AHIMA RHIT Exam Prep Questions and Answers: Glossary of Medical Terms, Exams of Advanced Education

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AHIMA RHIT Exam Prep Questions and

Answers

Abbreviated Injury Scale (AIS) - ANSWER A set of numbers used in a trauma registry to indicate the nature and severity of injuries by body system Abbreviations - ANSWER Shortened forms of words or phrases; in healthcare, when there is more than one meaning for an approved abbreviation, only one meaning should be used or the context in which the abbreviation is to be used should be identified ABC Codes - ANSWER A terminology created by Alternative Link that describes alternative medicine, nursing, and other integrative healthcare interventions Aberrancy - ANSWER Services in medicine that deviate from what is typical in comparison to the national norm Ability (achievement) tests - ANSWER Tests used to assess the skills an individual already possesses; Also called performance tests Abnormal Involuntary Movement Scale (AIMS) - ANSWER A standardized form that can be used in facilities to document involuntary movements Abortion - ANSWER The expulsion or extraction of all (complete) or any part (incomplete) of the placenta or membranes, without an identifiable fetus or with a live- born infant or a stillborn infant weighing less than 500 grams Absolute frequency - ANSWER The number of times that a score of value occurs in a data set Abstract - ANSWER Brief summary of the major parts of a research study Abstracting - ANSWER 1. The process of extracting information from a document to create a brief summary of a patient's illness, treatment, and outcome 2. The process of extracting elements of data from a source document or database and entering them into an automated system Abuse - ANSWER Provider, supplier, and practitioner practices that are inconsistent with accepted sound fiscal, business, or medical practices that directly or indirectly may result in unnecessary costs to the program, improper payment, services that fail to meet professionally recognized standards of care or are medically unnecessary, or services that directly or indirectly result in adverse patient outcomes or delays in appropriate diagnosis or treatment Abuses - ANSWER Coding errors that occur without intent to defraud the government

Accept assignment - ANSWER A term used to refer to a provider's or a supplier's acceptance of the allowed charges (from a fee schedule) as payment in full for services or materials provided Acceptance testing - ANSWER Final review during EHR implementation to ensure that all tests have been performed and all issues have been resolved; usually triggers the final payment for the system and when a maintenance contract becomes effective Acceptance theory of authority - ANSWER A management theory based on the principle that employees have the freedom to choose whether they will follow managerial directions Access - ANSWER 1. The ability of a subject to view, change, or communicate with an object in a computer system 2. One of the rights protected by the Privacy Rule; an individual has a right of access to inspect and obtain a copy of his or her own PHI that is contained in a designated record set, such as a health record Access control - ANSWER 1. A computer software program designed to prevent unauthorized use of an information resource 2. The process of designing, implementing, and monitoring a system for guaranteeing that only individuals who have a legitimate need are allowed to view or amend specific data sets Access control grid - ANSWER A tabular representation of the levels of authorization granted to users of a computer system's information and resources Access control system - ANSWER A system that defines who has access to what information in a computer system and specifies each user's rights and/or restrictions with respect to that information Accession number - ANSWER A number assigned to each case as it is entered in a cancer registry Accession registry - ANSWER A list of cases in a cancer registry in the order in which they were entered Accidents/incidents - ANSWER Those mishaps, misfortunes, mistakes, events, or occurrences that can happen during the normal daily routines and activities in the long- term care setting Accommodating - ANSWER In business, the practice whereby one party in a conflict or disagreement gives in to the other party as a temporary solution Account - ANSWER A subdivision of assets, liabilities, and equities in an organization's financial management system

