Chapter 3

1. Chapter 3 An Introduction to Medical Informatics and the Administrative Applications of Computers

2. Medical Informatics • Clinical applications—direct patient care • Special-purpose applications—education, pharmacy • Administrative—office and materials management, scheduling, accounting and financial applications • Telemedicine—delivery of health care through telecommunications

3. Administrative Applications: Earliest Applications • Programs designed to computerize administrative functions in a health-care environment • Allow organization of patient data, case data, and provider data • Enable electronic scheduling, electronic progress notes, creation of lists of codes for diagnosis, treatment, and insurance

4. Administrative Applications Earliest Applications (cont) • Allow bucket billing (billing one insurer after another until the patient is billed) • Organize information in a relational database • Each type of information is organized in its own table • Tables can be linked

5. Database • An organized collection of data created and maintained by a system called database management system (DBMS)

6. Database (cont) • A file contains related information on an entity • A file can have many tables, each containing related information • Tables can be linked by a common field • Tables are made up of records

7. Database (cont) • A record contains information on one item in the table • Records are made up of fields • A field is a piece of information in a record • A key field uniquely identifies a record

8. Coding and Grouping Systems • CPT holds procedure codes • ICD holds disease codes • MEDCIN codes symptoms, history, exams, tests, diagnosis, and treatment • SNOMED provides a common language • LOINC standardizes laboratory and clinical codes • NDC codes drugs

9. CMS-1500 • CMS-1500 is the most commonly used claim form

10. Accounting • Transactions: charges, payments, and adjustments • Case: condition that brings a patient to the doctor’s office

11. Insurance • Types of medical insurance • Indemnity (fee-for-service) plans • Health maintenance organizations • Preferred provider organizations • Government insurance: Medicare, Medicaid, CHAMPVA, TRICARE, CHAMPUS, Workers’ Compensation • Government insurance is administered by the Centers for Medicare and Medicaid Services www.cms.hhs.gov/forms

12. Claim • Request for payment from an insurer • Can be submitted: • Electronically through a clearinghouse • On paper

13. Response to Claims • An ERA (electronic remittance advice) accompanies a response to an electronic claim • An EOB (explanation of benefits) is a response to a paper claim

14. Balance or Bucket Billing • Balance billing is unique to the health care environment • A claim is filed with the primary insurer • Response and check are received • A claim is filed with the secondary insurer • Response and check are received • Only after claims have been filed with all insurers, and responses received, is the patient billed

15. Accounts Receivable • Accounts receivable—any invoices or payments

16. Superbill (Encounter Form) • List of diagnoses and procedures common to a practice

17. Reports • Procedure day sheet • Payment day sheet • Patient day sheet • Practice analysis report • Patient aging report