ESA HIM study guide

Longitudinal Record

- Record that follows a patients care overtime. - HIE initiatives have been developed in an effort to move toward a longitudinal patient record with complete information about the pt's available at any point of care.

migration plan

- Steps and process for adopting system - Is a step by step process that should be used when establishing, changing, and/or implementing a system

Medigap

- Supplement - health insurance plans that help pay expenses not covered by Medicare -a private insurance policy that pays the difference between the medical charge and the amount that Medicare pays

Data governance

- The overall management of the availability, usability, integrity, and security of the data employed in an organization or enterprise. - Enterprise authority that ensures control & accountability for enterprise data - Is the overall management of the availability, usability, integrity, & security of data used in an enterprise. - Governs input data

PKI (Public Key Infrastructure)

- enables users of a public network such as the Internet to securely and privately exchange data through the use of a pair of keys—a public one and a private one—that is obtained from a trusted authority and shared through that authority. - An encryption system that is composed of a CA, certificates, software, services, and other cryptographic components, for the purpose of verifying authenticity and enabling validation of data and entities. - HIE's protect patient privacy & security by requiring the use of usernames & passwords or security tokens such as PKI digital certificates to access the system.

Feedback controls

- non self correcting - back end processes that monitor and measure output and then compare it to the expectations and identify variations that then must be analyzed so corrective action plans can be developed and implemented. Processes with feedback controls in place are also called cybernetic processes or systems. Some may be self-regulating (such as thermostatic systems), but most are non-self regulating, meaning that they require intervention by an oversight agent ( supervisor, manager, or an auditor) to identify the variance and take action to correct it. A customer survey or routine performance reviews are examples of this type of control

ROI (Release of Information)

- process followed by employees of covered entities when releasing patient information - The process of disclosing patient-identifiable information from the health record to another party -An aspect of health information management which allows for the legal release of patient information to another party or to the patient. -ROI manager must gather statistics regarding performance (request turnaround time, number of requests processed per employee per month, number of subpoenas processed per employee per month)

Geographic Information System (GIS)

-DSS capable of assembling, storing, manipulating & displaying geographically referenced data & information. -GIS identify data according to their location EX: Pediatricians consult community-based GIS's to observe neighborhoods with high concentration of lead & decide whether lead screenings would be appropriate for certain patients.

qualitative analysis

-HIM personnel carefully review the quality and adequacy of record documentation and ensure that it is in accordance with the policies, rules, and regulations established by the facility; the standards of licensing and accrediting bodies; and government requirements. Like quantitative analysis, qualitative analysis may be done concurrently or retrospectively -Qualitative analysis is a review of medical record entries for inconsistencies and omissions which may signify that the medical record is inaccurate or incomplete. Such an analysis requires a knowledge of medical terminology, anatomy and physiology, fundamentals of disease processes, medical record content, and the standards of licensing, accrediting, and certifying agencies. It is usually performed by a qualified medical record practitioner. -Ex: Reviewing a medical record to ensure that all diagnoses are justified by documentation throughout the chart -Ex: During a retrospective review of Rose Hunter's inpatient health record, the health information clerk notes that on day 4 of hospitalization there was one missed dose of insulin. -Ex: I reviewed the health record of Sally Williams and found the physician stated on her post-op note, "examined after surgery".

Exclusive Provider Organizations EPO

-combination of HMOand PPO - restrictive in the number and types of providers (more like HMO) - will not pay anything if go outside of network provider - EPO beneficiaries do not receive reimbursement for services furnished by nonparticipating providers.

Nonparticipating providers (nonPARs)

-they expect to be paid the full fee charged for services rendered *In these cases, the patient may be asked to pay the provider in full and then be reimbursed by BCBS the allowed fee for each service, minus the patient's deductible and copayment obligations -even when the provider agrees to file the claim for the patient, the insurance company sends the payment for the claim directly to the patient and not to the provider -do not sign a participation agreement with Medicare but may or may not accept assignment. If the nonPAR physician elects to accept assignment, he or she is paid 95 percent (5 percent less than participating physicians) of the MFS. NonPAR providers who choose not to accept assignment are subject to Medicare's limiting charge rule, which states that a physician may not charge a patient more than 115 percent of the nonparticipating fee schedule.

Project Plan

A formal, approved document that manages and controls project execution

Secondary release of information

A type of information release in which the initial requester forwards confidential information to others without obtaining required patient authorization

Request for Proposal (RFP)

A type of procurement document used to request proposals from prospective sellers of products or services. In some application areas, it may have a narrower or more specific meaning. - RFP generally includes much more detail on the systems requirements & provides guidelines for vendors to follow in bidding. -Good idea to begin contact negotiation process with more than 1 vendor - provides leverage. -Part of system selection process, project team should conduct a cost-benefit analysis for each variable alternative. Cost should include acquision costs ( hardware, software, network, training). operating/maintenance costs (system upgrades, technical support, supplies & equipment)

comorbidity vs complication

Comorbidity: A condition that existed at admission. The co-occurrence of two or more disorders in a single individual. A condition that existed at admission and is thought to increase the length of stay at least one day for approximately 75 percent of patients. Complication: secondary condition that arises during hospitalization and is thought to increase the length of stay by at least one day for approximately 75 percent of patients.

Certification

Process by which government & non - government organizations evaluate educational programs, healthcare facilities and individual as having met pre- determined standards.

International Classification of Disease for Oncology

Provides a detailed classification system for coding the histology, topography, & behavior of neoplasms.

Safe Harbor

Provision in a law or regulation that provides some measure of protection from liability if certain conditions are met. - The "safe harbor" regulations describe various payment and business practices that, although they potentially implicate the Federal anti-kickback statute, are not treated as offenses under the statute. - An arrangement to avoid start law - MD must fit squarely within the requirements. If Safe Harbor or exception contains multiple elements or conditions, MD must satisfy each element or condition. - Ex: Fulltime lease agreement between MD & provider to whom the physician refers pts can meet the space rental safe harbor agreement - Safe harbor protects certain payment and business practices. An arrangement must fit squarely in order to be protected by Safe Harbor.

Quality Assessment for the Coding Process

Quality assessment for the coding process is also referred to as performance improvement for the coding process. Quality assessment of a process is generally ongoing.

nomenclature

Recognized system of terms used in a science or art that follows pre-established na,ing converntions. A disease nomenclature is a listing of the proper name for each disease entity with its specific code number - When vocabulatory assigns a name to a concept, its defined as nomenclature. Examples of nomenclature: - Snomed - Ct: Clinical & Anatomic Pathology - LOINC: Laboratory/Clinical Observations - NDC/NDF-RT: Pharmaceuticals -NIC/NOC: Nursing

Beacon Community Program

- A federal grant program for communities to build and strengthen their health information technology (HIT) infrastructure and health information exchange (HIE) capabilities -A federal grant program for communities to build and strengthen their health information technology (HIT) infrastructure and health information exchange (HIE) capabilities.

False Claims Act (FCA)

- A federal law that prohibits submitting a fraudulent claim or making a false statement or representation in connection with a claim. -The civil FCA protects the Government from being overcharged or sold shoddy goods or services. It is illegal to submit claims for payment to Medicare or Medicaid that you know or should know are false or fraudulent. EX) Cardiologist was prosecuted under FCA for submitting claims for E/M services even though he had already received payment for the same services under previously billed stress test claims. Claims may be false if the service is not actually rendered to the pt, is proved but already covered under another claim, is miscoded, is not support by the medical record.

Income Statement

- A financial statement that reports a company's revenues and expenses and resulting net income or net loss for a specific period of time. -A financial statement showing the revenue and expenses for a fiscal period.

all patient diagnosis-related group (AP-DRG)

- DRG system adapted for use by third-party payers to reimburse hospitals for inpatient care provided to non-Medicare beneficiaries (e.g., BlueCross BlueShield, commercial health plans, TRICARE); DRG assignment is based on intensity of resources. - system are still used in a number of states as a basis for payment of non-Medicare claims. AP-DRGs use the patient's age, sex, discharge status and ICD-9-CM diagnosis and procedure codes to determine a DRG that, in turn, determines reimbursement.

MDC: Major diagnostic categories

- Diagnosis-related groups are organized into: - Most MDCs are based on body systems and include diseases and disorders relating to a particular system. However, some MDCs include disorders and diseases involving multiple organ systems (for example, burns). The number of MS-DRGs within a particular MDC varies.

Medicaid

- Health assistance for people of any age - Administered by the federal government through state and local governments following federal and state guidelines - Medicaid regulations vary from state to state - Finances by federal, state and county tax dollars - Eligibility based on financial need - Medicaid can help pay Medicare deductibles, coinsurance, or copayment, and premiums - Comprehensive benefits include hospitals, preventive care, long-term care, and other services not covered under Medicare such as dental work, prescriptions, transportation, eyeglasses, and hearing aids.

Decision Support System (DSS)

- Models information to support managers and business professionals during the decision-making process. - Interactive computer systems that intend to help decision makers use data & models to identify & solve problems & make decisions. - Order entry system - DDS is based on either data repository model or data warehouse model. Both transfer data from an operational environment ( either in real time or retrospectively, in batches at fixed intervals) - DDS analysis helps companies to identify & solve problems & make decisions

System Development Life Cycle (SDLC)

The overall process for developing information systems from planning and analysis through implementation and maintenance. 1. Analysis Phase: Conduct focus groups, analyze where the problem lies & what needs fixing 2. Design Phase: New system built in house? will organization hire an outside development to build the system,? Or cloud computing? - Request for information (RFI), - Request for proposal (RFP) 3. Implementation: After contract negotiations have been finalized involved project manager. Test system before go-live date. 4. Maintenance & evaluation: ROI since implementation, backups, upgrades.

Stakeholder

The project also has stakeholder. The stakeholder is anyone in the organization who is affected by the project product. Stakeholders include personnel who are on the project team, personnel whose daily work will be change because of the projects product, and the managers and executives for those departments involved in the project. - Each stakeholder will evaluate the projects success based on these concerns and the expectations they hold for how the project will benefit them.

Initial planning and super use training

The project governance structure may be implemented with the various domain teams that support the EHR steering committee. This includes assigning responsibility and accountability for making the myriad decisions that must be made during the course of implementation

Parties

The recipients can be considered the "first parties" and the providers the "second parties." Third-party payers include commercial for-profit insurance companies, nonprofit Blue Cross and Blue Shield organizations, self insured employers, federal programs (Medicare, Medicaid, CHIP, TRICARE, CHAMPVA, and IHS), and workers' compensation programs.

Security

To control access & protect info from accidental or international disclosure to unauthorized persons

Freedom of information act, "FOIA

as a federal law through which individuals can seek access to information without authorization of the person to whom the information applies. This act applies only to federal agencies and not to the private sector. The veterans administration and defense department hospital systems are subject to this act, but a few other hospitals are the only protection of health information held by federal agencies exist when disclosure with "constitute a clearly unwarranted invasion of personal privacy".

global surgery payment

covers all the healthcare services entailed in planning and completing a specific surgical procedure. In other words, every element of the procedure from the treatment decision through normal postoperative patient care is covered by a single bundled payment.

Enterprise information management "EIM"

"EIM" is an essential organizational discipline and information governance as a commercial building block of EIM. Information governance is like that accountability rapper for EIM. Like all effective governance, information governance begins with the board of trustees and senior leaders. Hospital boards are now holding senior management accountable for steps being taken to avoid breaches of data. Information exchange and greater transparency in public at accountability for outcomes in cost raise the stakes EIM will have mechanisms to track who uses the data and how it is used. EIM will assess the Reliability of information to ensure that it is in line with the critically of these uses. EIM will ensure that those who view data information are authorized to do so. EIM will understand how long information should be retained and in what form. EIM will ensure that there is an internal learning system or feedback loops information management policies and practices are being adopted and improved continuously

Project components

"Related parameters of scope, resources, and scheduling with regard to a project". These components have a strong dependency. If one of the three components changes, then one of the other two parameters must change as well.

Coding and corporate compliance

** BAA = Balanced Budget Act The BBA focused on fraud and abuse issues specifically relating to penalties. The BBA also required that physicians and practitioners provide diagnostic information (to show medical necessity) prior to a facility performing lab or radiology services for a patient.

RAP (resident assessment protocol)

- A summary of a long-term care resident's medical condition and care requirements - Long term setting; these are problem - oriented frameworks for additional patient assessment based on problem identification items or triggered conditions.

QIO (Quality Improvement Organization)

- A private organization composed of practicing physicians and other health care professionals in each state that is paid by the Centers for Medicare & Medicaid Services under contract to review the care provided to Medicare beneficiaries. -The QIO Program, one of the largest federal programs dedicated to improving health quality for Medicare beneficiaries, is an integral part of the U.S. Department of Health and Human (HHS) Services' National Quality Strategy for providing better care and better health at lower cost. By law, the mission of the QIO Program is to improve the effectiveness, efficiency, economy, and quality of services delivered to Medicare beneficiaries. Based on this statutory charge, and CMS's program experience, CMS identifies the core functions of the QIO Program as: *Improving quality of care for beneficiaries; *Protecting the integrity of the Medicare Trust Fund by ensuring that Medicare pays only for services and goods that are reasonable and necessary and that are provided in the most appropriate setting; and *Protecting beneficiaries by expeditiously addressing individual complaints, such as beneficiary complaints; provider-based notice appeals; violations of the Emergency Medical Treatment and Labor Act (EMTALA); and other related responsibilities as articulated in QIO-related law. What are QIOs? A Quality Improvement Organization (QIO) is a group of health quality experts, clinicians, and consumers organized to improve the quality of care delivered to people with Medicare. Why does CMS have QIOs? CMS relies on QIOs to improve the quality of health care for all Medicare beneficiaries. The QIO Program is an important resource in CMS's effort to improve quality and efficiency of care for Medicare beneficiaries. QIO Reports to Congress: CMS is required to publish a Report to Congress every fiscal year that outlines the administration, cost, and impact of the QIO Program.

All-Patient refined DRGs (APR-DRGs)

- An expansion of the inpatient classification system that includes four distinct sub-classes (minor, moderate, major, and extreme) based on the severity of the patient's illness - Adjust patient data for severity of illness and risk of mortality, help to develop clinical pathways, are used as a basis for quality assurance programs, and are used in comparative profiling and setting capitation rates

OLTP (online transaction processing)

- Capturing and storing data from ERP, CRM, POS - Day-to-day business transactions - The main focus is on efficiency of routine tasks -Transactions such as claims submission -Ex: Hitting a button & submitting a claim to a a3rd party payor - & that will be recorded in OLTP -Operational -Relational & object-oriented database models for data repositories

IPSD (Inpatient Service Day)

- Census = count of people, county of population - IPSD: Unit of measure equivalent to the services received by one inpatient during 24 hour period. - Midnight is a common census taking time - Usual 24-hour reporting period begins at 12:01 am & ends 12:00 midnight. - In census count, adults, children (A&C) are reported separately from newborns. - Automatically generated based on admission, discharge & transfer data entered into the computer -through the day

ASTM International

- Formally known as the "American Society for Testing Materials". They develop the standards in many industries to improve product quality and safety. - Formerly known as the American Society for Testing and Materials, a system of standards developed primarily for various EHR management processes -originally known as the American Society for Testing and Materials, is an international standards organization that develops and publishes voluntary consensus technical standards for a wide range of materials, products, systems, and services

LOINC

- Identifying test results Terms and codes used for electronic exchange of lab results and clinical observations.

OASIS (Outcome and Assessment Information Set)

- Is a group of data elements that represent core items of a comprehensive assessment for an adult home care patient and form the basis for measuring patient outcomes for purposes of outcome-based quality improvement - Gather data about Medicare beneficiaries receiving home health - Used to access the quality of health services - Set of core data items that are collected on all adult home health patients Used as a basis of reimbursement - Data collected through OASIS are used to access the patient's ability to be discharged or transferred from home care services.

What are the entities that have roles in various medicare improper payment review processes?

