Chapter Two

Question 1

Care Provider

Answer 1

a physician, physicians assistance, dentist, psychologist, nurse practitioner, or midwife, these individuals can diagnose and give orders for diagnostic or therapeutic services

Question 2

Healthcare professional

Answer 2

generally refers to a nurse, medical assistant, or other technicians who directly cares for the patient

Question 3

Third-Party Payer

Answer 3

often refereed to as an insurance carrier or company, includes d, Medicaid,Blue Cross/Shield, Tricare, Champva, and any of the private health insurers.

Question 4

Medical Transcriptionist

Answer 4

healthcare professional who converts the recorded dictation of care providers into typed report form using word processing software

Question 5

Outguides

Answer 5

in a manual record- keeping system, these are cardboard or plastic folders that take the place of health records and have been removed from file. They include the date the files were removed and the locations to which the files were taken

Question 6

Electronic Health Record (EHR)

Answer 6

EHR captures more information than an EMR and its designed to be exchanged and used at any point of care, following the patient, EHRS need to meet Meaningful use standards

Question 7

Electronic Medical Record (EMR)

Answer 7

EMR provides a digital record for the traditional chart used within one location. It does not meet the certification requirements of Meaningful Use because of its limited functionality

Question 8

Digitized Health Records

Answer 8

health records kept in an electronic binary format

Question 9

Physician Extenders

Answer 9

providers of healthcare who have advanced education and can diagnose as well as give orders, includes physicians assistant, certified registered nurse anesthetist and nurse midwives.

Question 10

Quantitative Analysis

Answer 10

the review of a health record to ensure that required documentation is complete and part of the record-for instance- a history and physical report or an operative report-but it does not include a review of the quality of the documentation

Question 11

Authentication

Answer 11

in a paper record, the signature of the person who wrote an entry in a health record, showing authorship: in a digital environment, the security process of verifying an individual’s right to access a system or portion of it

Question 12

Delinquent Records

Answer 12

records that remain incomplete after 15-30 Days post discharge or encounter

Question 13

Medical Staff bylaws

Answer 13

a set of policies that define the code of conduct, categories of medical staff membership, rules and regulations related to individual departments with which they may be affiliated and health information related policies

Question 14

Document Imaging/scanning

Answer 14

the process of digitizing images of documents into a computer-readable format

Question 15

Privacy Officer

Answer 15

a higher-level position dealing with compliance with privacy laws, investigation of potential breaches in confidentiality, and monitoring of the facility’s release of information practices

Question 16

International Classification of Diseases, 9th revision. Clinical Modification (ICD-9-CM)

Answer 16

a classification system used to convert narrative diagnoses and procedures to numeric form for statistical and reimbursement purposes

Question 17

International Classification of Diseases, 10th revision, Clinical (ICD-10-CM)

Answer 17

a more specific and scalable classification system for coding of diagnoses that, through approved for use in the US, has not yet been implemented at the time of this writing

Question 18

International Classifcaion of Diseases, 10th revision Procedural Coding System (ICD-10-CM)

Answer 18

a more specific and scalable classification system for coding of inpatient procedures that , through approved for use in the US, has not yet been implemented at the time of this writing

Question 19

Current Procedural Terminology(CPT)

Answer 19

the coding system used to convert narrative procedures and services performed in an outpatient setting to numeric form

Question 20

Encoder software

Answer 20

Technology used to assign ICD or CPT codes based on the coder’s input of terms

Question 21

Grouper Software

Answer 21

Technology used to categorize an inpatient admission or an outpatient encounter into a payment classification

Question 22

Computer- assisted coding (CAC)

Answer 22

computer software that improves the efficiency and quality of coding by assessing documentation and suggesting possible code choices, which are then verified by the coder

Question 23

Uniform Hospital Discharge Data Set (UHDDS)

Answer 23

defined data elements that are required to be collected on all hospital discharges

Question 24

Compliance officer

Answer 24

a position responsible for monitoring activities that are susceptible to fraud, misuse, or overutilizaiton

Question 25

Revenue Cycle Managers

Answer 25

those responsible for the functions that lead to an efficient effective revenue cycle form the time a patient is registered for care until the bill is paid in full

Question 26

eHealth managment

Answer 26

the processes and policies that govern the digital collection, maintenance, and archival of data

Question 27

Enterprise system

Answer 27

a health system made up of a hospital or hospitals, physicians practices,long term care facilities, outpatient(ambulatory) diagnostic and therapeutic facilities, and the like

Question 28

Information (data) governance

Answer 28

the specification of decision rights and an accountability framework to ensure appropriate behavior in the valuation, creation, storage,use,archiving, and deletion of information: it includes the processes, role and policies, standards, and metrics, the ensure the effective and efficient use of information enabling an organization achieve its goals

Question 29

Information Security

Answer 29

the administrative, technical, and physical safeguards put in place to ensure the validity and safety of digital data

Question 30

Cancer Registry

Answer 30

a database of all patients diagnosed or treated for a malignant neoplasm (cancer) in a hospital; the hospital registry data are submitted to a state cancer registry, then reported to the Centers for Disease Control and Prevention (CDC)

Question 31

Recovery Audit Contractor (RAC)

Answer 31

a position resulting from the Medicare Modernization Act of 2003, with the purpose of recovering improper Medicare payments

Question 32

Voice Recognition

Answer 32

software that recognizes the dictation of care provider or other professional and converts the speech to text

Question 33

Commission on Accreditation for Health Informatics and Information Management Education (CAHIIM)

Answer 33

an independent accrediting organization whose mission is to serve the public interest by establishing and enforcing quality Accreditation Standards for Health informatics and Health Information Management (HIM,2014) educational programs (CAHIIM,2014)