RHIT Vocabulary

Policyholder

An individual or entity that purchases healthcare insurance coverage; See certificate holder; insured; member; subscriber

Stakeholder

An individual within the company who has an interest in, or is affected by, the results of a project

Preterm infant

An infant with a birth weight between 1,000 and 2,499 grams and/or a gestation between 28 and 37 completed weeks

Nosocomial infection

An infection acquired by a patient while receiving care or services in a healthcare organization; See also hospital-acquired infection

Hospital-acquired infection

An infection occurring in a patient in a hospital or healthcare setting in whom the infection was not present or incubating at the time of admission, or the remainder of an infection acquired during a previous admission; See nosocomial infection

Community-acquired infection

An infectious disease contracted as the result of exposure before or after a patient's period of hospitalization

Newborn (NB)

An inpatient who was born in a hospital at the beginning of the current inpatient hospitalization

Hippocratic oath

An oath created by ancient Greeks to embody a code of medical ethics

Medication list

An ongoing record of the medications a patient has received in the past and is taking currently; includes names of medications, dosages, amounts dispensed, dispensing instructions, prescription dates, discontinued dates, and the problem for which the medication was prescribed

Injury Severity Score (ISS)

An overall severity measurement maintained in the trauma registry and calculated from the abbreviated injury scores for the three most severe injuries of each patient (Trauma Org 2013)

Employer-based self-insurance

An umbrella term used to describe health plans that are funded directly by employers to provide coverage for their employees exclusively in which employers establish accounts to cover their employees' medical expenses and retain control over the funds but bear the risk of paying claims greater than their estimates

Random sampling

An unbiased selection of subjects that includes methods such as simple random sampling, stratified random sampling, systematic sampling, and cluster sampling

Reportable adverse event

An unintended act, either of omission or commission, or an act that does not achieve its intended outcome

Global Assessment of Functioning (GAF) Scale

A 100-point tool rating overall psychological, social, and occupational functioning of individuals, excluding physical and environmental impairment

Emergency Medical Treatment and Active Labor Act (EMTALA)

A 1986 law enacted as part of the Consolidated Omnibus Reconciliation Act largely to combat "patient dumping"—the transferring, discharging, or refusal to treat indigent emergency department patients because of their inability to pay (Public Law 99-272 1986)

Maximum out-of-pocket cost

A beneficiary's maximum out of pocket expense for a specific period of time (CMS 2013); See also catastrophic expense limit; stop-loss benefit

Halo effect

A bias that occurs when someone allows certain information to influence a decision disproportionately

Disease registry

A centralized collection of data used to improve the quality of care and measure the effectiveness of a particular aspect of healthcare delivery

Home health resource group (HHRG)

A classification system for the home health prospective payment system (HHPPS) derived from the data elements in the Outcome and Assessment Information Set (OASIS) with 80 home health episode rates established to support the prospective reimbursement of covered home care and rehabilitation services provided to Medicare beneficiaries during 60-day episodes of care; a six-character alphanumeric code is used to represent a severity level in three domains

RxNorm

A clinical drug nomenclature developed by the Food and Drug Administration, the Department of Veterans Affairs, and HL7 to provide standard names for clinical drugs and administered dose forms (NLM 2013)

Classification

A clinical vocabulary, terminology, or nomenclature that lists words or phrases with their meanings, provides for the proper use of clinical words as names or symbols, and facilitates mapping standardized terms to broader classifications for administrative, regulatory, oversight, and fiscal requirements

Unique identification number

A combination of numbers or alphanumeric characters assigned to a particular patient

Hybrid health record

A combination of paper and electronic records; a health record that includes both paper and electronic elements

Communicable disease

A disease that can be transmitted from an infected person, animal, or inanimate reservoir to a susceptible person or host by either direct or indirect contact

Skilled nursing facility (SNF)

A facility which primarily provides inpatient skilled nursing care and related services to patients who require medical, nursing, rehabilitative services but does not provide the level of care or treatment available in a hospital (CMS 2013)

Clinician

A healthcare provider, including physicians and others who treat patients

Low-volume hospital

A hospital with fewer than 200 discharges per fiscal year and located more than 25 miles from the nearest hospital

