Health Information Technology PROGRAM HANDBOOK

Health Information Technology PROGRAM HANDBOOK The mission of the Health Information Technology program is to offer an Associate in Applied Science degree designed to provide the healthcare community with a competent entry-level Health Information Technician prepared to work in various settings. The program is committed to the student s educational and professional development by emphasizing stateof-the art instruction and curriculum that integrates general, employability, and technical skills so learners will succeed in reaching their goals. Revised 2/2015

TABLE OF CONTENTS Welcome Message... 1 Introduction of Faculty and Staff... 2 The HIT Program at NWTC CAHIIM Accredited... 3 Goals and Standards... 3 Admission Requirements... 3 Requirements for Program Application... 3 Requirements for Program Entry... 3&4 Entry-Level Competencies... 4 Course / Curriculum Information... 4 Required, General Education and Elective Courses... 4 Courses shared with the Healthcare Business Services Program... 4 Software... 5 Flexible Learning Option... 5 Academic Planning... 5 Professional Practice Experience... 5 a. Health and Caregiver Background Requirements... 5 b. NWTC Health Science Student Drug Screening Policy. 5-7 c. Petition to Enter Professional Practice Experience 2... 7 d. Expenses... 7 e. Student IDs... 7 f. Format of the Professional Practice Experience... 7 g. Credit for Work Experience... 8 h. Mock RHIT Test... 8 About NWTC College Policies... 8 Outstanding Student Award... 8 Scholarships... 8 Employability Skills... 8&9 Attendance Policy... 9 Methods of Assessment... 9&10 Referrals... 10 Academic Probation, Program Dismissal and Program Re-entry... 10 Graduation... 10 Tips from Past HIT Students and Graduates.....10&11 The Health Information Profession What Does a Health Information Technology Professional Do?... 12 Type of Person to Enter this Field... 12 Employment Opportunities... 12&13 What credentials, in addition to RHIT, are available?... 13 2

National and State Associations Student Membership in AHIMA... 13 Fall/Spring WHIMA Meetings... 13 Active Membership in AHIMA... 13 National Certification Examination... 14 Maintenance of Certification/Continuing Education... 14 Progression to the RHIA... 14 Code of Ethics 2011 Ethical Principles... 14&15 Standards of Ethical Coding... 15&16 CDI Ethical Standards... 16 AHIMA Competency Statements... 17-20 3

Welcome Message To the Program Student: I am delighted that you have applied and been accepted into the Health Information Technology Program here at Northeast Wisconsin Technical College. Health Information Technology is a rewarding and evolving profession. Please review the contents of this Handbook before you start the program to ensure that you have chosen the correct career path and also to assist you in being successful within the Health Information Technology Program (HIT Program). If you have additional questions after reading this document and attending the orientation session, feel free to contact me. NWTC and the program faculty are committed to providing each student with the opportunity to successfully complete the HIT program. Sincerely, Julie Swavely Julie Swavely, MHA, RHIA HIT Program Director/Instructor Office: HS108N Email: julie.swavely@nwtc.edu Phone: 920-498-5579 1

Introduction of Faculty and Staff We are pleased to introduce the Health Information Technology faculty and staff who are dedicated to making this program and its graduates a success! Julie Swavely, MHA, RHIA Health Information Technology Program Director/Instructor Amy Janssen, RHIT Health Information Technology Instructor Linda Pristelski, RHIT Health Information Technology Instructor Scott Anderson, MSA Associate Dean Allied Health Chelsey Burke Administrative Assistant, Health Sciences 2

