Healthcare Information Management Terminology and Concepts, Exams of Medical Records

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DICOM (Digital Imaging and Communications in Medicine) - ANSWER>>>standard andprotocol used for transmitting digital radiographic and endoscopic images for clinical use. It is not used to transmit administrative data. CDISC (Clinical Data Interchange Standards Consortium) - ANSWER>>>an organizationthat creates standards for health care research and has the goal of promoting systems interoperability to advance medical research. It is not a computer protocol used for transmitting data. (NCPDP) national council for prescription drug programs - ANSWER>>>an organization that creates standards for transmitting prescription information between pharmacies and providers. abbreviations - ANSWER>>>American Hospital Association policy states that they should be eliminated from vital parts of the medical record, including final diagnoses and discharge summaries. advanced directive (living will) - ANSWER>>>legal document that contains informationabout the patients treatment choices when they are unable to make healthcare decisions aging report - ANSWER>>>report that identifies past due patient or insurance account balances and is usually run monthly assignment of benefits - ANSWER>>>a patient authorization to allow health insurancepayment to be made directly to the provider of services authorization - ANSWER>>>a document that approves disclosure of protected healthinformation unrelated to treatment under the HIPAA privacy rule benchmark - ANSWER>>>a measure of performance against industry standards business associate - ANSWER>>>a third party entity that has contact with protectedhealth information to provide services unrelated to treating patients

business associate agreement - ANSWER>>>a legal contract dictating a business associate to comply with protection of protected health information under the HIPAA privacy rule Centers for Medicare and Medicaid Services (CMS) - ANSWER>>>a federal regulated agency that is part of the Department of Health and Human Services, administers Medicare, works with the state governments to administer Medicaid programs, sets standards for interoperability of EHR, and overseas implementation of federal legislation clinical documentation improvement (CDI) - ANSWER>>>process for executing and improving and reviewing clinical documentation to ensure that it accurately reflects and supports CPT and ICD- 10 - CM codes submitted with claims for payment compliance program - ANSWER>>>internal policies designed to prevent claim error,fraud, and abuse computerized provider order entry (CPOE) - ANSWER>>>use of computer system toenter prescriptions and treatment at the point of care covered entity - ANSWER>>>a medical or health care service, organization, agency, orindividual that has protected health information Current Procedural Terminology (CPT) 4th edition - ANSWER>>>a coding classification system used to report professional services and procedures provided to a patient at ambulatory care centers, medical clinics, and other outpatient care facilities de-identification - ANSWER>>>the process of removing personal health information accessible to providers and other staff members with login credentials regardless of location electronic health record (EHR) - ANSWER>>>a record of patient health care information accessible to providers and other staff members with login credentials regardless of location electronic medication administration record (eMAR) - ANSWER>>>an electronic recordcontaining a patients medication, administration times, and who administered it encoder - ANSWER>>>software used to assign diagnosis and procedural codes encounter form - ANSWER>>>and itemized bill for services that contains diagnosis andprocedure codes and is used by administrative staff to complete claims forms; also known as a superbill, fee slip, or charge form encryption - ANSWER>>>converting email or other information into a code that only intended recipients can read

