 17

18 CURRICULUM - ASSOCIATE IN APPLIED SCIENCE IN HEALTH INFORMATION MANAGEMENT FIRST SEMESTER COURSES* CREDIT HOURS CS104 Computers in Healthcare 3 EN101 English Composition IA or 3 EN100 English Composition IB or EN107 Business English PS100 General Psychology or PS101 Human Relations 3 HR100 Health Record Applications I 1 HR103 Introduction to Health Information 3 HR105 Medical Terminology 3 SECOND SEMESTER COURSES BI103 Human Anatomy and Physiology** 6 IS104 Microcomputer Applications*** 3 HR107 Legal and Ethical Issues in Health Information 3 HR204 Healthcare Documentation and Transcription 2 THIRD SEMESTER COURSES AL153 Pharmacology 3 BU203 Principles of Supervision 3 HR203 Health Record Practicum I 1 HR212 Pathophysiology 4 HR214 Health Statistics 2 HR217 Health Record Applications II 1 HR222 ICD-10-CM/PCS I 4 FOURTH SEMESTER COURSES BU109 Business Communications or EN108 Technical Writing 3 HR208 Quality Management 2 HR210 CPT Coding 2 HR211 Health Record Practicum II 1 HR216 Reimbursement Methodologies 3 HR218 Health Record Applications III 1 HR223 ICD-10-CM/PCS II 3 HR224 Coding Lab 1 SPRING, SUMMER OR FALL SEMESTER HR215 Clinical Affiliation 2 TOTAL HOURS 66 * All first-time full-time students are required to enroll in Success Seminar/College Orientation (ED105) during their first semester. Part time students attending college for the first time are required to take the Success Seminar/College Orientation class. Students transferring in to the Health Information Management program from other 18

19 colleges who have a GPA of less than 2.0 or have been out of school for at least ten years are required to take the Success Seminar/College Orientation (ED105) during their first semester. This is a 1 credit hour course designed to provide students with the skills and knowledge important to success in college and beyond and is open to any student. **Students must meet the prerequisite for BI103 Human Anatomy and Physiology either College Biology and College Chemistry or BI100 Basic Concepts for Allied Health Students. Students who take BI100 must receive a C or better in the class to proceed to BI103 Human Anatomy and Physiology. ***IS103 is the prerequisite, unless the student has comparable coursework or computer experience. CURRICULUM - CERTIFICATE IN HEALTHCARE CODING SPECIALIST PREREQUISITES* CREDIT HOURS BI 100 Basic Concepts for Allied Health Studies** 1 CODING CORE COURSES BI103 Human Anatomy and Physiology** 6 HR105 Medical Terminology 3 HR107 Legal and Ethical Issues in Healthcare 3 HR212 Pathophysiology 4 CODING SPECIFIC COURSES AL153 Pharmacology 3 CS104 Computers in Healthcare 3 HR100 Health Record Applications I 1 HR103 Introduction to Health Information 3 HR202 ICD-10 Coding for Long Term Care 2 HR210 CPT Coding 2 HR216 Reimbursement Methodologies 3 HR222 ICD-10-CM/PCS Coding I 4 HR223 ICD-10-CM/PCS Coding II 3 HR224 Coding Lab 1 HR225 Health Coding Practicum 1 IS104 Microcomputer Applications*** 3 TOTAL HOURS 45 * All first-time full-time students are required to enroll in Success Seminar/College Orientation (ED105) during their first semester. Part time students attending college for the first time are required to take the Success Seminar/College Orientation class. Students transferring in to the Health Information Management program from other colleges who have a GPA of less than 2.0 or have been out of school for at least ten years are required to take the Success Seminar/College Orientation (ED105) during 19