The HIT Program at NWTC CAHIIM Accredited: NWTC s HIT Program is accredited by the Commission on the Accreditation for Health Informatics and Information Management Education (CAHIIM). Goals and Standards: The Health Information Technology (HIT) Program has goals and standards developed and approved with the assistance of its NWTC Advisory Committee. Goal: The HIM curriculum will include, at minimum, the required knowledge clusters with content and experiences to enable students to meet current entry-level competencies (required). Goal: Faculty will demonstrate current knowledge, skills, qualifications and professional development in the content areas they teach (required). Goal: The HIM program will demonstrate responsiveness to the needs of the community(ies) of interest (required). Goal: Program graduates will demonstrate the HIM entry-level competencies (required). Goal: Faculty will demonstrate participation and follow-through on college team and personal team action plans. Admission Requirements: Requirements for Program Application Completed application High school transcript or equivalent. (For a list of equivalents, go to www.nwtc.edu/gettingstarted.) Admission Assessment or equivalent or ACT assessment taken within the last five years. (For a list of equivalents, please contact a Counselor.) Two semesters in High School, or one semester in College of Biology, or equivalent, with a grade of "C" or better. Typing proficiency of 30 words per minute (mandatory preadmission typing test to be taken at the NWTC Assessment Center). Requirements for Program Entry As a requirement for program entry, an Academic Skills Assessment (Accuplacer) with appropriate benchmark scores is necessary. Program benchmarks are Arithmetic, 65; Reading Comprehension, 78; Sentence Skills, 90. Applicants not 3

meeting these benchmarks or the equivalent will be required to establish an individualized academic plan. Upon completion of the plan, full program or waitlist status will be granted. To learn more about these assessments and program benchmark scores, please contact an advisor at (920) 498-5444 or (888) 385-6982. Attend mandatory spring program orientation. Complete caregiver background check. A fee is charged for this service. Additional information will be provided upon acceptance into the program. Entry-Level Competencies: The American Health Information Management Association (AHIMA) has developed entry-level requirements called competencies and knowledge clusters for the Registered Health Information Technician (RHIT). The HIT Program at NWTC has incorporated these into the course curriculum. Students are given a copy of these (See the back of this handbook). Course / Curriculum Information: Required, General Education and Elective Courses: HIT core courses include: Medical Terminology; Intro to Health Record; Health Data Management; Human Disease for Health Professions; Healthcare Law & Ethics; ICD Diagnosis Coding; CPT Coding; Healthcare Reimbursement; ICD Procedure Coding, Healthcare Stats and Research; Healthcare Informatics; Professional Practice Experience 1; Health Quality Management; HIM Organizational Resources; Applied Coding, and Professional Practice Experience 2, Medical Terminology, Basic Anatomy. NWTC requires at least 21 credits of general education courses in associate degree programs. The following general education courses are required in the HIT program: Written Communications; Oral/Interpersonal Communications; Math with Business Applications; Intro to Psychology; Race, Ethnicity and Diversity; Economics, Basic Anatomy, Windows, Word, Excel, PowerPoint and Access and College 101. HIT students have no elective credits within the program. However, if additional courses are desired, students are strongly encouraged to take any of the following courses: computer courses, Insurance Health Principles, Medical Practice Procedures. The Academic Advisor is available to assist with course selection. Courses shared with the Healthcare Business Services program: The Health Care Business Service program (HCBS) and the Health Information Technology program (HIT) share course work. Beginning in the second semester, HCBS has more business/financial courses and HIT has more clinical courses. 4

Software: All courses are delivered through Blackboard. It is required that students have access to a computer with Internet access. Program courses may require the use of software. These include AHIMA s Virtual Lab for electronic medical records, master patient index, chart tracking, chart deficiency, encoder/drg/apc software, and coding reference software. The Microsoft Office Suite software is available. These are available at no cost. Neehr Perfect s EHR is used in Healthcare Informatics and Professional Practice Experience 1 through a subscription purchased by the student. Flexible Learning Option: A majority of the Health Information Technology program courses are offered in an online format. This program may be completed in a part-time or full-time format. Students should make an appointment with the HIT Academic Advisor to establish an individual plan for completing the program. Academic Planning Adequate time commitment is needed for success. Here is a recommended guideline. 1 credit class = 15 classroom hours per semester + 2-3 hours homework per week or 3-4 hours per week total 2 credit class = 30 classroom hours per semester + 2-3 hours homework per week or 6-8 hours per week total Again, the time commitment calculations provided above are a general rule of thumb, but definitely something to consider. Professional Practice Experience: Health and Caregiver Background Requirements Students must complete all the health and caregiver background requirements prior to going out on Professional Practice Experience 2. An influenza vaccination is required. A two-step TB test is required and is available for a minimal fee through the NEW Clinic located on the NWTC Green Bay campus. An appointment must be made. The Health Record Office located in HS409 is available to answer questions about the health requirements. The Caregiver Background check is completed through certifiedbackground.com. There is a fee for this service. NWTC Health Science Student Drug Screening Policy Health Program students participating in clinical at a clinical agency requiring drug screening must complete a drug test prior to their first clinical experience at that site. This mandatory drug test must be performed at facilities designated by CertifiedProfile (the agency NWTC uses for health records, background checks, and drug screening). Drug testing is done at the student s expense. Use of alcohol or illegal drugs, or misuse of prescription drugs, are strictly prohibited in the classroom, clinical or laboratory setting. Refer to the College s Student Handbook for the policy on rules and conduct (p. 40-41, 2014-15). 5

