ch6 vocab Flashcards
Case-mix index (CMI)
the average DRG relative weight for all Medicare admissions
Clinical documentation improvement (CDI)
the process an organization undertakes that will improve clinical specificity and documentation that will allow coding professionals to assign more concise disease classification codes
CDI specialist
a professional that serves as a bridge between multiple disciplines and departments in seeking high-quality clinical documentation
Coded data
information that can then be translated by a coder into a code
Complication and/or Comorbidity (cc)
Complication- a medical condition that arises during an inpatient hospitalization 1 a condition that arises during the hospital stay what prolongs the length of stay at least on day in approximately 75 percent of the cases
Comorbidity- a medical condition that coexists with the primary cause for hospitalization and affects the patient’s treatment and length of stay. 2. Pre-existing condition that, because of its presence with a specific diagnosis, causes an increase in length of stay by at least one day in approximately 75 percent of the cases.
Concurrent query
a question posed to the documenting physician during the patient’s hospital stay
Data
the dates, numbers, images symbols, letters, and words that represent basic facts and observations about people processes, measurements and conditions
Deficiency system
Software application or other monitoring method designed to track and report elements of documentation missing from health records
Diagnosis-related groups (DRGs)
- a unit of case-mix classification adopted by the federal government and some other payers as a prospective payment mechanism for hospital inpatients in which diseases are placed into groups because related diseases and treatments tend to consume similar amounts of healthcare resources and incur similar amounts of cost; in the Medicare and Medicaid programs, one of more than 500 diagnostic classifications in which cases demonstrate similar resource consumption and length-of-stay patients. Under the prospective payment system (PPS), hospitals are paid a set fee for treating patients in a single DRG category, regardless of the actual cost of care for the individual. 2. A classification system that groups patients according to diagnosis, type of treatment, age, and other relevant criteria. Under the prospective payment system, hospitals are paid a set fee for treating patients in a single DRG category, regardless of the actual cost of care for the individual
Evidence-based documentation
Physicians and clinicians practicing using the seven criteria for documentation legible, reliable, precise, complete, consistent, clear, and timely
Evidence-based medicine
Healthcare services based on clinical methods that have been thoroughly tested through controlled, peer reviewed biomedical studies
Health record analysis
this type of analysis contains two separate steps. the one step being quantitative analysis and the other stoep being qualitative analysis
Hospital-acquired condition (HAC)
Section 5001(c) of Deficit Reduction Act of 2005 requires the Secretary to identify conditions that are: (a) high cost or high volume or both, (b) results in the assignment of a case to a DRG that has a higher payment when present as a secondary diagnosis, (c) could reasonably have been prevented through the application of evidence based guidelines, Section 5001(c) provides that CMS can revise the list of conditions from time to time, as long as it contains at least two conditions
Major Complication/Comorbidity (MCC)
a secondary diagnosis that, if documented on a patient records, are likely to increase the intensity of services needed to care for the patient chapter
MedPAR database
a database developed by CMS that contains information for 100 percent of Medicare beneficiaries using hospital inpatient services. Data is provided by state and then DRG for all short stay and inpatient hospitals. The following fields are furnished: total charges, covered charges, Medicare reimbursement, total days, number of discharges an daverale total days. Data for PPS exempt hospitals and units has been grouped into DRGs for inclusion in these tables
Physician champion
an individual who assists in communicating and educating medical staff in areas such as documentation procedures for accurate billing and appropriate EHR processes
Physician query
the process by which questions are posed to a provider to obtain additional, clarifying documentation to improve the specific y and completeness of the data used to assign diagnosis and procedure codes in the patient’s health record
Present on admission (POA)
a status given to a diagnosis listen on a billing claim to indicate whether or not the condition was present at the time a patient was admitted to the hospital
Principal diagnosis
the disease or condition that was present on admission, was the principal reason for admission, and received treatment or evaluation during the hospital stay or visit of the reason stablished after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care
Qualitative analysis
a review of the health record to ensure that standards are met and to determine the adequacy of entries documentation the quality of care
Quantitative analysis
a review of the health record to determine its completeness and accuracy
Retrospective query
a question posed to the documenting or attending physician after the patient has been discharged to obtain additional, clarifying documentation with the expectation of improving the specificity and completeness of the data used when assigning diagnosis and procedure codes in the patient’s’ health record
Risk of Mortality (ROM)
the likelihood of an inpatient death for a patient
Secondary diagnosis
a statement of those conditions coexisting during a hospital episode that affect the treatment received of the length of stay
Severity of illness (SOI)
a type of supportive documentation reflecting objective clinical indicators of a patients; illness (essentially the patient is sick enough to be at an identified level of care) and referring to the extent of physiologic decompensation or organ system loss of function
Value-based purchasing
a part of CMS’ long standing effort to link Medicare’s payments system to a value-based system to improve healthcare quality, including the quality of care provided in the inpatient hospital setting Participating hospitals are paid for inpatient acute care services based on the quality of care, not just quantity of the services they provide. Authorized in the Affordable Care Act, the program uses the quality data reporting infrastructure authorized in the Medicare Prescription Drug, Improvement, and Modernization Act of 2003