Accountability - ANSWER 1. The state of being liable for a specific activity 2. All information is attributable to its source (person or device) Accountable - ANSWER Required to answer to a supervisor for performance results Accountable Care Organization (ACO) - ANSWER An organization of healthcare providers accountable for the quality, cost, and overall care of Medicare beneficiaries who are assigned and enrolled in the traditional fee- for-service program Accounting - ANSWER 1. The process of collecting, recording, and reporting an organization's financial data 2. A list of all disclosures made of a patient's health information Accounting entity - ANSWER The business structure, including the activities and records to be maintained for the preparation of an individual organization's financial statements Accounting of disclosures - ANSWER HIPAA requirement to list, upon patient request, all disclosures that meet the criteria. Currently, this does not require accounting for disclosures for treatment, payment, and healthcare operations (TPO), but under ARRA this changes to include these disclosures; awaiting final regulations Accounting period - ANSWER The entire process of identifying and recording a transaction and ultimately reporting it as part of an organization's financial statement Accounting rate of return - ANSWER The projected annual cash inflows, minus any applicable depreciation, divided by the initial investment Accounts Not Selected for Billing Report - ANSWER A daily financial report used to track the many reasons why accounts may not be ready for billing Accounts payable (A/P) - ANSWER Records of the payments owed by an organization to other entities Accounts receivable (A/R) - ANSWER 1. Records of the payments owed to the organization by outside entities such as third-party payers and patients 2. Department in a healthcare facility that manages the accounts owed to the facility by customers who have received services but whose payment is made at a later date Accreditation - ANSWER 1. 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 preestablished written criteria 2. A determination by an accrediting body that an eligible organization, network, program, group, or individual complies with applicable standards 3. The act of granting approval to a

healthcare organization based on whether the organization has met a set of voluntary standards developed by an accreditation agency

Accreditation Association for Ambulatory Health Care (AAAHC) - ANSWER A professional organization that offers accreditation programs for ambulatory and outpatient organizations such as single-specialty and multispecialty group practices, ambulatory surgery centers, college/university health services, and community health centers Accreditation Commission for Health Care (ACHC) - ANSWER An organization that provides quality standards and accreditation programs for home health and other healthcare organizations Accreditation organization - ANSWER A professional organization that establishes the standards against which healthcare organizations are measured and conducts periodic assessments of the performance of individual healthcare organizations Accreditation standards - ANSWER Preestablished statements of the criteria against which the performance of participating healthcare organizations will be assessed during a voluntary accreditation Accredited Standards Committee X12 (ASC X12) - ANSWER A committee of the American National Standards Institute (ANSI) responsible for the development and maintenance of electronic data interchange (EDI) standards for many industries. The ASC 'X12N' is the subcommittee of ASC X12 responsible for the EDI health insurance administrative transactions such as 837 Institutional Health Care Claim and 835 Professional Health Care Claim forms Accrediting body - ANSWER A professional organization that establishes the standards against which healthcare organizations are measured and conducts periodic assessment of the performance of individual healthcare organizations Accrete - ANSWER The term used by Medicare regarding the process of adding new members to a health plan Accrual accounting - ANSWER A method of accounting that requires business organizations to report income in the period earned and to deduct expenses in the period incurred Accrue - ANSWER The process of recording known transactions in the appropriate time period before cash payments/receipts are expected or due Accuracy - ANSWER The extent to which information reflects the true, correct, and exact description of the care that was delivered with respect to both content and timing Acid-test ratio - ANSWER A ratio in which the sum of cash plus short-term investments plus net current receivables is divided by total current liabilities

Acknowledgement - ANSWER A form that provides a mechanism for the resident to recognize receipt of important information ACOG - ANSWER American College of Obstetrics and Gynecology Acquired immunodeficiency syndrome (AIDS) - ANSWER A retroviral disease caused by infection with human immunodeficiency virus (HIV) Acquisition - ANSWER One healthcare entity purchase of another healthcare entity in order to acquire control of all of its assets Actinotherapy - ANSWER The use of ultraviolet light therapy in the treatment of skin diseases Action plan - ANSWER A set of initiatives that are to be undertaken to achieve a performance improvement goal Action steps - ANSWER Specific plans an organization intends to accomplish in the near future as an effort toward achieving its long-term strategic plan Active listening - ANSWER The application of effective verbal communication skills as evidenced by the listener's restatement of what the speaker said Active membership - ANSWER Individuals interested in the AHIMA purpose and willing to abide by the Code of Ethics are eligible for active membership. Active members in good standing shall be entitled to all membership privileges including the right to vote Active record - ANSWER A health record of an individual who is a currently hospitalized inpatient or an outpatient Activities of daily living (ADL) - ANSWER The basic activities of self-care, including grooming, bathing, ambulating, toileting, and eating Activity-based budget - ANSWER A budget based on activities or projects rather than on functions or departments Activity-based costing (ABC) - ANSWER An economic model that traces the costs or resources necessary for a product or customer Activity date or status - ANSWER The element in the chargemaster that indicates the most recent activity of an item Actor - ANSWER The role a user plays in a system Actual charge - ANSWER 1. A physician's actual fee for service at the time an insurance claim is submitted to an insurance company, a government payer, or a health

