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Chapter 1

Abstracting after the coding function is completed, this is performed to enter codes and other pertinent information (patient identification data, admission/discharge dates, and so on) utilizing computer software
Accreditation A voluntary process that a health care facility or organization(hospital) undergoes to demonstrate that it has met standards beyond those required by law
ACGME-accreditation council for graduate medical education has not used the term intern since 1975. It uses the word resident (although they still complete an internship)
Active Delivers most hospital medical services, performs significant organizational and administrative medical staff duties
Agenda The listing of all items of business to be discussed
American Recovery and Reinvestment Act authorized an expenditure $1.5 billion in grants for construction, renovation, and equipment and for the acquisition of health information technology services
Associate Advancement to active category is being considered
Biometrics An identifier that measures a borrower's unique physical characteristic or behavior and compares it to a stored digital tempplate to authenticate the identiy of the borrowwer, such as fingerprints, hand or face geometry , a retinal scan, or handwritten si
Governing Board (Board of trustees, Board of governors, board of directors) serves without pay, and its membership is represented by professionals from the business community
Bylaws rules and regulations Procedures based on federal and state regulations, and accreditation standards, which clarify claws
CMS- Centers for medicare & medicaid services In 2001 Replaced the HCFA (health care financing administration.
Chief resident Is a physician who is in their final year of residency or in the year after the residency has been completed. Plays a significant administrative or teaching role in guiding new residents
CFR- code of federal regulation IS the codification of the general and permanent rules published in the Federal Register by the executive departments and agencies of the federal government
Coding Involves assigning numeric and alphanumeric codes to diagnoses, procedures, and services (performed by CCS, CPC, RHIT)
Consulting includes highly qualified practitioners available as consultants when needed
Continuum if care A complete range of programs and services, with the type of of health care indicating the health care services provided
Contract services Facilities use these for health information services in addition to general services. Such as housekeeping, medical waster disposal, and clinical services sucj as physical therapy, emergency care and speech pathology. PURPOSE is to improve quality while c
Courtesy Admits an occasional patient to the hospital;
CPT- Current procedural terminology Published annually by the AMA and codes are 5 digit numbers assigned to ambulatory procedures and services
Deemed status Accreditation hospitals have met or exceeded Conditions of Participants to participate in the Medicare and Medicaid programs
Deeming authority Means that an accrediting organizations standards have met or exceeded CMS's Conditions of participation for Medicare certification, acceredited facilities are eligible for reimbursement under Medicare and Medicard and CMS is less liekly to conduct an on
Deficit reduction act of 2005 Created the MIP (Medicaid Integrity Program), which is a fraud and abuse detection program
Digital signature Type of electronic signature(uses public key cryptography)
Disaster recovery plan Ensures an appropriate response to internal and externaldisasters
DNR- do not resuscitate Instructs edical and nursing staff to not try to revive the patient if breathing or heartbeat stops. It is documented in the patients medical record by the physician
EHR- electronic health record An automated, accessible record that contains multimedia data (digital, scanned images, voice video and so on)
Electronic signature Encompasses all technology options available that can be used to authenticate a document
Created by: s.fitzpatrick410