Certified Professional in Healthcare Information and Management Systems (CPHIMS) Practice Exam

Which of the following functions are typical responsibilities of a health information management professional?

1. Diagnosis and procedure coding

2. System implementation

3. Content retention

4. Record administration

The correct answer is: Diagnosis and procedure coding

A health information management professional is primarily involved in managing patient health information and records, which includes the responsibility of diagnosis and procedure coding. This function is critical because accurate coding ensures appropriate reimbursement for healthcare services, supports data analytics for quality improvement, and is essential for compliance with regulatory requirements. Coding professionals translate the clinical terminology used by healthcare providers into standardized codes that capture the patient’s diagnosis and the procedures performed. This process requires a deep understanding of medical terminology, coding standards (like ICD and CPT), and an awareness of regulatory changes impacting coding practices. While system implementation, content retention, and record administration can also fall under the broader umbrella of health information management, they are often specialized roles or functions that may or may not be directly handled by every health information management professional. For instance, system implementation typically involves IT specialists focusing on the technical aspects of health information systems, while content retention involves ensuring compliance with legal and regulatory standards regarding how long various types of health information should be stored. Record administration, although related to managing patient records, encompasses broader operational functions that include record creation, maintenance, and the overall management of health information systems. Thus, coding remains a hallmark duty directly associated with health information management.