- MAC -RAC -QIO

Incident rate (IR)

- Measures Morbidity ( rate of disease in populations) - Measure used to describe the presence of disease in community or specific location ( ex: a nursing home) Incident Rate - used to compare the frequency of disease in populations. Populations are compared using rates instead of raw #s because rates adjust for differences in populations sizes. - Incident rate is the probability or risk of illness in population over a period of time EX: Nursing home of 110 patients, 2 have H1N1 ([2/110] x 100) = 2% (incident rate, round up) Equation: Total # of new cases of a specific disease during a given time period / total population at risk during the same time period x 100

OCE (Outpatient Code Editor)

- Portions of the NCCI are incorporated into the outpatient code editor, against which all ambulatory claims are reviewed. The OCE also applies a set of logical rules to determine whether various combinations of codes are correct and appropriately represent services

charge capture

- The process of collecting all services, procedures, and supplies provided during patient care. - Is a method of recording services and supplies or items delivered to the patient and directing them to be billed on a claim form. -Payment rates established for diagnosis-related groups (DRGs) and ambulatory patient classifications (APCs) is determined by analyzing historical cost data, and if true costs are not being reflected, reimbursement rates are set too low. Charges reflect resource utilization; this allows analysis and comparison of the resources used for patients with similar diagnoses treated in similar service lines or receiving similar treatments. -The primary responsibility for charge capture is assigned to staff in the departments providing the services, but there are complex regulatory requirements surrounding compliant charge capture, so ongoing charge capture education with well-documented policies and procedures is vital. -Organizations may utilize internal billing system edits designed to detect and correct charge capture errors before claims are submitted to the third-party payers. They may also utilize APC grouper software or Medicare claims scrubber software designed to detect errors that would result in payer denials. As errors are detected, they should appear on reports and be reviewed by the appropriate departments so corrections can be made and issues or problems can be detected and resolved.

Project Scope

- The work that must be performed to deliver a product, service, or result with the specified features and functions. - Cost is the project budget, performance relates to the quality of the project work, time is the schedule and project scope is the magnitude of the work to be done - Should the cost, performance, or schedule variable change, the relationships dictate that the scope will change -

Database

- a collection of organized data that allows access, retrieval, and use of data - is an organizational tool that manages data so that it can easily queried for the data that are included

data dictionary

- compiles all of the metadata about the data elements in the data model - - a descriptive list of names "also called representations or displays", definitions, and attributes of data elements to be collected in an information system or database. - Data dictionary is like a map of the database. Whenever accent of data is created, it should have an accompanying data dictionary. A data dictionary can share consistency by standardizing definitions

outcome measures

- data describing the results of healthcare services - Document the results of care for individual patients as well as for specific types of patients grouped by diagnostic category. EX: Acute-care hospitals overall rate of post-surgical infection would be considered an outcome or core measure. The core measures must be reported to TJC via software from vendors that have been approved by the TJC for this purpose.

respite care

- planned short-term care, usually for the purpose of relieving a full-time informal caregiver. - Any inpatient care provided to the hospice patients for the purpose of provided to the hospice patient for the purpose of providing caregivers a break from their caregiving duties.

Privileges

- professional relationships between the patient and specific groups of caregivers further affect use of the record and its contents as evidence. these relationships are referred to as privileges. - Physician - patient privilege ; provide that the physician is not permitted to testify as a witness about certain information gained as a result of this relationship without the patient's consent

prospective utilization review

-A review of a patient's health records before admission to determine the necessity of admission to an acute care facility and to determine or satisfy benefit coverage requirements - A process that determines the appropriateness of utilization before the care is actually delivered. - A prospective utilization review of a plan to hospitalize a patient for minor surgery might determine that the surgery could be safely performed less expensively in an outpatient setting. Prospective utilization review is sometimes called precertification.

Charge Description Master (CDM)

-Is a system file that contains the basic elements for identifying, coding, pricing any item that may be provided to patients, including procedures, services & supplies. - Information about health care services that patients have received and financial transactions that have taken place. - - Database used by healthcare facilities to house the price list for all services provided to patients. - A hospital's list of the codes and charges for its services. - is an electronic file that represents a master list of all services, supplies, devices, and medications charged for inpatient or outpatient services. The CDM contains the basic elements for identifying, coding, and billing items and services provided to patients, and it is the mechanism for representing captured charges on the billing claim. Each billable service or supply is set up in the CDM and assigned an internal charge code number, which links it to the various data elements necessary for billing and for tracking charge activity within the organization. Charge code- a unique identifier to identify and represent each billable service or supply. The number is meaningful only to the organization and does not appear on the billing claim. Charge code description- a narrative description of the service or supply. It does not appear on the billing claim but would be available on an itemized patient statement. CPT or HCPCS code-- a nationally recognized five digit code. Not all CDM line items have a CPT or HCPCS code because there are services and supplies for which no code has been developed. These charges are represented on the claim using only the revenue code. When a CPT or HCPCS code code does exist to represent a chargemaster line item, it is reported on the outpatient billing claim. Modifiers-- two digit numeric or alphanumeric extensions that are added to the CPT or HCPCS codes to provide further information about the code. The claim form allows room for one or two modifiers to be attached to a CPT or HCPCS code. Revenue code- a nationally recognized four-digit code that provides a general identification of what the line item charge represents (that is, room and board, lab services, radiology services, pharmacy items, supply items, surgical procedures). The revenue code and its description are required on each line item of a billing claim for both inpatients and outpatients. Price- the charge that is established for the line item service, item, or supply. Factors that may determine the established price include: Medicare and Medicaid reimbursement rates Reimbursement provided by other third-party payers Cost information that is calculated by the accounting or finance area Standard markup rates for services or supplies Benchmark data on pricing in comparable organizations Market competitive services. The chargemaster must continually be updated to ensure that it represents all billable services and supplies and to keep up with changes in CPT or HCPCS codes, revenue code assignment, and payer-specific requirements. Many larger organizations use a software system to assist with maintenance of the CDM and to view items that are set up in a department or cost center's chargemaster. The software is primarily designed to continuously apply edits that point out compliance issues, validity of elements such as CPT codes and revenue codes, and identification of items priced below national reimbursement levels. Maintenance of the CDM is a multidisciplinary activity. Proper chargemaster maintenance requires expertice in coding, clinical procedures, health record or clinical documentation, and billing regulations. Performing chargemaster review at least annually Consequences of improperly maintained or inaccurate chargemaster are the following: Services are provided, but associated charges are not set up in the CDM, so the organization is unable to bill and is providing free service. If a charge is not set up in the CDM until after the service is provided, the charge might not get posted to the patient's account during the bill hold time. When all services are not set up in the CDM, the department is only capturing part of its charges, and the result is reduced revenue. If charges are not set up in the CDM or if there are errors in the way they are set up, billing edits and APC edits may be generated, holding up processing of the claim. All billing delays result in increased accounts receivable (A/R) days. APC and billing edits result n multiple individuals investigating the issues and making necessary changes, which results in increased cost to the organization.

Meaningful Use (MU)

-The set of standards defined by the Centers for Medicare & Medicaid Services (CMS) Incentive Programs that governs the use of EHRs and allows eligible providers and hospitals to earn incentive payments by meeting specific criteria -Requirements established by the Centers for Medicare and Medicaid Services (CMS) as part of the Electronic Health Records (EHR) Incentives Program. The program provides financial incentives for healthcare organizations that "meaningfully used" their certified EHR technology. The requirements include implementing security measures to ensure the privacy of patients' EHRs. - among the many programs in HITECH, somewhere men to support and promote adoption and effective use of electronica health records, referred to as EH our incentive programs the EHR incentive program became known as the meaningful use program.- overtime eligible providers who do not meet the men meaningful use requirements will have their Medicare payments reduced.- to encourage early participation in the meaningful use program, the highest incentives were designed to be paid in the first two stages of the program. Items that were elective and stage 1 were predicted to become requirements in stage 2 and beyond.

incident report

-happening that is inconsistent with the standard of care - Anyone witnessing or involved in an incident should complete an incident report as soon as possible after the incident as a way to capture the details of what happened. - Because incident reports contain facts, hospitals strive to protect their confidentiality. In some states, incident reports are protected under statutes protecting QI studies and actives. Protection under this doctrine maybe be based on whether the primary purpose of the incident report is to provide information to the hospitals attorney or liability insurer. - Incident reports themselves are not part of the clinical record and are considered confidential and privileged in many states.

parties

1st parties - recipients 2nd parties - providers 3rd parties - insurance

Discharge summary report

A brief summary of the significant events of a patient's hospitalization.

Processing of reimbursement claims

A facility's patient accounts department is responsible for billing third-party payers, processing accounts receivable, monitoring payments from third-party payers, and verifying insurance coverage.

clinical terminology

A set of standardized terms and their synonyms that record patient findings, circumstances, events, and interventions with sufficient detail to support clinical care, decision support, outcomes research, and quality improvement

Clinical Decision Support System

A special subcategory of clinical information systems that is designed to help healthcare providers make knowledge-based clinical decisions -The clinician is expected to receive and be guidd by clinical decision support systems that process the structured data against a drug knowledge database (DKB) and other evidence based medicine ( EBM) into alerts, reminders, and context-sensitive templates for data capture, although often the volume of such incessant warnings

Commission on Accreditation of Rehabilitation Facilities (CARF)

Accredits Rehab programs and services, it includes elderly services, behavioral health, children and youth services, employment and community services, opioid treatment, vision rehab and service management networks.

ASTM CCR

American Society for Testing & Material Continuity of care record (CCR). Standard assists in the sharing of information from one provider to another for patient care. Standards is designed to permit easy creation by any provider using an electronic health record system at the end of an encounter.

Continuity of Care Record (CCR)

An early form of a document developed to make communication about patients' course of care available across facilities; CCD replaced it.

Physician champion

An individual who assists in communicating and educating medical staff in areas such as documentation procedures for accurate billing and appropriate EHR processes

Project manager

An individual who is an expert in project planning and management, defines and develops the project plan, and tracks the plan to ensure the project is completed on time and on budget

biomedical research

Biomedical Research: The area of science devoted to the study of the processes of life, the prevention and treatment of disease, and the genetic and environmental factors related to disease and health. Most biomedical research involves clinical trials, which are phased studies using human volunteers, designed to answer safety and efficacy questions about biologics, devices, pharmaceuticals, new therapies or new ways of using known treatments. Biomedical Research Trials: are often conducted in small group initially but expanding in later stages once safety and efficacy are demonstrated. Most clinical trials are FDA regulated,

Datasets

Compare uniform discharge data from from one hospital to the next led to the development of data sets or lists of recommended data elements with uniform definitions.

Completeness

Completeness refers to having not only adequate data elements present but also the correct pairing or linking of all existing records for that individual within & across information systems. - Is the elements of coding quality to which the codes capture all of the diagnoses & procedures documented in the patients health record.

DEEDS

Data Elements for Emergency Department Systems - A data set designed to support the uniform collection of information in hospital-based emergency departments. - Designed to provide uniform specifications for data elements chosen to be retained, revised, or added to their ED record systems to build re-usable clinical data definitions. - Purpose is to support the uniform collection of data in hospital-based ED and to substantially reduce incompatibilities in ED records. - Many states require the reporting of trauma cases to state agencies

Data Capture

Data capture methods identify which methods are permitted for sure and who is permitted to use them EX: structured data capture should be used for positive or negative findings, such as the documentation of positive or negative responses to questions about past history, family history, social history, and the review of systems. Structured text is also appropriate for documentation of diagnostic procedures ordered and the patients presenting problem. Free text narrative is appropriate for E/Ms compliance, medical necessity, history of present illness, details about past history, clinical impressions, and treatment options or whenever there needs to be more thorough explanations of findings.

integrity constraints

Databases contain rules known as integrity constraints and must be satisfied by the store data

Medicaid

Each state can determine which groups Meidicad will cover, each state also establishes its own financial criteria for Medicaid eligibility

Role-Based Access Control

Ensures that the user gains access only to the resources that the user should be able to access

Retrospective payment system

Exact amount of payment is determined AFTER services has been delivered

Data

Facts and statistics collected together for reference or analysis. Raw facts generally stored as characters, words, symbols, measurements or statistics

HIPAA (Health Insurance Portability and Accountability Act)

HIPAA authorizes the OIG to investigate cases of heathcare fraud that involve private heathcare plans as well as federally funded programs.

Risk Identification

Identifying the potential project risks and documenting their characteristics. - Incident report: is the essential tool that is used in identifying risk

retention

Length of time, based on policy records must be retained & the proper disposition of them when they should no longer be stored.

exclusion authorities

MANDATORY EXCLUSION: Imposed on the basis of certain criminal convictions PERMISSIVE EXCLUSION: Based on sanctions by other agencies, such as state medical board suspending or revoking a medical license or defaulting on health education loans or providing unnecessary or substandard care. -Exclude MDs cant bill for treating medicare or medicaid pt's, nor may their services be billed in-directly through an employer or group practice.

Accounts Receivable

Medicare Administrative Contractors (MACs) contract with CMS to serve as the financial agent between providers and the federal government to locally administer Medicare's Part A and Part B.

Medicare's Acute Care Prospective Payment System

Medicare Part A payments to hospitals were determined on a traditional FFS reimbursement methodology.

Fraud

Obtaining of something of value through intentional mis-representation or concealment of material facts.

Project risk vs project value

One of project managers responsibilities is mitigate risk. However, the organization will need to weigh the cost of potential risks against a perceived value to be gained.

Incident Reporting

One tool commonly used to conduct risk management activities is incident reporting. Incident reports are submitted by anyone who knows situations were injury or harm occurred or could have occurred. Incident reports are confidential and allow analysis of individual incidents to determine whenever the incident could've been prevented or resulting harm produced. Incident reports are not kept in a patient's health record, and complete candor about what happened is necessary if their information is to be useful.

Open record review vs closed record review

Open Record Review: A review of the health records of patients currently in the hospital or under active treatment; part of the Joint Commission survey process - Also called ongoing record review, point of care review, continuous record review. - Should be done on-going basis, when a qualitative analysis is done while the patient is in a facility or underactive treatment - benefit: Problems in the care process that are revealed through the review can be corrected immediately Closed record review: A review of records after a patient has been discharged from the organization or treatment has been terminated. -(Qualitative review is done retrospectively following discharge or termination of treatment) -Important way to obtain information about trends & patterns of documentation

managed care

Prepaid health plans that integrate the financial and delivery aspects of healthcare services

Principle Procedure UHDDS defines

Procedure - performed for definitive treatment ( rather than for diagnostic or exploratory purposes) or one that is necessary to care for a complication

emerging technologies

Speech recognition is one candidate for improving the coding process as well as coding accuracy. Speech recognition, combined with technology designed to extract and structure medical information contained in narrative text, can automate the coding process used in reimbursement.

Workers' Compensation Laws

State statutes that establish an administrative process for compensating workers for injuries that arise in the course of their employment, regardless of fault. - Some states exclude certain workers like business owners, independent contractors, farm workers

Death Summary

Summary statement is added to the final progress note or as a separate summary. Includes: reason for admission, findings, & course in the hospital, events leading to death.

System configuration

System configuration's sometimes called system built, is the structuring of the applications to fit the care delivery organizations environment. System build is the process whereby the organizations unique data and clinical standards are designed into the system

Quality Measures for Improvement

The Healthcare Financial Management Association (HFMA) defined key measures to evaluate revenue cycle performance. The tool allows hospitals to track its revenue cycle performance using industry-standard metrics and compare the results with peer groups based upon the aforementioned influences.

Point of Care Services

The ability to capture & retrieve data & information at the location where care is being performed EX: Touch screen, barcode, handheld devices, wireless

Entity Authentication

The corroboration that an entity is the one claimed; the computer reads a predetermined set of criteria to determine whether the user is who he or she claims to be ex: utilizing a password systems

Daily inpatient census

The number of inpatients present at census-taking time each day, plus any inpatients who were both admitted and discharged after the census-taking time the previous day. Total number o patients treated during a 24-hour period, the total number of inpatient present at the official census-taking time each day. Also, included are any patients who were admitted & discharged that same day.

