Critical Concept Review Flashcards
A few Key concepts to know
1
Q
Abuse
A
Abuse means actions that are improper, inappropriate, outside acceptable standards of professional conduct or medically unnecessary.
Examples of Abuse
- Pattern of waiving cost-shares or deductibles
- Failure to maintain adequate medical or financial records
- Pattern of billing claims for services not medically necessary
- Refusal to furnish or allow access to medical records
- Improper coding practices
2
Q
Accessibility
A
The level of ease and efficiency at which data are legally obtainable, within a well protected and controlled environment
3
Q
Accreditation
A
A voluntary program in which trained external peer reviewers evaluate a healthcare organization’s compliance and compare it with pre-established performance standards.
4
Q
Accuracy
A
The extent to which the data are free of identifiable errors
5
Q
Administrative Safeguards
A
Administrative actions, and policies and procedures, to manage the selection, development, implementation, and maintenance of security measures to protect electronic protected health information and to manage the conduct of the covered entity’s workforce.
6
Q
Aggregated Data
A
Data that has been extracted from individual health records and combined to form deidentified information about groups of patients that can be compared.
7
Q
AHIMA Code of Ethics
A
Core Values beliefs
8
Q
Alphabetic Filing System
A
Filed alphabetically by patients last name.
9
Q
Alphanumeric Filing System
A
First two letters of patients last name followed by a unique numeric identifier. Ex. SA1234
10
Q
Anti-kickback Statute
A
A criminal statute that prohibits transactions intended to induce or reward referrals for items or services reimbursed by the federal health care programs. Designed to program beneficiaries from the influence of money on referral decisions and thus is intended to guard against overutilization, increased costs, and poor quality services from healthcare professionals
11
Q
American Recovery and Reinvestment Act. (ARRA)
A
Major health information technology law that provides stimulus funds to the US economy in the midst of a major economic downturn. Created HITECH
12
Q
Audit Trail
A
A compliance manager’s reviewing tool that identifies when a user logs in and out
13
Q
Authorization-
A
Covered Entity may not use or disclose protected health information without consent
14
Q
Average length of Stay
A
Inpatient hospital stay that is 25 days or less
15
Q
Benchmarking-
A
Compares organization standards against internal standards or external organizations.
16
Q
Beneficence
A
Promoting good for others or providing services that benefit others. Such as releasing a record that will help someone.
17
Q
Board of Directors
A
Elected group who are responsible for successful operation of the healthcare organization.
18
Q
Cancer Registry
A
Records maintained by many states for the purpose of tracking the incidence new cases of cancer.
19
Q
Case Finding
A
A method used to identify the patients who have been seen or treated in the facility for the particular disease or condition of interest to the registry.
20
Q
Case Mix Index
A
The average relative weight of all cases treated a facility or by a given physician. This is calculated by dividing the sum of the weights of DRGS for patients discharged by the total number of patients discharged.
21
Q
Case Mix
A
The distribution of a patient into categories reflecting difference in severity of illness or resource consumption.
22
Q
Centralized Unit Filing
A
The patients encounters are filed in a single location.
23
Q
Chargemaster
A
List of charges for the healthcare services and supplies at an organization.
24
Q
Chief Privacy Officer
A
Responsible for privacy practices within the organization
25
Clinical Documentation Improvement-
The process an organization undertakes that will improve clinical specificity and documentation that will allow coders to assign more concise disease classification codes.
26
CMS
Centers for Medicare & Medicaid Services: Federal Agency within the US department of Health and Human Services. Oversight of Medicare & Medicaid programs and funding
27
Complete Worked Hours
Total work output - defective work = complete worked hours OR Completed Work / Hours worked to produce total work output
28
Compliance Officer
Checks the written standards of conduct
29
Comprehensiveness
The extent to which all required data within the entire scope are collected, documenting intended exclusions
30
Concurrent Review
Ongoing review while patient is in facility. From admission to discharge.
31
Conditions of Coverage-
Ensures patient quality
32
Conditions of Participation
Administrative and operational guidelines under which facilities are allowed to take part in the Medicare and Medicaid programs.
33
Confidentiality
Legal and ethical concept that requires healthcare providers to protect records and personal/private information. Responsibility to use
34
Consistency-
The extent to which the healthcare data are reliable, identical, and reproducible by different users across applications
35
Currency
The extent to which data are up-to-date; a datum value is up-to-date if it is current for a specific point in time, and it is outdated if it was current at a preceding time but incorrect at a later time
36
Custodian Records
When records for evidence is involved at the trial
37
Daily inpatient census
official count of inpatients present at midnight
38
Data Dictionary-
A listing of all the data elements within a specific system that defines each individual data element
39
Data Elements for Emergency Department Systems DEEDS
Emergency Room
40
Data Mapping
Allows for connections between two systems.
