Health Information Management Technology

An Applied ApproachFourth Edition

AHIMA Associate’s Degree Curriculum and

RHIT Certification Mappings

CAHIIM Curriculum Requirements—AHIMA 2011 Curriculum Competencies and Knowledge Clusters for Health Information Management (HIM) Education at the Associate Degree Level

The following chart summarizes the chapter location of the 2011 CAHIIM Health Information Management HIM Associate Degree curriculum (http://www.cahiim.org/policiescurriculum.html). The competency levels required for each cluster are indicated in parentheses are labeled with the appropriate level of Bloom’s Taxonomy:

Bloom’s Taxonomy: Revised Version1 = Remembering: Can the student recall or remember the information?2 = Understanding: Can the student explain ideas or concepts, and grasp the meaning of information?3 = Applying: Can the student use the information in a new way?4 = Analyzing: Can the student distinguish between the different parts, break down information, and infer to support conclusions?5 = Evaluating: Can the student justify a stand or decision, or judge the value of?

Column 1 - HIM Associate Degree Entry-Level Competencies (Student Learning Outcomes)

Column 2 - Knowledge Clusters (Curricular Components)

Column 3 – Chapter(s) that contain each of the Knowledge Clusters listed in Column 2

I. Domain: Health Data ManagementI.A. Subdomain: Health Data Structure, Content, and Standards1. Collect and maintain health data (such as data elements, data sets, and databases).

2. Conduct analysis to ensure that documentation in the health record supports the diagnosis and reflects the patient’s progress, clinical findings, and discharge status.

3. Apply policies and procedures to ensure the accuracy of health data.

4. Verify timeliness, completeness, accuracy, and appropriateness of data and data sources for patient care, management, billing reports, registries, and/or databases.

Data versus information (Analyzing, 4)

Concept is introduced in Chapter 2 and is reinforced in other chapters throughout the text.

Health information media (such as paper, computer, web-based) (Analyzing, 4)

Chapter 2, 3, 16, 17

Structure and use of health information (individual, comparative, aggregate) (Analyzing, 4)

Chapter 2, 3, 9, 16

Health record data collection tools (forms, screens, etc.) (Analyzing, 4)

Chapter 3, 7, 9

Data sources (primary/secondary) (Analyzing, 4)

Chapter 2,3, 8

Data storage and retrieval (Analyzing, 4)

Chapter 4, 14, 15, 16

Healthcare data sets (such as OASIS, HEDIS, DEEDS, UHDDS) (Understanding, 2)

Chapter 4, 6

I.B. Subdomain: Healthcare Information Requirements and Standards1. Monitor and apply organization-wide

health record documentation guidelines.

2. Apply policies and procedures to ensure organizational compliance with regulations and standards.

3. Maintain the accuracy and completeness of the patient record as defined by organizational policy and external regulations and standards.

4. Assist in preparing the organization for accreditation, licensing, and/or certification surveys.

Type and content of health record (paper, electronic, computer-based, e-health-personal, web-based, (Evaluating, 5)

Chapter 3, 16

Health record documentation requirements (such as accreditation, certification, licensure) (Evaluating, 5)

Chapter 3, 16

Data quality and integrity (Analyzing, 4)

Chapter 3, 16, 17

I.C. Subdomain: Clinical Classification Systems1. Use and maintain electronic applications

and work processes to support clinical classification and coding.

2. Apply diagnosis/procedure codes according to current nomenclature.

3. Ensure accuracy of diagnostic/ procedural groupings such as DRG, MSDRG, APC, and so on.

4. Adhere to current regulations and established guidelines in code assignment.

5. Validate coding accuracy using clinical information found in the health record.

6. Use and maintain applications and processes to support other clinical classification and nomenclature systems (ex. DSM IV, SNOMED-CT).

7. Resolve discrepancies between coded data and supporting documentation.

Classifications, taxonomies, nomenclatures, terminologies, and clinical vocabularies such as SNOMED-CT (Analyzing, 4)

Chapter 5, 6

Principles and applications of coding systems (such as ICD, CPT, DSM (Evaluating, 5)

Chapter 5,6

Diagnostic and procedural groupings (such as DRG, APC, RUGS) (Evaluating, 5)

Chapter 5

Case mix analysis and indexes (Analyzing, 4)

Chapter 5

Severity of illness systems (Analyzing, 4)

Chapter 5, 6

Coding compliance strategies, auditing, and reporting (such as CCS, plans) (Evaluating, 5)

Chapter 6

Coding quality monitors and reporting (Evaluating, 5)

Chapter 6

I.D. Subdomain: Reimbursement Methodologies

1. Apply policies and procedures for the use of clinical data required in reimbursement and prospective payment systems (PPS) in healthcare delivery.