Retrospective Review

The part of the utilization review process that concentrates on a review of clinical information following patient discharge

Prevalence rate

The total number of people infected at one time in a population, regardless of when the disease began. - Prevalence rate describes the magnitude of an epidemic & can be an indicator of the medical resources needed in a community for duration of the epidemic. EX: Community of 600,000 people...2,486 people have AIDS & an additional 309 cases identified. ([2,486+309]/600,000 x 1,000) = 4.66 Prevalence rate is 4.66 cases per 1,000 population Equation: All new & pre-existing cases of a specific disease during a given time period / Total population during the same time period

retrospective documentation practices

Those where healthcare providers add documentation after care has been given for the purpose of increasing reimbursement or avoiding a medical legal action.

5010

Transaction code used by providers to communicate claims info with CMS. information about eligibility, enrollment, premium payments, referrals, and claims with their business partners. without implementation of 5010, iCD 10 coding cannot be processed by healthcare providers, claims, processing entities, and insurance companies.

CDC Centers for Disease Control and Prevention

a federal agency that conducts and supports health promotion, prevention and preparedness activities in the United States with the goal of improving overall public health.

HIE (Health Information Exchange)

a network that enables the sharing of health-related information among provider organizations according to nationally recognized standards.

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.

contingency plan

an alternative course of action to be followed if a specific problem arises. - This standard is where covered entities must consider what to do in a natural disaster, or if they loser power. They can establish strategies for recovering access to ePHI "should the organization experience an emergency or other occurrence" EX: Organizations should know what type of back-up material is needed, i.e. recovery discs or back-up storage. How will ePHI be protected in various situations, such as if the power is out for an extended period of time?

Project management

application of knowledge, skills, tools and techniques to project activities to meet the project requirements. Project management is concerned with completing a project with an expected cost and timeline with high-quality results.

Global Surgery Payment

covers all the healthcare services entailed in planning and completing a specific surgical procedure. In other words, every element of the procedure from the treatment decision through normal postoperative patient care is covered by a single bundled payment.

loss reduction (risk control)

employ techniques used to manage events or claims that have already taken place ways to reduce losses in occurred include; - investigating reported accidents or addressing occurrence reports promptly. - Reviewing claims made against the facility - managing Worker's Compensation programs - being knowledgeable about alternative dispute resolution processes - treating employee injuries on side - implementing back to work programs - assisting with the depositions or other Pretrial activists - working closely with defense counsel.

Strategic profile; assessment process

identify as existing key services or products of the department organization, the nature of its customers in users, the nature of its market segments, and the nature of the geographic markets.

Probability factor

indicates that as of the particular risk occurring

Project office

is responsible for defined project management procedures, conducting a risk analysis on projects, and mentoring project managers.

Information integrity

is the dependability or trustworthiness of information - it encompasses the entire framework in which information is recorded, processed and used. The concept is larger than data quality whereas data quality focuses on guarding against in correcting bad data, information integrity encompasses three domains and the relationship among them; information content, process, system.

Steerage

is when an insurer provides financial incentive or discounted rates to a facility to obtain a flow of patients it would not otherwise receive. Contract management also includes a comprehensive understanding of competitors and the local market rates, for instance, what other providers of service are charging. Managers need to negotiate language and rates and be able to define payers' and providers' duties.

Long term care

long-term care describes the care provided for extended periods of time to patients recovering from illness or injury. Long-term care facilities offer a combination of services ranging from independent living to assisted living to skilled nursing care. Rehabilitation services are often part of the long-term care plan. The long-term care record must document a comprehensive assessment that includes items in the minimum data said "MDS" to meet CMS requirements.- uniform data collection is important in long-term care settings- The focus in long-term care is on the achievement of goals. The HIM functions are similar to those in other types of facilities, but a great deal of concurrent review is required to ensure that a complete medical record is maintained throughout the residence Lengthy this day.

Automated Review

no medical record needed; improper payments are determined based solely on the submitted claims and regulatory guidelines such as National Coverage Determinations, Local Coverage Determinations, and the CMS Manuals. Review occurs when the provider receives a demand letter for repayment from the RA. There is no prior review of the medical record prior to receiving the demand letter. Therefore, recoupment is automatic. The provider has 30 days to dispute the findings, the FI/MAC will offset the overpayment, if MD doesn't successfully dispute the findings after 30 days

Stark Law Exceptions

preventive screeing tests, immunications & vaccines

Risk Management

programs are designed to prevent or reduce accidents and injuries in healthcare facilities in organization. Today is to reduce risks to patient, visitors, employees, physicians, or volunteers working in or visiting healthcare facilities for Business or personal reasons.

Authorization management

protecting the security and privacy of data in the database. Two of The important aspects of authorization management are user access control and usage monitoring User access control - features within the database are designed to limit access to the database or some portion of it

Routine monitoring; generic screening

reviews are generically carry out using predetermined criteria to review medical records or other information that brings to light opportunities to improve. Examples of genetic reviews include checking whether consent forms are completed and signed according to the organizational policies; reviewing infection rates (again looking for trans by unit, department, operating room, and such) ; Or evaluating information about patients who returned unexpectedly to the operating room, repeatedly required emergency care, or required Brie admission to the hospital for the same condition a short time following discharge. Result reviews should look for trends In incidence quote by department, specialty, clinician, type of incident". Evidence of regular reviews is required by accrediting bodies and maybe used by insurers, surveyors, or investigators when deemed appropriate.

Gantt Chart (bar chart)

shows in a graphic manner the amount of time involved and the sequence in which activities can be performed - method to illustrate the time needed for each task

soap

subjective, objective, assessment, plan - Part of problem - oriented medical record approach most commonly used by physicians and other healthcare professionals intended to improve quality & continuity of client services by enhancing communication among healthcare professionals.

cloud computting

the practice of using a network of remote servers hosted on the Internet to store, manage, and process data, rather than a local server or a personal computer. Model for enabling, on demand network access to a shared pool of configurable computing resources (that is, networks servers, storage, application and services). Refers to an on-demand, self service internet infrastructure that enables the user to access computing resources anytime from anywhere.

Durable Power of Attorney (POA)

A legal document that permits an individual (principal) to appoint another person to make any decisions regarding health care if the principal becomes unable to make the decisions.

fee schedule

A list of charges or established allowances for specific medical services and procedures. - Most managed care plans negotiate with providers to develop a discounted fee schedule - Managed FFS reimbursement is common for inpatient hospital care

Near - misses

reporting of near misses, such as dosing error if medication order is not correctly interpreted by the pharmacy or staff member dispersing or delivering the medication to the patient, even if no harm results. Near miss reporting allows opportunity to proactively evaluate and improve systems, thereby preventing harm to patients or others. Harmful incidents involving patients should be recorded in a complete factual way in the health record near miss incidents are never recorded in a patient's health record, although an accident report may be filed.

Executive information system (EIS)

A specialized DSS that supports senior level executives within the organization - Capable of accessing broad range of internal & external data - So that managers can broad strategic issues & then explore the information to find the root causes of those issues

TJC (The Joint Commission)

Primary function: The accreditation of hospitals & other healthcare organizations. - A not-for-profit organization that surveys & accredits healthcare delivery systems such as medical equipment, suppliers, staffing firms, outpatient clinics - Accreditation is voluntary but if you're not accredited by TJC then you can collect payment from the government or commercial insurances, Only cash patients. - Some states set up their own accrediting processes

run chart

- A chart that displays the history and pattern of variation of a process over time -Tool for tracking results over a period of time

Serial Numbering

- A new number is assigned to the patient for each new encounter at the facility. -In serial numbering, a patient receives a new number each time he or she is admitted.

waste

The incurring of unnecessary cots as a result of deficient management, practices, systems, or controls

Project components; Resources

- "Related parameters of scope, resources, and scheduling with regard to a project" - Resources any physical asset needed to complete a task. This includes facilities, equipment, materials, and supplies. Resources also can include individuals from outside organizations such as suppliers or vendors. One reason why many projects failed to meet their objectives within the expected timeframe and budget is that their school begins to grow as they process. For example new functions or features are added to a software implementation. This commonly known as scope creep. The requester presents each change has a small revision with low impact and timeline or cost. However, several minor changes soon add up to a more significant modification to the original work or cost estimate. The project manager must be diligent to prevent scope creep.

Medical staff bylaws

-A collection of guidelines adopted by a hospital's medical staff to govern its business conduct and the rights and responsibilities of its members -Standards governing the practice of medical staff members; typically voted upon by the organized medical staff and the medical staff executive committee and approved by the facility's board; governs the business conduct, rights, and responsibilities of the medical staff; medical staff members must abide by these bylaws in order to continue practice in the healthcare facility

primary diagnosis

-First-listed diagnosis, used in the outpatient setting to identify the reason for the encounter -a diagnosis that represents the patient's major illness or condition for an encounter - The primary reason that an individual is seeking help in a healthcare organization & is the condition the doctor finds & diagnose

permanent variance

A financial term the refers to the difference between the budgeted amount and the actual amount of a line item that is not expected to reverse itself during a subsequent period

Upcoding

A fraudulent practice in which provider services are billed for higher procedural codes than were actually performed, resulting in a higher payment.

project team

A group assigned to coordinate the success of a specific task. is composed of individuals who possesses the knowledge and skill set to produce the project deliverables and work products. There are three types of project team structure; functional, projectized, matrixed.

Coding

CPT or HCPCS codes are assigned only for outpatient claims. When documentation is vague or ambiguous, they may need to query the physician for clarification. A bill cannot be generated until the coding is complete, so organizations routinely monitor the discharged, no final bill (DNFB) days. The goal for an efficient revenue cycle is to eliminate any backlog of uncoded charts and to complete the coding process within the time frame of the bill hold days that have been established for the organization.

QDM (Quality Data Model)

Clearly defines concepts used in quality measures & clinical care & is intended to enable automation of structured data capture in EHR's, PHR's & other clinical applications. It provides a grammar to describe clinical concepts in a standardized format so individuals monitoring clinical performance & outcomes can concisely communicate necessary info

Concurrent review vs Utilization Review

Concurrent review: - determines whether length of time and scope of inpatient stay is justified - A review of the health record while the patient is still hospitalized or under treatment - Review for medical necessity of tests and procedures ordered during an inpatient hospitalization -CR reviews the health record for missing reports and signatures that occurs when the patient is in the hospital. Utilization review:The process of determining whether the medical care provided to a specific patient is necessary according to preestablished objective screening criteria at time frames specified in the organization's utilization management plan

bill hold days

Each facility has a defined number of Bill hold days. These are the number of days in which accounts will be held from billing so charges can be entered after the patient is discharged. Bill hold assumes that there will be a delay in accumulating the charges incurred by a patient.

During implementation phase during SDLC, what chart should project manager use? Why?

Gantt chart or project management tool that identified the major tasks, their estimated start & completion dates & individuals responsible for performing them & the resources needed to complete them

MIC (Medicaid Integrity Contractors)

Governmental routine audit Who review medicaid claims to determine potential provider waste or abuse, identify overpayments & provide education to providers on payment integrity & quality-of-care issues.

Bridges stages of transition

Guide for how individuals experience change by transitioning through different phases. Stage 1: ending, losing letting go. - Resistance to the Change Initiative, Uncertainty and fear, emotional upheaval. Stage 2: Neutral Zone - Resentment towards the change initiative, low morale and low productivity, anxiety about their role or identity, skepticism about the change initiative. Stage 3: New Beginning - Acceptance..People have begun to embrace the change initiative, high energy, openness to learning, renewed commitment to the group or their role.

Code of Ethics

Guides the practice of people who chosen a given profession & sets forth the values & principles defined by the profession as acceptable behavior within a practice setting.

Compliance

HIM professional is responsible for ensuring that the most stringent time requirements are followed so that the facility is in compliance with state and federal laws and regulations, licensure standards, CMS conditions of participation, and accreditation requirements for the specific type of facility

What happens when ambulatory facility is closed or sold?

Health records are transferred to the successor provider. In ambulatory care settings or physician office, patients are informed of their options to transfer their records to another provider of choice before their health records are transferred to the successor provider. When MD leaves a group practice, pts should be given the choice to transfer their health records & move with MD or to have the health records & the responsibility of care transferred to another provider in the group.

Submission of Claims-

Healthcare facilities submit claims via the 837I electronic format, which replaces the UB-04 (CMS-1450) paper billing form. Physicians submit claims via the 837P electronic format, which takes the place of the CMS-1500 billing form. For those healthcare facilities with a waiver of the ASCA requirements, UB-04 and CMS-1500 are used.

Coding guidelines

In principle eight, a hospital with multiple clinics (for example, primary care, oncology, wound care, and such) may have different coding guidelines for each clinic, but the guidelines must be applied uniformly within each separate clinic. The hospital's various sets of internal guidelines must measure resource use in a relative manner in relation to each other. For example, resources required for a Level 3 established patient visit under one set of guidelines should be comparable to the resources required for a Level 3 established patient visit under all other sets of clinic visit guidelines used by the hospital. Regarding principle nine, CMS would generally expect hospitals to adjust their guidelines less frequently then every few months, and CMS believes it would be reasonable for hospitals to adjust their guidelines annually, if necessary. CMS would encourage fiscal intermediaries and medicare administrative contractors to review a hospital's internal guidelines when an audit occurs. Under the OPPS, the meanings of 'new' and 'established' pertain to whether or not the patient has been registered as an inpatient or outpatient of the hospital within the past 3 years. If a patient has been registered as an outpatient in a hospital's off-campus provider-based clinic or emergency department within the past 3 years that patient would still be considered an 'established' patient to the hospital for an on-campus or off-campus clinic visit even if the medical record was initially created by

Medical Necessity Coverage Issues

Medicare's national coverage policies are known as national coverage determinations (NCDs), and local fiscal intermediary policies are known as local coverage determinations (LCDs). These policies define the specific International Classification of Diseases (ICD) diagnosis codes that support medical necessity for many services provided.

Overlap vs. overlay

Overlap: Occurs when pt has more than one medical record number assigned across more than one database Overlay: When pt record is overwritten with data from another pt's record.

Semantic interoperability vs Functional Interoperability

Semantic interoperability: Similar to HL7 in which the info being transmitted is understood. Building on previous example - the receiving system would not only recognize that what was being sent is a lab value but would also understand the method used to calculate the value & the reference ranges for a normal result. The used of clinical terminologies in EHR to provide standardized data is essential to achieving semantic interoperability. Functional Interoperability: Refers to sending messages between computers with a shared understanding of the structure and format of the message. -With functional interoperability, the receiving computer can store information in a similar data field because nature (context) of the data being sent is understood. EX: The receiving computer could recognize that the info being sent is a lab result & store it accordingly.

Meaningful use stages

Stage 1: Set the foundation by establishing requirements for the electronic capture of clinical data, including providing patients with electronic copies of health information. Stage 2: Expanded upon the Stage 1 criteria with a focus on advancing clinical processes and ensuring that the meaningful use of EHRs supported the aims and priorities of the National Quality Strategy. Stage 2 criteria encouraged the use of CEHRT for continuous quality improvement at the point of care and the exchange of information in the most structured format possible. Patient/member web portals. Stage 3: In October 2015, CMS released a final rule that established Stage 3 in 2017 and beyond, which focused on using CEHRT to improve health outcomes. In addition, this rule modified Stage 2 to ease reporting requirements and align with other CMS programs.

Technical component vs Professional Component

Technical Component: - use of equipment and supplies for services performed. -term used in describing the services provided by the facility - supplied by a hospital or freestanding diagnostic or surgical center EX: radiological supplies, equipment, and support services. Professional Component: -services provided by a Physician in pathology radiology ; supervision, interpretation etc. - Supplied by physicians EX: radiologists

Governmental Audits

The federal government has a number of routine audits that are carried out to combat fraud and abuse. Some of the programs have overlapping authority, but each may have different operational requirements, which challenges healthcare organizations to comply. Some commonly known government auditors in healthcare are: - HEAT; Health Care Fraud Prevention and Enforcement Action Team - MAC; Medicare Administrative Contractors - MIC; Medicaid Integrity Contractors - RAC; Recovery Audit Contractors

Legal health record (LHR)

The form of a health record that is the legal business record of the organization and serves as evidence in lawsuits or other legal actions; what constitutes an organization's legal health record varies depending on how the organization defines it

Designated record set

The information that patients have the right to access is termed the designated record set. These types of information that HIPAA does not provide access to are - oral information,- psychotherapy notes, -information compiled in anticipation of, or for use in, as civil, criminal, or administrative action or proceeding - PHI the CE maintains that is subject to or exempted from the clinical laboratory improvement amendment (CLIA)

Graphical User Interface (GUI)

Type of user interface that allows a user to interact with software using text, graphics, and visual images, such as icons.