maintenance organization; may differ from the allowable charge 2. Amount provider actually bills a patient, which may differ from the allowable charge Acute care - ANSWER Medical care of a limited duration that is provided in an inpatient hospital setting to diagnose and/or treat an injury or a short-term illness Acute care prospective payment system - ANSWER The Medicare reimbursement methodology system referred to as the inpatient prospective payment system (IPPS). Hospital providers subject to the IPPS utilize the Medicare Severity-Diagnosis Related Groups (MS-DRGs) classification system, which determines payment rates ADFM - ANSWER Active duty family member; a designation used under TRICARE Ad hoc committee - ANSWER A group of individuals who join together to solve a particular task or problem Addendum - ANSWER A late entry added to a health record to provide additional information in conjunction with a previous entry. The late entry should be timely and bear the current date and reason for the additional information being added to the health record Addition of entries - ANSWER Changes to the health record in the form of late entries, amendments, or addenda Add-on codes - ANSWER In CPT coding, add-on codes are referred to as additional or supplemental procedures. Add-on codes are indicated with a '+' symbol and are to be reported in addition to the primary procedure code. Add-on codes are not to be reported as stand-alone codes and are exempt from use of the -51 modifier Addressable standards - ANSWER The implementation specifications of the HIPAA Security Rule that are designated 'addressable' rather than 'required'; to be in compliance with the rule, the covered entity must implement the specification as written, implement an alternative, or document that the risk for which the addressable implementation specification was provided either does not exist in the organization, or exists with a negligible probability of occurrence Adjunct diagnostic or therapeutic unit - ANSWER An organized unit of an inpatient hospital (other than an operating room, delivery room, or medical care unit) with facilities and personnel to aid physicians in the diagnosis and treatment of illnesses or injuries through the performance of diagnostic or therapeutic procedures; Also called ancillary unit Adjusted clinical groups (ACGs) - ANSWER A classification system that groups individuals according to resource requirements and reflects the clinical severity differences among the specific groups;

formerly called ambulatory care groups

Adjusted historic payment base (AHPB) - ANSWER The weighted average prevailing charge for a physician service applied in a locality for 1991 and adjusted to reflect payments for services with charges below the prevailing charge levels and other payment limits; determined without regard to physician specialty and reviewed and updated yearly since 1992 Adjusted hospital autopsy rate - ANSWER The proportion of hospital autopsies performed following the deaths of patients whose bodies are available for autopsy Adjustment - ANSWER The process of writing off an unpaid balance on a patient account to make the account balance Administrative agencies - ANSWER Executive branch agencies; source of administrative law Administrative agency tribunals - ANSWER A form of alternative dispute resolution in which tribunals are created by statute or the Constitution to hear disputes arising from administrative law Administrative controls - ANSWER Policies and procedures that address the management of computer resources Administrative data - ANSWER Coded information contained in secondary records, such as billing records, describing patient identification, diagnoses, procedures, and insurance Administrative information - ANSWER Information used for administrative and healthcare operations purposes, such as billing and quality oversight Administrative information systems - ANSWER A category of healthcare information systems that supports human resources management, financial management, executive decision support, and other business-related functions Administrative law - ANSWER A body of rules and regulations developed by various administrative entities empowered by Congress; falls under the umbrella of public law Administrative law judge - ANSWER A hearings officer who conducts appeal conflicts between providers of services, or beneficiaries, and Medicare contractors Administrative management theory - ANSWER A subdivision of classical management theory that emphasizes the total organization rather than the individual worker and delineates the major management functions Administrative provisions - ANSWER Documented, formal practices to manage data security measures throughout the healthcare organization