http://www.nwtc.edu/atnwtc/student-involvement/documents/student_handbook_finalwebcopy.pdf 1. All students scheduled for a clinical experience at a clinical agency with a drug screen requirement must submit to drug testing as a condition of enrollment in the Health Program (Nursing or Allied Health). 2. Students are notified of the potential for a drug test requirement prior to admission to the program (the requirement is specific to select clinical agencies). 3. Information regarding timing and process for drug testing is specific to each program and will be shared with students when clinical placement planning occurs. 4. Failure to meet the deadline provided by your instructor/program director for drug testing may result in failure to continue in the assigned Health Program. 5. Students must pay for the drug test at the time of the testing. Private health insurance will not pay for the testing. 6. In the case of a positive test result, the Medical Review Officer (CertifiedProfile appointee) will attempt to personally contact the student to discuss the positive test result, and information may be shared and analyzed to provide possible explanations for the positive test result. 7. Results of the test will be made available to both the student and a college designee. If a student provides a sample that is inconclusive, an additional test must be performed on that sample at an additional cost to the student. 8. Only students receiving negative drug tests may remain enrolled in the Nursing or Allied Health program. 9. A student who tests positive in the drug screening conducted under this procedure for drugs that are illegal substances, or are non-prescribed substances that require a prescription for lawful use, or are deemed unsafe for the clinical setting will be removed from the program. 10. If a student challenges the results of the test only the original sample will be tested. The student is responsible for the cost of the retest. Procedure for Drug Testing 1. Purchase drug test package at CertifiedProfile.com. 2. Follow directions provided by CertifiedProfile to complete the drug test. Directions will include names and locations of authorized drug testing sites. 3. Results will be available to you and a college designee in your CertifiedProfile account. Readmission following a positive drug test 1. Students who are withdrawn from the Nursing or Allied Health program for reasons related to a positive drug test must submit a letter to the Dean of Health Sciences requesting readmission to the program. The letter must be sent electronically to kay.tupala@nwtc.edu 2. Applicants must include documentation from a therapist specializing in addiction behaviors indicating status of recovery and/or documented rehabilitation related to the substances used or abused. Documentation must include a statement by 6

the therapist that the applicant will be able to function effectively and provide safe, therapeutic care for clients in the clinical setting. 3. If readmitted, the student will be subjected to random drug testing and/or for cause drug testing at the student s expense for the duration of his or her Nursing or Allied Health program. 4. If the student has positive results on a drug test after readmission to the Nursing or Allied Health program, the student will be dismissed from the program, with no option for readmission to any NWTC Health Programs. Petition to Enter Professional Practice Experience 2 Students must complete a Petition to Enter the Fall Professional Practice 2 by March 30 th and the Spring Professional Practice 2 by October 31st. The form can be obtained through the college website, Health Sciences Department office or from the HIT Academic Advisor. Every effort will be made to place students in their site of choice, but this is not guaranteed. If a student declines a clinical site, that student will be placed at the bottom of the placement list. Expenses Students need to travel (generally less than an hour one-way) to their site. Students are responsible for all travel expenses. Student IDs Students must purchase a NWTC photo ID at the Student Involvement office (SC118 near the Commons of the Green Bay campus). This ID must be worn at all times the student is at his/her Professional Practice site. Format of the Professional Practice Experience Professional Practice 1 consists of a 45 hour simulation experience. Twenty four additional hours are spent on campus with guest speakers, class simulations, tours, and group projects. The remainder of the coursework is completed online. Professional Practice 2 consists of a 45 hour rotation in a hospital, clinic, long term care or alternate site. Hours worked at the site are counted toward the 45 hour total. Lunch periods are not counted, but breaks are just as if the student were an employee. Management, quality case management, coding, and other hospital areas are covered. Twenty four additional hours are spent on campus with guest speakers, review for national accreditation exam, graded final exam, and a group project. The remainder of the coursework is completed online. Full-time students will have other coursework during these semesters. Students will work with the site assigned to determine their schedule at the site. However, the sites may not always be able to work around your particular schedule. Students need to plan far in advance to assure their flexibility to meet the requirements of the professional practice experiences. 7

