Health Information Technology Practice I

I.     Course Prefix/Number: HIT 251

       Course Name: Health Information Technology Practice I

       Credits: 3 (1 lecture; 12 lab)

II.    Prerequisite

Consent of instructor or department chair.

III.   Course (Catalog) Description

Course contains health information Professional Practice Experience (PPE) in a variety of healthcare facilities and other health information related organizations. Opportunity to gain knowledge and skill in health information and health information-related functions such as: healthcare regulatory, billing and reimbursement, and utilization of related software.

IV.   Learning Objectives

  1. Apply health information standard practice guidelines as detailed in Health Information Technology Program Professional Practice Experience (PPE) Student Handbook appropriate to the healthcare facility or health information related organization.
  2. Comply with health information ethical standards including the American Health Information Management Association’s (AHIMA) Code of Ethics.
  3. Apply confidentiality, privacy and security measures, policies and procedures to all health information.
  4. Perform health information functions and processes appropriate to the healthcare facility or health information related organization.
  5. Code diagnoses and procedures on inpatient and outpatient health records utilizing official coding guidelines, UHDDS guidelines, coding books, encoding, grouping and computer assisted coding (CAC) software.
  6. Assess the interrelationship between the coding function and the clinical documentation improvement function.
  7. Utilize health information software, electronic health records (EHR), and Microsoft Office software to complete assigned functions and projects.
  8. Use secondary data sources and registries including the Cancer Registry.
  9. Analyze data and create graphical displays of the data.
  10. Research health information, health information related, and healthcare regulatory, billing, and reimbursement issues.
  11. Perform health services billing and reimbursement functions and processes appropriate to the healthcare facility or health information related organization.
  12. Complete projects as assigned by the PPE site, utilizing project management methodologies.
  13. Demonstrate proficiency in cultural diversity, HIPAA regulations, infection control, fire and electrical safety, body mechanics, chemical hazards, bloodborne infections, and professionalism in healthcare.
  14. Design a resume and cover letter.
  15. Evaluate assigned professional practice experience (PPE) activities.

V.    Academic Integrity and Student Conduct

Students and employees at Oakton Community College are required to demonstrate academic integrity and follow Oakton's Code of Academic Conduct. This code prohibits:

• cheating,
• plagiarism (turning in work not written by you, or lacking proper citation),
• falsification and fabrication (lying or distorting the truth),
• helping others to cheat,
• unauthorized changes on official documents,
• pretending to be someone else or having someone else pretend to be you,
• making or accepting bribes, special favors, or threats, and
• any other behavior that violates academic integrity.

There are serious consequences to violations of the academic integrity policy. Oakton's policies and procedures provide students a fair hearing if a complaint is made against you. If you are found to have violated the policy, the minimum penalty is failure on the assignment and, a disciplinary record will be established and kept on file in the office of the Vice President for Student Affairs for a period of 3 years.

Please review the Code of Academic Conduct and the Code of Student Conduct, both located online at
www.oakton.edu/studentlife/student-handbook.pdf