State & local government regulations & licensure requirements

Various agencies and departments of federal, state and local government also review the quality of services provided in healthcare organizations. However, government regulations and licensure requirements are compulsory rather than voluntary and may vary greatly in their requirements from state to state and jurisdiction to jurisdiction. Every state government has required the licensure of hospitals and other types of healthcare organizations since the early 20th century, some city and county governments also regulate healthcare facilities that operate within local boundaries. The individual states issues licenses that permit facilities to operate within a defined scope of operation. EX: Long term care organization would be licensed to perform long term care services, but not acure-care services. To maintain its licensed status, each facility much adhere to the state regulations that govern issues related to staffing, physical facilities, services, documentation requirements, and quality of care. Each facilities performance is usually evaluated annually by survey teams from the state department of health. Healthcare facilities that lose their licenses are no longer allowed to operate in the state. Typically, state legislators have granted authority to state administrative agency to - develop standards hospital must meet - issue licenses to those hospitals that meet the standards - manager continuing compliance with the standards - penalize hospitals that violate the standards.Licensure - issued for the organization as a whole. It addresses policies and procedures, staffing, and hospital building integrity among many other facets of the organization. Some states require additional licenses for specific services in the hospital. For example, the laboratory, radiology, renal dialysis, and substance abuse services may require separate license is in addition to the facility license. Additional state and federal laws apply to the use of drugs and medical devices. Some states require separate licensure for hospital pharmacies where as other states regulate hospital pharmacies through the general state hospital licensing system. Some states require certain types of medical equipment to be separately licensed, such as x-ray equipment or medical waste disposal systems. Hospitals cannot operate without a license. License is government regulation that is mandatory for hospitals

inputs vs outputs

When the patient enters the hospital, he or she presents to the admitting clerk. The clerk uses a computer to collect data from the admitting system. The patient with knowledge of his or her condition, the admitting clerk with knowledge of the admitting process, and the computer with its admitting template can all be considered inputs for admitting system. When the clerk begins to asking for patients address, insurance coverage, and the reason for admission the patients begins responding, the admitting process is under way. The output of the process is the patients admission to the hospital and a completed face sheet for his or her medical record. These outputs can be viewed as inputs in the next system in the hospital, the patient care system .

Important tools for using controlling the quality of data in healthcare?

database, data dictionary, and data map.

Principal Diagnosis

defined as the condition that, after study, is determined to have caused the admission of the patient to the hospital for care, and it determines the MDC assignment.

Impact factor -

designates the effect the risk will have on the project if it does occur Probability and impact factor then multiplied together to calculate the risk factor

Attributable risk

is a measure of public health impact of a causative factor on the population

Risk assessment; Relative risk

risk is the probability that an individual will develop a disease over a specified period of time, provided that he or she did not die as a result of some other disease process during the same time.

Six Sigma

- A business process for improving quality, reducing costs, and increasing customer satisfaction - Uses a scientific methodology that involves the following steps: define, measure, analyze, improve, and control (DMAIC). DMAIC is a data-driven quality strategy used to improve processes. It is an integral part of a Six Sigma initiative, but in general can be implemented as a standalone quality improvement procedure or as part of other process improvement initiatives such as lean. DMAIC is an acronym for the five phases that make up the process: • Define the problem, improvement activity, opportunity for improvement, the project goals, and customer (internal and external) requirements. • Measure process performance. • Analyze the process to determine root causes of variation, poor performance (defects). • Improve process performance by addressing and eliminating the root causes. • Control the improved process and future process performance. Six Sigma uses statistics for measuring variation in a progress with the intent of producing error- free results.

OLAP (online analytical processing)

- A category of software tools that provide analysis of data stored in a database and is often used in data mining -OLAP is for data repository. Data repository is generating real time data -Data ware houses are often hierarchical or multidimensional and are designed to receive very large volumes of data (often as an extraction of data from a repository) and perform complex, analytical processes on the data. -Historical record over time or time variance encompassing all the organizational operating units by subject for comparison purposes -Database of the transactions -Ex: database that will record the data, time and all of the details regarding all of the transactions -Informational -Types of processing -Retrospective data analysis -Any data ware house system is OLAP -A computing method that enables users to easily and selectively extract and query data in order to analyze it from different points of view.

Present on admission (POA)

- A condition present at the time of inpatient admission -defined as a condition present at the time the order for inpatient admission occurs --- conditions that develop during an outpatient encounter, including in the emergency department, observation, or outpatient surgery, are considered as present on admission

Continuity of Care Document (CCD)

- A document that conforms to a standard, accepted format for electronically transmitting/sharing patient information securely in a format that is easy to read and share among provider locations - The widely-accepted and federally-mandated document for sharing patient health information across facilities; replaced the CCR and CDA, which were earlier attempts at addressing the continuity of patient care between facilities. -The result of ASTM's Continuity of Care Record standard content being represented and mapped into the HL7's Clinical Document Architecture specifications to enable transmission of referral information between providers; also frequently adopted for personal health records

Point of Service (POS)

- A health care plan in which members decide how to receive services at the time of service; it combines HMO and indemnity features. As with HMOs, providers are paid through a capitation or risk-based system and, as with preferred provider organizations, individuals can choose a non-plan provider by paying extra. - insurance plan in which a patient may choose an HMO or a non-HMO provider but must pay a deductible for using a non-HMO provider - is defined as the collection of the portion of the bill that is likely the responsibility of the patient prior to the provision of service. POS collection works well with scheduled and nonemergent patient visits. Access to billing data from both payers and the heathcare's own system is needed to be able to estimate what a patient owes at the point of service

sponsor

- A person or group who provides resources and support for the project, program, or portfolio and is accountable for enabling success. - Every project has an identified sponsor. The sponsor is the facility employee with the most vested interest in the projects success.

Utilization management

- A program that evaluates the healthcare facility's efficiency in providing necessary care to patients in the most effective manner. -Controls health care costs and the quality of health care by reviewing cases for appropriateness and medical necessity. - is the evaluation of the medical necessity, appropriateness, and efficiency of the use of heathcare services, procedures, and facilities under the provisions of the applicable health benefits plan; it is sometimes called utilization review. The utilization review (UR) staff is responsible for the day-to-day provisions of the hospital's utilization plan as required by the Medicare Conditions of Participation. Utilization personnel are required to perform the following functions: Review the medical record thoroughly to obtain information necessary to make UR decisions Apply criteria objectively for admissions, continued stay, level of care, and discharge readiness Provide services 24 hours a day, 7 days a week, to all relevant hospital departments, acting as a resouce Review, within 24 hours, all patients placed in a bed Screen and coordinate elective and emergency admissions and transfers, outpatient observations, and conversions of status as appropriate and compliant Provide UR to all admissions, regardless of payer status Review all continued stays at a scheduled frequency, but not less than every 3 days or sooner Screen for timeliness, safety, and appropriateness of the rendering or use of hospital services or resources The healthcare facility's utilization plan should include the state's specific requirements associated with denial or termination of benefits coverage. Utilization personnel take an active role in monitoring, reporting, and communicating adverse determination to patients and their families and ensuring all procedures are followed in rendering the communication.

migration path

- A strategic plan that identifies applications, technology, and operational elements needed for the overall information technology program in a healthcare organization is called: -is it strategic plan but is somewhat different than the traditional IT strategic plan that focuses only on applications in technology. Because the EHR is a tool to use for clinical transformation, the migration path should not only to reflect the IT architecture of hardware and software but also about operational elements of people, policy, and process changes to address improvements in clinical quality, patient safety, evidence-based practice, cost of care.

Resident Assessment Validation and Entry (RAVEN)

- A type of data-entry software developed by CMS for long-term care facilities and used to collect Minimum Data Set assessments and to transmit data to state databases - CMS developed a computerized data-entry system for skilled nursing facilities that offers users the ability to collect MDS assessments in a database and transmit them in CMS-standard format to their state database - imports and exports data in standard MDS record format; maintains facility, resident, and employee information; enforces data integrity via rigorous edit checks; and provides comprehensive online help. It includes a data dictionary and a RUG calculator.

Root Cause Analysis

- An analytical technique used to determine the basic underlying reason that causes a variance or a defect or a risk. A root cause may underlie more than one variance or defect or risk. - tools used by quality improvement professionals are commonly being used in risk management activities as well. Root cause analysis is a valuable tool to accurately identify the true cause of incidence or PCE. The use of root cause analysis keeps the focus on processes and s systems rather than people when evaluating incidents. Once the true cause of an event is understood the organization can focus on Remediating systems or processes that allow the event to occur. Rarely are individual people the true cause of an event. The usual culprits are organizational or clinical processes that cause an untoward event to occur

deemed status

- An official designation indicating that a healthcare facility is in compliance with the Medicare Conditions of Participation - A designation used when a hospital, by virtue of its accreditation by the Joint Commission or the American Osteopathic Association, does not require separate certification from the DHHS to participate in the Medicare and Medicaid programs.-In order to participate in and receive federal payment from Medicare or Medicaid programs, a health care organization must meet the government requirements for program participation, including a certification of compliance with the health and safety requirements called Conditions of Participation (CoPs) or Conditions for Coverage (CfCs), which are set forth in federal regulations. -The certification is achieved based on either a survey conducted by a state agency on behalf of the federal government, such as the Centers for Medicare & Medicaid Services (CMS), or by a national accrediting organization, such as The Joint Commission, that has been recognized by CMS (through a process called "deeming") as having standards and a survey process that meet or exceed Medicare's requirements. Health care organizations that achieve accreditation through a Joint Commission "deemed status" survey are determined to meet or exceed Medicare and Medicaid requirements. Voluntary deemed status through The Joint Commission is available for: • Ambulatory surgical centers • Clinical laboratories • Critical access hospitals • Home health agencies • Hospice agencies • Hospitals • Psychiatric hospitals Accreditation is required (and available through The Joint Commission) for: • Advanced diagnostic imaging services • Durable medical equipment, prosthetics, orthotics and supplies (DMEPOS) suppliers • Opioid treatment programs (deeming authority is granted through the Substance Abuse Mental Health Services Administration not CMS) A health care organization is eligible for reimbursement for the following procedures if it is certified by The Joint Commission for: • Ventricular assist device (VAD) destination therapy • Lung volume reduction surgery (LVRS)

Database Management System (DBMS)

- a program used to create, process, and administer a database -A system for managing data that allows the user to store, retrieve, and analyze information. - DBMS is developed in conjuction with development of a specific database. Modern DBMSs have built in data dictioanries that go beyond data definitions and store infromation about rtable and data relationships.

stark law (physician self-referral law)

- At issue is the practice of physicians referring patients to a medical facility in which the physician has a financial interest, whether ownership or other types of investment. Proponents of the Stark Law alleged that there was an inherent conflict of interest given the physicians the opportunity to benefit from the referral. - The Physician Self-Referral Law, commonly referred to as the Stark law, prohibits physicians from referring patients to receive "designated health services" payable by Medicare or Medicaid from entities with which the physician or an immediate family member has a financial relationship unless an exception applies. Financial relationships include both ownership/investment interests and compensation arrangements. For example, if you invest in an imaging center, the Stark law requires the resulting financial relationship to fit within an exception or you may not refer patients to the facility and the entity may not bill for the referred imaging services. -The Stark law is a strict liability statute, which means proof of specific intent to violate the law is not required. The Stark law prohibits the submission, or causing the submission, of claims in violation of the law's restrictions on referrals. Penalties for physicians who violate the Stark law include fines as well as exclusion from participation in the Federal health care programs.

National Correct Coding Initiative (NCCI)

- Automated edits that identify pairs of services that normally should not be billed by the same physician for the same patient on the same day - CMS implemented the National Correct Coding Initiative (NCCI) in 1996 to develop correct coding methodologies to improve the appropriate payment of Medicare Part B claims. The NCCI edits explain what procedures and services can not be billed together on the same day of service for a patient. The mutually exclusive edit applies to improbable or impossible combinations of codes. For example, code 58940, Oophorectomy, partial or total, unilateral or bilateral, would never be used with code 58150, Total abdominal hysterectomy, with or without removal of tubes, with or without removal of ovarys.

Ethical principals regarding release of patient information:

- Autonomy - would require the H I am professional to ensure that the patient, and that a spouse or third-party, makes the decision regarding access to his or her health informationBeneficence - would require the HIM professional to ensure that the information is released only two individuals who needed to do some things that will benefit the patient. For example - to an insurance company for payment of a claim. - Nonmaleficence - Would require the H I am professional to ensure that the information is not released to someone who does not have authorization to access it and who might harm the patient if access were permitted. For example - A newspaper seeking information about a famous person - Justice - would require the HIM professional to apply the rules fairly and consistently for all and not to make special exceptions based on personal or organizational perspectives. For example - releasing information more quickly to a favorite physicians office - Privacy - is the right of of an individual to be let alone. It includes freedom from observation or intrusion into one's private affairs and the right to maintain control over certain personal and health information. - Confidentiality - carries the responsibility for limiting disclosure of private matters. It includes the responsibility to use, disclose, or release such information only with the knowledge and consent of the individual. Confidential information may be written or verbal. - Security - includes a physical and electronic protection of the integrity, availability, and confidentiality of computer-based information and the resources used to enter, store, process, and communicated; in the means to control access and protect information from accidental or intentional disclosure

RAC - Recovery Audit Contractor

- CMS' contracting of several auditing companies to perform audits and determine improper payments and claim errors. Over and under payments. - The Medicare Fee for Service (FFS) Recovery Audit Program's mission is to identify and correct Medicare improper payments through the efficient detection and collection of overpayments made on claims of health care services provided to Medicare beneficiaries, and the identification of underpayments to providers so that the CMS can implement actions that will prevent future improper payments in all 50 states. What does a Recovery Audit Contractor (RAC) do? RAC's review claims on a post-payment basis. The RAC's detect and correct past improper payments so that CMS and Carriers, FIs, and MACs can implement actions that will prevent future improper payments.

Centralization vs. Decentralization

- Centralized organizational structures rely on a small number of top managers to make decisions and provide direction for the company, while decentralized organizational structures give a larger number of managers at lower levels of the hierarchy more responsibility and autonomy in making decisions and providing direction. -Top managers have decision-making power in centralized organizations, while decentralized organizations put more authority at lower levels - Centralized - Little authority is delegated to lower levels of management - De-Centralization- A great deal of authority is delegated to lower levels of management

DRG (Diagnosis Related Group Classification)

- Classified inpatient hospital cases into groups that are expected to consume similar hospital resources. - Unit of case-mix classification, a prospective payment mechanism for hospital inpatients in which diseases are placed into groups because related disease & treatments tend to consume similar amounts of healthcare resources & incur similar amounts of cost - Retrieved by Quality Improvement Organization (QIO)

SNOMED-CT (Systematized Nomenclature of Medicine Clinical Terms)

- Clinical concepts - Reference terminology -Used in EHR systems as a clinical reference terminology to capture data for problem lists & pt assessments at the point of care. It also supports alerts, warnings, or reminders used for decision support. -Snomed makes it easier for data to be portable from one system to another -Decreases the need to repeat health history -Has broad coverage of medical concept -Updated every 6 months. Released January & July of each year - Strict hierarchies: ex: bacterial meningitis is a meningitis - If you EHR system is using Snomed these will need to be "translated" into ICD-10 CM codes so they can be used for claims submission - Comprehensive, multi-hierarchical concept oriented clinical terminology owned, maintained & distributed bty IHTSDO - Concept - the most granular unit within a terminology - Multi descriptions are oftentimes assigned to a single concept. EX: Heart attack, myocardinal infraction, cardiac infraction would all be linked to a single concept. - Relationships - describes how the concepts within Snomed CT are linked to one another. EX: diabetes mellitus is an endocrine disorder.