Foreign key

A key attribute used to link a column or data point in one table to the column or data point in another table

Nonmaleficence

A legal principle that means "first do no harm"

Problem list

A list of illnesses, injuries, and other factors that affect the health of an individual patient, usually identifying the time of occurrence or identification and resolution; See patient summary; summary list

Formulary

A listing of drugs, classified by therapeutic category or disease class; in some health plans, providers are limited to prescribing only drugs listed on the plan's formulary. The selection of items to be included in the formulary is based on objective evaluations of their relative therapeutic merits, safety, and cost

General ledger

A master list of individual revenue and expense accounts maintained by an organization

Data reliability

A measure of consistency of data items based on their reproducibility and an estimation of their error of measurement

Reliability

A measure of consistency of data items based on their reproducibility and an estimation of their error of measurement

Code on Dental Procedures and Nomenclature (CDT)

A medical code set of dental procedures, maintained and copyrighted by the ADA, used for consistency and specificity when reporting dental procedures (ADA 2013)

Well newborn

A newborn born at term, under sterile conditions, with no diseases, conditions, disorders, syndromes, injuries, malformations, or defects diagnosed, and no operations other than routine circumcisions performed

Minimum Data Set for Post Acute Care (MDS-PAC)

A patient-centered assessment instrument that must be completed for every Medicare patient, which emphasizes a patient's care needs instead of provider characteristics

Master patient index (MPI)

A patient-identifying directory referencing all patients related to an organization and which also serves as a link to the patient record or information, facilitates patient identification, and assists in maintaining a longitudinal patient record from birth to death

External review (audit)

A performance or quality review conducted by a third-party payer or consultant hired for the purpose; See audit

Durable power of attorney (DPOA)

A power of attorney that remains in effect even after the principal is incapacitated; some are drafted so that they only take effect when the principal becomes incapacitated (CMS 2013)

Discharge utilization review

A process for assessing a patient's readiness to leave the hospital

Fetal death rate

A proportion that compares the number of intermediate or late fetal deaths to the total number of live births and intermediate or late fetal deaths during the same period of time

Essential Medical Data Set (EMDS)

A recommended data set designed to create a health history for an individual patient treated in an emergency service

Partial episode payment (PEP) adjustment

A reduced episode payment that may be based on the number of service days in an episode

Facility-based registry

A registry that includes only cases from a particular type of healthcare facility, such as a hospital or clinic

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

Mortality review

A review of deaths as part of an analysis of ongoing outcome and performance improvement

User-based access

A security mechanism used to grant users of a system access based on identity

Quality improvement (QI)

A set of activities that measures the quality of a service or product through systems or process evaluation and then implements revised processes that result in better healthcare outcomes for patients, based on standards of care

Data Elements for Emergency Department Systems (DEEDS)

A set of guidelines developed by the National Center for Injury Prevention and Control data set designed to support the uniform collection of information in hospital-based emergency departments

Healthcare Effectiveness Data and Information Set (HEDIS)

A set of standard performance measures that can give you information about the quality of a health plan. You can find out about the quality of care, access, cost, and other measures to compare managed care plans. The Centers for Medicare and Medicaid Services (CMS) collects HEDIS data for Medicare plans (CMS 2013)

Universal Medical Device Nomenclature System™ (UMDNS)

A standard international nomenclature and computer coding system for medical devices, developed by ECRI (ECRI Institute 2013)

Emergency preparedness

A state of readiness to react to an emergency situation

Registered health information administrator (RHIA®)

A type of certification granted after completion of an AHIMA-accredited four-year program in health information management and a credentialing examination

Managed care organization (MCO)

A type of healthcare organization that delivers medical care and manages all aspects of the care or the payment for care by limiting providers of care, discounting payment to providers of care, or limiting access to care; Also called coordinated care organization

Nonfeasance

A type of negligence meaning failure to act

Health record number

A unique numeric or alphanumeric identifier assigned to each patient's record upon admission to a healthcare facility

Newborn bassinet count day

A unit of measure that denotes the presence of one newborn bassinet, either occupied or vacant, set up and staffed for use in one 24-hour period

Productivity

A unit of performance defined by management in quantitative standards

Best of fit

A vendor strategy used when purchasing an EHR in which all the systems required by the healthcare facility are available from one vendor