Administrative safeguards - ANSWER Administrative actions such as policies and procedures and documentation retention to manage the selection, development, implementation, and maintenance of security measures to protect electronic protected health information and manage the conduct of the covered entity's or business associate's workforce in relation to the protection of that information Administrative services - ANSWER Business-related services provided by an insurance organization to self-insured employers or other parties according to an administrative services only contract (for example, actuarial support, benefit plan design, claims processing, data recovery and analysis, employee benefits communication, financial advice, medical care conversions, stop-loss coverage, and other services as requested) Administrative services only (ASO) contract - ANSWER An agreement between an employer and an insurance organization to administer the employer's self- insured health plan Administrative simplification - ANSWER A term referring to the Health Insurance Portability and Accountability Act (HIPAA) provisions which include standards for transactions and code sets that are used to exchange health data, standard identifiers for use on transactions, and privacy and security standards to protect personal health information. HIPAA included these administrative simplification provisions in order to improve the efficiency and effectiveness of the healthcare system. Admissibility - ANSWER The condition of being admitted into evidence in a court of law Admission agreement - ANSWER A legal contract signed by the resident that specifies the long-term care facility's responsibilities and fees for providing healthcare and other services Admission date - ANSWER The date the patient was admitted for inpatient care, outpatient service, or start of care. In the inpatient hospital setting, the admission date is the hospital's formal acceptance of a patient who is to receive healthcare services while receiving room, board, and continuous nursing services Admissions and readmissions processing policy - ANSWER A policy that provides the guidelines that are required when a resident is admitted or readmitted to the facility Admission-discharge-transfer (ADT) - ANSWER The name given to software systems used in healthcare facilities that register and track patients from admission through discharge including transfers; usually interfaced with other systems used throughout a facility such as an electronic health record or lab information system Admission type - ANSWER The required classification used to indicate the

priority of an admission/visit required for submitting claims using the electronic 837I format or the equivalent CMS-1450 claim form

Admission utilization review - ANSWER A review of planned services (intensity of service) and/or a patient's condition (severity of illness) to determine whether care must be delivered in an acute-care setting Admitting diagnosis - ANSWER A provisional description of the reason why a patient requires care in an inpatient hospital setting Adoption - ANSWER The decision to purchase, implement, and utilize an information system such as the EHR Adult day care - ANSWER Group or individual therapeutic services provided during the daytime hours to persons outside their homes; usually provided for individuals with geriatric or psychiatric illnesses Adult health questionnaire - ANSWER See patient history questionnaire Adult learning - ANSWER Self-directed inquiry aided by the resources of an instructor, colleagues/fellow students, and educational materials Advance beneficiary notice (ABN) - ANSWER A statement signed by the patient when he or she is notified by the provider, prior to a service or procedure being done, that Medicare may not reimburse the provider for the service, wherein the patient indicates that he will be responsible for any charges Advanced decision support - ANSWER Automated clinical practice guidelines that are built in to electronic health record systems and designed to support clinical decision making Advance directive - ANSWER A legal, written document that describes the patient's preferences regarding future healthcare or stipulates the person who is authorized to make medical decisions in the event the patient is incapable of communicating his or her preferences Advanced practice registered nurse (APRN) - ANSWER The term being increasingly used by legislative and governing bodies to describe the collection of registered nurses that practice in the extended role beyond the normal role of basic registered nursing Adverse action - ANSWER A term used to refer to an action taken against a practitioner's clinical privileges or medical staff membership in a healthcare organization; Also called licensure disciplinary action Adverse drug event - ANSWER A patient injury resulting from a medication, either because of a pharmacological reaction to a normal dose, or because of a preventable adverse reaction to a drug resulting from an error

Adverse drug reaction (ADR) - ANSWER Unintended, undesirable, or unexpected effects of prescribed medications or of medication errors that require discontinuing a medication or modifying the dose, require initial or prolonged hospitalization, result in disability, require treatment with a prescription medication, result in cognitive deteriororation or impairment, are life threatening, result in death, or result in congenital anomalies Adverse patient occurrences (APOs) - ANSWER Occurrences such as admission for adverse results of outpatient management, readmission for complications, incomplete management of problems on previous hospitalization, or unplanned removal, injury, or repair of an organ or structure during surgery; covered entities must have a system for concurrent or retrospective identification through medical chart-based review according to objective screening criteria Adverse selection - ANSWER A situation in which individuals who are sicker than the general population are attracted to a health insurance plan, with adverse effects on the plan's costs Affiliated covered entity - ANSWER Legally separate covered entities, affiliated by common ownership or control; for purposes of the Privacy Rule, these legally separate entities may refer to themselves as a single covered entity Affinity diagram - ANSWER A graphic tool used to organize and prioritize ideas after a brainstorming session Affinity grouping - ANSWER A technique for organizing similar ideas together in natural groupings Aftercare - ANSWER Healthcare services that are provided to a patient after a period of hospitalization or rehabilitation and are administered with the objective of improving or restoring health to the degree that aftercare is no longer needed Against medical advice (AMA) - ANSWER The discharge status of patients who leave a hospital after signing a form that releases the hospital from any responsibility or who leave a hospital without notifying hospital personnel Age Discrimination in Employment Act (1967) - ANSWER Federal legislation that prohibits employment discrimination against persons between the ages of 40 and 70 and restricts mandatory retirement requirements except where age is a bona fide occupational qualification Agency for Healthcare Research and Quality (AHRQ) - ANSWER The branch of the US Public Health Service that supports general health research and distributes research findings and treatment guidelines with the goal of improving the quality, appropriateness, and effectiveness of healthcare services

