CEHRS vocab notes

advance directives: A legal document that contains information about a patient's treatment choices when they are unable to make healthcare the decisions

aging report: Report that identifies past-due patient or insurance account balances and is usually run monthly

assignment of benefits: A patient's authorization to allow health insurance payment to be made directly to the provider of service

authorization: A document that approves disclosure of protected health information unrelated to treatment under the HIPAA Privacy Rule

benchmark: A measure of performance against industry standards, practice guidelines, or targets set by an organization

business associate agreement: A legal contract dictating a business associate to comply with protection of protected health information under the HIPAA Privacy Rule

business associate: A third-party entity that has contact with protected health information to provide services unrelated to treating patients:

Centers for Medicare and Medicaid Services (CMS). 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 the implementation of federal legislation (HIPAA, HITECH)

clinical decision support system (CDSS): A program designed to prompt providers with clinical decisions. clinical documentation improvement (CDI), 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

compliance program: Internal policies designed to prevent claim errors, fraud, and abuse

computerized provider order entry (CPOE): Use of a computer system to enter and process prescriptions and treatments at the point of care

covered entity: Any medical or health care service, organization, agency, or individual that has protected health information

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

de-identification: The process of removing personal health information that can clearly identify a patient

electronic health record (EHR): A record of patient medical and health care information accessible to providers and other staff members who have login credentials regarding location

electronic medication administration record (eMAR): An electronic record containing a patient's prescribed medications, administration times, and who administered it

encoder: Software used to assign diagnosis and procedure codes

encounter form: 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 charge form

encryption. Converting email or other information into a code that only intended recipients can read

explanation of benefits (EOB). A statement that shows a patient how the insurance carrier processed services provided

Health Information Technology for Economic and Clinical Health (HITECH) Act: Federal legislation that expands consumer rights and protections outlined by HIPAA and sets standards for the quality and use of electronic health records

Health Insurance Portability and Accountability Act (HIPAA): A federal law that regulates the use of patient personally identifiable information

Healthcare Common Procedure Coding System (HCPCS): A coding classification system in which level | (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: Attempts to address human strengths and weaknesses in programs or systems

hybrid system: System that uses both paper- and electronic-based processing for documentation of health information

internal audit: An in-house examination of medical records and related billing for appropriateness and accuracy

International Classification of Diseases, 10 Revision, Clinical Modification (ICD- 10-CM). A classification and coding system for diagnoses used by healthcare organizations

International Classification of Diseases, 10th Revision, Procedure Coding System (ICD-10-PCS): A classification system for procedures performed at inpatient facilities:

interoperability. The ability of systems to share information and use exchanged information

laboratory information system (LIS): A database of prescribed laboratory tests and results transferred from instruments used to analyze the tests

promoting interoperability: A standard of electronic health record technology that promotes the ability to exchange health information to improve the quality and health outcomes of a population

medical record number: A set of numbers used to identify a patient and associated recorded health data

minimum necessary concept: Protecting private health information by limiting access based on need

Notice of Privacy Practices (NPP): A document that is required by law to inform a patient how an organization will use their health care information

physical safeguard: Physical method, policy, or procedure to protect stored data and software from threats, natural and environmental hazards, and unauthorized invasion

physician query: A request that a provider add documentation to the electronic health record to clarify a diagnosis or procedure that has been performed

practice management system (PMS): A system that stores information on revenue cycle processes (appointments, registration, scheduling, health information management, coding, billing)

protected health information (PHI): Health information that is specific to a patient

quality measures: Standards and processes implemented to improve clinical quality as defined by clinical professionals and public health organizations

redundancy: Duplicate copies of data. registration form. A form that consists of administrative information about a patient, including personal, financial, legal, and some clinical data

remittance advice: A report from insurance carriers to a service provider describes payments and how the amount was determined

revenue cycle: All processes that relate to claims and payment or other ways of generating revenue

rollout: Start of process.

upcoding: Assigning a higher-level service or procedure to increase reimbursement

usability: The ease with which a person can interact with hardware and software to provide safe, efficient, quality patient care.