41
Data Mining-
Process of extracting information from a database then quantifying and filtering discrete
42
Data Normalization-
Critical process of bringing data into a common format that allows for collaborative research
43
Data Warehousing
Processes and systems used to archive data. Process of collecting data from sources within an organization for decision making purposes. Single database that helps locate data that exists in multiple databases.
44
Definition
The specific meaning of a healthcare-related data element
45
Delinquency Rate
Total number of delinquent records divided by/ number of discharges.
46
Disambiguated Data
A challenge in extracting meaningful data from unstructured text. Clinical notes often contain terms that have more than one meaning. Example: Cold- a disease or body temperature/ Discharge- body fluid or leaving hospital.
47
Duplicate Record
2 or more medical record numbers.
48
Electronic Document Management SystemEDMS-
Used to track manage and store documents.
49
EMTALA-
Emergency Medical Treatment and Active Labor Act- Determines if an emergency condition exists.
50
Enterprise MPI-
Links the patient's information at the different facilities when they go to multiple places.
51
Essential Medical Data Set EMDS
Emergency Care Setting
52
Expressed Consent-
Consent given by their words or in writing.
53
False Claims Act
Penalties to those who knowingly submit fraudulent claims to Government for payment.
54
fish bone chart
a performance improvement tool used to identify or classify the root causes of a problem or condition and to display the root causes graphically; also called the cause and effect diagram
55
flowchart
a graphic tool that uses standard symbols to visually display detailed information
56
Fraud-
Intentionally executes or attempts to execute a scheme to obtain money or any healthcare benefit program.
57
Granularity-
Data collected must be at appropriate level of detail
58
Guidelines-
Give direction
59
Health Information Exchange-
Sharing of patient information between providers electronically.
60
Health Insurance Portability and Accountability Act (HIPAA)-
United States legislation enacted to control fraud and abuse in healthcare
61
Healthcare Effectiveness Data and Information Set HEDIS
Designed to collect administrative
62
Histogram
Represents the frequency distribution of numerical data. Like a bar graph but continuous distributed in categories
63
HITECH Health Information Technology for Economic and Clinical Health-
created by ARRA- Allocates funds for implementation of a nationwide health information exchange and implementation electronic health records.
64
Information Assets-
Information collected during day-to-day operations of an organization that has value.
65
integrated Health Record-
Placed in chronological order. Subjective
66
Interface
- The zone between different computer systems across which users want to pass information. Provides the hard wiring.
67
Jacket Microfilm-
Microfilm is cut and inserted into 4x6 inch jackets with sleeves.
68
Legal Health Record
Defined by each organizations Documentation that supports revenue pursued by payers Documentation used for legal testimony
69
Licensure
Organizations are the legal authority from the authorities to carry on certain activities that require permission. Before healthcare organizations can provide services
70
Line Graph
Shows continuous data/trends over time.
71
Living Will-
Written statement detailing a person's desires regarding their medical treatment in circumstances in which they're no longer able to express informed consent
72
Master Patient Index (MPI)
Most common patient- identifying directory.
73
Meaningful Use
An incentive program to encourage the adoption and use, of certified EHR technology and demonstrates meaningful use also known as Promoting Interoperability.
74
Median
Middle number in a set of sequential numbers.
75
Medical Necessity
The determination that the services provided will benefit the patient and are needed.
76
Medicare Provider Analysis and Review File (MEDPAR)
Data for all Medicare claims for acute care hospital and skilled nursing facilities. Used to research topics related to types of care and DRGs but only for Medicare patients.
77
Metadata
Data that describes other data.
78
Microfiche
Copy of the jacket microfilm. Used to be sent out of the HIM Department instead of using the original Jacket Microfilm.
79
Minimum Data Set (MDS)
Long Term Care Setting
80
Mode
Value appearing most often in a sequence of values. Most
81
N
Diagnosis was not present at time of inpatient admission
82
National Patient Safety Goals (NPSG)
Goals issued by Joint Commission to improve patient safety in healthcare organizations nationwide.
83
National Practitioner Data Bank (NPDB)
Provide a database of medical malpractice payments
84
Noncustodial Parents rights to Medical Records-
By law
85
Office of Inspector General (OIG)
Office in the federal government working to combat fraud
86
OIG Workplan-
Sets forth various projects including OIG audits and evaluations that are underway or planned to be addressed during the fiscal year. Also provides information on new and ongoing reviews or audits each year.
87
Outcome and Assessment Information Set (OASIS)
Home healthcare data set
88
Outguide
Paper-based health record system to track the location of records removed.
89
Overlap
When a patient has more than one health record number at different locations within an enterprise.
90
Overlay
Mistakenly assigned another persons health record number.
91
Pareto Chart
Similar in appearance to a bar chart but the highest- ranking value is listed as the first column and the next highest ranking is second and so forth. 80/20 rule.