Agenda for Change - ANSWER An initiative undertaken by the Joint Commission that focused on changing the emphasis of the accreditation process from structure to outcomes Aggregate data - ANSWER Data extracted from individual health records and combined to form de-identified information about groups of patients that can be compared and analyzed Aggregate information system - ANSWER The combining of various data sets in order to compile overview or summary statistics Aging of accounts - ANSWER The practice of counting the days, generally in 30-day increments, from the time a bill was sent to the payer to the current day AHA Coding Clinic for HCPCS - ANSWER The official coding advice resource for coding information on HCPCS CPT codes for hospital providers and certain HCPCS level II codes for hospitals, physicians, and other healthcare professionals AHIMA Standards of Ethical Coding - ANSWER The American Health Information Management Association's principles of professional conduct for coding professionals involved in diagnostic and/or procedural coding or other health record data abstraction Alarm - ANSWER A type of warning that is generated by an automated medical device Alert - ANSWER A software-generated warning that is based on a set of clinical rules built in to a healthcare information system Algorithm - ANSWER A procedure for solving a mathematical problem in a finite number of steps, which frequently involves repetition of an operation Algorithmic translation - ANSWER A process that involves the use of algorithms to translate or map clinical nomenclatures among each other or to map natural language to a clinical nomenclature or vice versa Alias - ANSWER A name added to, or substituted for, the proper name of a person; an assumed name Alias policy - ANSWER A policy that is implemented when resident confidentiality is required by the resident, family, or responsible party Allied health professional - ANSWER A credentialed healthcare worker who is not a physician, nurse, psychologist, or pharmacist (for example, a physical therapist, dietitian, social worker, or occupational therapist) Allowable charge - ANSWER Average or maximum amount a third-party payer will reimburse providers for a service

All patient diagnosis-related groups (AP-DRGs) - ANSWER A case-mix system developed by 3M and used in a number of state reimbursement systems to classify non- Medicare discharges for reimbursement purposes All patient refined diagnosis-related groups (APR-DRGs) - ANSWER An expansion of the inpatient classification system that includes four distinct subclasses (minor, moderate, major, and extreme) based on the severity of the patient's illness ALOS - ANSWER See average length of stay Alphabetic filing system - ANSWER A system of health record identification and storage that uses the patient's last name as the first component of identification and his or her first name and middle name or initial for further definition Alphanumeric filing system - ANSWER A system of health record identification and storage that uses a combination of alphabetic letters (usually the first two letters of the patient's last name) and numbers to identify individual records Alteration - ANSWER Modifying the natural anatomic structure of a body part without affecting the function of the body part. The principal purpose of this procedure is to improve the patient's appearance Alternative delivery system (ADS) - ANSWER A type of healthcare delivery system in which health services are provided in settings such as skilled and intermediary facilities, hospice programs, nonacute outpatient programs, and home health programs, which are more cost-effective than in the inpatient setting Alternative hypothesis - ANSWER A hypothesis that states that there is an association between independent and dependent variables Alternative Link - ANSWER The original developer of the ABC codes Ambulatory care - ANSWER Preventive or corrective healthcare services provided on a nonresident basis in a provider's office, clinic setting, or hospital outpatient setting Ambulatory care information system - ANSWER A type of information system designed specifically for use and support in ambulatory care settings Ambulatory care organization - ANSWER A healthcare provider or facility that offers preventive, diagnostic, therapeutic, and rehabilitative services to individuals not classified as inpatients or residents Ambulatory Care Quality Alliance - ANSWER An organization consisting of a broad base of healthcare professionals who work collaboratively to improve