explanation of benefits (EOB) - ANSWER>>>a statement that shows a patient howservices provided were processed by the insurance carrier Health Information Technology for Economic and Clinical Health (HITECH) Act - ANSWER>>>federal legislation that expands consumer rights and protections outlined by HIPAA and sets standards for quality and use of EHR Health Insurance Portability and Accountability Act (HIPAA) - ANSWER>>>a federal law that regulates use of patient personal identifiable information Healthcare Common Procedure Coding System (HCPCS) - ANSWER>>>a coding classification system in which level I (CPT codes) are used to bill outpatient procedures and physician services, and level II (HCPCS codes) are used to bill professional services, supplies, and products not included in CPT codes human factors engineering - ANSWER>>>attempt to address human strengths and weaknesses into programs or systems hybrid system - ANSWER>>>system that uses both paper and electronic basedprocessing for documentation of health information internal audit - ANSWER>>>examination of in house government and financial processes for appropriateness and accuracy International Classification Of Disease, 10th revision, Clinical Modifications (ICD- 10 - CM) - ANSWER>>>a diagnostic classification and coding system for diagnosis used byhealthcare organizations International Classification Of Disease, 10th revision, Procedural Coding System (ICD- 10 - PCS) - ANSWER>>>a classifications system for procedures performed at inpatient facilities interoperability - ANSWER>>>the ability of systems to share and use information laboratory information system (LIS) - ANSWER>>>a data base or prescribed laboratorytest and results transferred from instruments used to analyze the test medical record number (MRN) - ANSWER>>>a set of numbers used to identify a patientand associated recorded health data minimum necessary concept - ANSWER>>>protecting private health information by limiting access to information based on minimum need notice of privacy practices (NPP) - ANSWER>>>a document that is required by law to inform patient how the organization will use their health care information

physical safeguards - ANSWER>>>physical method, policy, or procedures to protect stored data and software from threats, natural and environmental hazard, and unauthorized invasion physician query - ANSWER>>>a request that a provider add documentation to an EHRto clarify a diagnosis or procedure that has been performed practice management system (PMS) - ANSWER>>>a system that stores information onrevenue cycle processes, appointments, registration, scheduling, health information management, coding, and billing protected health information (PHI) - ANSWER>>>health information specific to a patient quality measures - ANSWER>>>standards or processes implemented to improve clinicalquality as defined by clinical professionals and public health organizations redundancy - ANSWER>>>duplicate copies of data registration form - ANSWER>>>a form that consist of administrative information about apatient, including personal, financial, and some clinical data remittance advice - ANSWER>>>a report from insurance carriers to a service providerthat describes payments and how the payment amount was determined revenue cycle - ANSWER>>>all processes that relate to claims or payments or other ways of generating revenue rollout - ANSWER>>>a start of a process upcoding - ANSWER>>>assigning a higher level service or procedural code usability - ANSWER>>>the ease with which a person can interact with hardware and software to provide safe, efficient, quality patient care precertification - ANSWER>>>the process of determining whether a procedure or test iscovered under the insurance contract. review of systems - ANSWER>>>The review of systems section is used to record the subjective physical assessment of each body system. It would not include vital signs. past medical history - ANSWER>>>The past medical history section contains the objective findings from a patient's previous visit, including operations, injuries, and treatments. superbill - ANSWER>>>form generated for billing that includes commonly used services and diagnoses. It would not include vital signs.

assessment - ANSWER>>>includes the diagnosis codes determined by the provider. Itwould not include vital signs. growth chart - ANSWER>>>A pediatric growth chart is a graphic sheet of the measurements of a child's growth rate. preventive care screen - ANSWER>>>includes suggestions of preventive care, such ascancer screenings, based on age, sex, and medical history. immunizations screen - ANSWER>>>includes the patient's immunization records. Thepreventive care screen includes suggestions of preventive care, such as cancer screenings, based on age, sex, and medical history. test results screen - ANSWER>>>includes a list of tests and results. The preventive carescreen includes suggestions of preventive care, such as cancer screenings, based on age, sex, and medical history. work-list report - ANSWER>>>helps coders prioritizes patient accounts for coding from oldest to newest. UB- 04 form - ANSWER>>>is used for inpatient and facility billing. This form is used to submit the codes for reimbursement after they are captured during the visit. CMS-1500 form - ANSWER>>>the universal claim form used for outpatient and professional billing. This form is used to submit the codes for reimbursement after they are captured during the visit. progress note template - ANSWER>>>the location a provider would document a patient's progress and would not be used during a detailed eye examination. specialized template - ANSWER>>>address the specific documentation needs, such asthose of an ophthalmologist performing a detailed eye examination. treatment plan template - ANSWER>>>outlines what treatment the provider will use to alleviate a patient's condition and would not be used during a detailed eye examination. problem list template - ANSWER>>>identifies a patient's current conditions and would not be used during a detailed eye examination. CDT codes - ANSWER>>>codes that reference dental procedure codes and allows theproviders to bill for dental services. DSM- 5 - ANSWER>>>used in the diagnosis of mental health disorders and conditions.

