Data Doctors Slides
Code Breakers
Mastering Health Information Management
What is HIM?
Health Information Management (HIM) is the practice of acquiring, analyzing, and protecting digital and traditional medical information.
- Ensures health records are accurate and complete.
- Protects patient privacy and security.
- Connects clinical, financial, and administrative data.
The "Business" of Medicine
Without HIM, hospitals can't track outcomes, get paid, or stay legal.
Alphabet Soup: Key Terms
HIPAA
Health Insurance Portability and Accountability Act
The federal law that protects sensitive patient health information from being disclosed without consent.
EHR / EMR
Electronic Health / Medical Record
Digital versions of a patient's paper chart. EHRs are designed to be shared across different healthcare providers.
PHI
Protected Health Information
Any information in a medical record that can be used to identify an individual (Name, DOB, SSN, etc.).
ROI
Release of Information
The process of providing medical records to authorized individuals or entities.
Medical Coding
Coding is the process of translating medical reports into universal alphanumeric codes used for billing and data analysis.
Diagnosis
ICD-10-CM
International Classification of Diseases, 10th Revision
"What is wrong with the patient?"
Example: J01.00 (Acute maxillary sinusitis)
Procedure
CPT
Current Procedural Terminology
"What was done for the patient?"
Example: 99213 (Office visit, established patient)
How It Works
Provider Documenting
Coder Reviewing
Assigning Codes
Billing & Reimbursement
Key Rule: If it wasn't documented, it didn't happen!
Coders cannot assume a diagnosis. They must follow the "Golden Rule" of medical documentation.
Knowledge Check
1. Which code set identifies the diagnosis?
A) CPT
B) ICD-10-CM
2. Is a patient's date of birth considered PHI?
A) Yes
B) No
3. What does HIPAA primarily protect?
Patient Privacy and Data Security
HIM Decoded Worksheet
HIM Decoded
Health Information Management & Coding Practice
Student:
Date:
Part 1: Terminology Match-Up
1. HIPAA
2. PHI
3. EHR
4. ICD-10-CM
5. CPT
6. ROI
A. Digital record shared across orgs.
B. Code set for medical procedures.
C. Law protecting patient privacy.
D. Information that identifies a patient.
E. Releasing records to authorized parties.
F. Code set for identifying diagnoses.
Part 2: Code Classifier
1. A patient is diagnosed with "Type 2 Diabetes Mellitus".
ICD-10-CM
CPT
2. A physician performs a "Chest X-Ray".
ICD-10-CM
CPT
3. A patient presents with "Acute Pharyngitis" (Sore Throat).
ICD-10-CM
CPT
4. A surgeon performs an "Appendectomy".
ICD-10-CM
CPT
Part 3: Scenario Analysis
Case: A coder assigned a "fracture" code to a chart where the doctor noted "possible fracture" but hadn't signed the report, just to speed up billing.
1. Why is this action a violation of HIM standards?
2. Privacy acronym?
3. Three PHI examples?
HIM Decoded Answer Key
HIM Decoded
Teacher Answer Key
INTERNAL
Part 1: Terminology Match-Up
C
1. HIPAA
D
2. PHI
A
3. EHR
F
4. ICD-10-CM
B
5. CPT
E
6. ROI
A. Shared digital health record.
B. Code set for procedures.
C. Privacy/security law.
D. Information identifying a patient.
E. Releasing records authorized.
F. Code set for diagnoses.
Part 2: Code Classifier
1. Type 2 Diabetes Mellitus diagnosis.
ICD-10-CM
CPT
2. Performing a "Chest X-Ray".
ICD-10-CM
CPT
3. Patient has "Acute Pharyngitis".
ICD-10-CM
CPT
4. Performing an "Appendectomy".
ICD-10-CM
CPT
Part 3: Scenario Analysis
Context: Coder coded "possible fracture" before signature to speed up billing.
1. Why is this a violation?
"Golden Rule": If not documented/signed, it didn't happen. Cannot code for "possible" conditions; must wait for signature.
2. Privacy acronym?
HIPAA / PHI
3. PHI examples?
Name, DOB, SSN, MRN.