Credit for Work Experience Credit for work experience is available for the Professional Practice Experience 2. Students will be expected to complete a portfolio illustrating and/or specifying prior work experience along with their employer s confirmation of this. The Professional Practice Experience 2 instructor guides this process. There is a fee for the application for Credit for Work Experience which may vary annually. Mock RHIT Test Students will be given a timed mock RHIT test during Professional Practice Experience 2. Students will be given the results of the test and required to look up the correct answer to any that were marked incorrect. Students must pass the mock test with a C or better to pass this course. College policies: About NWTC The HIT Program adheres to all college policies outlined in the Student Handbook. These include Non-discrimination, FERPA, and Student Code of Conduct. Outstanding Student Award: The program instructors may choose an outstanding student each year who meets criteria specified by NWTC. This student is honored at the Annual Awards Banquet. Scholarships: The NWTC Education Foundation has a number of general scholarships that are available to all students and specifically to health students annually. Please refer to the website or obtain a scholarship book in the Student Involvement. The American Health Information Management Association (AHIMA) and the Wisconsin Health Information Management Association (WHIMA) offer scholarships to students annually. Visit www.ahima.org, the Foundation on Research and Education, or www.whima.org, for information. Employability Skills In addition to specific job-related training, NWTC has identified employability skills that are transferable and go beyond the context of a specific course. This program addresses the following employability skills: Demonstrate Personal Accountability Think Critically and Creatively 8

Value Individual Differences and Abilities Works Cooperatively and Professionally Communicate Effectively Demonstrate Community & Global Accountability Solve Problems Effectively Attendance Policy: Attendance and participation in courses are important aspects of student learning. All students are expected to attend class and be prepared to participate in discussions and activities related to learning. As a result, students who cannot attend class are required to contact their instructor within 24 hours of a class absence. An email message or voice message may be left on the instructor s telephone message service if the instructor is not in his/her office at the time of the call. If you are absent from class, it is your responsibility to get the information you missed. Each individual course syllabus will contain information specific to the instructor s attendance and work expectations. Methods of Assessment: Specific information about assignments are listed in each course syllabus. Due to the importance of writing skills in a business setting, grammar, spelling and punctuation will be graded in addition to substantive content for all assignments. Assignments may be in the form of: Written assignments Written tests may consist of multiple choice, short completion, essay, true/false, matching or definitions Computer lab exercises Journal or portfolio completion Professional Practice Experience All tests are evaluated on a percentage scale and averaged to determine a final course grade. See individual course syllabi for specifics. Failure to turn in any assignment on time will result in having points deducted. Each course instructor will determine how many points per day will be deducted according to a particular assignment. See individual course syllabi for specifics. Academic dishonesty is inexcusable and will not be tolerated. If it occurs, the student will be given a sanction which could include a grade of zero for that graded activity, failure in the course, or dismissal from the program. A professional practice site supervisor has the right to withdraw the student from the worksite for unprofessional behavior. 9