2. Apply policies and procedures to comply with the changing regulations among various payment systems for healthcare services such as Medicare, Medicaid, managed care, and so forth.

3. Support accurate billing through coding, chargemaster, claims management, and bill reconciliation processes.

4. Use established guidelines to comply with reimbursement and reporting requirements such as the National Correct Coding Initiative.

5. Compile patient data and perform data quality reviews to validate code assignment and compliance with reporting requirements, such as outpatient prospective payment systems

6. Ensure accuracy of diagnostic/ procedural groupings such as DRG, APC, and so on.

Commercial, managed care and federal insurance plans (Analyzing, 4)

Chapter 6

Compliance strategies and reporting (Applying, 3)

Chapter 6

Payment methodologies and systems (such as capitation, prospective payment systems, RBRVS) (Analyzing, 4)

Chapter 6

Billing processes and procedures such as claims, EOB, ABN, electronic data interchange) (Analyzing, 4)

Chapter 6

Chargemaster maintenance (Evaluating, 5)

Chapter 6

Regulatory guidelines (NCDs and QIOs (Applying, 3)

Chapter 6, 10

Reimbursement monitoring and reporting (Evaluating, 5)

Chapter 6

II. Domain: Health Statistics, Biomedical Research, and Quality ManagementII.A. Subdomain: Healthcare Statistics and Research

1. Collect, maintain, and report data for clinical indices/databases/registries to meet specific organization needs such as medical research and disease registries.

2. Collect, organize, and present data for quality management, utilization management, risk management, and other related studies.

3. Comprehend basic descriptive, institutional, and healthcare vital statistics.

Indices, databases, and registries (Analyzing, 4)

Chapter 8

Vital statistics (Evaluating, 5) Chapter 9

Healthcare statistics (Evaluating, 5)

Chapter 9

Descriptive statistics (such as means, frequencies, ranges, percentiles, standard deviations) (Understanding, 2)

Chapter 9

Statistical applications with health care data (Applying, 3)

Chapter 9

Data selection, interpretation, and presentation (Evaluation, 5)

Chapter 9

Knowledge-based research Chapter 9

techniques (such as library, MEDLINE, web-based) (Evaluating, 5)

II.B. Subdomain: Quality Management and Performance Improvement1. Abstract and report data for facility-

wide quality management and performance improvement programs.

2. Analyze clinical data to identify trends that demonstrate quality, safety, and effectiveness of healthcare.

Quality assessment and improvement (such as process, collection tools, data analysis, reporting techniques) (Applying, 3)

Chapter 10

Utilization management, risk management and case management (Understanding, 2)

Chapter 10

Regulatory quality monitoring requirements (Applying, 3)

Chapter 10

Outcomes measures and monitoring (Applying, 3)

Chapter 10

III. Domain: Health Services Organization and DeliveryIII.A. Subdomain: Healthcare Delivery Systems1. Apply current laws, accreditation,

licensure, and certification standards related to health information initiatives from the national, state, local, and facility levels.

2. Differentiate the roles of various providers and disciplines throughout the continuum of healthcare and respond to their information needs.

Organization of healthcare delivery in the United States (Analyzing, 4)

Chapter 11

Healthcare organizations structure and operation (Analyzing, 4)

Chapter 11

External standards, regulations, and initiatives (such as licensure, certification, accreditation, HIPAA, ARRA) (Analyzing, 4)

Chapter 3, 11, 13, 17

Healthcare providers and disciplines (Analyzing, 4)

Chapter 11

III.B. Subdomain: Healthcare Privacy, Confidentiality, Legal, and Ethical Issues1. Adhere to the legal and regulatory requirements related to the health information infrastructure.

