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Billing and Coding
Chapter 2
| Term | Definition |
|---|---|
| Abuse | Action that improperly uses another person's resources |
| Accountable Care Organization (ACO) | A network of doctors and hospitals that shares responsibilities 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 records 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 | a formal examination of a physicians accounting or patient medical records |
| Authorization | Document signed by a patient to permit release of particular medical information under the stated specific conditions |
| 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 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, and clinical laboratories (under the CLIA program), and other government health programs |
| Clearinghouse | A company (billing service, repricing company, or network) 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 no |
| Code Set | Alphabetic and/or numeric representation for data |
| Compliance Plan | a structured program that ensures a healthcare organization adheres to laws, regulations, and ethical standards, preventing fraud, abuse, and protecting patient privacy |
| Covered Entity (CE) | an organization or individual that handles protected health information (PHI) and must comply with the regulations |
| De-Identified Health Information | medical data from which individual identifiers have been removed; also known as a redacted or blinded record |
| Designated Record Set (DRS) | A covered entity's records that contain protected health information (PHI) |
| Documentation | The systematic, logical, and consistent recording of a patient's health status-history, examinations, test, 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 so they can be deciphered without the use of a confidential process or key |
| Evaluation and Management (E/M) | providers 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 1966 | federal act that sets 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 rules 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 plans and patient systems are yet to be created |
| HIPAA Privacy Rule | law that regulates use and disclosure of patients' protected health information (PHI) |
| HIPPA 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 |
| 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 healthcare system |
| Medical Documentation and Revenue Cycle | a series of steps that explain how using EHR's is integrated with practice management programs as the 10 steps billing process is formed |
| Medical Record | a file that contains the document 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 |
| 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) | unique individual identification system to be created under HIPAA National Identifiers |
| 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 for 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 that investigates and prosecutes fraud against government healthcare programs such as Medicare |
| Omnibus Rule | set of regulations enhancing patient's 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) | form that includes patients personal, employment, and insurance company data needed to complete a healthcare claim. Also known as registration form |
| Relator | person who makes an accusation of fraud or abuse in a qui tam case |
| Transaction | the electronic exchange of information between two parties to carry out administrative and financial activities related to healthcare services |
| Treatment, Payment, and Healthcare Operations (TPO) | patients protected health information may be shared without authorization for the purposes of treatment, payment, or operations |
Created by:
Tshaiya1
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