The grading scale for Health Sciences core courses is: A 93-100 B 85-92 C 77-84 D 70-76 F 0-69 Referrals: If a student is having difficulty in a course, an alert will be issued utilizing Starfish Early Alert system and other college resources such as academic advising, academic coaching, accommodations and personal counseling as necessary to aid in the success of the student through the program. Academic Probation, Program Dismissal and Program Re-entry: A final grade of a C is required to pass all core courses within the program. A student receiving a grade lower than a C (including withdrawals past the College s refund window) may apply for re-entry to the program one time. A student allowed to re-enter the program will be considered on Academic Probation until completion of the program. A failure or withdrawal in any core course after re-entry will result in being dismissed from the program. Graduation: Students are eligible for graduation when the following requirements are met: A student must have completed an application and been accepted to the program/plan from which he or she wishes to graduate. A student must have completed all the classes published in the program s curriculum with a cumulative grade point average of 2.00 or better ( C average). You must fulfill all financial obligations to NWTC before you can receive a diploma or transcript. Tips from Past HIT Students and Graduates: 1. Prior to entering the program, job shadow or do some research to see exactly what an RHIT does. 2. Try to get the basics out of the way so when you are in the program you won t be as loaded down and you can concentrate on core classes. 3. As far as coursework goes, study, study, study, and keep on top of things. Don t wait until the last minute. You won t learn as much. Review the whole semester to keep things fresh, otherwise you will lose it because it is not applied every day. 4. I would suggest not overloading yourself with classes. If you do, you tend to do things halfway and you don t learn as much. Some people like study groups. 10

5. Be serious about your work and what you learn every day, because when you do get a job it s amazing how much you will use just about everything you learned. Take the (RHIT) exam ASAP. 6. If only there were a way for even more on-the-job experience. Even though it was long, it didn t seem long enough. 7. Keep all your HIM-related books and do not sell them back to the book store. Also keep all your paperwork from your classes to use in studying for the RHIT exam. 11

The Health Information Profession What Does a Health Information Technology Professional Do? HIT professionals may be employed in any one of following positions: Medical Coding Specialist Release of Information Specialist Health Information Technician Insurance/Business Reimbursement Coordinator Data Quality & Integrity Monitor Privacy and/or Security Officer Data Analyst HIM Supervisor Cancer (or other disease) Registrar Utilization Review Coordinator Type of Person to Enter this Field Interest in medicine and the business side of health care Likes detail work and organizing Likes to work with computers Likes to work with other people, but not hands-on patient care Able to use own initiative, work hard and stay abreast in the field (outside reading, taking classes, etc.). Confidence in decision making capabilities Employment Opportunities Health Care Facilities hospitals, nursing homes, clinics, hospices, mental health facilities, home health, rehabilitation facilities, veterinary clinics/hospitals Insurance Companies Government Agencies public health, state, federal Private Vendors document management, release of information, EHR, etc. Consulting Industry health and wellness programs Education Law firm 12

Anywhere health information is stored What credentials, in addition to RHIT, are available? Certified Documentation Improvement Practitioner (CDIP) Certified Health Data Analyst (CDHA) Certified in Healthcare Privacy and Security (CHPS) Certified Healthcare Technology Specialist (CHTS) Certified Coding Associate (CCA) Certified Coding Specialist (CCS) Certified Coding Specialist-Physician-based (CCS-P) Certified Tumor Registrar (CTR) Certified Professional Coder (CPC) Certified Outpatient Coder (COC) Certified Inpatient Coder (CIC) Certified Professional Coder Payer (CPC-P) Student Membership in AHIMA: National and State Associations It is recommended that students become members of the American Health Information Management Association (AHIMA). The cost to become a student member is $45 annually. Students receive the Journal of the AHIMA, reduced registration fees at workshops, automatic membership in the Wisconsin Health Information Management Association (WHIMA), professional mailings, and opportunity to participate in the webbased Communities of Practice resource. The student member s annual fee pays for itself through the reduced application fee to take the national registration exam for those that are student AHIMA members. See below for more information on the national certification examination. Fall/Spring WHIMA Meetings: Students are encouraged to attend the September Fall WHIMA Conference and especially the Spring WHIMA Annual Conference. These are usually 2-3 day meetings and are held at various locations in the state. Students are given a significant break on the registration cost. Active Membership in AHIMA: Upon achievement of RHIT credentials, individuals can become active members of AHIMA. The annual fee for new graduate active membership, including the $10 continuing education assessment fee for the RHIT or RHIA, is $110. Thereafter, it is $185 annually. This fee is also subject to change periodically. Some employers may pay this fee. 13

