RAD 100 - Ch 25 Health Records and Health Information Management - Key Terms

Ambulatory Patient Classifications (APCs):

Classification system of patients based on the International Classification of Diseases, clinical modification codes for diagnoses, current procedural terminology evaluation and management codes, and procedure codes, age, sex, and visit disposition used for reimbursement for health care provided in the hospital outpatient setting

Current Procedural Terminology, 4th Edition (CPT-4):

Comprehensive listing of medical terms and codes for the uniform designation of diagnostic and therapeutic procedures; used in the United States for coding for physician reimbursement and hospital outpatient and ambulatory surgical procedures

Diagnosis-Related Groups (DRGs):

System that categorizes into payment groups patients who are medically related with respect to diagnosis and treatment and statistically similar with regard to length of stay

Electronic Health Record (EHR)/ Electronic Medical Record (EMR):

Electronic health record system generally considered as the portal through which clinicians access a patient's health record, order treatments or therapy, and document care delivered to patients; allows providers to gather multiple types of data about a patient (clinical, financial, administrative, and research)

Healthcare Facilities Accreditation Program (HFAP):

An accreditation program "authorized by the Centers for Medicare and Medicaid Services (CMS) to survey" all hospitals and many other types of healthcare settings (Healthcare Facilities Accreditation Program, 2017)

Health Information Management Practitioners:

Term used to encompass both registered health information administrators and registered health information technicians as individuals with either of these credentials who hold a variety of positions within the health information management profession

Health Insurance Portability and Accountability Act of 1996 (HIPAA):

Federal legislation passed to improve the efficiency and effectiveness of the health care system; components that affect health information include privacy, security, and the establishment of standards and requirements for the electronic transmission of certain health information

Health Records:

Permanent or long-lasting documentation of all patient care information that applies to individual patients

International Classification of Diseases, 9th edition, Clinical Modification (ICD-9-CM):

The classification system used in the United States to report morbidity and mortality information until September 30, 2015

International Classification of Diseases, 10th revision, Clinical Modification (ICD-10-CM):

The classification system that replaced ICD-9-CM, Volumes 1 and 2 on October 1, 2015. This classification system is used for diagnosis coding in all health care settings in the United States

International Classification of Diseases, Procedure Coding System (ICD-10-PCS):

A classification system used in the United States for reporting of inpatient hospital procedures. This classification system replaces the ICD-9-CM Volume 3 procedure codes on October 1, 2015

The Joint Commission:

Organization that accredits and certifies health care organizations and other programs in the United States (The Joint Commission, 2017)

Performance Improvement:

Process by which the quality of the care and services provided to patients within a health care facility is monitored and evaluated

Prospective Payment System (PPS):

System for Medicare patients by which a predetermined level of reimbursement is established before services are provided

Registered Health Information Administrators (RHIAs):

Professionals who possess the expertise to develop, implement, and/or manage individual, aggregate, and public health care data in support of patient safety and privacy, as well as the confidentiality and security of health information

Registered Health Information Technicians (RHITs):

Professionals who are technical experts in health data collection, analysis, monitoring, maintenance, and reporting activities in accordance with established data-quality principles, legal and regulatory standards, and professional best practice guidelines