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CODE NAMES

EHR

QuestionAnswer
HCPCS Healthcare Common Procedural Coding system
What is the HCPCS used for? LE VEL 1 : the services of the provider codes LEVEL 2 : the supplies and equipment of service
CFO Chief Financial Officer
all financial and fiscal decisions are to be discussed with? CFO
CCR Continuity of Care Record
makes it possible to integrate external and internal in electronic health records CCR
CCD Continuity of Care Document
which system replaced CCR? CCD
CCHIT Certification Commission for Health Information Technology
Certifications of EHR/EMR come from..... CCHIT
HITECH Health Information Technology for Economic and Clinical Health (Act)
encourages adoption of EHR with commissions HITECH
PCU Patient Care Unit
a general census of patients in the hospital (helps decide clinical schedules) PCU
NCVHS National Committee on Vital and Health Statistics
name on of the national data warehouses NCVHS
C.D.C Center of Disease Control and Prevention (no P)
division in the Department of Health and Human Services CDC
NCHS National Center of Health Statistics
primary statistics organization on health to guide and influence health policy and practice to best serve the population NCHS
NAMCS National Ambulatory Medical Care Survey
who collects data on outpatient services in provider offices and clinics? NAMCS
ALOS Average Length of Stay (O in of included)
a count of days that a patient has stayed ALOS
PPS Prospective Payment System
pay based on original diagnosis of the patient PPS
PDR Physicians Desk Reference
Database of medications and manufactures, as well as prescribing info PDR
NPDB National Practitioner Data Bank
what is the name of the database of physicians? NPDB
Why would you use the NPDB? To help define the scope of practice for any one specific physician
Privacy Rules (HIPAA) helps to understand when info can be shared for patient care and business purposes
Security Rules (HIPAA) General protection of PHI (physical, administrative, and technical safeguards)
What is the difference between security and privacy? Privacy will protect PHI with an understanding of when and what can be shared, whilst security protects PHI in general
MPI Master Patient Index
a record of every patient that had been treated, seen, evaluated in a facility and must forever be maintained MPI
Fully integrated EHR replaced paper records entirely
HIS Hospital Information System
storage, collection, manipulation (addendums) and management of data generated in daily operations HIS
WOW Wireless on wheels
used generally to collect patient info and has a barcode scanner, this acronym is used instead of COW WOW
Medical terminology language of medicine, has more than one dictionary
CPT Current Procedural Terminology
a naming system CPT
ICD-9-CM International Code of Diseases, 9th revision, Clinical Modifications
contains many codes, organized with I or O to prevent number confusion ICD-9-CM
Volume 1 Tabular list of disease and injuries
Volume 2 The alphabetic index to disease and injuries
Volume 3 The Classification for Procedures and reporting hospital procedures
V-Codes codes used to classify visits when there are other circumstances than disease or injury are the reason for the appointment
E-Codes Codes used to classify causes of injury, poisoning, other adverse events
Practice Management System Software designed to assist office workflow
Third party Vendor Billing company, transcription companies, and coding firms
Encounter Forms form filled out by provider containing service charges, how much had been already paid (used for bills)
E & M Evaluation and Management codes
time provider spent in treating a patient. E & M
SNOMED-CT SYSTEMIZED Nomenclature of Medicine- Clinical Terms
medical vocab that standardizes the naming of medical/health care terminology SNOMED-CT
Medical Staff Committee committee formed to discuss and recommend practices, policies, and other activities specific to staff
Med Rec Medication Reconciliation
what is it called when you gather and document a patients list of meds, including new ones and current ones Med Rec
ePrescribing software used by providers to electronically prescribe medication to a patient; is sent to pharmacy
RBACs Role-Based Access Controls
controls the ability to access certain areas of the system based on the person roles RBACs
CPT codes Current Procedural Terminology codes
numeric codes developed by the American Medical Association (AMA) to standardize medical services/procedures CPT codes
EHR Electronic Health Records
data created, managed, consulted by clinical staff WITHIN ONE health care organization EHR
EMR Electronic Medical Records
data created, managed, consulted by clinical staff ACROSS more than one health care organization EMR
Interoperability capacity of systems to communicate and exchange information with one another
Standards Organizations Government agencies, Voluntary groups, and industry associations involved in establishing guidelines to assist uniformity
data repository electronic holding place for data
Examples of standards organizations I American National Standards Institute (ANSI) Accredited standards committee X12 (ASC X12)
Examples of Standards organizations II The American Society for Testing and Materials (ASTM) Digital Imaging and Communications in Medicine (DICOM)
Examples of Standards Organizations III Health Level 7 (HL7) National Council for Prescription Drug Programs (NCPDP)
CPOE Computerized Provider Order Entry
Providers use this to order medication, IV Therapies, lab tests, imaging studies, rehabilitation services, Dietary requirements CPOE
Joint Commission (TJC) The Joint Commission on the Accreditation of Health Care Organizations
independent organization that accredits/certifies more than 19,000 hcf/programs in the US, recognized as gold standard TJC (Joint Commission)
CMS Centers for Medicare and Medicaid Services
charged with administration of Medicare/ Medicaid programs as well as children's health insurance CMS
H & P History and Physical
required to be filed into inpatient record with 24 hrs, and cannot be more than thirty days old H & P
interoperability the capacity of systems to communicate and exchange information with one another
standards organizations government agencies, voluntary groups, and industry associations that establish guidelines for efficiency
data repository electronic holding place for data
reminders automated notices to practitioners or patients regarding actions that need to be taken
alerts automated notices to practitioners of info that requires immediate or special attention
treatment protocols established guidelines for treatment of specific diseases
telemonitoring using telecommunications technology to gather physiologic or diagnostic data and transmit to health care providers
Created by: awierman20