Sole proprietorship

A venture with one owner in which all profits are considered the owner's personal income

Web portal technology

A website entryway serving as a starting point to access, find, and deliver information and including a broad array of resources and services, such as e-mail, forums, and search engines

Subpoena duces tecum

A written order commanding a person to appear, give testimony, and bring all documents, papers, books, and records described in the subpoena. The devices are used to obtain documents during pretrial discovery and to obtain testimony during trial

Malfeasance

A wrong or improper act

Body of Knowledge (BoK)

AHIMA's collected resources, knowledge, and expertise within and related to health information management

Hospital newborn bassinet

Accommodations including incubators and isolettes in the newborn nursery with supporting services (such as food, laundry, and housekeeping) for hospital newborn inpatients

Hospital inpatient beds

Accommodations with supporting services (such as food, laundry, and housekeeping) for hospital inpatients, excluding those for the newborn nursery but including incubators and bassinets in nurseries for premature or sick newborn infants

Long-term care hospital (LTCH)

According to the Centers for Medicare and Medicaid Services (CMS), a hospital with an average length of stay for Medicare patients that is 25 days or longer, or a hospital excluded from the inpatient prospective payment system and that has an average length of stay for all patients that is 20 days or longer (CMS 2013)

Sentinel event

According to the Joint Commission, 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 risk thereof" includes any process variation for which a recurrence would carry a significant chance of serious adverse outcome.

Audit trail

1. A chronological set of computerized records that provides evidence of information system activity (log-ins and log-outs, file accesses) used to determine security violations 2. A record that shows who has accessed a computer system, when it was accessed, and what operations were performed; See also audit log

Case mix

1. A description of a patient population based on any number of specific characteristics, including age, gender, type of insurance, diagnosis, risk factors, treatment received, and resources used 2. The distribution of patient into categories reflecting differences in severity of illness or resource consumption (CMS 2013)

Corporate compliance program

1. A facility-wide program that comprises a system of policies, procedures, and guidelines that are used to ensure ethical business practices, identify potential fraudulence, and improve overall organizational performance

Business associate

1. A person or organization other than a member of a covered entity's workforce that performs functions or activities on behalf of or affecting a covered entity that involve the use or disclosure of individually identifiable health information 2. As amended by HITECH, with respect to a covered entity, a person who creates, receives, maintains, or transmits PHI for a function or activity regulated by HIPAA.

Case management

1. A process used by a doctor, nurse, or other health professional to manage a patient's healthcare (CMS 2013) 2. The ongoing, concurrent review performed by clinical professionals to ensure the necessity and effectiveness of the clinical services being provided to a patient

Pay for performance (P4P)

1. A type of incentive to improve clinical performance using the electronic health record that could result in additional reimbursement or eligibility for grants or other subsidies to support further HIT efforts 2. The Integrated Healthcare Association initiative in California based on the concept that physician groups would be paid for documented performance

Diagnosis-related groups (DRGs)

1. A unit of case-mix classification adopted by the federal government and some other payers as a prospective payment mechanism for hospital inpatients in which diseases are placed into groups because related diseases and treatments tend to consume similar amounts of healthcare resources and incur similar amounts of cost; in the Medicare and Medicaid programs, one of more than 500 diagnostic classifications in which cases demonstrate similar resource consumption and length-of-stay patterns. Under the prospective payment system (PPS), hospitals are paid a set fee for treating patients in a single DRG category, regardless of the actual cost of care for the individual. 2. A classification system that groups patients according to diagnosis, type of treatment, age, and other relevant criteria. Under the prospective payment system, hospitals are paid a set fee for treating patients in a single DRG category, regardless of the actual cost of care for the individual (CMS 2013)

Data element

1. An individual fact or measurement that is the smallest unique subset of a database 2. Under HIPAA, the smallest named unit of information in a transaction (45 CFR 162.103 2012)

