Chapters 7&8 Quiz Review Flashcards
accountability measures
specifically refers to Joint commission system that measures quality and accountability for treatment of certain diagnosis such as a myocardial infarction (heart attack)
there are specific measures that the organization will meet for accreditation
allowed charges
the maximum amount Medicare (or any 3rd party payer) will reimburse for services
ambulatory payment classifications (APCs)
- payment system for ambulatory stay
are assigned to certain outpatient encounters (for example, ambulatory surgery, emergency department visits, or blood transfusions) and are based on the CPT codes assigned to each service
copy (cut) and paste
the copying of previous encounter that may or may not be accurate for the current encounter
-can lead to note bloat-documenting more than actually applies to the current encounter, such as past medical problems that no longer exist but are being carried forward to future encounters
designated record set (DRS)
as defined by HIPAA
any records maintain by a covered entity that are used for patient care to make payment decisions, such as
health records billing records insurance enrollment records, insurance claims coverage decisions
Hospital Acquired Conditions (HAC)
Diagnoses that appeared after a patient was admitted but which perhaps should not have occurred- for instance a urinary tract infection in a patient who was catharized while hospitalized or a fall that resulted in a fracture
Hospital Readmission Reduction Program (HRP)
part of the affordable care act
a program that requires CMS to reduce payments to hospitals with excessive readmission rates
Incident (occurrence) report
data collected about any abnormal occurrence involving a patient, a visitor, or an employee that detail the circumstances surrounding the incident and are used in the facility’s internal investigations
-it is never filed as part of the patient’s record, nor is the report itself referred to in the record since its purpose is that of an internal investigation tool.
MS-DRG
payment system for the in patient stay–
-takes into account severity of illness and resource utilization and results in a more accurate computation of the costs incurred to care for each patient
Pioneer ACO Program
an ACO Model for hospitals and care providers who have experience with coordinating care for patients across the continuum of care (across different care settings)
Provider network
A network of hospitals, physicians, ambulatory clinics, and so forth with which a managed care insurance plan contracts to provide services to enrollees at an agreed upon reduced rate, saving the enrollee out of pocket expenses for medical care; often referred to as “in Network”
Resource-based relative value scale (RBRVS)
reimbursement method used by Medicare and Medicaid to reimburse physicians according to a fee schedule that is based on weights assigned to resources used to provide the services. Including
cost of work performed
the expenses incurred to operate a medical practice
cost of malpractice insurance
and that is adjusted based on the geographic region where the practice is located
The HIPAA-Designated Record Set
DRS- Any group of any records maintained by a covered entity including
- patients’ medical and billing records as maintained by (or for) the healthcare provider
- enrollment, payment, claims adjudication (determination of whether the plan will pay and the amount), and case management or medical management record systems maintained by or for a health plan
- medical records that are used in whole or in part by the covered entity to make decisions about individuals
The Health Record in Assessing Quality
- Assessing the quality of healthcare and healthcare documentation is performed by audits done internally through quality assessment and externally through outside agencies
- HIM professions are responsible to understand the flow of information as well as data sources within the organization and to use this to supply information to governing board of the institution to make educated decisions
Internal quality assessment
focuses on qualitative analysis of health records
Quantitative analysis
ensures required reports and signatures are present
Qualitative analysis
focuses on the content of each report and ensures that the information on the report is complete, accurate, and thorough
Digital records can be
analyzed using software programs that identify completeness and accuracy as well as chart bloat
External quality assessment
initiatives are required by the Joint Commission as well as the CoP
“hospitals must develop, implement, and maintain an effective, ongoing, hospital wide, data driven quality assessment and performance improvement program”
Utilization management
is performed to review the appropriateness of admission and facility services
Professional Standards Review Organization (PSROs)
perform periodic reviews on utilization and quality on behalf of the federal government
Peer Reviews
organization that replaced PSROs to perform medical necessity and quality of care monitoring
which contain recommendations from peers inside the organization, are a benefit
Hospital Quality initiative
helps to assure quality healthcare through accountability and public disclosure
A core measurement system using accountability measures
by the Joint Commission to measure the quality and safety of healthcare
Quality Improvement (QI)
is an ongoing program that is supported by the organization’s governing board with the goal to regularly improve quality of all levels
- Plan, Do, Study, Act (PDSA)
- Plan, Do, Check, Act (PDCA)
- Six Sigma
Benchmarking
provides a way for organizations to identify areas for improvement using public information on the performance or outcomes
What is the health record used for?