Two general types of data dictionaries

- Database Management System Data Dictionary - Organization-Wide Data Dictionary

Two methods to achieve de-identification in accordance with the HIPAA Privacy Rule?

- Expert Determination: - Safe Harbor Expert determination and safe harbor The HIPAA Privacy Rule provides mechanisms for using and disclosing health data responsibly without the need for patient consent, or for situations where they can't obtain consent. These mechanisms center on two HIPAA de-identification standards - Safe Harbor and the Expert Determination Method. Safe Harbor relies on the removal of specific patient identifiers while the Expert Determination Method requires knowledge and experience with generally accepted statistical and scientific principles and methods to render information not individually identifiable.

Civil Monetary Penalties Law (CMPL)

- Fine issued in civil court which penalizes a violator who profited from an illegal or unethical action. The penalty is typically equal to the gains made from the activity. EX: Broker who profited $1,000 from circular trading will be required to pay a fine of atleast $1,000 -law passed by the fed gov to prosecute cases of medicaid fraud. OIG may seek civil monetary penalties and sometimes exclusion for a wide variety of conduct and is authorized to seek different amounts of penalties and assessments based on the type of violation at issue. Penalties range from $10,000 to $50,000 per violation. Some examples of CMPL violations include: - Presenting a claim that the person knows or should know is for an item or service - that was not provided as claimed or is false or fraudulent; - Presenting a claim that the person knows or should know is for an item or service - for which payment may not be made; - Violating the AKS; - Violating Medicare assignment provisions; - Violating the Medicare physician agreement; - Providing false or misleading information expected to influence a decision to - discharge; - Failing to provide an adequate medical screening examination for patients who present to a hospital emergency department with an emergency medical condition or in labor; and - Making false statements or misrepresentations on applications or contracts to participate in the Federal health care programs.

data repository

- Generically refers to a general place where data is stored and maintained. - Real-time data. - Allow hospitals to quickly get as much health record info online. - Consolidates data from various clinical sources, as as an EMR or Lab system. - Collect & store data - Data warehouse is a large data repository that aggregates data usually from multiple sources or segments of business without data being necessarily related.

MAC (Medicare Administrative Contractor)

- Governmental Audit -A Medicare Administrative Contractor (MAC) is a private health care insurer that has been awarded a geographic jurisdiction to process Medicare Part A and Part B (A/B) medical claims or Durable Medical Equipment (DME) claims for Medicare Fee-For-Service (FFS) beneficiaries. CMS relies on a network of MACs to serve as the primary operational contact between the Medicare FFS program and the health care providers enrolled in the program. MACs are multi-state, regional contractors responsible for administering both Medicare Part A and Medicare Part B claims. MACs perform many activities including: - Medicare Administrative Contractors (MACs) contract with CMS to serve as the financial agent between providers and the federal government to locally administer Medicare's Part A and Part B. Medicare Administrative Contractors (MACs) process Part A and Part B claims from hospitals, physicians and other providers.

Medicare

- Health insurance for people age 65 and older, or people under 65 who are entitled to Medicare because of disability or are receiving dialysis for permanent kidney failure. - Administered through fiscal intermediaries, insurance companies under contact to the government to process Medicare claims - Medicare regulations are the same in all states - Financed by monthly premiums paid by the beneficiary and by payroll tax deductions - For people age 65 and over, eligibility is based on Social Security or Railroad Retirement participation. For people under age 65, eligibility is based on disability. For people who undergo kidney dialysis, eligibility is not dependent on age - Beneficiary responsible for paying deductibles, coinsurance or copayments, and part B premiums - Hospital and medical benefits; preventive care and long-term care benefits are limited

data integrity

- In a database or a collection of databases, the condition that exists when data values are consistent and in agreement with one another. - happens when all of the data in the database conform to all integrity constraints rules. Database integrity constraints include; - data type - the data entered into a field should be consistent with the data type for that field. For example, if a field is a numeric field, it should only except numbers. If it is a date field, he should only except a legitimate date. - Legal values - many fields have a limited number of "legal" values for example, a health record number may only be entered as 00001 through 99999. - Format - certain fields, such as dates, must be entered in certain format, such as MM/Dd/YYYY - Key constraints - constraints placed on the primary and foreign keys within the database. A foreign key, for example, cannot be entered into the database unless a corresponding primary key already exists. A primary key is an essential attribute within the database that is used to link cases or records together or to query the database for specific information this concept is called referential integrity. These constraints help ensure that the original enter data in changes to these data follow certain rules data type - the data entered into a field should be consistent with the data type for that field. For example, if a field is a numeric field, it should only except numbers. If it is a date field, he should only except a legitimate date.

MPI: Master Patient Index

- Is the permanent record of every pt ever seen in a healthcare facility. -Permanent database including every pt ever admitted to or treated by the facility. Even though pts health records may be destroyed after legal retention periods have been met, the info contained in the MPI must be kept permanently. -MPI is an important key to the health record because it contains the pts identifying info including pt names and health record # -Index helps with not assigning new unit numbers to former pts. -Because health records are filed numerically in most facilities, the MPI is an important source of pts health record numbers. These numbers enable the facility to quickly retrieve health information for specific pts. -Master Patient Index, permanent database including every patient ever admitted, MPI retained permanently, can have overlap where one patient has more than one MRN, and overlay is when one patient record is overwritten with data from another patient's record

Complex review

- Medical record required In a revenue audit contractor (RAC) review, this type of review results in an overpayment or underpayment determination based on a review of the health record associated with the claim in question. - CR is the actual physical review of the Medical Record or other documentation where the RAC individually reviews the medical record. Under a complex review, the RAC communicates all the results directly to the provider including results where no improper payment was identified. When there has been an improper payment, the RAC must inform the provider of which coverage, coding, payment policy or article was violated.

UHDDS: Uniform Hospital Discharge Data Set

- Obtain uniform comparable discharge data on all inpatient. - Collect minimum set of data about inpatient - UHDDS lists and defines a set of common, uniform data elements for every hospital inpatient & includes principal & previous diagnosis, the principal procedure. - UHDDS data definitions are a component of DRG's & required to accurately calculate DRG payment. - Data elements: Demographics, Residence, Admission Data, Type of Admission, Attending MD, Operational MD, Discharge Data.

EMTALA - emergency medical treatment and activity labor act;

- Only emergency rooms to stop the practice of refusing to treat people because of inability to pay or insufficient insurance. Patients in the situation where transferred or discharged solely on the basis of the dissipation of high diagnosis or treatment cost from emergency departments under EMTALA, hospitals have three obligations; - individuals ( or their representatives of the patient is unable) requesting emergency care must receive a medical screening examination to determine whenever the emergency medical condition exists examination cannot be delayed in inquire about payment or insurance citizenship or legal status. The process of payment inquiry and billing may only start after the patient has been stabilized in his or her care not compromised. - Patients with an emergency medical condition must be treated until the condition is resolved or stabilized and the patient is able to care for himself or herself or can otherwise receive continuing care. Patients may not be discharged prior to stabilization if insurance is canceled or otherwise discontinued during the course of patients day - if the hospital does not have the capability to treat the condition, and appropriate transfer of the patient to a hospital that is capable of delivering the required care must be arranged, including long-term or rehabilitation facilities if appropriate. Hospitals are offering specialize capabilities must except transfers and may not discharge a patient until the condition is resolved, the patient is able to provide self-care, or the patient is transferred to another facility

Medicare fee schedule (MFS)

- Providers participating in Medicare must accept the charges listed in this schedule as payment for covered services. The MFS is developed by using the Resource-Based Relative Value Scale. The participating physician may bill the patient for coinsurance and deductibles but may not collect excess charges. -A feature of the resource-based relative value system that includes a complete list of the payments Medicare makes to physicians and other providers - -The RBRVS-based allowed fees that are reimbursable to Medicare participating physicians. - is the listing of allowed charges that are reimbursable to physicians under medicare. Each year's MFS is published by CMS in the Federal Register.

Red Flags Rule

- Requires financial institutions and creditors to have identity theft programs. - The FTC has confirmed that if patients are allowed to pay in installments, the provider bills for services, or the provider excepts insurance with understanding that the patient is ultimately responsible for the bill, the providers are creditors under the law. Therefore, it is prudent to have procedures in place that call out situations where a patient's financial or medical identity could be in question. A red flag rule program should include activities that - identify patterns, practices or specific actions that indicate the potential of identity theft - detect such patterns, practices, or actions - provide for an appropriate response to detect red flags - ensure that the program is updated periodically to reflect changes in technology, employee and patient behaviors, and theft methodologies

MS-DRG grouper

- Software that helps coders assign the appropriate Medicare severity diagnosis-related group based on the level of services provided, severity of the illness or injury, and other factors. - is a computer software program that assigns appropriate MS-DRGs according to the information provided for each episode of care. - Reimbursement for each episode of care is based on the MS-DRG assigned. Different diagnosis require different levels of care and expenditures of resources. Therefore, each MS-DRG is assigned a different level of payment that reflects the average amount of resources required to treat a patient assigned to that MS-DRG. In some cases, the MS-DRG payment received vy the hospital may be lower than the actual cost of providing Medicare Part A inpatient services. In such cases, the hospital must absorb the loss. In other cases, the cost of providing care is lover than the MS- DRG payment, and the hospital may receive a payment for more than its actual cost and, therefore, make a profit.

Encoder

- Specialty software used to facilitate the assignment of diagnostic and procedural codes according to the rules of the coding system - An encoder is a software program that enables coders to assign codes based on using text typed into a look-up screen analogous to the coder looking up a term in the index of the printed codebook. Encoders come in two distinct categories: logic-based and automated codebook formats. Logic Based: An encoder that takes a coder through a series of questions and choices. - prompts the user through a variety of questions and choices based on the clinical terminology entered. Automated Codebook Format: computerized codebook that mimics the structure of the coding books -is an encoder that lists diagnoses and procedures in alphabetic order much like the alphabetic index located in the international ICD-10-CM & Current procedural terminology (CPT) codebooks

ORYX initiative

- The Joint Commission on Accreditation of Healthcare Organizations' initiative that supports the integration of outcomes data and other performance measurement data into the accreditation process - TJC introduced ORYX initiative to integrate outcomes data & other performances measurement data into its accreditation process - Goal of the initiative is to foster a comprehensive, continuous, data-driven accreditation process for healthcare facilities. - Goal of ORYX initiative is to integrate outcomes & other performance measures into the accreditation process through data collection about specific core measures. -HEDIS and Joint Commission's ORYX program are constructed to collect data for Performance improvement programs

Interoperability

- The ability, generally by adoption of standards, of systems to work together. Interoperability - Ability to exchange information between computer systems - Ability to communicate & exchange data accurately, effectively, securely, consistently, with different information technology systems, software applications, and networks in various settings, exchange data such that clinical or operational purpose. - Interoperability is described in levels. The NCVHS has identified 3 levels : basic, functional, semantic. - Basic Interoperability related to the ability to successfully transmit & receive data from one computer to another.

Blanket authorization

- The patient signs an authorization allowing the release of information specialist to release any and all information from that point forward. - Authorization for the release of confidential information from a certain point in time and any time thereafter -Is a common ethical problem when misused. Patients often sign a blanket authorization, which authorizes the release of information from that point forward, without understanding the implications. The problem is the patient is not aware of what information is being accessed EX: Patients often sign a blanket authorization, which authorizes the release of information from that point forward, without understanding the implications. The requestor of the information then could use the authorization to receive health information for many years. The problem with the use of blanket authorizations is that there is no way for the patient to know that the information is being accessed. Patients cannot authorize the release of information in 2003 for diagnoses or care that has not yet been provided. For example, by 2021, the patient might have AIDS or cancer and might not want this information released

Risk analysis

- The process by which an organization assesses the value of each asset being protected, estimates the probability that each asset might be compromised, and compares the probable costs of each being compromised with the costs of protecting it. - to account for the inevitable changes the project manager should perform a risk analysis

red flag rule

- The rule requiring that all health care providers who act as creditors have a written identity theft detection and prevention program. - enacted for the purpose of legislating certain businesses to implement a program to prevent, detect, and mitigate medical identity theft -a set of provisions created by the Federal Trade Commission (FTC) to help prevent identity theft from patient billing accounts maintained by medical and financial institutions - The FTC indicated that financial institutions were not the only entities covered ; healthcare providers, attorneys, and other businesses were also covered because they provide goods and services and bill after the fact or in installments. - It is important to understand that since healthcare providers may allow deferred payments or bill patients for services provided, most fit the definition of "creditor" under the rule.

PPS (Prospective Payment System)

- Third-party payers generally will not reimburse a claim that does not include the clinical diagnostic and procedural codes. This is true whether the reimbursement is based on a prospective payment system (PPS), actual charges, or some other method. For this reason, the patient accounts department cannot drop a bill until the patient record has been coded. Therefore, timely, accurate coding is critical to the reimbursement process and directly affects the facility's cash flow. -The exact amount of of payment is determined before the service is delivered. The federal Medicare program uses PPSs

Intrahospital transfer

- Transfers within the hospital (from one department to another) -A change in medical care unit, medical staff unit, or responsible physician during hospitalization - Intrahospital transfers is included in the census reports - EX: Pt transferred from ICU to medicine unit

SWOT analysis

- a planning tool used to analyze an organization's strengths, weaknesses, opportunities, and threats - assessment process, another critical step and assessment process is to conduct is SWOT "strengths, weaknesses, opportunities, and threats" analysis of the department and organization. SWOT analysis evaluates the internal organization based on its strengths compared to the competitors and regional and societal demands, witnesses compared to the competitors or related to just the internal functions, opportunities for advancing ahead of competitors or serving a patient population not served well currently, and threats from external or internal agents that could stymie the organization success.

Benchmarking

- a process by which a company compares its performance with that of high-performing organizations -Comparing an organization's practices, processes, and products against the world's best.- Bench mark is a systematic comparison of one organizations measured characterizes with those of another similar organizations or with reginal or national standards. - Once a benchmark for a performance measure is determined, analyzing data collection results become more meaningful. Often, further study or more focused data collection on performance measure is triggered when data collection results fall outside the established benchmark. - Set of standards or outcomes used to compare to your actual performance: indicators, measurements, outcomes. -When an organization compares its current performance to its own internal historical data, or uses data from similar external organization across the county, it helps establish an organizational benchmark, also known as a standard of performance or best practice, for a particular process or outcomes. -establishing a benchmark for each monitored performance measure assists the healthcare organization in setting performance baselines, describing process performance or stability or identifying area for more focused data collection. - Systematic comparison of products, services, outcomes of one organizations to similar organizations, national standards. Internal: used to id best practices within an org, compare current practice over time. External: comparative data between 2 organizations, judge performance and id improvements successful in other organizations

Request for Information (RFI)

- a screening document for gathering vendor information and narrowing the list of potential vendors. It can help manage the selection of vendors by focusing on the project requirements that are crucial to selecting vendors - Sent to fairly extensive list of vendors that are known to offer products or systems that meet the organizations needs. -RFI is used to obtain general product information & to pre-screen vendors. -Responses to RFI are used to narrow the list to a smaller number of vendors who will be invited to respond to the request for proposal (RFP)

Scope Creep

- adding functions to an information system after the project has begun - Condition in which a project seems to have lost its way. -The uncontrolled expansion to product or project scope without adjustments to time, cost, and resources.

Stakeholders

- any persons or groups who will be affected by an action. -Has an interest in, or is affected by the results of the project. It's person, group or organization that has interest or concern in an organization. -Stakeholders can affect or be affected by the organization's actions, objectives, & policies. -Stakeholder team will drive the creation of the legal health record documentation, undertake the LHR definition project & be responsible for it continued maintenance. Establishment of the stakeholder team should be the 1st step in the LHR definition process.