automatic alert message - ANSWER>>>would send a alert text or page to notify the provider of the change in the patient's laboratory values. entity authentication - ANSWER>>>method used to verify proof of identify. integrity controls - ANSWER>>>protocols that verify the data sent is the same as the data received. chief complaint - ANSWER>>>information about the patient's reason for the visit. It doesnot contain information about active problems documented on a prior visit. problem list - ANSWER>>>current list of any of the patient's diagnosed conditions that ismaintained from visit to visit. radiology information system (RIS) - ANSWER>>>database that stores information on radiology ordering, scheduling, appointments, referrals, reporting, and other items used by the radiology professionals to track patient data. RIS does not store imaging pictures. picture archiving and communication system (PACS) - ANSWER>>>imaging storage system that enables radiology providers to interpret the results of imaging procedures. Information from PACS integrates into the EHR through observance of interoperability standards, such as the use of HL7. clinical encoder - ANSWER>>>software that assists with assigning accurate diagnosis and procedure codes for billing purposes. clinical decision support system (CDSS) - ANSWER>>>A special subcategory of clinical information systems that is designed to help healthcare providers make knowledge- based clinical decisions and integrated with the facility's EHR system to provide statistics and monitoring for a variety of health system functions and to identify areas forprocess and quality improvement. production by procedure report - ANSWER>>>indicates the number of total procedurescompleted within a given timeframe along with the associated revenue generated by each type of procedure. billing/payment status report - ANSWER>>>lists the financial status of every patient account. remittance advice report - ANSWER>>>lists patient information and the amount paid bythird-party payers to the provider. clinical encoder program - ANSWER>>>helps the coding professional with the coding pathways by assigning codes and diagnostic-related groups.

security management process - ANSWER>>>1st Risk analysis is performed first to identify potential security risks 2nd Risk management is performed to address the security risk. 3rd Sanction policy is performed to determine the consequences for failure to comply. 4th information system activity review is performed last because it is an ongoing process that includes record review after all the other steps are complete. physical examination section - ANSWER>>>documentation of the patient's height, weight, blood pressure, temperature, pulse, and respirations. open hours scheduling - ANSWER>>>patients are seen by the provider on a first- come,first-served basis. This scheduling method is often used in urgent care facilities. wave scheduling - ANSWER>>>several patients are scheduled to arrive at the same time, and the number of appointments is determined by the length of the average appointment. cluster scheduling - ANSWER>>>similar appointment types are scheduled together at specific times. Scheduling well-child visits in the morning and sick child visits in the afternoon is an example of cluster scheduling. modified wave scheduling - ANSWER>>>several patients are scheduled to arrive atintervals in the first half hour, and then the provider uses the second half hour to conclude visits with all the patients. production by provider report - ANSWER>>>lists the number of patients seen by each provider and the income received by the organization for their services assignment of benefits - ANSWER>>>a signed statement that allows the provider's office to receive direct payment for services provided. computer workstation - ANSWER>>>consists of a computer; an input device to enterdata, such as a keyboard, mouse, or touchscreen; and an output device such as a screen or monitor, which displays the data. advanced beneficiary notice (ABN) - ANSWER>>>waiver of liability that indicates a service is not covered by Medicare and is the patient's financial responsibility. The EHR specialist should check for an ABN prior to billing a patient. physical examination - ANSWER>>>documentation of vital signs, including temperature, pulse, respirations, and blood pressure administrative safeguards - ANSWER>>>covers individual security responsibilities andsecurity and safety training for users and employees.