2. Apply policies and procedures for access and disclosure of personal health information.

3. Release patient-specific data to authorized users.

Legislative and regulatory processes (Applying, 3)

Chapter 13

Legal terminology (Applying, 3)

Chapter 13, 17

Health information/record laws and regulations (such as retention, patient rights/advocacy, advanced

Chapter 13

4. Maintain user access logs/systems to track access to and disclosure of identifiable patient data.

5. Apply and promote ethical standards of

practice

directives, privacy) (Evaluating, 5)

Confidentiality, privacy, and security policies, procedures, and monitoring (Evaluating, 5)

Chapter 13, 17

Release of information policies and procedures (Evaluating, 5)

Chapter 13

Professional and practice-related ethical issues (Evaluating, 5)

Chapter 12

IV. Domain: Information Technology & SystemsIV.A. Subdomain: Information and Communication Technologies 1. Use technology, including hardware and software, to ensure data collection, storage, analysis, and reporting of information.

2. Use common software applications such as spreadsheets, databases, word processing, graphics, presentation, e-mail, and so on in the execution of work processes.

3. Use specialized software in the completion of HIM processes such as record tracking, release of information, coding, grouping, registries, billing, quality improvement, and imaging.

4. Apply policies and procedures to the use of networks, including intranet and Internet applications, to facilitate the electronic health record (EHR), personal health record (PHR), public health, and other administrative applications.

5. Participate in the planning, design, selection, implementation, integration, testing, evaluation, and support for EHRs.

Computer concepts (hardware components, systems architectures, operating systems and languages, and software packages and tools) (Applying, 3)

Chapter 14

Communication and internet technologies (such as networks, intranet, standards) (Applying, 3)

Chapter 14

Common software applications (such as word processing, spreadsheet, database, graphics) (Applying, 3)

Chapter

Health information systems (such as administrative, patient registration, ADT, EHR, PHR, lab, radiology, pharmacy) (Analyzing, 4)

Chapter 15, 16

Voice recognition technology (Applying, 3)

Chapter 15, 16

Health information specialty systems (such as ROI, coding, registries) Evaluating, 5)

Chapter 7

Application of systems and policies to health information systems and functions and health care data requests (Evaluating, 5)

Chapter 7, 14, 15, 16

System acquisition and evaluation (Applying, 3)

Chapter 14, 16

IV.B. Subdomain: Data, Information, and File Structures1. Apply knowledge of database architecture and design (such as data dictionary) to meet departmental needs.

Chapter 14

IV.C. Subdomain: Data Storage and Retrieval1. Use appropriate electronic or imaging

technology for data/record storage.

2. Query and generate reports to facilitate information retrieval using appropriate software.

3. Apply retention and destruction policies for health information.

Document archival, retrieval, and imaging systems (Analyzing, 4)

Chapter 15

Maintenance and monitoring of data storage systems (Analyzing, 4)

Chapter 14

IV.D. Subdomain: Data Security and Healthcare Information Systems

1. Apply confidentiality and security measures to protect electronic health information.

2. Protect data integrity and validity using software or hardware technology.

3. Apply departmental and organizational data and information system security policies.

4. Use and summarize data compiled from audit trails and data quality monitoring programs.

System architecture and design (Applying, 3)

Chapter 14

Screen design (Analyzing, 4) Chapter 7

Data retrieval and maintenance (Analyzing, 4)

Chapter 15, 16

Data security concepts (Applying, 3)

Chapter 17

Data integrity concepts (Analyzing, 4)

Chapter 17

Data integrity and security processes and monitoring (Applying, 3)

Chapter 17

V. Domain: Organizational ResourcesV.A. Subdomain: Human Resources

1. Apply the fundamentals of team leadership.

2. Participate in and work in teams and committees.

3. Conduct orientation and training programs.

4. Monitor and report staffing levels and productivity standards for health information functions.

5. Use tools and techniques to monitor, report, and improve processes.

6. Comply with local, state, and federal

Roles and functions of teams and committees (Evaluating, 5)

Chapter 18

Teams/consensus building and committees (Analyzing, 4)

Chapter 10, 18

Communication and interpersonal skills (Evaluating, 5)

Chapter 10, 18

Team leadership concepts and techniques (Analyzing, 4)

Chapter 10, 18

Orientation and training (such as content, delivery, media)

Chapter 14, 18

labor regulations. Workflow and process monitors (Analyzing, 4)

Chapter 7, 14

V.B. Subdomain: Financial and Resource Management1. Make recommendations for items to include in budgets and contracts.