Semi-automated review

- claims review using data and potential human review of a medical record or other documentation; medical records supplied at the discretion of the provider to support a claim identified by data analysis as an improper payment - Consists of two parts. During the 1st part, which the automated review process, the deviation in the billing process identified. During the 2nd part, the RA sends a demand letter to the provider with an explanation of the billing error. The provider then has 45 days to submit the evidence to the RA. Two possible outcomes of the semi-automated review: - If the provider sends documentation, and the documentation refutes the RA claim, then the claim will not be sent for an adjustment and the provider will be notified that the case is closed. - If the provider does not submit documentation, or the submitted documentation does not refute the claim, then the claim will be sent to Medicare Claims Processing for adjustment and follow up demand letter will be sent to the provider.

NPP (Notice of Privacy Practices)

- document that describes practices regarding the use and disclosure of protected health information -a HIPAA-mandated document stating the privacy policies and procedures of a covered entity -A written document detailing a health care provider's privacy practices. - Must explain & give examples of the uses of the patients health information for treatment, payment, healthcare operations, as well as other disclosures for purposes established in the regulations.

PPS (Prospective Payment System)

- fixed payment scale/schedule based o your DRG, effected Medicare Part A, resulted in shorter hospital stays - Commercial insurance plans usually reimburse healthcare providers under some type of retrospective payment systems, the exact amount of the payment is determined after the service has been delivered. In a PPS, the exact amount of the payment is determined before the service is delivered. The federal Medicare program uses PPSs.

RBRVS (Resource Based Relative Value Scale)

- implemented by CMS as reimbursement for physician services of beneficiaries covered under medicare part B -national fee system used to calculate the approved amount for Medicare payments value assigned to each CPT code based on work involved, cost, and malpractice expenses conversion factors published Federal Register each December

CDI (Clinical Documentation Improvement) program

- is designed to provide a link between coders and physicians and to ensure completeness and accuracy of a patient care documentation. - programs to assure the health record accurately reflects the actual condition of the patient. The American Health Information Management Association (AHIMA) developed a toolkit for clinical documentation improvement, stating its purpose is to "initiate concurrent and, as appropriate, retrospective reviews of inpatient health records for conflicting, incomplete, or nonspecific provider documentation" and identified the following key goals for a CDI program: Identify and clarify missing, conflicting, or nonspecific physician documentation related to a diagnoses and procedures Support accurate diagnostic and procedural coding, DRG assignment, severity of illness, and expected risk of mortality, leading to appropriate reimbursement. Promote health record completion during the patient's course of care Improve communication between physicians and other members of the healthcare team Provides education

Ownership of the record

- licensed entity originally responsible for the record "owns" the record even if electronically stored. - Re-disclosure - of health information is of significant concern to the healthcare industry. As such, the HIM professional must be alerted to state and federal statute is addressing this issue. Consent obtained by hospital for pursuant to the privacy rule does not permit another hospital, Healthcare provider, or clearinghouse to use or disclose information. However, the authorization content required in the privacy rule must include a statement that the information disclosed persuaded to the authorization may be disclosed by the recipient is no longer protected. Regardless of the format, the patient and others, as authorized under state and federal laws, rules and regulations, have the right to access information and to control the use and disclosure of the information

Key performance indicators (KPIs)

- measurements that define and measure the progress of an organization toward achieving its objectives - Quantifiable measures of performance used to gauge progress toward strategic objectives or agreed standards of performance. - The quantifiable metrics a company uses to evaluate progress toward critical success factors -allow healthcare facilities to measure and benchmark their data against best practice. Metrics need to be used to conduct root cause analysis to facilitate changes throughout the healthcare system. HFMA developed additional indicators to consistently measure the key performance indicators known as MAP keys. The purpose was to develop the standard for revenue cycle excellence. Each MAP key measures a specific revenue cycle function and provides the purpose for the measurement, the value of the measurement, and the specific equation (numerator and denominator) to consistently calculate the measure.

To accept assignment

- participating physician's agreement to accept allowed charge as full payment -means the provider or supplier accepts, as payment in full, the allowed charge (from the fee schedule). The provider or supplier is prohibited from balance billing, which means the patient cannot be held responsible for the charges in excess of the Medicare fee schedule. However, participating providers may bill patients for services that are not covered by Medicare. Physicians must notify a patient that the service will not be paid for by giving the patient a Notice of Exclusions from Medicare Benefits. If a provider believes that a service may be denied by Medicare because it could be considered unnecessary, he must notify the patient before the treatment begins using an Advance Beneficiary Notice of Noncoverage (ABN).

revenue cycle management (RCM)

- process of making sure sufficient monies flow into the practice to pay the practice's bills - - managing the activities associated with a patient encounter to ensure that the provider receives full payment for services Front-End Process Payor negotiation and renegotiation; patient access, including scheduling, preauthorization, insurance verification, point-of-service collection, and financial counseling. Middle Process Charge capture, case management, clinical documentation, and coding Back-End Process Claims processing and payment posting, follow-up, customer service, collections, and denial management.

Need-to-know principle

- security levels can establish users, allowing users access only those portions of the record that are necessary for their job. -The release-of-information principle based on the minimum necessary standard that means that only the information needed by a specific individual to perform a specific task should be released - The minimum necessary standard for ROI EX: In response to the request to verify an admission for cholecytectomy, the history and physical, the operative report, the discharge summary and the laboratory report could be copied. That documentation could reveal social habits, genetic risks, and family history of disease that have nothing to do with the surgery. Patient privacy could be violated as a result of the release of information through subsequent discrimination.

Preventive Controls

- self correcting - Are front end processes that guide work in such a way that input and process variations are minimized. Simple things such as standards operating procedures, edits on data entered into computer-based systems, and training processes are ways to reduce the potential for error by using preventive controls.

Unbundling

- submitting multiple CPT codes when one code should be submitted -is the practice of using multiple codes that describe individual components of a procedure rather than an appropriate single code that describes all steps of the procedure performed. - Unbundling is a target of the NCCI.

Case Mix Index (CMI)

- sum of DRG-relative weights of all patients seen in years time divided by patients hospitalized - The average relative weight of all cases treated at a given facility or by a given physician, which reflects the resource intensity or clinical severity of a specific group in relation to the other groups in the classification system; calculated by dividing the sum of the weights of diagnosis-related groups for patients discharged during a given period by the total number of patients discharged - A measure of the clinical severity or resource requirements of the patients in a particular hospital or treated by a particular clinician during a specific time period. -The Ms- DRG system creates a hospital's case-mix index (types or categories of patients treated by the hospital) based on the relative weights of the MS-DRG. The case-mix index can be figured by multiplying the relative weight of each MS-DRG by the number of discharges within that MS-DRG -The hospital's case mix index (CMI) is also measured and analyzed. The case mix index allows an organization to compare its cost of providing care to its DRG mix of patients compared to other hospitals. Medicare determines DRG weights by comparing the average cost of treating patients in one DRG to the average cost of all patients receiving hospital inpatient care. The DRG weights do not reflect an individual hospital's cost relative to another hospital or peer group. The CMI is calculated by summing the Medicare DRG weight for every inpatient discharge and dividing by the number of discharges. Medicare DRG weights are used and applied to patients within all payers. The accuracy of clinical documentation and of code assignment can influence a facility's case mix index. By missing diagnoses or procedures that should be coded, or failing to assign the most specific coding possible, the coding staff can cause the case mix index to be lower than it should be.

Global payment

-A form of reimbursement used for radiological and other procedures that combines the professional and technical components of the procedures and disperses payments as lump sums to be distributed between the physician and the healthcare facility -Global payment methodology is sometimes applied to radiological and similar types of procedures that involve professional and technical components. Global payments are lump-sum payments distributed among the physicians who performed the procedure or interpreted its results and the healthcare facility that provided the equipment, supplies, and technical support required. The procedure's professional component is supplied by physicians (for example, radiologists), and its technical component ( for example, radiological supplies, equipment, and support services) is supplied by a hospital or freestanding diagnostic or surgical center. Professional component: Injection of radiopaque contrast material by the surgeon. Technical Component: X-ray of neck region. Global payment: The facility received a lump-sum payment for the procedure and paid for the services of the surgeon from that payment.

Excludes 1

-A type 1 Exclude note is a pure exclude note. It means "NOT CODED HERE!" An Exclude 1 note indicates that the code excluded should never be used at the same time as the code above the Exclude 1 note. -exclusion note used when two conditions could not exist together, such as an acquired and a congenital condition; means "not coded here" - The software would need to recognize when codes cannot be used together

RAI (Resident Assessment Instrument)

-A uniform assessment instrument developed by the CMS to standardize the collections of skilled nursing facilities patient data; includes the MDS 2.0 triggers & Resident assessment protocols. - The process is federally mandated standard assessment used to collect demographic and clinical data on residents in Medicare or Medicaid certified long term care facility. it consists of three components: 1) the Minimum Data Set 2) Care Area Assessment (CAA) 3) RAI utilization guidelines

HL7 (Health Level 7)

-Acronym used to refer a standard of interoperability and exchange of clinical data-standards that will insure that each federal agency can share information that will improve coordinated care for patients - Develops messaging, data content, document standard to support the exchange of clinical information

HEDIS HealthCare Effectiveness Data Information Set

-Compare the performance of manage healthcare plans - Set of standardized measures used to compare managed care plans in terms of the quality of services they provide. The standards cover areas such as plan membership, utilization of and access to services and financial indicators. - Set of standard performance measures designed to provide purchasers & consumers of healthcare with information they need to comparing the performance of managed healthcare plans -Used by NCQA as part of the accrediting process for managed care organizations - This set includes: administrative data, claims, health record review data. HEDIS took is used by more than 90% of american health plans to measure performance in important dimensions of care and service - HEDIS data form the basis of performance improvement efforts for health plans -HEDIS data used to develop physician profiles, the goal of physician profiling is to positively influence physician to practise patterns. -HEDIS is an example of a population-based collection tool. It illustrates the need for developing standardized data definition & uniform collection methods. It also emphasizes the importance of data quality management - NCQA is a private, not-for-profit organization that accredits, assesses, and reports on the quality of managed care plans in US. It worked with public and private healthcare purchasers, health plans, researchers, and consumer advocates to develop HEDIS

CMS (Centers for Medicare and Medicaid Services)

-Federal agency in the Department of Health and Human Services that runs Medicare, Medicaid, clinical laboratories, and other government health programs; responsible for enforcing all HIPAA standards other than the privacy and security standards. -Developed the "Conditions Of Participation" that healthcare organizations must meet in order to qualify to participate in Medicare & Medicaid -Utilization review committes deal with the issues of the medical necessity of admissions & efficient utilization of facility resources. -Regulates all laboratory testing except research performed on humans in the United States through the clinical laboratory improvement amendments "CLIA"

Reference Sets (snomed)

-Flexible standard approach used by snomed-ct to support a variety of requirements for customization & enhancements of snomed-ct. -These include the representation of subsets, language preferences for use of particular terms & mapping from or to other code systems. -Every reference has a unique numeric concept identified.

HEAT (Healthcare Fraud Prevention & Enforcement Action Team )

-Governmental routine audit -Goal: To identify fraud perpetrators & those preying on Medicare & Medicaid beneficiaries

Coordination of Benefits (COB)

-In many instances, patients have more than one insurance policy, and the determination of which policy is primary and which is secondary is necessary so that there is no duplication of benefits paid. This process is called the coordination of benefits (COB) or the coordination of benefits transaction.

quantitative analysis

-Often called discharge analysis, is a review of the health record for completeness and accuracy. It is generally conducted retrospectively, that is, after the patients discharged from the facility or at the conclusion of treatment. Quantitative analysis also may be done while the patient is in the facility, in which case it is referred to as concurrent review or concurrent analysis. -Quantitative Analysis is the review of patient records for completeness, including identification of charge deficiencies, which included missing reports and other documentation and missing signatures. A deficiencies that are flagged in the record for providers completion. -Quantitative review is based on quantities obtained using a quantifiable measurement process. -EX: type of analysis identifies deficiencies in recording (omissions) such as no missing, reports, forms or required signatures.

minimum necessary standard

-Principle that individually identifiable health information should be disclosed only to the extent needed to support the purpose of the disclosure. - Stipulation of the HIPAA privacy rule that requires healthcare facilities and other covered entities to make reasonable efforts to limit to the patient-identifiable information they disclose to the least amount required to accomplish the intended purpose for which the information was requested.

Capitation

-System of payment used by managed care plans in which physicians and hospitals are paid a fixed, per capita amount for each patient enrolled over a stated period regardless of the type and number of services provided; reimbursement to the hospital on a per-member/per-month basis to cover costs for the members of the plan. - It is based on per person premiums or membership fees rather than on itemized per-procedure or per service charges. The capitated managed care plan negotiates a contract with an employer or a government agency representing a specific group of individuals. - The capitated managed care organization may own or operate some or all of the healthcare facilities that provide care to members and directly employ clinical professionals. Staff model HMOs operate in this way.

Non-Participating Provider

-a physician to whom the patient is expected to pay charges before submitting the claim to the insurance company, which pays the patient directly -If MD is a non-participating physcian they do not receive direct payment from Medicare. Rather, MDs bill their pts & pts seek reimbursement from Medicare. -It's illegal for non-participating MD's to charge more than 15% above the Medicare fee schedule

Generally accepted record keeping principles "GARP"

-accountability - his senior executive oversees the record-keeping program and delegates program responsibility to appropriate individuals. The organization adopts policies and procedures to guide personnel and ensure the program can be audited. -Transparency - the process in activities of an organizations record-keeping program are documented in a manner that is open and verifiable and is available to all personnel in appropriate interested parties. -Integrity - the record-keeping program shall be constructed so the records information generated or mandated by or for the organization have a responsible and suitable guarantee of authenticity and reliability. -Protection - a record-keeping program shall be constructed to ensure a reasonable level of protection to records and information that are private, confidential, privileged, Secret, or essential to business continuity. -Compliance - record-keeping program shall be constructed to comply with applicable laws and other binding authorities, as well as the organizations policies. -Availability - an organization shall maintain records in a manner that ensure is timely, efficient, and accurate retrieval of needed information. -Retention - organization shall maintain its records and information for an appropriate time, taking into account to legal, regulatory, fiscal, operational, and historical requirements. -Disposition - an organization shall provide secure and appropriate disposition for records that are no longer required to be maintained by applicable laws in organizations policies. -Implementation - refers to a system haven't been installed and configured to meet a specific organizational needs

OBRA (Omnibus Budget Reconciliation Act)

-federal law that includes minimum standards for nursing assistant training, staffing requirements, resident assessment instructions, and information on rights for residents - law passed by federal government establishing minimum standards for nursing home care and for nursing assistant training - passed by congress and mandated that CMS develop a prospective system for hospital-based outpatient services provided to Medicare beneficiaries. In subsequent years, Congress mandated the development of PPSs for other healthcare providers.

MDS (minimum data set)

-is the minimum core of defined and categorized patient assessment data that serves as the basis for documentation and reimbursement in an SNF. The MDS form contains a facesheet for documentation of resident identification information, demographic information, and the patients customary routine- a detailed form with guidelines for assessing residents in long-term care facilities; also details what to do if resident problems are identified - MDS is far more extensive and includes more clinical data than either the UHDDS or the UAACDS - Used to develop care plans & document placement at appropriate care level - Collect data about long term care residents -Provides a structured way to develop a long term care resident care plan - Resident Assessment Instrument (RAI) process is a federal mandated standard assessment used to collect demo & clinical data on residents in Medicare & Medicaid certified long-term care facility -MDS is a core of set of screening, clinical & functional status elements based on common definitions. To meet federal requirements, long term care facilities must complete an assessment for every resident at the time of admission and at designated reassessment points throughout the residents stay. - The data collected via MDS are used to develop care plans for residents & to document placement at the appropriate level of care. The MDS is also used as a data collection tool to classify Medicare residents into Resource utilization Groups ( RUGs) - The focus in long-term care is on the achievement of goals. The HIM functions are similar to those in toher types of facilities, but a great deal of concurrent reviews is required to ensure that a complete medical record is maintained throughout the residents often lengthy stay

Coding guidelines

A (7th character coding guidelines) - Initial Encounter. While the patient is receiving active treatment including continuing treatment by the same or different physician. D ( 7th character coding guidelines) - Subsequent encounter. Routine care during the healing or recovery phase, such as aftercare & follow up. S (7th character coding guidelines)- Sequela. Complications or conditions that arise as direct results of a condition, such as scar formation after burn.

