Administration
A legal document that contains information about a patient's treatment choices when they are unable to make health decisions.
1. ROI
2. AD
3. RA
4. EOB
Advanced Directives
A measure of performance against the industry standards, practice guidelines, or targets set by an organization.
1. benchmark
2. 2 cc's
3. Denial
4. Inequivalent
Benchmark
Processes for executing and reviewing clinical documentation to ensure that it accurately reflects and supports CPT and ICD-10-CM codes submitted with claims for payment.
What am I?
What is Clinical Documentation Improvement (CDI)?
A record of patient medical and health care information accessible to providers and other staff members who have login credentials regardless of location.
What am I?
What is Electronic Health Record (EHR)?
Report that identifies past-due patient or insurance account balances and is usually run monthly.
1. EOB
2. Release of Information
3. Aging Report
4. Face sheet
What is Aging Report?
A legal document explaining the procedure and it's risks
1. Implied consent
2. Informed consent
3. parental consent
4. Bill of Rights
Informed Consent
Internal policies designed to prevent claim errors , fraud, and abuse.
What am I?
What is Compliance Program?
An electronic record containing a patient's prescribed medications, administration times, and who administered it.
What am I?
What is Electronic Medication Administration Record (EMAR)?
A patient's authorization to allow health insurance payment to be made directly to the provider of the service.
1. Explanation of Benefits
2. Remittance Advice
3. Assignment of Benefits
4. Interoperable
What is Assignment of Benefits?
A third party entity that has contact with protected health information to provide services unrelated to treating patients.
What am I?
What is Business Associate?
Use of computer system to enter and process prescriptions and treatments at the point of care.
What am I?
What is Computerized Provider Order Entry (CPOE)?
Software used to assign diagnosis and procedure codes.
What am I?
What is Encoder?
A document that approves disclosure of protected health information unrelated to treatment under the HIPAA Privacy Rule.
1. Authorization
2. EOB
3. Registration form
4. PHI
Authorization
A federal regulatory agency that is part of the Division of Health and Human Services, administers Medicare, works with state governments to administer Medicaid programs, sets standards for interoperability of electronic health records, and oversees implementation of federal legislation (HIPAA, HITECH).
a. CMS
b. Worker's Comp
c. CPOE
d. HIM
What is Centers for Medicare and Medicaid Services (CMS)?
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 organizations.
What am I?
What is Current Procedural Terminology 4th Edition (CPT-4)?
An itemized form for services that contains diagnosis and procedure codes and is used by office staff to complete claim forms; also known as a superbill, fee slip, or change form.
What am I?
What is Encounter Form?
NCCI
National Correct Coding Initiative
A program designed to prompt providers with clinical decisions.
a. CDSS (Clinical decision support system)
b. EOB (Explanation of Benefits)
C. RA (Remittance Advice
D. AD (Advanced Directive)
D. MDM
What is Clinical Decision Support System (CDSS)?
The process of removing personal health information that can clearly identity a patient.
What am I?
What is De-identification?
Converting email or other information into a code that only intended recipients can read.
What am I?