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Chapter 25
Vocab
| Term | Definition |
|---|---|
| Ambulatory Patient Classifications (APCs) | Classification system of patients based on the International Classification of Diseases, clinical modification codes for diagnoses, current procedural terminology evaluation and management codes, and procedure codes |
| Current Procedural Terminology, 4th Edition (CPT-4) | Comprehensive listing of medical terms and codes for the uniform designation of diagnostic and therapeutic procedures |
| Diagnosis-Related Groups (DRGs) | System that categorizes into payment groups patients who are medically related with respect to diagnosis and treatment and statistically similar with regard to length of stay |
| Electronic-Health Record (EHR)/Electronic Medical Record (EMR) | Electronic health record system generally considered as the portal through which clinicians access a patents health record, order treatments or therapy, and document care delivered to patients |
| Healthcare Facilities Accreditation Program (HFAP) | An accreditation program "authorized by the Centers for Medicare and Medicaid Services (CMS) to survey" all hospitals and many other types of health care settings |
| Health Information Management Practitioners | Term used to encompass both registered health information administrators and registered health information technicians as individuals with either of these credentials who hold a variety of positions within the health information management profession |
| Health Insurance Portability and Accountability Act of 1996 (HIPPA) | Federal legislation passed to improve the efficiency and effectiveness of the health care system |
| Health Records | Permanent or long-lasting documentation of all patient care information that applies to individual patients |
| International Classification of Diseases, 9th edition, Clinical Modification (ICD-9-CM) | The classification system used in the United States to report morbidity and mortality information until September 30, 2015 |
| International Classification of Diseases, 10th revision, Clinical Modification (ICD-10-CM) | The classification system that replaced ICD-9-CM, Volumes 1 and 2 on October 1, 2015. This classification system is used for diagnosis coding in all health care settings in the United States |
| International Classification of Diseases, Procedure Coding System (ICD-10-PCS) | A classification system used in the United States for reporting of inpatient hospital procedures. This replaces the ICD-9-CM Volume 3 procedure codes on October 1, 2015 |
| The Joint Commission | Organization that accredits and certifies health care organizations and other programs in the United States (The Joint Commission, 2017) |
| Performance Improvement | Process by which the quality of the care and services provided to patients within a health care facility is monitored an evaluated |
| Prospective Payment Solution (PPS) | System for Medicare patients by which predetermined level of reimbursement is established before services are provided |
| Registered Health Information Administrators (RHIAs) | Professionals who possess the expertise to develop, implement, and/or manage individual, aggregate, and public health care data in support of patient safety and privacy, as well as the confidentiality and security of health information |
| Registered Health Information Technicians (RHITs) | Professionals who are technical experts in health data collection, analysis, monitoring, maintenance, and reporting activities in accordance with established data-quality principles, legal and regulatory standards, & professional best practice guidelines |