Anti-Kickback Statute

A criminal law that prohibits the exchange of anything of value to reward the referral of a patient sponsored by a government insurance plan. - The statue basically states that anyone who knowingly and willfully receives or pays anything of value that influences the referral of business of federal healthcare programs may face felony charges. - AKS is a criminal law that prohibits the knowing and willful payment of "remuneration" to induce or reward patients referrals or the generation of business involving any item or service payable by the federal healthcare programs( drugs, supplies, or health care services for Medicare & Medicaid patients). - Asking for remuneration in exchange for MD's referral of federal healthcare program business is a crime. - AKS laws applies to both payers & recipients of kickbacks. Just asking for or offering a kickback could violate the law. - Rumination: anything of value - Illegal for MD's to accept money from providers or vendors, suppliers in return for the referral of Medicare or Medicaid pts. - Makes it criminal offense to knowingly & willfully offer, pay, solicit, or receive any payment directly or indirectly encourage or reward referrals of items or services reimbursable by a federal healthcare program - Its illegal to ask for any favors to get a doctor to order tests from a lab. - Safe harbor protects certain payment & business practices that could otherwise implicate the AKS from criminal and civil prosecution. To be protected by a safe harbor an arrangements MD must fit squarely in the safe harbor and satisfy all of its requirements. Some safe harbors address personal services and rental agreements, investments in ambulatory surgical centers, and payments to bona fide employees - Besides the AKS, the beneficiary inducement statute also imposes civil monetary penalties on physicians who offer remuneration to Medicare and Medicaid beneficiaries to influence them to use their services. The Government does not need to prove patient harm or financial loss to the programs to show that a physician violated the AKS. A physician can be guilty of violating the AKS even if the physician actually rendered the service and the service was medically necessary. Taking money or gifts from a drug or device company or a durable medical equipment (DME) supplier is not justified by the argument that you would have prescribed that drug or ordered that wheelchair even without a kickback.

Discharged Not Final Billed (DNFB) -

A report that includes all patients who have been discharged from the facility but for whom, for one reason or another, the billing process is not complete

Continuous Quality Improvement (CQI)

A system of internal and external reviews and audits of all aspects of an EMS system. Executive leaders must be committed to the philosophy of continuous quality improvement and work to ensure that every manager and every employee is committed to its value. This commitment demands an investment in people and requires substantial time and training. PI ( performance improvement) depends on everyone in the organization actively seeking to meet internal and external customers spoken or anticipated needs. This is particularly important for employees who have direct contact with external customers. These employees are perhaps in the best position to recognize which needs of the customer are not being met. They often offer helpful ides for improvement. It works to the organizations benefit when staff are empowered to make a difference for their fellow workers and the patients they serve - emphasizes importance of knowing meeting customer expectations, reducing variation in processes. - continuous cycle of planning, measuring & monitoring performance & making knowledge based improvements.

Excludes 2

A type 2 excludes note represents "Not included here". An excludes 2 note indicates that the condition excluded is not part of the condition represented y the code but a patient may have both conditions at the same time. It is acceptable to use both the code and the excluded code together, when appropriate.

Episode-of-care (EOC) reimbursement

AKA bundle payment, lump-sum payments are issued to providers to compensate them for all the healthcare services delivered to a patient for a specific illness or over a specific period of time.

Flexibility for Breach Notification

After investigation, if access is determined to have been un-intentional & the employee or other person was acting under the authority of the covered entity or business associate, it may be forgiven. However, there must be evidence that the PHI was reviewed in good faith & the PHI was not further used or disclosed. ARRA requirement address breach notification

Revenue Audit and Recovery

After payment has been received, it is audited against the terms of the contract to determine whether the organization has received the correct reimbursement. To achieve optimum benefit, audits should occur for all payment relationships that can be modeled.

Billing guidelines

An additional responsibility in revenue cycle management is determining items or services that are not separately billable. Routine supplies are commonly defined as a supply used as part of the normal course of service where the care is delivered, given to most patients treated in a particular setting or incidental to the procedure, or inherent to a procedure. These supplies are not billable and are considered part of the room and board charge for a hospital or an overhead cost for the healthcare facility. Examples of routine supplies include specimen collection containers, syringes, needles, gloves, pillows, sponges, heating pads, and irrigation solutions. Equipment available to all patients in an area or commonly used during a procedure is also considered not separately billable.

Loss Prevention

Another component of a successful risk management program is loss prevention some of the ways that risk prevention can be attained include; - Educating all employees and medical staff to write recognize and properly report all potentially adverse occurrences. - Ensuring all employees and medical staff are doing their jobs to do best of their ability. - Developing early warning and reporting systems that it identify areas of potential adverse effects. - Creating databases to track events and help point out areas where systems can be improved. - Making changes to the systems requiring improvement and monitoring these areas to determine success. - Provide employees with appropriate safety training.

Charge conversion vs Data conversion

Charge Conversion: is a key issue for EHR implementation, especially in physician practices where access to the information from a patient's last visit is critical, particularly for patients with chronic disease. Data Conversion: is the movement of existing electronic data from an old system to a new system. If the EHR implementation entails new applications for admissions and registration or billing (or practice management in a physician office), it will be very likely need to be considerable conversion of data from the old systems to the new one. An MPI cleaner project is often performed at this time as well, especially if the implementation entails and move on an enterprisewide MPI. - Taking Data already in one automated system & putting it in another

Common Cause Variation vs Special Cause Variation

Common Cause Variation -Every system has some degree of variation built into it. No system produces the exact same output everytime. It should be desirable to reduce variation within systems as much as possible so that system output could be more predictable or better controlled. Variation that is inherent with teh system is called Common Cause Variation. -EX - When nurse takes patients blood pressure, she may believe that she is performing the procedure in exactly the same way every-time, but she will get slightly different readings each-time. Although the blood pressure cuff, the patient and the nurse are all the same inputs in the system, variations can occur. The cuff maybe applied to a different place on the patients arm. The patient may have a slightly different emotional or physiological status at the time of the measurement. the nurse may have a different level of focus or concentration. Any one of these factors, plus countless others, can affect the values obtained. However, they are potentially present in every single patient. It is important to recognize that not ever variation is a defect. The variation maybe just an example of common cause variation found inherently in the process. -The source variation is a process that is inherent within the process, caused inherently by the system. Special Cause Variation: An unusual source of variation that occurs outside a process but affects it. Some variations are caused by factors outside the system. This type of variation is known as special cause variation. If the special cause produces a negative effect, we will want to identify the special cause and eliminate it. If the special cause produces a positive effect, we will want to reinforce it so the good effect will continue and perhaps be expanded into the processes of others in the organization. EX: This type of variation occurs when a patient is taking blood pressure medication and there is a substantial drop is measurement. The medication has caused a decrease in blood pressure values and can clearly be considered a special cause. In this situation, the variation is intentional and desired. In other situations, the variation may produce an undesirable and unintentional effect. EX: If a patient is upset about a phone call he received just before the nurse came in to take this vitals, his blood pressure could be exceptionally high. the change in values occurred due to a special cause ( a phone call) and resulted in the blood pressure reading much higher than normally expected. ex: In HIM department, theres always some common cause variation in the number of records can be coded each day. On a day when one of the regular coders is out sick, however, the number of records coded might drop significantly. This would be an example of special cause variation. As much as is possible, the goal should be to remove special causes if theyre creating an undesirable effect.

data mining

Computer-based process of extracting quantifying & filtering discrete data, its computing process of discovering patterns in large sets involving methods at the intersection of machine learning, database system. Process of extracting and analyzing large volumes of data form databases for the purpose of identifying hidden and sometimes subtle relationships. In healthcare, this is used to identify methods for cutting healthcare costs, suggest more appropriate medical treatments, and predict medical outcomes Process that identifies patterns and relationships by searching through large amounts of data. This is also known as database exploration or information discovery Process of extracting and analyzing large volumes of data from a a database for the purpose of identifying hidden and sometimes subtle relationships.

safe harbor

Congress authorize the designation of specific "save harbors" for some business or payment arrangements that could be prohibited under the statue but would not be prosecuted. There are currently 13 safe harbors identified; 1 investments in large publicly held healthcare companies; 2 investments in small healthcare joint ventures; 3 space rentals 4 equipment rental 5 personal services in management contracts. 6 sales of retiring physicians practices to other physicians. 7 referral services. 8 warranties. 9 discounts 10 employee compensation. 11 group purchasing organization. 12 waivers of Medicare part A inpatient cost sharing amounts. 13 practices in managed-care settings. To be protected in a safe harbor provision, the payment or business arrangements must fit completely within the safe harbor definition. Compliance should be evaluated on a case-by-case basis to be certain that arrangements qualify for this protection.

Management Information Systems (MIS)

DSS - based MIS's enable management to interrogate the computer on an AD-HOC basis for various kinds of information within organizations. So as to predict the effect of potential decisions. - Broad range of data, document, knowledge drive DSS that provide information concerning with an organizations administrative functions. - A business function, like accounting and human resources, which moves information about people, products, and processes across the company to facilitate decision-making and problem-solving

dashboards vs scorecards

Dashboard: - ( like dashboards on a car) - Reports of process measures that help leaders know what is currently going on so that they can plan strategically where they want to go next. -Reports of process measures to help leaders follow progress to assist with strategic planning; Also called scorecards Scorecards: (like baseball scorecards) - Reports of outcomes measures to help leaders know what they have accomplished. - These concise reports help leaders align organizational effort to achieve higher levels of organizational performance. - Another means by which customers can see how a healthcare organization performs is through the publication of dashboard & scorecards.

HIM Compliance Program

Education for coders should be provided monthly. Auditing involves the performance of internal and external reviews to identify variations from established baselines (for example, review outpatient coding as compared with CMS outpatient coding guidelines). Internal reviews are conducted by facility-based staff (for example, HIM professionals), and external reviews are conducted by either consultants hired for this purpose (for example, corporations that specialize in such reviews and independent heath information consultants) or third- party payers. Three-day payment window, formerly called 72-hour rule (Under this rule, diagnostic services provided within three days of admission should be included, or bundled, in DRG, whether or not they are related to the admission. Non-diagnostic services provided within three days of admission should be included in the DRG only if they are related to the admission.) The goal of compliance programs is to prevent accusations of fraud and abuse, make operations run more smoothly, improve services, and contain costs.

EOB vs MSN vs RA

Explanation of benefits - EOB: - The statement mailed to the patient summarizing how the insurance carrier determined the reimbursement - is a statement sent by a third-party payer to the patient to explain services provided, amounts billed, and payments made by the heath plan Medicare Summary Notice - MSN: - document patients receive that details the services they were provided over a 30-day period; it details their services and charges. - to a beneficiary to show how much the provider billed, how much Medicare reimbursed the provider, and what the patient must pay the provider by the way of deductible and copayments. Remittance Advice - RA: - an explanation of benefits transmitted electronically by a payer to a provider - is sent to the provider to explain payments made by third-party. Payments are typically sent in batches with the RA sent to the facility and payments electronically transferred to the provider's bank.

Hard Coding vs Soft Coding

Hard coding: When codes are assigned by the CDM without human intervention Soft Coding: When codes are manually assigned by coding specialist

HITECH Act

Health Info Technology for Economic & Clinical Health Act. Part of ARRA. Additional privacy regulations on top of HIPAA, breach notification rules & stiffer civil and criminal penalties for security violations. - Was designed to ensure coordination & alignment between states, establish connectivity to the public health community, & properly train the workforce to be meaningful users of EHR's - Will expand the HIPAA requirements for disclosure accounting to include treatment, payment and operations "TPO"; reduce the time. That must be documented; and limit what is released from the EHR. HITECH also mandates that HHS conduct periodic privacy and security audits of HIPAA covered entities in business associates - ARRA - included the HITECH act provisions.

Contract Management

Heathcare facilities negotiate contract terms with third-party insurers for payment of services rendered to patients. This is where allowable costs or chargeable services or supplies provided by a hospital or physician that qualify as covered expenses are defined. Contract management has its own life cycle. Persons responsible for contract management must first understand service lines provided with in their facility and then analyze the financial needs to provide the services. Contract managers need to be able to analyze steerage vs. discounts.

internal customers vs external customer

Internal Customer: - Employees are internal customers. They receive services from other areas in the organization that make it possible for them to do their jobs. - Located within the organization. They may be anyone within the work unit who is affected by the HIS function. Physicians and clinical staff need high quality, expedient patient health information in order to deliver high-quality patient care. Administrative staff members are customers of the information harvested from collective database for use in planning facilities and services. And not least among the department's internal customers are the HIS department staff who work in each of the functional areas and rely on each other in various ways to get their work done. EX: Nurse on an intensive care unit would be an internal customer of the hospital pharmacy. The nurse depends on the pharmacy to provide medications needed to fill the physicians orders for his/her patients. External Customer: -A person who is outside the organization for whom it provides the services. External customers of a hospital : patients, physicians, 3rd party payers - Reside outside of the organization. Physicians seen by patients who originated at the facility for care are considered external customers, as are payers.

Differences between incident & prevalence rate?

Is in the numerators of their formulas. Incident rate - rate of new cases occurring in given time period Prevalence rate - all cases present during a given time period In addition, the incident rate includes only patients whose illness began during a specified time period whereas the prevalence rate includes all patients from a specified cause regardless of when the illness began. Moreover, the prevalence rate includes a patient until she/he recovers.

Identity theft

It generally theft may take two forms in healthcare; financial identity theft or medical identity theft. Financial identity theft occurs when a party steals demographic and financial information about a patient for its own use. This compromise is the financial welfare of the person whose identity was stolen. Medical identity theft occurs when a patient uses another persons name and insurance information to receive healthcare benefits. Most often this is done so a person can receive medical care with an insurance benefit and pay less or nothing for the care he or she receives

One method of preserving data?

Its to develop a data dictionary that includes the data elements, variables, descriptions, data type, and format for each of the data elements collected in the EHR. Data dictionary is a file that defines the organization of the database. It does not contain any actual data, only information about what is in the database so that it will be easy to preserve and maintain. In order to effectively main an EHR system, data content standards are crucial. There are many data content standards organizations such as Hl7, ASTM International, LOICN, SNOMED

Accession number

Number generated by laboratory information system (LIS) when specimen request is entered into the computer. Number assigned to patients in a cancer registry in the order that the patients are entered in the registry every year. Without having access to that hospital's specific database that ties accession numbers to a specific service done on a specific patient, you cannot identify a patient.

Medicare Skilled Nursing Facility Prospective Payment System

OBRA required CMS to develop an assessment instrument to standardize the collection of SNF patient data. That document is called the Minimum Data Set 3.0 (MDS). The MDS is the minimum core of defined and categorized patient data assessment data that serves as the basis for documentation and reimbursement in an SNF. The MDS form contains a face sheet for documentation of resident identification information, demographic information, and the patient's customary routine.

EOC; Episode of Care

Plans that use episode-of-care (EOC) reimbursement methods issue lump-sum payments to providers to compensate them for all the healthcare services delivered to a patient for a specific illness or over a specific period of time. EOC payments are also called bundled payments. Bundled payments cover multiple services and also may involve multiple providers of care. EOC reimbursement methods include capitated payments, global payments, global surgery payments, Medicare ambulatory surgery center rates, and Medicare PPSs.