healthcare quality and

patient safety through performance measurement, data aggregation, and reporting in the ambulatory care setting Ambulatory payment classification (APC) - ANSWER Hospital outpatient prospective payment system (OPPS). The classification is a resource-based reimbursement system. The payment unit is the ambulatory payment classification group (APC group) Ambulatory payment classification group (APC group) - ANSWER Basic unit of the ambulatory payment classification (APC) system. Within a group, the diagnoses and procedures are similar in terms of resources used, complexity of illness, and conditions represented. A single payment is made for the outpatient services provided. APC groups are based on HCPCS/CPT codes. A single visit can result in multiple APC groups. APC groups consist of five types of service- significant procedures, surgical services, medical visits, ancillary services, and partial hospitalization. The APC group was formerly known as the ambulatory visit group (AVG) and ambulatory patient group (APG) Ambulatory payment classification (APC) relative weight - ANSWER A number reflecting the expected resource consumption of cases associated with each APC, relative to the average of all APCs, that is used in determining payment under the Medicare hospital outpatient prospective payment system (OPPS) Ambulatory payment classification (APC) system - ANSWER The Medicare reimbursement methodology system referred to as the hospital outpatient prospective payment system (OPPS). Hospital providers subject to the OPPS utilize the ambulatory payment classification (APC) system, which determines payment rates Ambulatory surgery center (ASC) payment rate - ANSWER The Medicare ASC reimbursement methodology system referred to as the ambulatory surgery center (ASC) payment system. The ASC payment system is based on the ambulatory payment classifications (APCs) utilized under the hospital OPPS Ambulatory surgery center or ambulatory surgical center (ASC) - ANSWER Under Medicare, an outpatient surgical facility that has its own national identifier; is a separate entity with respect to its licensure, accreditation, governance, professional supervision, administrative functions, clinical services, recordkeeping, and financial and accounting systems; has as its sole purpose the provision of services in connection with surgical procedures that do not require inpatient hospitalization; and meets the conditions and requirements set forth in the Medicare Conditions of Participation Ambulatory surgical center (ASC) list - ANSWER The Medicare ASC list which indicates procedures that are covered and paid if performed in the ASC setting Ambulatory surgical center (ASC) services - ANSWER ASC diagnostic and therapeutic procedures which can be safely performed outside a hospital

setting

Amendment - ANSWER Alteration of health information by modification, correction, addition, or deletion Amendment request - ANSWER The right of individuals to ask that a covered entity amend their health records, as provided in Section 164.526 of the Privacy Rule American Academy of Professional Coders (AAPC) - ANSWER The American Academy of Professional Coders provides certified credentials to medical coders in physician offices, hospital outpatient facilities, ambulatory surgical centers, and in payer organizations American Accreditation Healthcare Commission/URAC - ANSWER A healthcare quality improvement organization that offers managed care organizations, as well as other organizations, accreditation to validate quality healthcare, and provides education and measurement programs American Association for Accreditation of Ambulatory Surgery Facilities (AAAASF) - ANSWER An organization that provides an accreditation program to ensure the quality and safety of medical and surgical care provided in ambulatory surgery facilities American Association of Health Plans (AAHP) - ANSWER The trade organization for health maintenance organizations, preferred provider organizations, and other network- based health plans created by the merger of the Group Health Association of America and the American Managed Care and Review Association American Association of Medical Record Librarians (AAMRL) - ANSWER The name adopted by the Association of Record Librarians of North America in 1944; precursor of the American Health Information Management Association American Association of Preferred Provider Organizations (AAPPO) - ANSWER A national association composed of preferred provider organizations (PPOs) and affiliate organizations, which advocates for consumer awareness of their healthcare benefits and advocates for greater access, choice, and flexibility American College of Healthcare Executives (ACHE) - ANSWER The national professional organization of healthcare administrators that provides certification services for its members and promotes excellence in the field American College of Obstetricians and Gynecologists (ACOG) - ANSWER The professional association of medical doctors specializing in obstetrics and gynecology American College of Radiology-National Electrical Manufacturers Association (ACR- NEMA) - ANSWER The professional organizations (ACR) and trade associations (NEMA) that work collaboratively to develop digital imaging standards