Consent to use and disclose information

1. As amended by HITECH, a covered entity is permitted to use or disclose protected health information as follows: (i) To the individual; (ii) For treatment, payment, or health care operations as permitted by 164.506. (iii) Incident to a use to disclosure otherwise permitted or required by this subpart, provided that the covered entity has complied with the applicable requirements of 164.502, 164.514, and 164.530 with respect to such otherwise permitted or required use or disclosure; (iv) Except for uses and disclosures prohibited under 164.502, pursuant to and in compliance with a valid authorization (v) pursuant to an agreement under 164.510, and (vi) as permitted by and in compliance with this section. 2. As amended by HITECH, a business associate may use or disclose protected health information only as permitted or required by its business associate contract or other arrangement pursuant to 164.504 or as required by law (45 CFR 164.506 2013)

Grouper

1. Computer program that uses specific data elements to assign patients, clients, or residents to groups, categories, or classes 2. A computer software program that automatically assigns prospective payment groups on the basis of clinical codes

Contingency plan

1. Documentation of the process for responding to a system emergency, including the performance of backups, the line-up of critical alternative facilities to facilitate continuity of operations, and the process of recovering from a disaster 2. A recovery plan in the event of a power failure, disaster, or other emergency that limits or eliminates access to facilities and electronic protected personal health information (ePHI); See also business continuity plan

Critical access hospitals (CAHs)

1. Hospitals that are excluded from the outpatient prospective payment system because they are paid under a reasonable cost-based system as required under section 1834(g) of the Social Security Act 2. Under HITECH incentives, a facility that has been certified as a critical access hospital under section 1820(e) of the Act and for which Medicare payment is made under section 1814(l) of the Act for inpatient services and under section 1834(g) of the Act for outpatient services (42 CFR 495.4 2012)

Cross-claim

1. In law, a complaint filed against a codefendant 2. A claim by one party against another party who is on the same side of the main litigation

Managed care

1. Payment method in which the third-party payer has implemented some provisions to control the costs of healthcare while maintaining quality care 2. Systematic merger of clinical, financial, and administrative processes to manage access, cost, and quality of healthcare

Primary care physician (PCP)

1. Physician who provides, supervises, and coordinates the healthcare of a member and who manages referrals to other healthcare providers and utilization of healthcare services both inside and outside a managed care plan. Family and general practitioners, internists, pediatricians, and obstetricians and gynecologists are primary care physicians (CMS 2013) 2. The physician who makes the initial diagnosis of a patient's medical condition

Physical access controls

1. Security mechanisms designed to protect an organization's equipment, media, and facilities from physical damage or intrusion 2. Security mechanisms designed to prevent unauthorized physical access to health records and health record storage areas

Hold harmless

1. Status in which one party does not hold the other party responsible 2. A term used to refer to the financial protections that ensure that cancer hospitals recoup all losses due to the differences in their ambulatory payment classification payments and the pre-APC payments for Medicare outpatient services

Outcome

1. The end result of healthcare treatment, which may be positive and appropriate or negative and diminishing 2. The performance (or nonperformance) of one or more processes, services, or activities by healthcare providers

Validity

1. The extent to which data correspond to the actual state of affairs or that an instrument measures what it purports to measure 2. A term referring to a test's ability to accurately and consistently measure what it purports to measure

Data integrity

1. The extent to which healthcare data are complete, accurate, consistent, and timely 2. A security principle that keeps information from being modified or otherwise corrupted either maliciously or accidentally; Also called data quality

Clinical trial

1. The final stages of a long and careful research process that tests new types of medical care to see if they are safe (CMS 2013) 2. Experimental study in which an intervention or treatment is given to one group in a clinical setting and the outcomes compared with a control group that did not have the intervention or treatment or that had a different intervention or treatment

Malpractice (MP), medical malpractice

1. The improper or negligent treatment of a patient, as by a physician, resulting in injury, damage, or loss 2. Element of the relative value unit (RVU): costs of the premiums for professional liability insurance 3. The professional liability of healthcare providers in the delivery of patient care

Mortality

1. The incidence of death in a specific population 2. The loss of subjects during the course of a clinical research study; Also called attrition

Medical necessity

1. The likelihood that a proposed healthcare service will have a reasonable beneficial effect on the patient's physical condition and quality of life at a specific point in his or her illness or lifetime 2. As amended by HITECH, a covered entity or business associate may not use or disclose protected health information, except as permitted or required (45 CFR 164.502 2013) 3. The concept that procedures are only eligible for reimbursement as a covered benefit when they are performed for a specific diagnosis or specified frequency (42 CFR 405.500 1995); Also called need-to-know principle

