Module 1 Key Terms

Question 1

Abstracting

Answer 1

data extraction from docs in medical record. Entering data into software system to code/analyze

Question 2

Accounts Receivable

Answer 2

An accounting of payments owed to the organization by 3rd party payers/pts for services rendered

Question 3

Accreditation

Answer 3

voluntary process by a facility for a evaluation of performance rvw & adherence to policies. The facility has met criteria that meets standards.

Question 4

Acute care

Answer 4

Care given to a pt on a limited basis as an inpt in a hospital setting

Question 5

APC Group

Answer 5

Software used for Ambulatory Payment Classification payment system: used for outpt coding & billing with CPT & HCPCS codes

Question 6

AAPC

Answer 6

American Academy of Professional Coders - national membership that provides credentials, education & coding info to medical coders in all settings

Question 7

AHIMA

Answer 7

American Health Info Managemnt (HIM) Assoc: national membership that provies credentials, educ & coding ingo for HIM. They also focus on specialized & new areas of Health Information such as risk mngmnt, clinical doc improvement & quality analysis. Also provides Virtual lab tools for accredited schools

Question 8

AHA

Answer 8

American Hospital Assoc: National trade membershp that servers individ healthcare providers & hospital healthcare organizations

Question 9

AMA

Answer 9

American Medical Assoc: National trade membership for physicians that assists in legislative matters for the medical profession.

Question 10

CMS

Answer 10

Centers for Medicare & Medicaid Services: has oversight on healthcare policy in the U.S. Has oversight of federal Medicare progrm & is part of the Health & Human Srvcs fed govt.

Question 11

CDM

Answer 11

Charge Description Master: Software/forms that contain itemized lists of charges for every srvc/supply a facility provides for pts. One person is notmally designated to keep charge mastr info up to date & accurate.

Question 12

Chart Deficiency Systm

Answer 12

Manual/computerized systm used by a facility to track docs/signatures that are incomplete/missing in a pt’s chart. Missing items = deficiencies. A staff mmbr goes thru pt’s charts & ID’s missing docs, signatures, dates or times for legal purposes.

Question 13

Claim

Answer 13

A req for payment of srvcs submitted to a 3rd-party payer/pt.

Question 14

Clinical or medical coding

Answer 14

Coding conducted to assign numberic/ABC codes to diagnostic/procedural docs

Question 15

CDS

Answer 15

Clinical Doc Specialist: Promotes capture of docs representative of clinical severity to supprt level of srvc rendered to pt.

Question 16

Coding Pathways

Answer 16

basic steps a coder follows to determine the most accurate code based on medical record or clinical docs. Steps will be differ in each of the coding systms, but in all 3 systms, guidelines provided must be followed

Question 17

Coding Specialist

Answer 17

The health information staff mmbr responsible for assigning # & ABC codes to diagnostic/procedural docs

Question 18

CAHIIM

Answer 18

Commission on Accreditation for Health Informatics & Information Management Education: accrediting organization that oversees educational programs in higher educatn for health information managment.

Question 19

Comorbidity

Answer 19

Med diagnosis that is present in addtion to the principle diagnosis that impacts the pt’s treatment & length of stay. Ie: diabetes would be the principle diagnosis & COPD is the secondary.

Question 20

Complication

Answer 20

a condition that arises during the hospital stay that prolongs the length of stay

Question 21

Computer-Assisted Coding

Answer 21

Computerized software that interfaces with EHR systms to generate codes directly based off clinical docs in electronic record.

Question 22

DRG

Answer 22

Diagnosis Related Group: A formula created by fed govt (CMS) & used by other payers as a way to determine pymnt for inpt stay. Related diagnoses are grouped together b/c mngmnt & treatment would be similar/interrelated & tend to incur similar cost/length of stay. Each diagnostic related group is assigned a # which factors cost for inpt stay. 1 DRG is assigned/pt/hospital encounter/stay.

Question 23

DRG Grouper

Answer 23

Software that auto takes the codes entered by coding specalist & organizes them into proper DRG based on principal diagnosis, additional diagnosis & procedures.

Question 24

Encoder

Answer 24

Special designed software that helps the coding specialist assign diagnostic/procedure codes in accordance w/ guidelines/rules for each coding systm.

Question 25

EOB

Answer 25

Explanation of Benefits: Not a bill. A statement from health insurance carrier explaining the health care expenses that are covered & the pt’s payment responsbility.

Question 26

First-listed Diagnosis

Answer 26

In the outpt setting, used in lieu of principal diagnosis

Question 27

Global Surgery Payment System

Answer 27

A payment made for a surgical procedure which includes all aspects of the surgery from diagnosis thru post procedural care. One payment is made which includes all aspects of care.

Question 28

HIIM

Answer 28

Health Information Management: allied health profession that is responsible for the mngmnt of all health info for healthcare given to pts. Mngmnt includes accuracy, legality, privacy, timeliness & availability

Question 29

HIT

Answer 29

Health Information Technology: Technical aspect of Health Info Management including coding, data quality, abstracting, registration, auditing, info storage & aligning w/ regulations & guidelines.

Question 30

HIPPA

Answer 30

Health Insurance Portability & Accountability Act of 1996: Legislation implemented by fed govt to oversee privacy, fraud, abuse, continuity of health care, reduce health care costs, preexisting medical conditions, & ID theft.

Question 31

Hybrid Records

Answer 31

Medical records that consist of a combo of paper, scanned docs & electronic-generated med records.

Question 32

TJC

Answer 32

The Joint Commission: A private, non-for-profit agency that evaluates hospitals & healthcare organizations based on predetermined standards/criteria. If standards are met, the facility is granted Joint Commission accreditation & is an indication that the facility is meeting high standards of pt care.

Question 33

MPI

Answer 33

Master Patient Index: A database created to house the pt’s name & ID info for each facility. Each facility is responsible for their own MPI of every pt who has been admitted/treated by them.

Question 34

Principal Diagnosis

Answer 34

The condition, after study, which occasioned the admission (as an inpt) to the hospital, according to the ICD-10-CM Official guidelines for Coding & Reporting

Question 35

Principal Procedure

Answer 35

The procedure performed for definitive treatment rather than diagnostic or exploratory purposes, whcih is necessary to take care of a complication. The main procedure preformed & often tied to the principal diagnosis.

Question 36

Problem List

Answer 36

List of diagnosis, injuries or conditions found in a pt’s chart that impacts the health & treatment of the pt.

Question 37

ROI

Answer 37

Release of Information: an aspect of health info management which allows for the legal release of pt’s info to another party or to the pt.

Question 38

RAC

Answer 38

Recovery Audit Contractor: An outside contractor hired by Medicare to audit coded pt’s accounts for improper coding or billing in the Medicare program.

Question 39

Revenue Cycle

Answer 39

A series of administrative & clinical functions that contribute to the capture, mngmnt & collection of info, charges & data in support of pt healthcare services that result ina submission of a claim for reimbursement. Includes all aspects from creating of a pt account (Registration) to pyment of a claim (Reimbursement)

Question 40

SNOMED- CT

Answer 40

Systemized Nomenclature of Medicine Clinical Terminology - Clinical Terms: System creates standardized terminology of pt information.

Question 41

UHDDS

Answer 41

Uniformed Hospital Discharge Data Set: Core data set of inpt admissions. Data is collected on inpt hospital discharges for Medicare & Medicaid programs. The goal is to obtain uniform comparable discharge data for all pts.