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MIC Bootcamp Alpha

Ms. Moneybags MIC Bootcamp Alpha Session

Acronym or TermDefinition
MDS Minimum Data Set
Minimum Data Set used in long term facilities; assesses residents;required by Medicare and Medicaid
UHDDS Uniform Hospital Discharge Datra Set
Uniform Hospital Discharge Data Set data created to collect inpatient data by acute care hospitals
Tumor registry every case entered is assigneda unique accession number preceeded by accession year
TNM tumor staging system for staging malignant neoplastic disease
T in TNM Tumor
N in TNM Regional lymph node involvement
M in TNM Metastases
CTR Cancer Tumor Registry
COP Conditions of participation
Conditions of Participation published by CMS; set of regulations health care institutions must follow to receive Medicare reimbursement
Disease index Lists in diagnostic order
Number control Index ID's new health record numbers and patients assigned to those numbers
Physician index ID's all patients treated by a physician
Master patient index links each patient treated in a facility with the health number
Operation index ID's operations performed
Procedure index ID's procedures performed
Patient care plan foundation of care for long term facilities
Charting by exception method of charting only abnormal or unusual findings or deviations of standard of care
Hospital bylaws general principals and policies of the medical staff
Federal Register where CMS publishes Conditions of Participation (COP) for hospitals
SOAP subjective;objective;assessment;physical
ROS Review of systems
CC chief complaint
Nomenclature system of terms that is structured according to pre-established naming rules
Data Dictionary Descriptive list of data elements to be collected in an information system or database
Patient self determination act of 1991 requires advance directives not need to be placed in patients charts
HEDIS Healthplan Employer Data and Information Set
Healthplan Employer Data and Information Set measures outcome of care for managed care plan
OASIS Outcome and Assessment Information Set
Outcome and Assessment Information Set core items of an assessment for adult home care patient; measures patient outcomes
Interrator reliability the extent to which two coders agree' addresses consistency
Data encryption changes readable text into different set of characters and numbers
audit trail program that records the action of a user
Firewall system that prevents access to a private network from the outside or limits it
Utilization review assessment of appropraiteness and economy of an admission. Length of stay is compared with other similar diagnoses.
Peer Review evaluation of individuals professional performance by others in the profession
Continuity of Care ensures that care stays consistent
CCI Correct Coding Initiative; implemented in 1996
42 Code of federal Regulations part 2 refers to regulations on confidentiality of alcohol and drug abuse patients records
Social Security Act of 1935 established the social security program
Omnibus Budget Reconciliation Act of 1989 created the Agency for Health Care Policy and Research
Health care Quality Improvement Act of 1986 provided immunity to peer review entities and created national Practitioner Data Bank
ad hoc means "for a special purpose"
POMR Problem oriented medical record
granularity relates to the fact that data can not be furhter subdivided
QIO Quality Improvement Organization
SI/IS severity of illness/ intensity of service
Auto authentication allows dictated reports to be automatically considered signed unless the health management dept. is notified that revisions are needed
RVG's Relative value guide
Relative Value Guide reflects the difficulty and time spent by an anesthesiologist for a particular service
DRG Diagnosis resource group
Diagnosis Resource Group classify hospital cases into approximately 500 groups according to diagnoses
APC Ambulatory Payment Classification group
HHRG Home health resource Group
Home health resource group source of payment for Home Health Agencies
RBRV's Resource Based Relative Value
Created by: msmoneybags