2. Monitor and order supplies needed for work processes.

3. Monitor coding and revenue cycle processes.

4. Recommend cost-saving and efficient means of achieving work processes and goals.

5. Contribute to work plans, policies, procedures, and resource requisitions in relation to job functions.

Revenue cycle monitors (Analyzing, 4)

Chapter 6

Organizational plans and budgets (framework, levels, responsibilities, etc.) (Analyzing, 4)

Chapter 18

Resource allocation monitors (Analyzing, 4)

Chapter 9, 18

BIOMEDICAL SCIENCES

Anatomy (Analyzing, 4)

Physiology (Analyzing, 4)

Medical Terminology (Analyzing, 4)

Pathophysiology (Analyzing, 4)

Pharmacotherapy (Analyzing, 4)

Not within scope of the textbook

Registered Health Information Technician (RHIT) Certification Exam Chapter Map to Domains (Effective October 2011)

Domain I: Data Analysis and Management (20% of exam)Content Area Chapter

1. Abstract information found in health records (i.e., coding, research, physician deficiencies, etc.)

Chapter 7

2. Analyze data (i.e., productivity reports, quality measures, health record documentation, case mix index)

Chapter 3, 6, 7, 8, 9, 10, 18

3. Maintain filing and retrieval systems for health records Chapter 7, 14, 16

4. Identify anomalies in data Chapter 9

5. Resolve risks and/or anomalies of data findings Chapter 96. Maintain the master patient index (i.e., enterprise systems,

merge/unmerge medical record numbers, etc.)Chapter 7

7. Eliminate duplicate documentation Chapter 3, 148. Organize data into a useable format Chapter 3, 169. Review trends in data Chapter 8, 910. Gather/compile data from multiple sources Chapter 3, 5, 8, 9, 10,

14, 15, 1611. Generate reports or spreadsheets (i.e., customize, create, etc.) Chapter 14, 15, 1812. Present data findings (i.e., study results, delinquencies,

conclusion/summaries, gap analysis, graphical)Chapter 7, 8, 9

13. Implement workload distribution Chapter 1814. Design workload distribution Chapter 1815. Participate in the data management plan (i.e., determine data

elements, assemble components, set time-frame)Chapter 3, 14

16. Input and/or submit data to registries Chapter 817. Summarize findings from data research/analysis Chapter 918. Follow data archive and backup policies Chapter 1819. Develop data management plan Chapter 3, 1420. Calculate healthcare statistics (i.e., occupancy rates, length of stay,

delinquency rates, etc.)Chapter 9

21. Determine validation process for data mapping Chapter 522. Maintain data dictionaries Chapter 14

Domain II: Coding (18% of exam)Content Area Chapter

1. Apply all official current coding guidelines Chapter 62. Assign diagnostic and procedure codes based on health record

documentationChapter 6

3. Ensure physician documentation supports coding Chapter 3, 64. Validate code assignment Chapter 65. Abstract data from health record Chapter 7, 86. Sequence codes Chapter 67. Query physician when additional clinical documentation is needed Chapter 68. Review and resolve coding edits (i.e. correct coding initiative, outpatient

code editor, National Coverage Determination, Local Coverage Determination, etc.)

Chapter 6

9. Review the accuracy of abstracted data Chapter 2, 8, 9, 1010. Assign POA (present on admission) indicators Chapter 611. Provide educational updates to coders Chapter 612. Validate grouper assignment (i.e. MS-DRG, APC, etc.) Chapter 613. Identify HAC (hospital acquired condition) Chapter 614. Develop and manage a query process Chapter 615. Create standards for coding productivity and quality Chapter 6, 1816. Develop educational guidelines for provider documentation Chapter 317. Perform concurrent audits Chapter 10

Domain III: Compliance (16% of exam)Content Area Chapter

1. Ensure patient record documentation meets state and federal regulations

Chapter 3, 13

2. Ensure compliance with privacy and security guidelines (HIPAA, state, hospital, etc.)

Chapter 13, 17

3. Control access to health information Chapter 174. Monitor documentation for completeness Chapter 3, 75. Develop a coding compliance plan (i.e., current coding guidelines) Chapter 66. Manage release of information Chapter 7, 137. Perform continual updates to policies and procedures Chapter 188. Implement internal and external audit guidelines Chapter 6, 179. Evaluate medical necessity (CDMP – clinical documentation10. management program)