20 their first semester. This is a 1 credit hour course designed to provide students with the skills and knowledge important to success in college and beyond and is open to any student. **Students must meet the prerequisite for BI103 Human Anatomy and Physiology either College Biology and College Chemistry or BI100 Basic Concepts for Allied Health Students. Students who take BI100 must receive a C or better in the class to proceed to BI103 Human Anatomy and Physiology. ***IS103 is the prerequisite, unless the student has comparable coursework or computer experience. CURRICULUM - CERTIFICATE IN HEALTHCARE DOCUMENTATION AND TRANSCRIPTION SPECIALIST PREREQUISITES CREDIT HOURS BU128 Intermediate Keyboarding 3 IS104 Microcomputer Applications 3 FIRST SEMESTER COURSES* BI103 Human Anatomy and Physiology** 6 HR103 Introduction to Health Information 3 HR105 Medical Terminology 3 HR130 Medical Style and Grammar 3 SECOND SEMESTER COURSES AL153 Pharmacology for Allied Health Students 3 HR107 Legal and Ethical Issues in Healthcare 3 HR204 Healthcare Documentation and Transcription 2 HR212 Pathophysiology 4 HT255 Introduction to Information and Computer Science 2 THIRD SEMESTER COURSES HR226 Advanced Healthcare Documentation and 4 Transcription HR227 Healthcare Professional Development 2 HR199 Healthcare Documentation Transcription Practicum 2 HT271 The Culture of Healthcare 2 TOTAL HOURS 39 * All first-time full-time students are required to enroll in Success Seminar/College Orientation (ED105) during their first semester. Part time students attending college for the first time are required to take the Success Seminar/College Orientation class. Students transferring in to the Health Information Management program from other colleges who have a GPA of less than 2.0 or have been out of school for at least ten 20

21 years are required to take the Success Seminar/College Orientation (ED105) during their first semester. This is a 1 credit hour course designed to provide students with the skills and knowledge important to success in college and beyond and is open to any student. **Students must meet the prerequisite for BI103 Human Anatomy and Physiology either College Biology and College Chemistry or BI100 Basic Concepts for Allied Health Students. Students who take BI100 must receive a C or better in the class to proceed to BI103 Human Anatomy and Physiology. 21

22 HEALTH INFORMATION COURSE DESCRIPTIONS AL 153 Pharmacology 3 Credit Hours Basic pharmacology for students pursuing allied health professions-basic drugs as related to diseases, effects of drugs on different systems of the body, interaction of drugs, side effects, contraindications and effectiveness in relation to dosages. Prerequisites: None HR 100 Health Record Applications I 1 Credit Hour Lab providing overview of the health information profession; experience in assembly, analysis, and filing of health records; data entry and abstracting of health information; indices; filing of reportable events. Prerequisite: Admission to the HIM Program or department consent Co-requisite: HR 103 HR 103 Introduction to Health Information 3 Credit Hours Introduction to the health care field and health records with emphasis on the roles of health professionals, functions of the health information department, content and analysis of health records in a variety of health care settings and storage and retrieval of health information and common registries. Prerequisite: Admission to the HIM Program or department consent Co-requisite: HR 100 HR 105 Medical Terminology 3 Credit Hours Elements of medical language including common abbreviations. Emphasis is placed on spelling, pronunciation, correct usage, and meaning relating to body systems, medical science, and medical specialties. Prerequisites: None HR 107 Legal and Ethical Issues in Healthcare 3 Credit Hours Introduction to the U.S. legal system, laws and ethical issues and how they relate to healthcare. Prerequisite: HR 103 or department consent 22

23 HR 130 Medical Style and Grammar 3 Credit Hours The study and application of the rules of English as it applies to the transcription of medical documentation. Prerequisites: None HR 199 Healthcare Documentation and Transcription Practicum 2 Credit Hours Learning experience under the supervision of a transcription supervisor at an approved health care facility. A minimum of 90 clock hours including 80 clock hours on site and 10 clock hours of online work. Approval of program coordinator required. Prerequisite: Successful completion of first two semesters of the Healthcare Documentation and Transcription Specialist Program. HR 202 ICD-10 Coding for Long Term Care 2 Credit Hours Fundamentals of ICD-10 Coding principles for the long term care setting. This class does not meet the ICD-10 Coding requirements for the HIM program. Prerequisites: HR105 or Department consent HR 203 Health Record Practicum I 1 Credit Hour Learning experience designed to give students the opportunity to practice skills learned in the health information courses to help prepare students to perform technical functions used with the electronic health record (EHR). Prerequisites: HR 100, HR103, HR 107, or Department consent HR 204 Healthcare Documentation and Transcription 2 Credit Hours Machine transcription of medical reports that make up the health record. Particular emphasis is placed on spelling, accuracy of terminology, neatness, and format of report. Prerequisites: HR 105 or department consent. HR 208 Quality Management 2 Credit Hours Introduction to quality management concepts with emphasis on performance improvement; utilization and risk management. 23