VI.   Sequence of Topics

  1. Professional Practice Experience (PPE) Training
    1. Body mechanics
    2. Chemical hazards in the healthcare environment
    3. Confidentiality: legal and ethical concerns in healthcare
    4. Culturally competent care: an overview
    5. Electrical safety
    6. Fire safety
    7. HIPAA for healthcare workers: an overview
    8. HIPAA for healthcare workers: The Privacy Rule
    9. HIPAA for healthcare workers: The Security Rule
    10. Infection control and standard precautions
    11. Preventing bloodborne infections: bloodborne viruses
    12. Preventing bloodborne infections: engineering controls and workplace practice
    13. Preventing bloodborne infections: preventing transmission, protecting yourself
    14. Professionalism in healthcare: professional behavior, attitude, and attire
    15. Professionalism in healthcare: patient interactions, communication, and personal Development
  2. Health Information Technology Program Professional Practice Experience (PPE) Student Handbook
    1. Introduction to the Professional Practice Experience (PPE) Program
    2. Essential skills expected of a Health Information Technician
    3. Ethics and confidentiality
    4. Professional Practice Experience (PPE) Policy
    5. Waiver of liability
    6. Criminal background check and drug screening
    7. Professional Practice Experience (PPE) procedures
    8. Dress code for HIT students
    9. American Health Information Management Association (AHIMA) Code of Ethics
    10. American Health Information Management Association (AHIMA) Professional Experience (PPE) – Student guide
    11. Oakton Community College Code of Student Conduct
    12. Facility/Organization information sheet
    13. Student summary evaluation
    14. Sample thank-you letter
    15. Practice modules
  3. Record Processing Procedures
    1. Record reconciliation
    2. Assembly of health records in a paper environment
    3. Prep, scan, index and quality assurance health records in an electronic environment
    4. Quantitative analysis of medical, surgical, obstetrical and newborn health records
    5. Chart tracking and chart deficiency systems
    6. Loose reports
    7. Secondary analysis of health record
  4. Coding and abstracting
    1. ICD-10-CM/PCS and CPT coding systems
    2. Principal diagnosis and principal procedure
    3. Secondary diagnoses, procedures, complications, and co-morbidities.
    4. Sequencing of diagnoses and procedures affecting the MS-DRG assignment
    5. Present on admission (POA) conditions
    6. Encoder and computer assisted coding (CAC) systems
    7. Quality and quantity standards
    8. Abstracting process including data elements and system
    9. Quality of abstracting
    10. Process for resolving billing issues with MS-DRG and APC assignment
    11. Code and MS-DRG assignment and relationship to clinical documentation improvement
    12. Maintenance and role of the chargemaster in capturing accurate codes for billing
    13. Staffing procedures and employee performance appraisals
    14. Continuing education and in-house education for coding staff
    15. Procedures for handling CMS (Center for Medicare and Medicaid Services) reviews
    16. Disease, operative and physician indices and databases
    17. NCD (National coverage determinations) and LCD (local coverage determinations) for medical necessity
    18. RAC (Recovery audit contractor) protocol, auditing for and process for Responding to RAC requests
    19. Ambulatory surgery coding
  5. Physicians incomplete health record procedures
    1. Incomplete and delinquent health records
    2. Medical Staff bylaws, rules and regulations, and policies for documentation and incomplete and delinquent health records
    3. Notify physicians of the status of their incomplete and delinquent health records.
    4. Suspension a physician’s admitting privileges or assessment of fines
  6. Release of information
    1. Appropriate authorized requests for release of health information
    2. Control, use, and release of health information
    3. User access logs and systems that track patient identifiable data
    4. Response to a subpoena duces tecum and/or a court order
    5. Transmittal of health information to and from other health care facilities upon transfer or discharge of a patient within HIPAA and facility guidelines
    6. Release of information for special authorizations for psychiatric, alcohol or drug treatment records
    7. Out-sourcing the release of information function
    8. Considerations and management concerns when out-sourcing the release of information function
  7. Registration/Scheduling Department
    1. Relationship of processes between the Registration/Scheduling Department and the Health Information Department for all types of registrations (inpatient, outpatient, Emergency Department, etc.)
    2. How a master patient index (MPI) search is performed and what type of method(s) is (are) used (alphabetical, matching, phonetic, etc.)
    3. Process of the assignment of a health record number at different stages of the registration process including scheduling, pre-registration and registration
    4. Process of how a duplicate health record number is identified and corrected and How other areas of the hospital are notified of a correction
    5. How the admitting diagnosis, chief complaint, and reason for visit diagnoses are captured and coded, including the use of any hard-coded diagnoses.
