医学信息学论文：Lorraine_The State Of HIM and PCS in China HIM Meeting 2013.ppt

Resection – Root Operation T Resection T Definition Cutting out or off, without replacement, all of a body part Explanation N/A Examples Total nephrectomy, total lobectomy of lung, total mastectomy Resection is similar to Excision except Resection includes all of a body part, or any subdivision of a body part that has its own body part value in ICD-10-PCS, while Excision includes only a portion of a body part. * And so on through all root operations Transplantation, Reattachment, Reposition, Transfer Drainage, Extirpation, Fragmentation Inspection and Map Bypass, Dilation, Occlusion, Restriction Insertion, Replacement, Supplement, Removal, Change and Revision Division and Release Control and Repair Alternation, Creation, Fusion * Conclusion PCS is detailed, logical and workable Makes coding without an operative report impossible Requires different thinking and a strong background in anatomy and physiology Will happen on October 1, 2014!! * Thank you Thank you for inviting me again this year to this Conference. I enjoy being in China very much The VERY BEST to all of you!! Margaret A. Skurka, MS, RHIA, CCS, FAHIMA Professor, HIM College of Health and Human Services Indiana University Northwest, Gary, Indiana * * * * DEVELOPING TRENDS IN HIM IN THE US AND ICD-10-CM/PCS Presentation to the Chinese Medical Record Association, 18 October, 2013 Margaret A. Skurka, MS, RHIA,CCS, FAHIMA Past President, IFHIMA; Past President AHIMA HIM Current Big Issues EHR Implementation –The Good and the Bad ICD-10-CM and ICD-10-PCS—less than 1 year away Federal Regulations—Always a challenge Privacy of Data Big Data * The Electronic Record Significant concerns regarding “cloning” Copy forward, cut and paste Template content Data capture from the provider/physician Clinical Documentation Improvement * ICD-10-CM and ICD-10-PCS OCTOBER 1, 2014 Hospital Readiness Physician readiness Gap Analysis Dual Coding * Federal Regulations Abound Meaningful Use of the Data