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CBCS 2.1 Reg Comp

NHA Certified Biller and Coder Specialist Certification Review

documentation requirements include detailed, current, and accurate information
documentation usually includes_1 1. dates of the clinical encounters 2. author of document 3. patient's medical history and pertinent family history 4. medications the patient is currently taking report of the patient's initial physical exam 5. food and medication allergies
documentation usually includes_1 6. diagnostic and therapeutic orders 7. results and reports of diagnostic and therapeutic procedures preformed: lab tests, pathologic examples of tissue samples, results of imaging procedures (MRI/X-ray
informed vs implied consent informed: information explained directly to patient; medical and diagnostic procedures planned&surgical interventions. Pts. can ask questions. Pt. signatures are required for verification. implied: consent is assumed/not discussed. signatures not req.
ARRA (American Recovery and Reinvestment Act) signed into law in 2009. eforces HITECH Act changes to HIPAA Privacy Rule.
Protected Health Information (PHI) individually identifiable health info transmitted by electronic media and maintained by electronic or paper sources by a covered entity or business associate (BA)
Business Associate individuals, groups, or organizations that are not members of the covered entities workforce but preform functions or activities on their behalf
individually identifiable 1 documents that either identify the person or provide enough info to identify the person 2 info on past, present, future physical or mental condition 3 info including provisions of health care 4 info on payments of the provisions of health care
Use the way PHI is handled internally by the covered entity or business associate
minimum necessary use of patient information limited to only the amount of information required to accomplish the specific purpose
disclosure way PHI is disseminated (spread/dispersed) from a covered entity or BA
notice of privacy practices legal obligation (requirement) of medical providers to explain to pts. how their PHI will be used and disclosed.This should be done at first visit.
To ensure proper de-identification providers must complete the following: 1. strip off certain elements to ensure that the patient's information is impossible to identify 2. have an expert apply generally accepted statistical and scientific principles and minimize the risk that the information might be used to identify
consent permission for treatment, payment, or health care operations
authorization permission granted by the patient or patient's representative to release information not related to treatment, payment, or health care operations
authorizations include 1 specific description of information used/ disclosed 2 name or other specific ID of person(s) 3 expiration date 4 right to revoke authorization in writing 5 redisclosure by recipient 6 signature and date 7 description of representatives authority
Created by: tina.reynolds