Phlebotomy Technician (CPT) - Revenue Cycle and Regulatory Compliance

Flashcards covering the Revenue Cycle, HIPAA Privacy and Security Rules, and different types of consent for the Certified Phlebotomy Technician exam.

Privacy Rule

Regulations that ensure patients have control of their health information, including how it is used and who it can be shared with.

Release of Information (ROI)

A feature of the HIPAA Privacy Rule and a method of controlling and tracking access to Protected Health Information (PHI) about a patient.

Consent Form

A written authorization obtained by a health care provider when a privacy restriction applies, signed by the patient or a legal guardian if the patient is a minor.

Implied Consent

An act of agreement, such as a patient following a nurse to the lab for blood work, which does not require a signature or specific medical record documentation.

Informed Consent

Communication where a provider explains the nature, risks, benefits, and alternatives of a procedure to allow the patient to make a decided choice.

Written Consent

A signed document providing permission for a service or procedure, typically required when there is a significant risk of complication.

30 calendar days

The time limit for processing medical record requests from the date they are received, though extensions are permitted for archived or off-site records.

TPO

An acronym for Treatment, Payment, and Operations, representing the only instances where a provider can send records without patient permission.

Treatment

The coordination and management of a patient's health care, such as sending records to a specialist for diagnosis.

Payment

Provider activities related to billing and reimbursement, such as releasing notes to a third-party payer.

Operations

Administrative processes typical for health care organizations, such as quality improvement activities and reporting.

Subpoena

A legal document used for legal proceedings that allows the disclosure of medical records without patient authorization.

Psychotherapy Notes

Confidential discussions between a mental health provider and patient that must be kept separate from other medical records and require specific signed authorization for release.

CFR Title 42: Part 2

Federal regulations specifying that patient records related to drug and alcohol substance use must be kept confidential.

Security Rule

HIPAA standards designed to protect clinical health information used in applications like computerized physician order entry (CPOE) and EHR systems.

HITECH Act

The Health Information Technology for Economic and Clinical Health Act, which promotes EHR use and strengthens HIPAA Privacy and Security Rules.

Storage

The mechanism used for securing documentation involving record retention mandated by federal and/or state law.