RE

AP

AN

Total

Domain 1:  Health Records and Data Content                                                                                             

• Collect and maintain health data
• Analyze health records to assure that documentation supports the patient's diagnosis and procedures, reflects progress, clinical findings and discharge status
• Request patient-specific documentation from other sources (e.g., ancillary departments; physicians office; etc.)
• Apply clinical vocabularies and terminologies used in the organization's health information systems

5

11

2

18

Domain 2:  Health Information Requirements and Standards

• Evaluate the accuracy and completeness of the patient record as defined by organizational policy and external regulations and standards
• Monitor compliance with organization-wide health record documentation guidelines
• Report compliance findings according to organizational policy.
• Assist in preparing the organization for accreditation, licensing and/or certification surveys

5

7

1

13

Domain 3:  Clinical Classification Systems

• Utilize electronic applications to support clinical classification and coding (e.g., encoders)
• Assign secondary diagnosis procedure codes using ICD-9-CM official coding guidelines
• Assign principal diagnosis (Inpatient) or first listed diagnosis (Outpatient)
• Assign secondary diagnosis(es), including complications and comorbidities (CC)
• Assign principal and secondary procedure(s)
• Assign procedure codes using CPT coding guidelines
• Assign appropriate HCPCS codes
• Identify discrepancies between coded data and supporting documentation
• Consult reference materials to facilitate code assignment

5

24

3

32

Domain 4:  Reimbursement Methodologies

• Validate the data collected for appropriate reimbursement
• Validate Diagnosis Related Groups (DRGs)
• Validate Ambulatory Payment Classifications (APCs)
• Comply with the National Correct Coding Initiative
• Verify the National and Local Coverage Determinations (NCD/LCD) for medical necessity

7

2

0

9

Domain 5:  Information and Communication Technologies

• Use personal computer to ensure data collection, storage, analysis and reporting of information
• Use common software applications (e.g., word processing; spreadsheets; e-mail; etc.) in the execution of work processes
• Use specialized software in the completion of HIM processes

4

1

0

5

Domain 6:  Privacy, Confidentiality, Legal, and Ethical Issues

• Apply policies and procedures for access and disclosure of personal health information
• Release patient-specific data to authorized individuals
• Apply ethical standards of practice
• Recognize and report privacy issues/problems
• Protect data integrity and validity using software or hardware technology

3

7

3

13

TOTAL

29

52

9

90