Risk management activities to identify, evaluate and control areas of risk within an organization
Data Compiled on incidence reports
documenting abnormal occurrences are used in assessing the controlling risk
Health Information professionals
are responsible for reporting inappropriate documentation
Private health insurance, Blue Cross
Payment Model
began in the 1920s and soon group health insurance through employers became the norm
The Hill-Burton Act (1946)
Payment Models
provided a way for more hospitals to be built and for improved facilities to be added
Title XVII of the Social Security Act AKA Medicare
Payment Model
became effective in 1966
Medicare covers US citizens and legal residents who are 65 years of age and older or who receive Social Security Disability Insurance (SSDI). Also covered are patients with end-stage renal disease or other conditions, such as ASL. Other Qualifications include having paid into the fund through a payroll tax or having paid into the Railroad Retirement fund.
Medicaid
a federal program run through each state, was developed to assist low-income individuals with healthcare costs
Coverage required by Federal government includes inpatient hospital services, out patient hospital services, diagnostic laboratory and radiology, skilled nursing long term care, some home health services, physicians office visits, special programs for family planning, the services of a nurse midwife, vaccines for children, rural healthcare, and some periodic screening services (mammograms or colonoscopy)
TRICARE
was designed to provide health coverage for active armed service personnel and their dependents and retirees
Premium
amount paid for health coverage
Meaningful Use Stage 1
the capture and sharing of data by EHRs and health information exchange
Meaningful Use Stage 2
advancing clinical outcomes through improved measurement and patient-directed exchange
Quality and coordination of care
Meaningful Use Stage 3
improved outcomes through coordination of element built under the earlier stages
logical Observation Identifiers Names and Codes (LOINC)
Standard for coding laboratory
Standard required under all stages of meaningful use
used to identify and code laboratory observations (eg test results) to be exchanged between labs, providers, and other steak holders
Affordable Care Act
designed to change both healthcare delivery and payment models
HITECH
is centered on the digital capture, exchange, and analysis of clinical and financial patient records and the efficient use of these records
Goals are to-
achieve improved patient outcomes
lower healthcare costs
The programs funded by HITECH ensure that tax dollars are being well spent and that resulting system support interoperability
American Recovery and Reinvestment Act
designed to change both healthcare delivery and payment models
HIM Professional
progression of meaningful use means that patient data are going to be used in more places and for new uses. as such the responsibilities of health information management will increase and more healthcare workers with a wide variety of job responsibilities will need to understand HIM principles and guidelines
The ONC Health IT standards Committee focuses on what three broad areas?
- Clinical Operations
- Clinical Quality
- Privacy and Security
Vaccine Administered
standard for immunization messages. The CDC develops and maintains CVX codes under HL-7. The use of CVX standards is required for the immunization objectives encompassed under Meaningful Use
RxNorm
standard for pharmacies
provides for the normalization of names for clinical drugs used in pharmacy management and drug interaction software
Health Information Exchange (HIE)
is the efficient and effective exchange of electronic health data with other healthcare-related entities
- States are responsible to develop their own strategic plan for HIE and commonly choose a Health Information Organization to run the exchange of information while ensuring privacy and security
List the Role of HIE
efficient and effective exchange of electronic health data with other healthcare-related entities
States are responsible to develop their own strategic plan for HIE and commonly choose a Health Information Organization to run the exchange of Information while ensuring privacy and security
What is the ONC policy?
(add more from 218) to encourage Health Information Exchange and Promote it as a Verb
What are Benefits of Health Information exchange?
Patient generated data
Electronic disease surveillance
Reduction in redundant tests
What does Direct Messaging Service do?
sends patient data as attachments
Compliance coordinator (or could be manager) is often resonsible
for managing questions about the legal health record
Covered HIPAA entities do include
health insurance companies
The JC maintains
a database of its intuitions quality reports
The MPI is a crucial aspect of
quality assurance checks
- ensure the right patient
- ensure there isn’t duplicates
Risk management has only been recognized since?
Previous to this what where hospitals viewed as?
Risk management-areas of risk are identified for instance a high infection rate for a particular nursing unit
1970s
Previous to this hospitals were viewed as charitable organizations
Prior to 1966 elderly people may not have had access to
health care
Present on Admission documentation ties to
reimbursement to quality of care
POA- chronic or comorbid conditions, such as the presence of diabetes mellitus or hypertension, which the patient contracted prior to admission
covered entity
is any health plan (insurance or third party payer), clearinghouse (an entity that verifies that coded diagnoses and procedures are valid and in the proper format). or healthcare provider who stores, processes, and transmits any identifiable health information electronically
The HIPAA Legal Health Records
LHR-information available to physicians, nursing staff, and ancillary staff on which diagnostic and treatment decisions are made, as opposed to what is protected by the HIPAA privacy rule in the case of the DRS
**each organization will follow federal Guidelines for HIPAA and they will follow their state law for what can be released to whom
