Abbrev/Defs

CARF

Commission on Accreditation of Rehabilitation Facilities

An independent, nonprofit accrediting organization to meet the survey needs of various rehabilitation-based healthcare providers. These rehabilitation-based healthcare providers include independent and nonprofit providers, aging services, behavioral health, and opioid treatment programs. They also assists healthcare providers with establishing best practices in these specialized areas of rehabilitation treatment.

CARF

DEEDS

Data Elements for Emergency Department Systems

collects data for hospital-based emergency departments.

DEEDS

UACDS

Uniform Ambulatory Care Data Set

collects data specific to ambulatory care settings with an intent to improve data comparison across different settings of health-care

UACDS

UHDDS

Uniform Hospital Discharge Data Set

This core set of data elements is collected by acute-care, short-term stay (usually less than 30 days) hospitals to report inpatient data elements in a standardized manner. For inpatients admissions

UHDDS

CMS

Centers for Medicare and Medicaid Services

The Department of Health and Human Services agency responsible for Medicare and parts of Medicaid.

CMS

HHS

Health and Human Services

CDC

Centers for Disease Control and Prevention

A federal agency dedicated to protecting health and promoting quality of life through the prevention and control of disease, injury, and disability. Committed to programs that reduce the health and economic consequences of the leading causes of death and disability, thereby ensuring a long, productive, healthy life for all people

CDC

EHR

electronic health record

EMR

electronic medical record

HIPAA

Health Insurance Portability and Accountability Act

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The federal legislation enacted to provide continuity of health coverage, control fraud and abuse in healthcare, reduce healthcare costs, and guarantee the security and privacy of health information; limits exclusion for pre-existing medical conditions, prohibits discrimination against employees and dependents based on health status, guarantees availability of health insurance to small employers, and guarantees renewability of insurance to all employees regardless of size; requires covered entities (most healthcare providers and organizations) to transmit healthcare claims in a specific format and to develop, implement, and comply with the standards of the Privacy Rule and the Security Rule; and mandates that covered entities apply for and utilize national identifiers

HIPPA

MPI

Master Patient Index

A patient-identifying directory referencing all patients related to an organization, which also serves as a link to the patient record or information, facilitates patient identification, and assists in maintaining a longitudinal patient record from birth to deatH

MPI

PHI

Personal Health Information

An electronic or paper health record maintained and updated by an individual for himself or herself; a tool that individuals can use to collect, track, and share past and current information about their health or the health of someone in their care

PHR

MDS

minimum data set

A federally mandated standard assessment form that Medicare- and Medicaid-certified nursing facilities must use to collect demographic and clinical data on nursing home residents; includes screening, clinical, and functional status elements

MDS

What healthcare setting falls under MDS?

Long-term care

OASIS

Outcome and Assessment Information Set

What healthcare setting falls under OASIS?

Home healthcare Setting

SNOMED

Systemized Nomenclature of Medicine

CDI

Clinical Documentation Integrity

This term is defined as the process of reviewing medical in-formation to verify that documentation is clinical specific, is appropriate, and supports the medical codes assigned

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help healthcare organizations enhance patient documentation, reduce errors within the health record, and improve the quality of the patient data entered in the system while supporting patient care and reimbursement for the organization.

CDI

CFO

Chief Financial Officer

CEO

chief executive officer

ROI

release of information

MEDPAR

Medicare Provider Analysis and Review

BC/BS

Blue Cross Blue Shield

JCAHO

Joint Commission on Accreditation of Healthcare Organizations

PI

present illness

HCUP

Healthcare Cost and Utilization Project

HL7

Health Level 7

IG

Information Intelligence

RW

relative weight

RCM

Revenue Cycle Management

CPT

Current Procedural Terminology

HCPCS

Healthcare Common Procedure Coding System

ICD 10 CM

International Classification of Diseases, 10th Revision, Clinical Modification

ICD 10 PCS

International Classification of Diseases, Tenth Revision, Procedure Coding System

POA

present on admission

COPD

chronic obstructive pulmonary disease

OIG

Office of Inspector General

EDMS

Electronic document management system

An initiative of TJC that implements 5 core measures to improve safety and quality of health care.

ORYX

CC

chief complaint

AHIMA

American Health Information Management Association

HEENT

head, eyes, ears, nose, throat

RBRVS

Resource Based Relative Value Scale

WHO

World Health Organization

DNFB

discharged not final billed

NCPDP

National Council for Prescription Drug Programs

LOINC

Logical Observation Identifiers Names and Codes

ADT system

A computer system that records hospital admissions, discharges, and transfers.

HEDIS

Healthcare Effectiveness Data and Information Set

It is a set of performance measures used to assess the quality of healthcare services provided by health plans and healthcare organizations sponsored by NCQA. This set measures cover various aspects of healthcare, including preventive care, chronic disease management, and patient satisfaction. The data collected through It helps evaluate and compare the performance of different healthcare providers, identify areas for improvement, and promote evidence-based practices. Healthcare purchasers and consumers can use the in-formation to compare the performance of managed healthcare plans to help decide which plan to con-tract with or enroll in.

HEDIS

HITECH

Health Information Technology for Economic and Clinical Health Act

CDR

crude death rate

CPOE

Computerized Provider Order Entry

APC

Ambulatory Payment Classification

H&P

history and physical

E/M

Evaluation and Management

COBRA

Consolidated Omnibus Budget Reconciliation Act

LOS

Length of stay

HIV

human immunodeficiency virus

EOB

explanation of benefits

I&D

incision and drainage

NCCI

National Correct Coding Initiative

AMA

American Medical Association

AHA

American Hospital Association

LTCH

Long-Term Care Hospital (LTCH)

After acute care is finished, those patients that have serious long-term conditions may require extended stays. These patients may have multiple acute and chronic diseases and certainly can require complex care. Part A of Medicare provides services for this long-term care hospitalization for its beneficiaries. Services consist of 90-days in this setting.

EMTALA

Emergency Medical Treatment and Active Labor Act

PPS

Prospective Payment System

ONC

tumor

SNF

skilled nursing facility

UPIN

Unique Physician Identification Number

RUGS

resource utilization groups

RVU

Relative Value Unit

MSN

Medicare Summary Notice

NPI

National Provider Identifier

QIO

Quality Improvement Organization

NLM

National Library of Medicine

NPDB

National Practitioner Data Bank

NIH

National Institutes of Health

NCHS

National Center for Health Statistics

IOM

Institute of Medicine

GPCI

Geographic Practice Cost Index

DSM

Diagnostic and Statistical Manual of Mental Disorders

HAC

Hospital acquired conditions

MCC

major complication/comorbidity

CC

complication/comorbidity

OBRA

Omnibus Budget Reconciliation Act

UCR

usual, customary, and reasonable

FFS

fee for service

PHO

Physician Hospital Organization