    6. Process for medical necessity verification including the issuing of Advanced Beneficiary Notices (ABNs) for Medicare patients
    7. Maintenance of HIPAA compliance in the Registration/Scheduling Department
  8. Vital statistics
    1. Birth certificates
    2. Reporting requirements for birth certificates
    3. Death certificates
    4. Requirements for reporting deaths
  9. Medical transcription
    1. Services provided by the transcription area or outsourced service
    2. Out-sourcing the transcription function
    3. Considerations and management concerns when out-sourcing the transcription function
    4. Evaluating employee and/or service productivity
    5. Quality control measures and evaluating employee and/or service quality
    6. Equipment used for dictation and transcription
    7. Voice recognition
      1. Front end
      2. Back end
      3. Types of health record reports
  10. Cancer registry
    1. Policies and procedures for the Cancer Registry
    2. Case finding procedures
    3. Accessioning
    4. Staging
    5. Abstracting
    6. Follow-up
    7. Cancer Registry required reporting for both the state cancer registry and the American College of Surgeons, including required timeframes for reporting
    8. Cancer Registry software and database
    9. Tumor Board and Cancer Committee meetings
    10. Cancer Registry annual reporting
  11. Long-term care
    1. Organization of health records in a long-term health care facility setting
    2. Regulatory and accrediting bodies with standards for long-term care facilities
    3. Patient Care Plan, MDS (Minimum Data Set), and RAP (Resident Assessment Plan)
    4. Content and use of the patient transfer form
    5. Quantitative analysis of long-term care health records
    6. Role of ICD-10-CM coding in long-term care
    7. Prospective payment system (PPS) for long term care
    8. Quality improvement and utilization management functions in long term-care facilities
  12. Health services billing
    1. HIPAA compliance practices
    2. Quality Improvement practices
    3. Organization of the patient health record and/or billing record
    4. Claim processing procedures for physicians and facilities
    5. ICD-10-CM and CPT code verification procedures
    6. Procedures for claim denials
    7. Role of private insurance, managed care organizations, preferred provider organizations (PPO), and health maintenance organizations HMO)
    8. Release of information procedures
    9. Management functions
    10. Billing processing and tracking software and systems
    11. Accreditation, regulatory or licensing agency requirements that apply to physician billing
    12. Relationship of physician, billing service and documentation of clinical care in the reimbursement process
  13. Project management and special projects
    1. How a project differs from an organization’s daily operations
    2. How an organization selects the need for a specific project
    3. How a project is planned and organized - the steps needed
    4. Project team’s structure
    5. Need for a project manager
    6. Project manager’s responsibilities
    7. Estimate work, length and resource requirements of a project
    8. Project team selection including technical and people skills needed to complete a project
    9. Project tracking – Gantt chart
    10. How to revise and when to revise an ongoing project
    11. Project management methodologies
  14. Reimbursement
    1. HIPAA compliance practices
    2. Quality Improvement
    3. Organization of the patient health record and/or billing record.
    4. Claim processing procedures for physicians and facilities
    5. ICD-10-CM/PCS and CPT code verification procedures
    6. Procedures for claim denials
    7. Role of private insurance, managed care organizations, preferred provider organizations (PPO), and health maintenance organizations (HMO)
    8. Release of information procedures
    9. Management functions
    10. Billing processing tracking software and systems
    11. Accreditation, regulatory or licensing agency requirements that apply to physician billing
    12. Relationship of physician, billing service and documentation of clinical care in the reimbursement process
  15. Cultural diversity
    1. Cultural competence
    2. How cultural issues affect health, healthcare quality, cost and health information management
    3. Cultural diversity
    4. Generation differences
    5. Occupational cultures
    6. Respect
    7. Self-awareness of own culture
    8. Assumptions, biases, and stereotypes
    9. Employee training
  16. Clinical documentation improvement
    1. American Health Information Management Association (AHIMA) Clinical Documentation Improvement (CDI) Toolkit
    2. Relationship of coding function and clinical documentation improvement function
  17. Computer assisted coding (CAC)
    1. American Health Information Management Association (AHIMA) Practice Brief
  18. Research
    1. American Health Information Management Association (AHIMA) Body of Knowledge (BoK)
    2. Reputable sites
    3. Regulatory sites including CMS (Centers for Medicare and Medicaid Services) website
  19. Cover letter and resume
    1. Cover letter
    2. Resume
    3. Job search
  20. Professional practice experience (PPE) activity logs
    1. Activities
    2. Likes
    3. Dislikes
  21. Self-evaluation
    1. Strengths – include specific examples
    2. Weaknesses – include specific examples
    3. Develop a plan to focus on and improve weaknesses
    4. Observations at professional practice experience (PPE) site
    5. Grade