American College of Surgeons (ACS) - ANSWER The scientific and educational association of surgeons formed to improve the quality of surgical care by setting high standards for surgical education and practice American College of Surgeons Commission on Cancer - ANSWER The organization that approves cancer-related programs, including cancer registries and trauma centers American Correctional Association (ACA) - ANSWER An organization that provides education, training, correctional certification, and accreditation for correctional healthcare organizations American Dental Association (ADA) - ANSWER A professional dental association dedicated to the public's oral health, ethics, science, and professional advancement American Health Information Community (AHIC) - ANSWER A public-private federal advisory committee associated with the Office of the National Coordinator that makes recommendations to the secretary on how to accelerate adoption of interoperable electronic health information technology American Health Information Management Association (AHIMA) - ANSWER The professional membership organization for managers of health record services and healthcare information systems as well as coding services; provides accreditation, advocacy, certification, and educational services American Hospital Association (AHA) - ANSWER The national trade organization that provides education, conducts research, and represents the hospital industry's interests in national legislative matters; membership includes individual healthcare organizations as well as individual healthcare professionals working in specialized areas of hospitals, such as risk management; one of the four Cooperating Parties on policy development for the use of ICD-9-CM American Medical Association (AMA) - ANSWER The national professional membership organization for physicians that distributes scientific information to its members and the public, informs members of legislation related to health and medicine, and represents the medical profession's interests in national legislative matters; maintains and publishes the Current Procedural Terminology (CPT) coding system American Medical Informatics Association (AMIA) - ANSWER A professional association for individuals, institutions, and corporations that promotes the development and use of medical informatics for patient care, teaching, research, and healthcare administration American Medical Record Association (AMRA) - ANSWER The name adopted by the American Association of Medical Record Librarians in 1970; precursor of the American Health Information Management Association

American National Standards Institute (ANSI) - ANSWER An organization that governs standards in many aspects of public and private business; developer of the Health Information Technology Standards Panel American Nurses Association (ANA) - ANSWER The national professional membership association of nurses that works for the improvement of health standards and the availability of healthcare services, fosters high professional standards for the nursing profession, and advances the economic and general welfare of nurses American Occupational Therapy Association (AOTA) - ANSWER The nationally recognized professional association of more than 40,000 occupational therapists, occupational therapy assistants, and students of occupational therapy American Osteopathic Association (AOA) - ANSWER The professional association of osteopathic physicians, surgeons, and graduates of approved colleges of osteopathic medicine that inspects and accredits osteopathic colleges and hospitals American Physical Therapy Association (APTA) - ANSWER The national professional organization whose goal is to foster advancements in physical therapy practice, research, and education American Psychiatric Association (APA) - ANSWER The international professional association of psychiatrists and related medical specialists that works to ensure humane care and effective treatment for all persons with mental disorders, including mental retardation and substance-related disorders American Psychological Association (APA) - ANSWER The professional organization that aims to advance psychology as a science and profession and promotes health, education, and human welfare American Recovery and Reinvestment Act of 2009 (ARRA) - ANSWER An economic stimulus package enacted by the 111th United States Congress in February 2009; signed into law by President Obama on February 17, 2009; an unprecedented effort to jumpstart the economy, create/save millions of jobs, and put a down payment on addressing long-neglected challenges; an extraordinary response to a crisis unlike any since the Great Depression; includes measures to modernize our nation's infrastructure, enhance energy independence, expand educational opportunities, preserve and improve affordable healthcare, provide tax relief, and protect those in greatest need; Also called Recovery Act; Stimulus American Society for Healthcare Risk Management (ASHRM) - ANSWER The professional society for healthcare risk management professionals that is affiliated with the American Hospital Association and provides educational tools and networking opportunities for its members

American Society for Quality (ASQ) - ANSWER A quality improvement organization whose members' interests are related to statistical process control, quality cost measurement and control, total quality management, failure analysis, and zero defects American Society for Testing and Materials (ASTM) - ANSWER A national organization whose purpose is to establish standards on materials, products, systems, and services American Society for Testing and Materials Committee E31 (ASTM E31)- Healthcare Informatics - ANSWER A committee within the American Society for Testing and Materials that creates standards on the content, structure, and functionality of electronic health record systems, health information confidentiality policies and procedures, health data security, and the exchange of information across clinical systems, such as laboratory devices with information systems American Society for Testing and Materials Standard E1384 (ASTM E1384)- Standard Guide for Description of Content and Structure of an Automated Primary Record of Care