Chapter 10

11. Collaborate with staff to prepare the organization for accreditation, licensing, and/or certification surveys

Chapter 2, 3

12. Evaluate medical necessity (Outpatient services) Chapter 613. Evaluate medical necessity (Data management) Chapter 614. Responding to fraud and abuse Chapter 615. Develop forms (i.e., chart review, documentation, EMR, etc.) Chapter 7, 1416. Evaluate medical necessity (Case management) Chapter 6, 1017. Analyze access audit trails Chapter 1718. Ensure valid healthcare provider credentials Chapter 10

DOMAIN IV: Information Technology (12% of exam)Content Area Chapter

1. Train users on software Chapter 142. Maintain database Chapter 143. Set up secure access Chapter 174. Evaluate the functionality of applications Chapter 145. Create user accounts Chapter 176. Troubleshoot HIM software or support systems Chapter 147. Create database Chapter 148. Perform end user audits Chapter 179. Participate in vendor selection Chapter 1410. Perform end user needs analysis Chapter 1411. Design data archive and backup policies Chapter 13, 1712. Perform system maintenance of software and systems Chapter 1413. Create data dictionaries Chapter 14

DOMAIN: V Quality (12% of exam)Content Area Chapter

1. Audit health records for content, completeness, accuracy, and timeliness

Chapter 7

2. Apply standards, guidelines, and/or regulations to health records Chapter 4, 5, 6, 10, 13, 17

3. Implement corrective actions as determined by audit findings (internal and external)

Chapter 13, 17

4. Design efficient workflow processes Chapter 185. Comply with national patient safety goals Chapter 106. Analyze standards, guidelines, and/or regulations to build criteria for

auditsChapter 13, 17

7. Apply process improvement techniques Chapter 108. Provide consultation to internal and external users of health

information on HIM subject matterChapter 7

9. Develop reports on audit findings Chapter 9, 1710. Perform data collection for quality reporting (core measures, PQRI,

medical necessity, etc.)Chapter 7, 10

11. Use trended data to participate in performance improvement plans/initiatives

Chapter 9

12. Develop a tool for collecting statistically valid data Chapter 7,1413. Conduct clinical pertinence reviews Chapter 1014. Monitor physician credentials to practice in the facility Chapter 10

DOMAIN VI: Legal (11% of exam)Content Area Chapter

1. Ensure confidentiality of the health records (paper and electronic) Chapter 132. Adhere to disclosure standards and regulations (HIPAA privacy, HITECH

Act, breach notifications, etc.) at both state and federal levelsChapter 4, 5, 6, 13, 17

3. Demonstrate and promote legal and ethical standards of practice Chapter 124. Maintain integrity of legal health record according to organizational

bylaws, rules and regulationsChapter 3, 13, 17

5. Follow state-mandated and/or organizational record retention and destruction policies

Chapter 7, 13

6. Serve as the custodian of the health records (paper or electronic) Chapter 77. Respond to release of information (ROI) requests from internal and

external requestorsChapter 7, 13

8. Work with risk management department to provide requested documentation

Chapter 10, 13

9. Identify potential health record related risk management issues through auditing

Chapter 10, 13

10. Respond to and process patient amendment requests to the health record

Chapter 13

11. Facilitate basic education regarding the use of consents, healthcare Power of Attorney, Advanced Directives, DNRs, etc.

Chapter 3, 13

12. Represent the facility in court-related matters as it applies to the health record (subpoenas, depositions, court orders, warrants)

Chapter 13

DOMAIN VII: Revenue Cycle (11% of exam)Content Area Chapter

1. Communicate with providers to discuss documentation deficiencies (i.e. queries)

Chapter 6

2. Participate in clinical documentation improvement programs to ensure proper documentation of health records

Chapter 7

3. Collaborate with other departments on monitoring accounts receivable (i.e. unbilled, uncoded)

Chapter 6

4. Provide ongoing education to healthcare providers (i.e. regulatory changes, new guidelines, payment standards, best practices, etc.)

Chapter 6

5. Identify fraud and abuse Chapter 6, 136. Assist with appeal letters in response to claim denials Chapter 67. Monitor claim denials/over-payments to identify potential revenue

impactChapter 6

8. Prioritize the work according to accounts receivable, patient type, etc. Chapter 69. Distribute the work according to accounts receivable, patient type, etc. Chapter 610. Maintain the chargemaster. Chapter 611. Ensure physicians are credentialed with different payers for

reimbursement.Chapter 6