VII.  Methods of Instruction

Professional Practice Experiences (PPE) may include and are not limited to assignment at a health care facility or a health information related organization, health information technology (HIT) lab activities, field trips, guest speakers, American Health Information Management (AHIMA) virtual lab activities and assignments, AHIMA PPE modules and other activities and assignments.

An HIT faculty member assigns the student to professional practice experience (PPE) site(s) as available. The student completes supervised training in the procedures listed in the learning objectives. Students will observe as well as participate in the suggested activities. HIT lab activities, field trips, AHIMA virtual lab activities and assignments, AHIMA PPE modules and other activities and assignments will be used and assigned when PPE sites not available.

The students will prepare a cover letter and resume using computer software.  The students will perform research on the Cancer Registry and complete a Cancer Registry module. The students will complete an ambulatory surgery coding module, be on a team and create a  cultural diversity awareness training program, research a current health information topic or an AHIMA practice brief and present findings, research a current job opening and present findings, complete professional practice experience (PPE) activity logs and complete a self-evaluation.


Course may be taught as face-to-face, hybrid or online course.

VIII. Course Practices Required

Students are expected to follow the Professional Practice Experience (PPE) schedule and requirements in the PPE Student Handbook. Students are required to follow regulations regarding confidentiality of health information, attend seminar, participate in class discussion and complete homework assignments. Students will use computer software and hardware in the HIT lab to complete projects. Student professional practice experience (PPE) activity logs are required to be submitted electronically to the instructor via the course website, documenting each PPE day.  

IX.   Instructional Materials

Note: Current textbook information for each course and section is available on Oakton's Schedule of Classes.

Students will use a course website to obtain and submit PPE activity logs electronically to the instructor. The website will also be used for assignment instructions and communication with the class. HIT lab computers and software will be used for selected activities and projects. The internet including the AHIMA website and AHIMA Virtual Lab will also be used for assignments. Materials for PPE activities will be provided at the PPE site.

X.    Methods of Evaluating Student Progress

Determination of the final grade will be based on whether the student has achieved the     learning objectives. This will be accomplished by:

  1. PPE Site Supervisor's Evaluation: The PPE Site Supervisor will submit a written evaluation of the student's progress in meeting the learning objectives. Students must demonstrate competency in each area of the professional practice experience (points equal 45% of grade).
     
  2. Faculty Evaluation: The HIT faculty member will evaluate the student through written and oral assignments, evaluation of the PPE activity logs, quizzes, observation at the PPE site, professional behavior, attendance, arrival to class on time, remaining in class for the entire time and class participation. Please see attendance policy as this may impact your final grade (points equal 55% of grade).

HIT Grading Scale

A = 94%
B = 88%
C = 82%
D = 76%
F = 75%

XI.   Other Course Information

If you have a documented learning, psychological, or physical disability you may be entitled to reasonable academic accommodations or services. To request accommodations or services, contact the Access and Disability Resource Center at the Des Plaines or Skokie campus. All students are expected to fulfill essential course requirements. The College will not waive any essential skill or requirement of a course or degree program.

CAHIIM Curriculum Entry-Level Competencies for Health Information Management (HIM) at the Associate Degree Level

Domain
Entry-Level Competencies
I. Data Content, Structure & Standards
Subdomain I.A. Classification Systems
1.  Apply diagnosis/procedure codes according to current guidelines
3.  Apply 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
2.  Apply graphical tools for data presentations
 
Subdomain I.E. Secondary Data Sources
1.  Identify and use secondary data presentations
Domain II. Information Protection: Access, Disclosure, Archival, Privacy & Security
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
Domain V. Compliance
Subdomain V.B. Coding
2.  Determine accuracy of computer assisted coding assignment and recommend corrective action
Domain VI. Leadership
Subdomain VI. H. Ethics
1.  Comply with ethical standards of practice
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.1. Project Management
1.  Summarize project management methodologies


If you have a documented learning, psychological, or physical disability you may be entitled to reasonable academic accommodations or services. To request accommodations or services, contact the Access and Disability Resource Center at the Des Plaines or Skokie campus. All students are expected to fulfill essential course requirements. The College will not waive any essential skill or requirement of a course or degree program.

Oakton Community College is committed to maintaining a campus environment emphasizing the dignity and worth of all members of the community, and complies with all federal and state Title IX requirements.

Resources and support for
  • pregnancy-related and parenting accommodations; and
  • victims of sexual misconduct
can be found at www.oakton.edu/title9/.

Resources and support for LGBTQ+ students can be found at www.oakton.edu/lgbtq.