National Certification Examination: Students who graduate from an approved Health Information Technology Program are eligible to take the National Certification Exam to become Registered Health Information Technicians (RHIT). This is a computer-based exam and is held week days throughout the year at NWTC and throughout the nation. Candidates who pass the exam are certified by the AHIMA and earn the right to use the RHIT credential after their name. There is an application process and fee which may change annually. The fee is currently $229 if a student AHIMA member and $299 if a non-ahima student member. The fee is included in the tuition for PPE2. Students may opt out or request a waiver by submitting a written request to the Associate Dean, Allied Health Sciences. A refund will be issued or the fee waived. Request to opt out or request a waiver must be submitted prior to the first day of the semester. The student will not have an opportunity to change their decision. A transcript fee payable to NWTC is also required for those sitting for the national examination. The fee is currently $10. The RHIT exam must be completed within a four month window of submitting the application. It is highly recommended that students sit for the exam as close to graduation as possible. Statistics show that those who do are more successful. Maintenance of Certification/Continuing Education: Every two years, Registered Health Information Technicians (RHIT) must provide proof to AHIMA of continuing education (CE) credits earned during their two year certification cycle. RHIT s are required to earn 20 continuing education hours per two year cycle Fifty percent (50%) of the required CE credits must be from defined core content areas. AHIMA informs newly credentialed members what the defined core content areas are. AHIMA also provides opportunities to obtain CE credits in the Journal of AHIMA or online at www.ahima.org. Progression to the RHIA: Students may wish to earn their baccalaureate degree in Health Information Administration. There are several progression programs in the country or students may work individually with the college/university of their choice who offer the Health Information Administration degree. The HIT degree merges nicely with advanced degrees in computer science, business, law, and a variety of disciplines. Ensure the program is CAHIIM accredited. Lists of accredited programs may be found at www.ahima.org or www.cahiim.org. AHIMA Code of Ethics 2011 Ethical Principles Ethical Principles: The following ethical principles are based on the core values of the American Health Information Management Association and apply to all AHIMA members and certificants. A health information management professional shall: 1. Advocate, uphold, and defend the individual's right to privacy and the doctrine of confidentiality in the use and disclosure of information. 14

2. Put service and the health and welfare of persons before self-interest and conduct oneself in the practice of the profession so as to bring honor to oneself, their peers, and to the health information management profession. 3. Preserve, protect, and secure personal health information in any form or medium and hold in the highest regards health information and other information of a confidential nature obtained in an official capacity, taking into account the applicable statutes and regulations. 4. Refuse to participate in or conceal unethical practices or procedures and report such practices. 5. Advance health information management knowledge and practice through continuing education, research, publications, and presentations. 6. Recruit and mentor students, peers and colleagues to develop and strengthen professional workforce. 7. Represent the profession to the public in a positive manner. 8. Perform honorably health information management association responsibilities, either appointed or elected, and preserve the confidentiality of any privileged information made known in any official capacity. 9. State truthfully and accurately one s credentials, professional education, and experiences. 10. Facilitate interdisciplinary collaboration in situations supporting health information practice. 11. Respect the inherent dignity and worth of every person. http://library.ahima.org/xpedio/groups/public/documents/ahima/bok1_024277.hcsp?ddocnam e=bok1_024277#principles Standards of Ethical Coding Coding professionals should: 1. Apply accurate, complete, and consistent coding practices for the production of high-quality healthcare data. 2. Report all healthcare data elements (e.g. diagnosis and procedure codes, present on admission indicator, discharge status) required for external reporting purposes (e.g. reimbursement and other administrative uses, population health, quality and patient safety measurement, and research) completely and accurately, in accordance with regulatory and documentation standards and requirements and applicable official coding conventions, rules, and guidelines. 3. Assign and report only the codes and data that are clearly and consistently supported by health record documentation in accordance with applicable code set and abstraction conventions, rules, and guidelines. 4. Query provider (physician or other qualified healthcare practitioner) for clarification and additional documentation prior to code assignment when there is conflicting, incomplete, or ambiguous information in the health record regarding a significant reportable condition or procedure or other reportable data element dependent on health record documentation (e.g. present on admission indicator). 5. Refuse to change reported codes or the narratives of codes so that meanings are misrepresented. 6. Refuse to participate in or support coding or documentation practices intended to inappropriately increase payment, qualify for insurance policy coverage, or skew data by means that do not comply with federal and state statutes, regulations and official rules and guidelines. 7. Facilitate interdisciplinary collaboration in situations supporting proper coding practices. 8. Advance coding knowledge and practice through continuing education. 15