• ANSWER A standard that identifies the basic information to be included in electronic health records and requires the information to be organized into categories American Standard Code for Information Interchange (ASCII) - ANSWER Electronic code that represents text, which makes it possible to transfer data from one computer to another Americans with Disabilities Act (ADA) of 1990 - ANSWER Federal legislation which ensures equal opportunity for and elimination of discrimination against persons with disabilities America's Health Insurance Plans (AHIP) - ANSWER A national trade association representing companies providing health benefits to Americans; formerly known as the Health Insurance Association of America (HIAA) Analog - ANSWER Data or information that is not represented in an encoded, computer- readable format Analysis - ANSWER Review of health record for proper documentation and adherence to regulatory and accreditation standards Analysis of discharged health records policy - ANSWER A policy that outlines steps to be taken to process discharged resident records Analysis phase - ANSWER The first phase of the systems development life cycle during which the scope of the project is defined, project goals are identified, current systems are evaluated, and user needs are identified Analysis session - ANSWER The process of mining a data segment

Analyte - ANSWER Any material or chemical substance subjected to analysis Anatomical modifiers - ANSWER Two-digit CPT codes that provide information about the exact body location of procedures, such as -LT, Left side, and -TA, Left great toe Ancillary packaging - ANSWER The inclusion of routinely performed support services in the reimbursement classification of a healthcare procedure or service Ancillary services - ANSWER 1. Tests and procedures ordered by a physician to provide information for use in patient diagnosis or treatment 2. Professional healthcare services such as radiology, laboratory, or physical therapy Ancillary service visit - ANSWER The appearance of an outpatient in a unit of a hospital or outpatient facility to receive services, tests, or procedures; ordinarily not counted as an encounter for healthcare services Ancillary systems - ANSWER Electronic systems that generate clinical information (such as laboratory information systems, radiology information systems, pharmacy information systems, and so on) Ancillary unit - ANSWER See adjunct diagnostic or therapeutic unit Androgynous leadership - ANSWER Leadership in which cultural stereotyped masculine and feminine styles are integrated into a more effective hybrid style Anesthesia death rate - ANSWER The ratio of deaths caused by anesthetic agents to the number of anesthesias administered during a specified period of time Anesthesia report - ANSWER The report that notes any preoperative medication and response to it, the anesthesia administered with dose and method of administration, the duration of administration, the patient's vital signs while under anesthesia, and any additional products given the patient during a procedure Anesthetic risk - ANSWER The risk of harm resulting from the administration of anesthetic agents Antegrade - ANSWER Extending or moving forward Antipsychotic Dyskinesia Identification System - ANSWER One of several standardized forms for assessing and documenting abnormal movements (of face, eyes, mouth/tongue, or body) that may occur in the course of treatment with some psychotropic medications; See also discus monitoring form

Antipsychotic medications - ANSWER Drugs that are used in the management of psychotic conditions, bipolar disorders, or major depression with psychotic features

Any and all records - ANSWER A phrase frequently used by attorneys in the discovery phase of a legal proceeding. Subpoena-based requests containing this phrase may create a situation where the record custodian or provider's legal counsel can work to limit the records disclosed to those defined by a particular healthcare entity's legal health record. Typically, this is only during a subpoena phase, unless the information is legally privileged or similarly protected; the discovery phase of litigation probably can be used to request any and all relevant materials APC grouper - ANSWER Software programs that help coders determine the appropriate ambulatory payment classification for an outpatient encounter Appeal - ANSWER 1. A request for reconsideration of a denial of coverage or rejection of claim decision 2. The next stage in the litigation process after a court has rendered a verdict; must be based on alleged errors or disputes of law rather than errors of fact Appellate court - ANSWER Courts that hear appeals on final judgments of the state trial courts or federal trial courts Append - ANSWER The operation that results in adding information to documentation already in existence Application controls - ANSWER Security strategies, such as password management, included in application software and computer programs Application programming interface (API) - ANSWER A set of definitions of the ways in which one piece of computer software communicates with another or a programmer makes requests of the operating system or another application; operates outside the realm of the direct user interface Applications and data criticality analysis - ANSWER A covered entity's formal assessment of the sensitivity, vulnerabilities, and security of its programs and the information it generates, receives, manipulates, stores, and/or transmits Application service provider (ASP) - ANSWER A third-party service company that delivers, manages, and remotely hosts standardized applications software via a network through an outsourcing contract based on fixed, monthly usage, or transaction-based pricing Applied artificial intelligence - ANSWER An area of computer science that deals with algorithms and computer systems that exhibit the characteristics commonly associated with human intelligence Applied healthcare informatics - ANSWER Automated information systems applied to healthcare delivery business and workflow processes, including the diagnosis, therapy, and systems of managing health data and information within the healthcare setting