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Chapter 1 Terms
| Term | Definition |
|---|---|
| Acute Care | a branch of secondary health care where a patient receives active but short-term treatment for a severe injury or episode of illness |
| Admitting Diagnosis | means the patient's condition that necessitated or prompted the admission to the hospital and coded according to International Classification of Diseases |
| Advanced Directives | a written statement of a person's wishes regarding medical treatment, often including a living will, made to ensure those wishes are carried out should the person be unable to communicate them to a doctor. |
| Advanced Beneficiary Notice | also known as a waiver of liability, is a notice a provider should give you before you receive a service if, based on Medicare coverage rules, your provider has reason to believe Medicare will not pay for the service. |
| Appeal | make a serious or urgent request, typically to the public. |
| Assignment of benefit | is an agreement that transfers the insurance claims rights or benefits of the policy to a third-party. |
| Attending Physician | is a physician (M.D. or D.O.) who has completed residency and practices medicine in a clinic or hospital, in the specialty learned during residency. |
| Authorization of release of medical information | A medical release written authorization for health care providers to release information to the patient as well as some one other the patient |
| Case Management | a collaborative process of assessment, planning, facilitation , care coordination. evaluation and advocacy for options and services to meet an individual's family comprehensive health |
| Center for Medicare and Medical Services (CMS) | is a federal agency that administers the nation's major health care programs including Medicare, Medicaid, and CHIP. ... The agency aims to provide a health care system with better care, access to coverage, and improved health. |
| Charge capturing | a process used by doctors and other healthcare providers so they get paid for their services |
| Clinical documentation improvement (CDI) | offers an opportunity to improve coding and maximize reimbursement. |
| Compliance | the action or fact of complying with a wish or command |
| Computer-assisted physician documentation (CAPD) | |
| Computer -assisted coding | Is the set of instructions forming a computer program which is executed by a computer |
| Consent to treat | means a person must give permission before they receive any type of medical treatment, test or examination |
| Direct admit | Patient transferred from another acute care facility and taken to the operating room or interventional suite prior to hospital admission, or admitted directly to intensive care or other unit of the hospital. |
| Electronic health record (EHR) | Is an electronic version of a patients medical history, that is maintained by the provider over time, and may include all of the key administrative clinical data relevant to that persons care under a particular provider |
| Encoder/grouper software | system that classifies a patient's hospital stay into an established DRG based on the diagnosis and procedures provided to the patient. |
| Facility charge | A facility fee is a charge that you may have to pay when you see a doctor at a clinic that is not owned by that doctor. Facility fees are charged in addition to any other charges for the visit |
| Health information management (HIM) | Is the practice of acquiring, analyzing, and protecting digital and traditional medical information |
| Health Insurance Portability and Accountability Act(HIPAA) | The primary goal of the law is to make it easier for people to keep health insurance, protect the confidentiality and security of healthcare information and help the healthcare industry control administrative costs. |
| Hospital-based physician | as a physician who furnishes substantially all of their services in a hospital setting (whether inpatient or outpatient), and who uses the hospital facilities and equipment, including qualified EHRs. |
| Hospital-owned physician practices | In these settings, physicians work in practices or departments that are managed and owned either outright or partly by the hospital. |
| Inpatient | a patient who stays in a hospital while under treatment. |
| Joint Commission | |
| National Committee for Quality Assurance (NCQA) | |
| National Provider Identifier(NPI) | |
| Office of the Inspector General (OIG) | |
| Physician employees | |
| Physician's order | |
| Professional charge | |
| Protected health information (PHI) | |
| Provider-based clinic | |
| Referring physician | |
| Technical charge | |
| Third-party contract | |
| Utilization review (UR) | |
| Utilization Review Accreditation Commission (URAC) |
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