CH 25 Flashcards
CPT-4 (current procedural terminology)
Medical terms and codes for the uniform designation of diagnostic and therapeutic procedures; coding for physician reimbursement and hospital outpatient and ambulatory surgical procedures
Electronic health record (EHR)
patient heath information generated by one or more encounters in any care setting
Health information management (HIM)
management of healthcare record in its physical form & management of data within medical record
Health insurance portability and accountability act of 1996 (HIPAA)
improve the efficiency and effectiveness of the healthcare system; components that affect health information include privacy, security, and the establishment of standards and requirements for the electronic transmission of certain health information
Health informatics
electronic nature of medical information with secure mechanisms to ensure accuracy, Security, accessibility, transferability
- The interdisciplinary field that studies and pursues the effective uses of biomedical data & information for scientific inquiry, problem solving and decision making, motivated by efforts to improve human health
ICD-10-CM (international classification of diseases clinical modification)
Used of diagnosis coding in all healthcare settings in US
Medical necessity
Healthcare services or supplies that are needed to diagnose or treat an illness , injury, condition, disease, or its symptoms
Revenue cycle
Process of patient financial and health information moving into, through, and out of the healthcare organization, culminating with the healthcare organization receiving reimbursement for services provided
What is the health information manager responsible for?
Ensuring complete health record
Guiding development, review, and updates of organizational policies for documentation and management of health record
How do errors in patient identity occur and how do they resolve it?
What are the components of patient health record?
Chief complaint
History of present illness
Review of systems (see what body systems are acting up)
Past medical history
Family history
Social history
Physical examination
Impression/diagnosis & treatment plan
Describe the revenue cycle management process
Front end: patient access (scheduling, pre authorization, insurance verification, financial counseling) medical necessity
Middle process: charge capture, charge master, case management, clinical documentation, coding
Back end: claims processing and payment posting, follow-up, collections, denial management
When registration personal is uncertain that a diagnosis will meet medical necessity for an exam, who can perform verification?
Coder
Patient’s bill includes _____codes while insurance bill includes _____ codes.
CPT-4
ICD-10-CM
What are the 8 parts to the privacy rule?
- What and how protected health info (PHI) can be used
- Business associate agreements are required when a business associate performs business for a covered entity
- Notice of privacy practices (NPP) inform patient of how their health info may be used/shared and how to exercise privacy rights
- Right to request privacy protection establishes a patient’s right to restrict the use and disclosure of PHI
- Right of access to health records establishes patient’s right to inspect and obtain copy of PHI
- Amendment of PHI establishes patient’s right to request amendment
- Accounting of disclosures establishes a patient’s right to receive an accounting of disclosures of PHI made by facility
- Administrative requirements include privacy offer, workforce training programs, privacy safeguards, process for individual to make complaints, establishment of anti-retaliatory standards for filing complaint
