Domain 1 Study Guide Flashcards
Coding guidelines
are found at the beginning of each CPT section. Guidelines define items that are necessary for appropriately interpreting and reporting the procedures and services contained within that section of the CPT manual. The guidelines specific to each section of CPT codes are strictly followed. Guidelines are provided at the start of each main section, but guidelines, or notes, may also appear at the beginning of the subsection. Coders should read and review each of the guideline sections at the start of each year for any noted changes that may have been made from the prior year’s guidelines. (Bowie, 2021)
Medical staff bylaws
are voted on by participating medical staff, and their executive committee and then approved by the organization’s board of directors. This is significant to the documentation standards and development.
The Centers for Medicare and Medicaid Services (CMS),
an agency within the Health and Human Services Department, requires medical staff bylaws to do the following:
What is Required of the of CMS
-Be approved by the governing body of the medical staff
-Address the duties and privileges of each type of medical staff member
-Describe the organization of medical staff
-Describe the qualifications that must be met by any individual wishing to seek appointment to the medical staff
The Joint Commission Standards
Legibility and completeness
Dating and timing of entries
Order sets
Abbreviations
History and physical component requirements
Informed consent (among others)
State statutes
vary by state in terms of what components of health record documentation are regulated and to what degree it is regulated by law. Statute is a piece of legislation written and approved by a state/federal legislature and then signed into law by the state’s governor, or the President of the United States.
Meaningful use
A regulation that was issued by the Centers for Medicare and Medicaid outlining an incentive program for eligible professionals, eligible hospitals, and critical access hospitals participating in Medicare and Medicaid programs that adopt and successfully demonstrate meaningful use of certified EHR technology.
Conditions of Participation
Become certified to take part in the federal government reimbursement plan i.e. Medicare/Medicaid.
Master Patient Index (MPI)-
Part of the hospital information system; it is a patient-identifying directory, referencing all patients related to a healthcare facility; that also serves as a link to the patient health record or information, facilitates patient identification, and assists in maintaining a longitudinal patient record from birth to death. *Must be kept permanently
Chargemaster
A financial management form of software that contains information about the healthcare facility charges for the services it provides to patients; it automates the coding process for routine procedures.
Vocabulary standards
A list or collection of clinical words or phrases with their meanings address the problem of multiple ways to define, classify, and represent language. Language generally refers to a system of communication using an arbitrary set of vocal sounds, written symbols, signs, or gestures in conventional ways with conventional meanings.
Accreditation
A voluntary process of institutional or organizational review in which a quasi-independent body created for this purpose periodically evaluates the quality of the entity ]s work against reestablished written criteria.
Licensure
The legal authority or formal permission from authorities to carry on certain activities that by law or regulation require such permission.
Certification
The process by which a duly authorized body evaluates and recognizes an individual, institution, or educational program as meeting predetermined requirements.