technical safeguards - ANSWER>>>covers automated processes, such as the encryptionand decryption of data. Flow sheet - ANSWER>>>used to record a patient's vital signs over time, which would include temperature values. concurrent coding - ANSWER>>>allows coders to see documentation while the patient isstill receiving treatment so coding can occur on an ongoing basis. Allows a coder to query a provider during patients stay care plan - ANSWER>>>clinical document detailing the type of treatment that will be provided to a patient. structured data - ANSWER>>>Data already stored in a specific fashion in a database. pharmacy information system (PIS) - ANSWER>>>System that assists care providers inordering, allocating, and administering medication; focuses on patient safety issues, especially medication errors and providing optimal patient care charge entry - ANSWER>>>The act of entering ICD- 10 - CM, CPT, or HCPCS codes intoa computerized billing system for services provided during a patient visit or procedure. In the EHR, this process occurs automatically past history - ANSWER>>>⦁ Medications ⦁ Allergies ⦁ Previous health problems or injuries ⦁ Surgeries ⦁ Prior hospitalizations ⦁ Age appropriate immunization status ⦁ Age appropriate feeding/dietary status chief complaint documentation - ANSWER>>>⦁ Location of pain or symptoms ⦁ Quality (sharp, dull, burning) ⦁ Severity ⦁ Duration ⦁ Timing ⦁ Context (e.g., blood sugar elevations that occur after eating certain foods) ⦁ Modifying factors ⦁ Associated signs and symptoms HIPAA eligibility transaction system (HETS) - ANSWER>>>Medicare system for verifying coverage of services (eg. skilled nursing facilities and inpatient stays) EHR incentive program requirements - ANSWER>>>⦁ Use of a certified EHR in ameaningful manner (e-prescribing, computerized provider order entry,

recording demographic information) ⦁ Use of certified EHR technology for the electronic exchange of health information to public health agencies for immunization registries, reportable laboratory results, and syndromic surveillance ⦁ Use of certified EHR technology to submit clinical quality measures (CQM) reports digital dashboards - ANSWER>>>integrates information from multiple components andtailors the information to individual preferences such as charts or graphs balanced scorecards - ANSWER>>>compares the actual performance to the actual goal,such as in a bar graph form day sheet report - ANSWER>>>a report that providers information on practice activitiesfor 24 hours, 3 types: patient/payment/procedure code production by insurance report - ANSWER>>>the summary of all proceeds received from insurance carriers. The report lists the companies, charges, amounts paid, and adjustments. The report is used to monitor all claims sent to each insurance carrier and the amount received from each one. deposit report - ANSWER>>>The report includes payments made through electronic transfer, paper checks, cash, and credit card payments by insurance carriers and individuals. The report displays the date of payment, payer, type of carrier, and provider whose services are being reimbursed. ledger report - ANSWER>>>A patient's financial status is displayed in a ledger report. The report includes itemized statements, payments, and adjustments of all charges incurred by the patient for services rendered by providers in the organization. Each statement includes the amount charged, the amount paid by the insurance company, and the amount due from the patient or guarantor. This report tracks the patient's responsibility in terms of payments for services provided. optical character recognition (OCR) - ANSWER>>>the capability of specialized software to interpret the actual letters and numbers on a page to create a digital document that can be edited, rather than a flat picture the joint commission (TJC) - ANSWER>>>An organization that accredits health care organizations and programs risk analysis and management - ANSWER>>>identifies areas of uncertainty that could negatively affect value, analyzes and evaluates those uncertainties, and develops and manages ways of dealing with the risks

