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key terms

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QuestionAnswer
Acute care An inpatient acute care facility provides medical care and treatment to patients who require care for their acute condition, illness, or injury.
Admitting diagnosis Medical necessity must be met with information obtained from the physician for patient status as well as the services provided through assignment of proper diagnostic codes. These serve as admitting codes and are included on the billing send to insurance.
Advance directives in the case of an inpatient admission, the facility will request a copy of any advance directives, such as a living will or durable power attorney. the documents are to ensure the patients wishes are considered in a life/death situation.
Advance Beneficiary Notice (ABN) This form identifies those services that may not be covered by the patient's insurance, and the patient's signature indicates that the patient will be financially responsible for such services.
Appeal request for additional consideration and payment will be made.
Assignment of benefits when the patient signs the assignment of benefits form, the patient gives consent for any benefits or payments for services to be sent directly to the facility.
Attending physician Physician who is chiefly responsible for the patient's care during hospitalization
Authorization for release of medical information which allows the facility to release information to the patient's third-party carrier when required for treatment purposes or for payment purposes to be sent directly to the facility.
Case management review patient care, treatment planning, referral, follow-up, and discharge planning.
Center for Medicare and Medicaid Services (CMS) organization that oversees the Medicare & Medicaid programs for the federal government.
Charge capturing is the gathering of charges and charge documents from all departments within the facility that have provided services to patients.
Clinical documentation improvement (CDI) wherein documentation is reviewed and suggestions are made to improve upon the documentation is reviewed and suggestion made to improve upon the documentation for future use by the clinical documentation improvement specialist to the provider.
Compliance The process of ensuring that all regulatory guidelines are met.
Computer-Assisted Physician Documentation (CAPD) aids the physician in completing the needed information for documentation and billing purposes and "Prompts" the provider when additional information will be needed.
Computer-Assisted Coding (CAC) assist in the assigning of some CPT, ICD-9/10 - CM codes in the record.
Consent to treat indicates that the patient has been made aware of the possible adverse affects of the treatment or procedure and agrees to have the service provided.
Direct admit has an order from their private physician to be admitted to observation. ( observation can last up to 24 hours or longer in order to determine whether they are stable or need acute, inpatient care).
Electronic health record (EHR) stores patient's clinical data electronically, which allows easy access for all facility staff as needed.
Encoder or grouper software assist the coder in correct coding and adhering to Medicare and third-party coding and billing guidelines.
Facility charge The equipment, technician, and disposable supplies that are necessary to perform a test are coded/billed by the facility.
Health information management (HIM) The process of reviewing documentation for services provided and assigning the appropriate International Classification of Diseases, 9/10th edition, clinical Modification (ICD-9/10 - cm) and Current Procedural Terminology (CPT) codes.
Health Insurance Portability and Accountability Act (HIPAA) of 1996 is monumental and encompasses a number of areas of provider care, some of the major areas are covered follows: HIPPA privacy, HIPPA security, HIPPA Electronic Care Transaction and Code Sets Standards.
Hospital-based physicians physician who provides services only in hospital setting.
Hospital-owned physician practices The physicians are typically employees of the hospital and the actual practice is owned, operated, and regulated by the hospitals guidelines.
Inpatients typically required a minimum 24-hour stay and continuous medical attention .
Joint Commission (or JCAHO) verifies compliances of accreditation standards for hospitals and other health care facilities.
Created by: mariaparra