9. Refuse to participate in or conceal unethical coding or abstraction practices or procedures. 10. Protect the confidentiality of the health record at all times and refuse to access protected health information not required for coding-related activities ( examples of coding-related activities include completion of code assignment, other health record data abstraction, coding audits, and educational purposes). 11. Demonstrate behavior that reflects integrity, shows a commitment to ethical and legal coding practices, and fosters trust in professional activities. http://library.ahima.org/xpedio/groups/public/documents/ahima/bok2_001166.hcsp?ddocnam e=bok2_001166 CDI Ethical Standards Certified Documentation Improvement Professionals should: 1. Facilitate accurate, complete, and consistent clinical documentation within the health record to support coding and reporting of high-quality healthcare data. 2. Support the reporting of all healthcare data elements (e.g., diagnosis and procedure codes, and present on admission indicator) required for external reporting purposes (e.g., reimbursement and other administrative uses, population health, quality and patient safety measurement, and research) completely and accurately, in accordance with regulatory and documentation standards and requirements and applicable official coding conventions, rules, and guidelines. 3. Query provider (physician or other qualified healthcare practitioner), whether verbal or written, for clarification and additional documentation when there is conflicting, incomplete, or ambiguous information in the health record regarding a significant reportable condition or procedure or other reportable data element dependent on health record documentation (e.g. present on admission indicator). 4. Refuse to participate in or support documentation practices intended to inappropriately increase payment, qualify for insurance policy coverage, or distort data by means that do not comply with federal and state statutes, regulations and official rules and guidelines. 5. Facilitate interdisciplinary collaboration in situations supporting proper reporting practices. 6. Advance professional knowledge and practice through continuing education. 7. Refuse to participate in or conceal unethical reporting practices. 8. Protect the confidentiality of the health record at all times and refuse to access protected health information not required for job-related activities. 9. Demonstrate behavior that reflects integrity, shows a commitment to ethical and legal reporting practices, and fosters trust in professional activities. http://library.ahima.org/xpedio/groups/public/documents/ahima/bok1_047842.hcsp?ddocnam e=bok1_047842 16

AHIMA Competency Statements RHIT Certification Domain I. Data Content, Structure & Standards (Information Governance) Subdomain I.A Classification Systems 1. Apply diagnosis/procedure codes according to current guidelines 2. Evaluate the accuracy of diagnostic and procedural coding 3. Apply diagnostic/procedural groupings 4. Evaluate the accuracy of diagnostic/procedural groupings Subdomain I.B. Health Record Content and Documentation 1. Analyze the documentation in the health record to ensure it supports the diagnosis and reflects the patient s progress, clinical findings, and discharge status 2. Verify the documentation in the health record is timely, complete, and accurate 3. Identify a complete health record according to, organizational policies, external regulations, and standards 4. Differentiate the roles and responsibilities of various providers and disciplines, to support documentation requirements, throughout the continuum of healthcare Subdomain. I.C. Data Governance 1. Apply policies and procedures to ensure the accuracy and integrity of health data Subdomain I.D. Data Management 1. Collect and maintain health data 2. Apply graphical tools for data presentations Subdomain I.E. Secondary Data Sources 1. Identify and use secondary data sources 2. Validate the reliability and accuracy of secondary data sources Domain II. Information Protection: Access, Disclosure, Archival, Privacy & Security Subdomain II.A. Health Law 1. Apply healthcare legal terminology 2. Identify the use of legal documents 3. Apply legal concepts and principles to the practice of HIM Subdomain II.B. Data Privacy, Confidentiality & Security 1. Apply confidentiality, privacy and security measures and policies and procedures for internal and external use and exchange to protect electronic health information 2. Apply retention and destruction policies for health information 3. Apply system security policies according to departmental and organizational data/information standards Subdomain II.C. Release of Information 1. Apply policies and procedures surrounding issues of access and disclosure of protected health information Domain III. Informatics, Analytics and Data Use Subdomain III.A. Health Information Technologies 1. Utilize software in the completion of HIM processes 2. Explain policies and procedures of networks, including intranet and Internet to facilitate clinical and administrative applications 17