TEFRA (Tax Equity and Fiscal Responsibility Act)

TEFRA modified Medicare's retrospective reimbursement system for inpatient hospital stays by requiring implementation of the DRG PPS in 1983. UNDER DRGs, Medicare paid most hospitals for inpatient hospital services according to a predetermined rate for each discharge. The DRG system was a way of classifying patients on the basis of diagnosis. Patients within each DRG were said to be "medically meaningful"

Sentinel Events

TJC requires healthcare originations to conduct in-depth investigations of occurrences that resulted in or could have resulted in life threating injuries to patients, medical staff, visitors, and employees. Sentinel events - undesirable outcomes usually occurring only one. The occurrence, points to serious issues involved in care process that must be resolved in order not to suffer the occurrence again. EX: medical error, explosions, fires, act of violence. A sentinel event is an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof. Serious injury specifically includes loss of limb or function. The phrase "or the risk thereof" includes any process variation for which a recurrence would carry a significant chance of a serious adverse outcome. Such events are called "sentinel" because they signal the need for immediate investigation and response. The terms "sentinel event" and "error" are not synonymous; not all sentinel events occur because of an error, and not all errors result in sentinel events. - the joint commission initiated Sentinel events reviews in 1988 requiring immediate evaluation in cases when an unexpected incident involves death or serious injury. Immediate evaluation permits changes to be made and prompt way to prevent serious injury or death to others. Organizations are encouraged but not required to report Sentinel events to the joint commission. I route- cause analysis and an action plan must be completed regardless of whether the event is reported to the joint commission. Healthcare organizations reporting a sentinel event can benefit by having an outside, Objective third-party review their action plan and by obtaining consultation as needed. The organization should show that public a sincere effort to remedy problems and show improvement.

Maintenance of The chargemaster

The chargemaster must be updated routinely. Maintenance of the chargemaster is best accomplished by representatives from health information management, clinical services, finance, the business office or patient financial services, compliance, and information systems. The HIM professionals are generally consulted regarding the update of CPT codes. The CDM is updated when new CPT codes become available, when departments request a new item, and when the medical fee schedules or PPS rates are updated. An inaccurate chargemaster adversely affects the facility reimbursement, compliance, and data quality. According to an AHIMA practice brief (RHODES 1999), negative effects that may result from an inaccurate chargemaster include overpayment, underpayment, undercharging for delivery of healthcare services, claims rejections, and fines or penalties. Chargemaster programs are automated and involve the billing of numerous services for high volumes of patients, often without human intervention. Therefore, it is highly likely that a single error on the chargemaster could result in multiple errors before it is identified and corrected, resulting in a serious financial impact.

management of chargemaster

The chargemaster, also called the charge description master (CDM), contains information about healthcare services (and transactions) provided to a patient. Its primary purpose is to allow the provider to accurately charge routine services and supplies to the patient. Services, supplies, and procedures included on the chargemaster generate reimbursement for almost 75 percent of claims submitted for outpatient services alone. Item description: The actual name of the service or supply. Expamples might be the evaluation and management visit, observation, or emergency room visit. CPT/HCPCS code: This code must correspond to the description of the service. Revenue code: The revenue code is a three digit code that describes a classification of a product or service provided to the patient. These revenue codes are required by CMS for reporting services. Charge amount: This is the amount the facility charges for the procedure or service. It is not necessarily what the facility will be reimbursed by the third-party payer. Charge code: The charge or service code is an internally assigned number that is unique to the facility. It identifies each procedure listed on the chargemaster and identifies the department or revenue center that initiated the charge. The charge code can be very useful for revenue tracking and budget analysis. General ledger key: is a two-or three-digit number that assign a line item to a section of the general ledger in the hospital's accounting system. Activity/status date: The activity/status date indicates the most recent activity of an item The CDM can also be a tool for collecting workload statistics that can be used to monitor production and compile budgets. It is often used as a decision support tool to evaluate costs related to resources and to prepare for contract negotiations with managed care organizations. The CDM relieves coders from coding repetitive services and supplies that require little, if any, formal documentation analysis. In these circumstances, the patient is billed automatically by linking the service to the appropriate CPT/HCPCS code (referred to as hard-coding). The advantage of hard-coding is that the code for the procedure will be reproduced accurately each time that a test, service, or procedure is ordered.

Governments rights of access to health records

The government, whether federal or state, has the right to access health information with or without patient authorization in certain circumstances. Healthcare provider must sign an agreement with HHS to receive payments for care provided to patients covered under the Medicare program. Medicaid is a joint federal and state program to provide medical care to individuals unable to pay for care. Healthcare providers applying to the responsible state agency for a contract with the state to provide services to Medicaid recipients in return for payment for services provided. HHS in the state Medicaid agency may request information from the health record to support the healthcare providers bills submitted for payment. By signing up with Medicare or Medicaid, the patient gives permission for the healthcare provider to disclose confidential health information to the appropriate agency without further authorization. The government also may require access to health information for other investigative purposes such as pursuant to the federal fraud and abuse statuses and require information sharing arrangements to be undertaken in the arms length transaction and pursuant to brighten agreement. - An arm's-length transaction is a transaction in which "parties are dealing from equal bargaining positions, neither party is subject to others control or dominant influence, and the transaction is treated with fairness, integrity, in the Legality " - Another important federal statue for which the government may need access to health information as part of an investigation is the emergency medical treatment and labor act "EMTALA". This act involves the transfer of an uninsured individual from one Hospital emergency Department to another for financial reasons. Individuals are personally liable for their own acts of an authorized disclosure of confidential health information. The individuals liability is based on fault because he or she did something wrong or failed to do something he or she should've done. Employers also may be held liable for any job related acts of their employees or agents. It must be distinguished but the hospital is not liable for a breach of confidentiality by the members of its medical staff because they are not employees or agents of the hospital. However, the hospital may be liable for the consequences of any unauthorized disclosures weather by employees, agents or medical staff members, because of the breach of his duty to maintain information confidential. The injured person benefits from these concepts of fault because he or she can sue the employer, employee, or both. On authorized disclosure by various healthcare professionals also may be addressed in professional licensing and certifying laws or regulations. These provisions subject the professional to potential discipline by the licensing or certifying agency for breach of confidentiality because it is considered unprofessional conduct

dashboards/scorecards

These are visual tools for presenting performance data defined by users. Dashboards & scorecards are tools that present metrics from a variety of quality aspects in one concise report. They may present measures of clinical quality (such as infection rate), financially quality, volume, & patient satisfaction. The indicators provide snapshots of all areas of quality to give leaders & communities of interest an overall perspective of the service the organization is providing.

Reimbursement Support Processes

Third-party payers revise fee schedules, and healthcare facilities revise charge-masters, evaluate the quality of documentation and coding, conduct internal audits, and implement compliance programs.

Management of the fee schedules

Third-party payers that reimburse providers on a fee-for-service basis generally update fee schedules on an annual basis. A fee schedule is a list of healthcare services and procedures (usually CPT/HCPCS codes) and charges associated with each. The fee schedule (sometimes referred to as a table of allowances) represents the approved payment levels for a given insurance plan. Physicians, practitioners, and suppliers must notify Medicare by December 31st of each year whether they intend to participate in the MEdicare program during the coming year. Medicare participation means that the provider or supplier agrees to accept assignment for all covered services provided to Medicare patients.

Tools for strategic thinking - scenario building ; story telling

To bring out the best strategic thinking of a team or a work group, it is often helpful to use techniques that help participants consider factors from different perspective. A number of group process techniques such as brainstorming, nominal group technique and help families each individual's creative talent. Storytelling is a powerful group process technique stories are defined as one way we transmit and organizations truths, inside, and commitments using compelling stories is a powerful way to persuade people by uniting an idea with an emotion. In the story, you not only weave a lot of information into the telling but also arouse your listeners emotions and energy. Essentially, the story expresses how and why life changes.

UCADS (uniform ambulatory care data set)

Use to improve data comparison in ambulatory & outpatient care settings. It provides a uniform definition that helps provide analysis patterns of care. Set include reasons for encounter, living arrangements, marital status. - The goal of UCADS is to improve data comparison in ambulatory and outpatient care settings. It provides uniform definitions that help providers to analyze patterns of care. -Data elements in UHDDS & UACDS are the same - The purpose of keeping the same demo data elements is to make it easier to compare data for inpatient and ambulatory inpatient in the same and different facilities

The project management process; Scalable

a project follows a define process regardless of size, type, or industry. The process is called scalable, meaning that the depth to which a particular process is performed may vary according to project length, scope, or other para meters. However, to ensure the success of the project, all these processes must be performed to some degree

Whistleblower

an employee who exposes unethical or illegal conduct within the federal government or one of its contractors. - They are protected from retaliation by FCA cannot be fired or disciplined because of the suit, dont have to tell the company they have filed a suite or leave the company after they have filed the suit & they often remain on the job & continue to gather evidence for their case.

attributes

are characteristics of the data fields that make up the database MA include a name, and medical record number, and address.

Remediation activities

are intended to offer providers another chance to prove they are worthy of participating in federal healthcare programs.

OIG work plans

are issued at the beginning of each fiscal year and provide for new and ongoing reviews for audits and more than 300 programs administered by the HHS.

Revenue Cycle Middle Process; Case management

as "a collaborative process of assessment, planning, facilitation, care coordination, evaluation, and advocacy for options and services to meet an individual's and family's comprehensive heath needs through communication and available resources to promote quality cost effective outcomes". The goals of case management include the achievement of optimal heath, access to care, and appropriate utilization of resources, balanced with the patient's right to self-determination. Both organizations support professionals who evaluate the appropriateness of hospital admissions according to pre-established criteria. Case manager's responsibilities were initially to manage and ensure the appropriate utilization of acute care resources with a focus on improving quality and reducing costs. The case manager can have a positive impact on the revenue cycle by avoiding delays, navigating the patient through the healthcare process, and acting as an advocate for the patient resulting in higher patient satisfaction with the heathcare facility. - A nursing care pattern; a case manager (an RN) coordinates a person's care from admission through discharge and into the home setting - development of patient care plans to coordinate and provide care for complicated cases in a cost-effective manner.

Project implementation; baseline

before the project begins, he or she will capture a baseline of the project schedule and work effort. The baseline is a copy of the original estimates for the project. It is captured so that the process of the project can be compared to the original plan.

Corporate compliance program

every healthcare organization should designate a compliance officer who serves as the focal point for the compliance activities. Responsibility for the compliance maybe sol duty of the individual or added to other management responsibilities, depending on the organization. For the program to be successful, the compliance officer must have the necessary authority to conduct the program. The compliance officer must also be provided sufficient staff in funding to carry out the duties of the office. - Typically the organizations compliance program is described during new employee orientation and retaining may be required annually. - there's often discussion of scenarios that could present ethical questions for employees. For example a common scenario and healthcare is one of vendor invites an employee to lunch or dinner. Even though the decision to do business with that vendor may be outside the influence of that employee, the perception could be that the employee was being rewarded for the vendors contract with the organization. Even though there are arguments that can legitimately be made that the employee would not be influenced by such an action, it may be against corporate policies for the employee to except such invitation. Employees should check their organizations policies before taking any action.

Information design and capture

information design and captures the first cluster of EIM functions. The key requirements for this process depend on who is setting them. - For clinicians, data capture and documentation to facilitate decision making by individual conditions and communication with other members of the clinical team. - patients want the care team is well-informed and coordinated. -Risk managers require the data capture and documentation produce a complete and logical chronology - Quality managers require data that support the measures being tracked- financial services must ensure that information substantiate the billing claim

Confidential communications

information exchanged between patient and caregiver pursuant to a privilege

Stewardship

information governance might best be viewed as stewardship duty. Stewardship is the responsible management of something interested to one's care. Healthcare organizations are entrusted to one's care. Healthcare organizations are entrusted with managing patient data, and that responsibility is best performed if the organizations stewardship values are laid out

Corporate integrity agreement (CIA)

is a detailed and restrictive agreement imposed and providers by the OIG. CIA may last for many years and are imposed when serious misconduct "fraud and abuse" is discovered through an audit or self disclosure. Remediation initiatives, such as training or designation of compliance officer, or part of the CIA. These initiatives are designed to ensure that fraudulent activities do not occur in the future. -CIA generally do not result from unintentional errors or mistakes when those errors are reported appropriately. CIA are only imposed where there is evidence of intentional fraud

Database management system data dictionary "DBMS"

is developed in conjunction with development of a specific database. Modern DBMS have a built in data dictionary's that go beyond data definitions and store information about tables and data relationships. These integrated data dictionaries are sometimes referred to as system catalogs, reflecting their technical nature. - tables names - all attribute or field names - a description of each attribute - data type of the attribute (text, number , date, ) - the format of each attribute, such as DD_MM_YYYY for the date - the size of each attribute, such as 12 characters in a phone number with dashes - an appropriate range of values, such as integers 100000-99999 for the health record number - whether the attribute is required - relationships among attributes Other descriptions that might be stored in the data dictionary associated with the database include; - Who created the database - when the database was created - where the database is located - what programs can access the database - who the end-users and administrators of the database are-how access authorization is provided to all users

Denial Management Denials

may simply be defined as a payer's refusal to provide payment. A denial management program requires facilities to seek both prevention and recovery. Denials management requires a cross-functional team to evaluate reasons for the denials and to facilitate changes in work processes to prevent further denials from occurring.

Quality Dimensions

performance, features, reliability, durability, conformance, aesthetics, serviceability, perceived quality Process indicators: Measure the actions by which services are provided, the things people or devices do, from conducting appropriate tests, to making a diagnosis, to actually carrying out a treatment. - Measure actions by which services are provided Structure Indicators: Measure the attributes of the setting, such as number and qualifications of the staff adequacy of equipment and facilities, adequacy of organizational policies and procedures EX: 50% of HIM dept staff have a nationally recognized credential Outcome Indicators: Measure the actual results of care for patients & populations, including patients & family satisfaction

(PCE) Potentially Compensable Event

risk management program seek to identify and prevent PCE and reduce liability from injuries or accidents that occur within healthcare facility. Risk management programs may be simple or very sophisticated. Accrediting bodies such as the joint commission review risk management programs and activities during accreditation service insurance carriers for both liability and healthcare require risk management programs to be in place. Federal and state governments require risk management activities aimed at reducing in preventing injuries or accidents in healthcare facilities. Patient safety has become an issue with national visibility.

Contingency

should be put in place for any risk with the high risk factor. The contingency describes what the project team will do if the risk is realized. For example to mitigate the risk of losing a key project team, the project manager would ensure that the project documentation is kept current. The impact of the contingency should be reflected in the project plan. For the example cited, The project manager would make sure that a task is in the project plan for updating project documentation.

Benefits realization

should be the culmination of the implementation. This is the point in time when the organization believes all end-users are trained, the system has gone live, and there has been some period of time to get acclimated and adopt as much of the process changes in functionality as possible.

Chief Complaint (CC)

specific symptom or problem for which the patient is seeing the provider today.

discharge planning

systematic process of preparing the patient to leave the health care facility and for maintaining continuity of care -Discharge planning also can be considered a type of utilization control. The managed care plan may be able to move the patient to a less intensive, and therefore less expensive, care setting as soon as possible by coordinating his or her discharge from inpatient care.

Data map and crosswalk

terms used to describe the connections or paths between classifications in vocabulary's. For examples - when a researcher is studying MRIs for diagnosis cancer from 1998 to 2013, uses to map icd 9 code to icd 10.

Revenue Cycle Back-End Process Claims Processing accounts receivable (A/R) days

the average number of days between the provision of services and the receipt of payment for those services as a measure of how successful their revenue cycle is. Most billing systems are programmed to automatically submit claims to the payers (after the bill hold time frame) if the account is not being held for any type of edit resolution, and those are oven referred to as clean claims.

Organization wide data dictionary

the second type of data dictionary is developed outside the framework of a specific database design process this data dictionary serves to promote data quality through data consistency across the organization. Individual data element definitions are agreed-upon and defined this leads to better quality data and facilitates the details, technical data dictionary's that are integrated with the databases themselves. Ideally, every healthcare organization will develop a data dictionary to define common data in their formats. For example, although everyone may think he or she knows the definition of a last name, can all agree that it will be stored as no more than 25 characters? How should the middle name be handled? Will it be the maiden name for married women? Is the medical record number to be stored with leading zeros? All these issues can be settled with the development of an organization wide data dictionary

Privacy Act

this ad gives individuals some control over information collected about them by the federal government. It is not applied to records maintained by institutions in the private sector. Under the privacy act people have the right to - learn what information has been collected about them - if you and have a copy of that information - maintain limited control over this closure of that information to other persons or entities