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Billing and Coding
Chapter 2 Terms
| Term | Definition |
|---|---|
| Abuse | Action that improperly uses another person’s resources. |
| Accountable Care Organization (ACO) | A network of doctors and hospitals that shares responsibility for managing the quality and cost of care provided to a group of patients. |
| accounting of disclosure | The documentation of the disclosure of a patient’s PHI in his or her medical record in cases when the individual did not authorize it and it was not a permitted disclosure. |
| Affordable Care Act (ACA) | Health system reform legislation that offers improved insurance coverage and other benefits. |
| audit | Methodical review; in medical insurance, a formal examination of a physician’s accounting or patient medical records. |
| authorization | Document signed by a patient to permit release of particular medical information under the stated specific conditions. (2) see definition for preauthorization. |
| breach | An impermissible use or disclosure under the Privacy Rule that compromises the security or privacy of PHI and also that could pose significant risk of financial, reputational, or other harm to the affected person. |
| breach notification | The document notifying an individual of a breach. |
| Business Associate (BA) | A person or organization that performs a function or activity for a covered entity but is not part of its workforce. |
| Centers for Medicare and Medicaid Services (CMS) | Federal agency within the Department of Health and Human Services (HHS) that runs Medicare, Medicaid, clinical laboratories (under the CLIA program), and other government health programs. |
| Clearinghouse | A company that converts nonstandard transactions into standard transactions and transmits the data to health plans; also handles the reverse process, changing standard transactions from health plans into nonstandard formats for providers. |
| Code set | Alphabetic and/or numeric representations for data. Medical code sets are systems of medical terms that are required for HIPAA transactions. Administrative (nonmedical) code sets, such as taxonomy codes and ZIP codes, are also used in HIPAA transactions. |
| compliance plan | A medical practice’s written plan for the following: the appointment of a compliance officer and committee; a code of conduct for physicians’ business arrangements and employees’ compliance; |
| Covered Entity (CE) | Under HIPAA, a health plan, clearinghouse, or provider who transmits any health information in electronic form in connection with a HIPAA transaction |
| De-identified health information | Medical data from which individual identifiers have been removed; also known as a redacted or blinded record. |
| Designated record set (DSR) | A covered entity’s records that contain protected health information (PHI); for providers, the designated record set is the medical/financial patient record. |
| Documentation | The systematic, logical, and consistent recording of a patient’s health status—history, examinations, tests, results of treatments, and observations—in chronological order in a patient medical record. |
| Electronic Data Interchange (EDI) | The system-to-system exchange of data in a standardized format. |
| Encounter | An office visit between a patient and a medical professional. |
| Encryption | A method of scrambling transmitted data so they cannot be deciphered without the use of a confidential process or key. |
| Evaluation and Management (E/M) | Provider’s evaluation of a patient’s condition and decision on a course of treatment to manage it. |
| Fraud | Intentional deceptive act to obtain a benefit. |
| Health Care Fraud and Abuse Control Program | Government program to uncover misuse of funds in federal healthcare programs; run by the Office of the Inspector General. |
| Health information Exchange (HIE) | Enables the sharing of health-related information among provider organizations |
| Health Information Technology for Economic and Clinical Health (HITECH) Act | Law promoting the adoption and use of health information technology. |
| Health Insurance Portability and Accountability Act (HIPAA) of 1996 | Federal act that set forth guidelines for standardizing the electronic data interchange of administrative and financial transactions, exposing fraud and abuse in government programs, and protecting the security and privacy of health information. |
| HIPAA Electronic Health Care Transactions and Code Sets (TCS) | The HIPAA rule governing the electronic exchange of health information. |
| HIPAA National Identifiers | HIPAA-mandated identification systems for employers, healthcare providers, health plans, and patients; the NPI, National Provider System, and employer system are in place; health plan and patient systems are yet to be created. |
| HIPAA Privacy Rule | Law that regulates the use and disclosure of patients’ protected health information (PHI). |
| HIPAA Security Rule | Law that requires covered entities to establish administrative, physical, and technical safeguards to protect the confidentiality, integrity, and availability of health information. |
| Informed Consent | The process by which a patient authorizes medical treatment after discussion about the nature, indications, benefits, and risks of a treatment a physician recommends. |
| Malpractice | Failure to use an acceptable level of professional skill when giving medical services that results in injury or harm to a patient. |
| Meaningful Use | The utilization of certified EHR technology to improve quality, efficiency, and patient safety in the healthcare system. |
| Medical documentation and revenue cycle | A series of steps that explain how using EHRs is integrated with practice management programs as the 10-step billing process is formed. |
| Medical Record | A file that contains the documentation of a patient’s medical history, record of care, progress notes, correspondence, and related billing/financial information. |
| Medical Standards of Care | State-specified performance measures for the delivery of healthcare by medical professionals. |
| Minimum Necessary Standard | Principle that individually identifiable health information should be disclosed only to the extent needed to support the purpose of the disclosure. |
| National Provider Identifier (NPI) | Under HIPAA, unique ten-digit identifier assigned to each provider by the National Provider System. |
| Notice of Privacy Practices (NPP) | A HIPAA-mandated description of a covered entity’s principles and procedures related to the protection of patients’ health information. |
| Office of Civil Rights (OCR) | Government agency that enforces the HIPAA Privacy Act. |
| Office of E-Health Standards and Services (OESS) | A part of CMS, which helps to develop and coordinate the implementation of a comprehensive e-health strategy for CMS. |
| Office of the Inspector General (OIG) | Government agency that investigates and prosecutes fraud against government healthcare programs such as Medicare. |
| Omnibus Rule | Set of regulations enhancing patients’ privacy protections and rights to information and the government’s ability to enforce HIPAA |
| Operating Rules | Rules that improve interoperability between the data systems of different entities, such as health plans and providers, and so increase their usefulness. |
| Password | Confidential authentication information composed of a string of characters. |
| Protected Health Information (PHI) | Individually identifiable health information that is transmitted or maintained by electronic media. |
| Relator | Person who makes an accusation of fraud or abuse in a qui tam case. |
| Transaction | Under HIPAA, structured set of electronic data transmitted between two parties to carry out financial or administrative activities related to healthcare |
| Treatment, Payment and Healthcare Operations (TPO) | Under HIPAA, patients’ protected health information may be shared without authorization for the purposes of treatment, payment, and operations. |
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