Subdomain III.B. Information Management Strategic Planning 1. Explain the process used in the selection and implementation of health information management systems 2. Utilize health information to support enterprise wide decision support for strategic planning Subdomain III.C. Analytics and Decision Support 1. Explain analytics and decision support 2. Apply report generation technologies to facilitate decision-making Subdomain III.D. Health Care Statistics 1. Utilize basic descriptive, institutional, and healthcare statistics 2. Analyze data to identify trends Subdomain III.E. Research Methods 1. Explain common research methodologies and why they are used in healthcare Subdomain III.F. Consumer Informatics 1. Explain usability and accessibility of health information by patients, including current trends and future challenges. Subdomain III.G. Health Information Exchange 1. Explain current trends and future challenges in health information exchange Subdomain III.H. Information Integrity and Data Quality 1. Apply policies and procedures to ensure the accuracy and integrity of health data both internal and external to the health system Domain IV. Revenue Management Subdomain IV.A. Revenue Cycle and Reimbursement 1. Apply policies and procedures for the use of data required in healthcare reimbursement 2. Evaluate the revenue cycle management process Domain V. Compliance Subdomain V.A. Regulatory 1. Analyze policies and procedures to ensure organizational compliance with regulations and standards 2. Collaborate with staff in preparing the organization for accreditation, licensure, and/or certification 3. Adhere to the legal and regulatory requirements related to the health information management Subdomain V.B. Coding 1. Analyze current regulations and established guidelines in clinical classification systems 2. Determine accuracy of computer assisted coding assignment and recommend corrective action Subdomain V.C. Fraud Surveillance 1. Identify potential abuse or fraudulent trends through data analysis Subdomain V.D. Clinical Documentation Improvement 1. Identify discrepancies between supporting documentation and coded data 2. Develop appropriate physician queries to resolve data and coding discrepancies 18

Domain VI. Leadership Subdomain VI.A Leadership Roles 1. Summarize health information related leadership roles 2. Apply the fundamentals of team leadership 3. Organize and facilitate meetings Subdomain VI.B. Change Management 1. Recognize the impact of change management on processes, people and systems. Subdomain VI.C. Work Design and Process Improvement 1. Utilize tools and techniques to monitor, report, and improve processes 2. Identify cost-saving and efficient means of achieving work processes and goals 3. Utilize data for facility-wide outcomes reporting for quality management and performance improvement Subdomain VI.D. Human Resources management 1. Report staffing levels and productivity standards for health information functions 2. Interpret compliance with local, state, federal labor regulations 3. Adhere to work plans, policies, procedures, and resource requisitions in relation to job functions Subdomain VI.E. Training and Development 1. Explain the methodology of training and development 2. Explain return on investment for employee training/development Subdomain VI.F. Strategic and Organizational Management 1. Summarize a collection methodology for data to guide strategic and organizational management. 2. Understand the importance of healthcare policy-making as it relates to the healthcare delivery system 3. Describe the differing types of organizations, services, and personnel and their interrelationships across the health care delivery system 4. Apply information and data strategies in support of information governance initiatives 5. Utilize enterprise-wide information assets in support of organizational strategies and objectives Subdomain VI.G. Financial Management 1. Plan Budgets 2. Explain accounting methodologies 3. Explain budget variances Subdomain VI.H. Ethics 1. Comply with ethical standards of practice 2. Evaluate the consequences of a breach of healthcare ethics 3. Assess how cultural issues affect health, healthcare quality cost, and HIM 4. Create programs and policies that support a culture of diversity Subdomain VI.I. Project Management 1. Summarize project management methodologies Subdomain VI.J. Vendor/Contract Management 1. Explain Vendor/Contract Management Subdomain VI.K. Enterprise Information Management 1. Apply knowledge of database architecture and design Supporting Body of Knowledge (Pre-requisite or Evidence of Knowledge) 1. Pathophysiology and Pharmacology 2. Anatomy and Physiology 19

3. Medical Terminology 4. Computer Concepts and Applications 20