92
Patient Assessment Instrument (PAI)
Completed shortly after admission and discharges
93
Physician Advisor/Champion-
Well-respected physician who can informally help physician community adapt to and ultimately adopt health IT. Is the communicator between CDI and actual physician.
94
POA INDICATIORS
Applied to inpatient admitting diagnosis to determine if a condition was present or arrival or not. Affects MS-DRG. Y N U W
95
Policies
Principles describing how a department or organization will handle a specific situation or evaluate a specific process. They are clear simple statements of how an HIM department will conduct it's services.
96
Precision-
Data values should be strictly stated to support the purpose.
97
Primary Keys-
Ensure that each row in a table is unique. It can not change in value.
98
Privacy
The right of a patient to control the disclosure of PHI.
99
Problem Oriented Health Record
A problem oriented record most often uses the S.O.A.P. note method of documentation and contains a problem list in order of appearance in the chart.
100
Procedures
Once policies are in place. Step-by-Step instructions for how something is done.
101
Prospective Review
Review that takes place prior to elective procedures and missions.
102
Qualitative Analysis
Reviewing a record and ensuring that standards are being met. HIM professionals can review legibility, search for banned abbreviations, and compare records for quality standards
103
Query
Communication tool for CDI staff to communicate with providers to obtain clinical clarification
104
Range
High- Low
105
Reasonable Diligence
Taken reasonable actions to comply.
106
Record Reconciliation
Making sure that all the records have been received by the HIM department after patient has been discharged.
107
Red Flag Rule
Used as triggers to alert organizations of potential identity theft.
108
Rehab Facilities are accredited through (CARF)
Commission on Accreditation of Rehabilitation Facilities
109
Relevancy
The extent to which healthcare-related data are useful for the purposes for which they were collected.
110
Retrospective Review
Review after patient has been discharged.
111
Revenue Cycle Back End
Claims transmission
112
Revenue Cycle Middle
The documentation of the encounter in the health record
113
Revenue Cycle- Front End-
Patient Registration
114
ROI Turnaround Time
Time between receipt of request and when the request is sent to the requester 30 days on site
115
Roll Microfilm
Images stored on a long roll of film
116
Run Chart
Displays data points for specific time frame to provide information about performance. In a run chart the measured points of a process are plotted on a graph at regular time intervals so health team members identify whether there are substantial changes in numbers over time.
117
Secondary Data
Data derived from the primary patient record such as an index
118
Security
To control/protect access of health information and records.
119
Sentinel Event
Unexpected occurrence involving death or serious physical injury. Adverse outcome.
120
Serial Numbering System
System that makes unique numerical identifer number for every encounter. Example: If a patient is admitted five times
121
Serial-Unit Numbering System
Issued a new medical record number with each encounter and all documentation is moved from last number to new number.
122
Skilled Nursing Prospective Payment System
Resource Utilization Group (RUG) classifications
123
Source Oriented Health Record
Record is organized by source. Example: All nursing notes together.
124
Standards
Fixed rules that must be followed.
125
Statute
Piece of legislation written and approved by state/federal legislature
126
Straight Numeric
Filed based directly by the record number in numeric order.
127
Terminal- Digit filing
Filed by the last two digits terminal digits then the middle two secondary unit then first two tertiary units.
128
The Joint Commission (TJC)
Industry leader in the area of healthcare provider organization accreditation.
129
The Plan-Do-Study-Act (PDSA)
Worksheet is a useful tool for documenting a test of change. The PDSA cycle is shorthand for testing a change by... developing a plan to test the change Plan
130
Timeliness
Concept of data quality that involves whether the data is up-to-date and available within a useful time frame. Timeliness is determined by how the data are being used and their context.
131
Tracer
Joint Commissions method for following patient.
132
U
Documentation insufficient to determine if the condition was present at the time of inpatient admission.
133
Unbundling
Unbundling refers to using multiple CPT codes for the individual parts of a procedure that should be bundled together, either due to misunderstanding or in an effort to increase payment
134
Uniform Ambulatory Care Data Set (UACDS)
Collects data specific to ambulatory care
135
Uniform Hospital Discharge Data Set (UHDDS)
Hospital inpatients acute care -UB04 is a form used for this data set
136
Unit Numbering System
Most common Health record number is issued at first encounter and used for all subsequent encounters.
137
Universal Chart Order
Reverse chronological order.
138
Utilization Review.
Process of determining whether the medical service provided to a specific Medicare or Medicaid patient is necessary.
139
Variance
Average of the squared deviations from the mean.
140
Vocabulary standards
Provide consistent descriptions of medical terms for an individual's condition in the health record. Also provides a foundation for interoperability by improving the effectiveness of information exchange.
141
W
Clinically undetermined. Provider unable to clinically determine whether the condition was present at the time of inpatient admission
142
Willful Neglect
Intentionally failing to comply with HIPAA provisions.
143
Y
Diagnosis was present at time of inpatient admission