objective data - ANSWER>>>anything that can be observed or measured by clinical staffsuch as vital signs, prior records, lab results, imaging and physical examination findings narrow network - ANSWER>>>A limited group of providers who contracted with an insurance company CPT category I - ANSWER>>>classify medical, surgical, and diagnostic services and procedures provided for patients. These codes are used for reporting to both private and public insurers for billing. CPT category II - ANSWER>>>OPTIONAL tracking codes for performance measurement., represent services and/or test results that contribute to positive health outcomes and quality patient care. 5-digit alphanumeric code with the alpha character F in the last position. CPT category III - ANSWER>>>temporary codes applied to emerging technology(ends in letter T) codes are held for 5 years by FDA permanent national codes - ANSWER>>>are maintained by the HCPCS National Panel,which is composed of representatives from the Blue Cross/Blue Shield, Association (BCBSA), the Health Insurance Association (HIAA), & CMS. miscellaneous codes - ANSWER>>>National codes used when a supplier is submitting abill for an item or service where no existing national code exists to describe the item or service being billed; must contain a complete description of services or product modifiers (CPT) - ANSWER>>>a two-digit character that is appended to a CPT code to report special circumstances involved with a procedure or service such as complications or major complications Office of the National Coordinator for Health Information Technology (ONC) - ANSWER>>>created tohelp the industry reach interoperability. Merit-based Incentive Payment System (MIPS) - ANSWER>>>A reimbursement systemthat replaces the Sustainable Growth Rate formula previously used by Medicare Part Bto a value-based system. The value-based system is called the Quality Payment Program. Systemized Nomenclature of Medicine-Clinical Terms (SNOMED-CT) - ANSWER>>>thestandard used by the U.S. government electronic systems for the exchange of clinical health data. HL7 (Health Level 7) - ANSWER>>>protocol and universal specifications to enable the smooth translation of data among EHR systems.

LOINC (Logical Observation Identifiers Names and Codes) - ANSWER>>>enablescomputer programs to locate and report laboratory tests. CMS Security Standards Matrix - ANSWER>>>It is a set of criteria for EHR implementation and use. adjudication - ANSWER>>>the process of denying or paying a claim. It is not a methodused to transmit documentation. preauthorization - ANSWER>>>the process of determining whether or not a procedure iscovered and medically necessary. It is not a method used to transmit documentation. fee schedule - ANSWER>>>a document that includes a list of procedures matched to their allowable amounts. revenue cycle phase I - ANSWER>>>consists of registration functions such as insuranceverification, HIPAA notification, copying insurance information, obtaining signatures, assignment of benefits, and establishing an account. fielded and coded data - ANSWER>>>a unique code is assigned to each laboratory component so it can be located and organized sequentially. It is then easily placed on a graph as a visual representation of trends over time. claim scrubbing - ANSWER>>>check for edits and billing rules, and it finds errors and generates error reports. This allows staff to review and correct before transmission of the final bill to the payer. overlapping schedules - ANSWER>>>Some appointments are longer than others or canbe completed by a nurse or a medical assistant instead of the provider trend analysis - ANSWER>>>used to compare data across multiple dates, events, andtests. medical service order - ANSWER>>>authorization from the employer for the health careorganization to treat an injured employee. It should be photocopied and scanned into the patient's record. office of inspector general (OIG) - ANSWER>>>in the U.S. Department of Health and Human Services when improper documentation is discovered. patient-entered data - ANSWER>>>the patient completes a questionnaire on their own medical history and the reason for the current visit, which makes interaction with the provider easier and less time-consuming. predetermination - ANSWER>>>the process of discovering the maximum amount thethird-party payer will pay for a particular service.

preregistration - ANSWER>>>the process of entering the patient's demographic and historical information into the EHR prior to a visit medicare severity diagnosis related group (MS-DRG) - ANSWER>>>system is used forinpatient hospital billing coded data - ANSWER>>>Data that are translated into a standard nomenclature of classification so that they may be aggregated, analyzed, and compared the joint commission (Joint Commission on Accreditation of Healthcare Organizations "JCAHO") - ANSWER>>>An organization that accredits health care organizations and programs and maintains official "Do Not Use" list to verify acceptable abbreviations. birthday rule - ANSWER>>>The guidelines that determines which of two married parentswith medical coverage from different employers has the primary insurance for a child; the parent whose day of birth is earlier in the calendar year is considered primary face sheet - ANSWER>>>a form initiated by the admitting department and included in the inpatient medical record that contains personal and demographic information, usually computer generated at the time of admission. evaluation and management (E/M Codes) - ANSWER>>>these are listed 1st in the CPT manual because they are used by all different specialties. they cover physician servicesthat are performed to determine the best course for patient care. clearinghouse - ANSWER>>>performs centralized claims processing for providers and health plans