Health Information Management Principles and Organization for Health Information Services,

313 Pages·2017·6.268 MB·English

by  Margaret Skurka

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Health Information
Management
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Health
Information
Management
Principles and Organization
for Health Information
Services
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S I X T H E D I T I O N
M A R G A R E T A . S K U R K A
E d i t o r
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LibraryofCongressCataloging-in-PublicationData
Names:Skurka,MargaretFlettre,editor.
Title:Healthinformationmanagement:principlesandorganizationforhealth
informationservices/editedbyMargaretA.Skurka.
Othertitles:Healthinformationmanagement(Skurka)
Description:6thedition.|Hoboken,NewJersey:Jossey-Bass[2017]Includes
bibliographicalreferencesandindex.
Identifiers:LCCN2016053257(print)|LCCN2016054679(ebook)|ISBN
9781119151203(pbk.:alk.paper)|ISBN9781119151234(pdf)|ISBN
9781119151210(epub)
Subjects:|MESH:HealthInformationSystems—organization&administration|
MedicalRecords|HospitalInformationManagement
Classification:LCCRA976(print)|LCCRA976(ebook)|NLMWX173|DDC
651.5/04261—dc23
LCrecordavailableathttps://lccn.loc.gov/2016053257
CoverDesignandIllustration:Wiley
PrintedintheUnitedStatesofAmerica
FIRSTEDITION
PBPrinting 10 9 8 7 6 5 4 3 2 1
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C O N T E N T S
About the Editor vii
About the Contributors ix
Preface xv
Acknowledgments xvii
1 Health Information Management and the Healthcare
Institution 1
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Felecia Williams
2 Health Record Content and Structure of the Health
Record 25
Linda Galocy
3 The Health Record: Electronic and Paper 55
Linda Galocy
4 Healthcare Topics in Data Governance
and Data Management 81
Dilhari R. DeAlmeida and Suzanne Paone
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5 Health Law, Data Privacy and Security, Fraud,
and Abuse 105
Dorinda M. Sattler
6 Informatics, Analytics, Data Use, and System Support 143
Dorinda M. Sattler
7 Coding, Compliance, and Classification Systems 171
Sandra K. Rains, Margaret A. Skurka, and Margie White
8 Clinical Documentation Improvement 205
Sandra K. Rains
9 Revenue Cycle and Reimbursement 227
Karen Wright
10 Strategic, Financial, and Organizational Management 253
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Janelle Wapola and Katie Kerr
Index 283
vi Contents
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A B O U T T H E E D I T O R
MargaretA.Skurka,MS,RHIA,CCS,FAHIMA,isaProfessorandDirec-
tor of the Health Information Technology Program at Indiana University
NorthwestinGary.ShehasservedasAssistantDeanandDepartmentChair
ofHIMforthepast40-plusyearsattheuniversity.ShereceivedherBSin
Health Information Management (HIM) from the University of Illinois
and was awarded a Master of Science from Purdue University. She has
been actively involved in the American Health Information Management
Associationforherentirecareer.Sheservedasix-yeartermonthenational
(cid:2) BoardofDirectorsofAHIMA,andwasthenationalpresidentin2000.She (cid:2)
receivedtheAssociation’shighesthonorofDistinguishedMemberin2010.
She wasnamed the Alumnusof the Yearin the Allied HealthProfessions
attheUniversityofIllinoisatChicagoin2002.Skurkawasthepresidentof
the International HIM Association in 2013 and was on the board of that
association for 12 years. She was named a Chancellor’s Professor, one of
the university’s highest honors, at Indiana University Northwest in 2015.
As a consultant, Skurka has provided consulting services to numerous
physician practices and ambulatory surgery centers and conducted
extensive nationwide training for AHIMA as an approved trainer for
ICD-10-CMandPCS.
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A B O U T T H E C O N T R I B U T O R S
Dilhari R. DeAlmeida, PhD, RHIA, is an Assistant Professor in the
Department of Health Information Management at the University of
Pittsburgh. She received her Bachelor of Science degree in Cell and
Molecular Biology from University of Toronto, Canada. Prior to joining
the HIM department, she had over 12 years of experience working in
government, academic, and the private sector in the field of Molecular
Biology.ShereceivedherMasterofScience(HIS/RHIAoption)andDoc-
toratedegreesfromtheUniversityofPittsburgh.Herdissertationresearch
involved evaluating the ICD-10-CM coding system for documentation
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specificity and reimbursement. Documentation specificity in the ICD-10
coding system and the Electronic Health Record have been a great area
of interest and she is an AHIMA-approved ICD-10-CM/PCS trainer. In
addition to research, she teaches both the undergraduate and graduate
coursesinHIM.
Linda Galocy, MS, RHIA, is a Clinical Assistant Professor and Program
Chair in the Health Information Management programs at Indiana
University Northwest in Gary, Indiana. She received her baccalaureate
degree in Health Information Management from Indiana University
Purdue University in Indianapolis (IUPUI), and Master of Science in
Adult Education from IUPUI School of Continuing Education. Prior to
joining the full-time faculty at Indiana University Northwest, she held a
variety of roles in health information management in acute care. She has
been active in her local professional association and the Indiana Health
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