Hard coding

1. The process of attaching a CPT/HCPCS code to a procedure located on the facility's chargemaster so that the code will automatically be included on the patient's bill 2. Use of the charge description master to code repetitive services

Compliance

1. The process of establishing an organizational culture that promotes the prevention, detection, and resolution of instances of conduct that do not conform to federal, state, or private payer healthcare program requirements or the healthcare organization's ethical and business policies 2. The act of adhering to official requirements 3. Managing a coding or billing department according to the laws, regulations, and guidelines that govern it

Revenue cycle

1. The process of how patient financial and health information moves into, through, and out of the healthcare facility, culminating with the facility receiving reimbursement for services provided 2. The regularly repeating set of events that produces revenue

Level of service/significance

1. The relative intensity of services given when a physician provides one-on-one services for a patient (such as minimal, brief, limited, or intermediate) 2. The relative intensity of services provided by a healthcare facility (for example, tertiary care)

Triage

1. The sorting of, and allocation of treatment to, patients 2. An early assessment that determines the urgency and priority for care and the appropriate source of care

Transplantation

1. Under ICD-10-PCS, a root operation that involves putting in or on all or a portion of a living body part taken from another individual or animal to physically take the place and function of all or a portion of a similar body part 2. A surgical procedure that involves removing a functional organ from either a deceased or living donor and implanting it in a patient needing a functional organ to replace a nonfunctional organ (CMS 2013)

Descriptor

1. Wording that represents the official definition of an item or service that can be billed using a particular code. 2. Under HIPAA, the text defining a code (45 CFR 162.103 2012) 3. Under Medicare, the text defining a code in a code set (CMS 2013)

Total billed charges

All charges for procedures and services rendered to a patient during a hospitalization or encounter

Compensation

All direct and indirect pay, including wages, mandatory benefits, and benefits such as medical insurance, life insurance, child care, elder care, retirement plans, and longevity pay

Quality Data Model (QDM)

Also known as Quality Data Set, it clearly defines concepts used in quality measures and clinical care and is intended to enable automation of structured data capture in EHRs, PHRs, and other clinical applications; it provides a grammar to describe clinical concepts in a standardized format so individuals (such as providers, researchers, or measure developers) monitoring clinical performance and outcomes can concisely communicate necessary information

Tort

An action brought when one party believes that another party caused harm through wrongful conduct and seeks compensation for that harm

Perinatal death

An all-inclusive term that refers to both stillborn infants and neonatal deaths

Functional needs assessment

An assessment that describes the key capabilities or application requirements for achieving the benefits of the EHR as the organization has envisioned it

Data administrator

An emerging role responsible for managing the less technical aspects of data, including data quality and security

Float employee

An employee who is not assigned to a particular shift, function, or unit and who may fill in as needed in cases of standard employee absence or vacation

Remittance advice (RA)

An explanation of payments (for example, claim denials) made by third-party payers

Primary key

An explanatory notation that uniquely identifies each row in a database table; See key field

Biometric identification system

An identification system that analyzes biological data about users, such as voiceprints, fingerprints, handprints, retinal scans, faceprints, and full-body scans

Delinquent health record

An incomplete record not finished or made complete within the time frame determined by the medical staff of the facility

Consent to treatment

Legal permission given by a patient or a patient's legal representative to a healthcare provider that allows the provider to administer care and treatment or to perform surgery or other medical procedures

False Claims Act

Legislation passed during the Civil War, amended in 1986, that prohibits contractors from making a false claim to a governmental program; used to reinforce the prevention of healthcare fraud and abuse (Public Law 99-562 1986)

Discoverability

Limitations on the ability of parties to discover pretrial information held by another

Home health (HH)

Limited part-time or intermittent skilled nursing care and home health aide services, physical therapy, occupational therapy, speech-language therapy, medical social services, durable medical equipment (such as wheelchairs, hospital beds, oxygen, and walkers), medical supplies, and other services (CMS 2013); Also called home care

Acute care

Medical care of a limited duration that is provided in an inpatient hospital setting to diagnose and treat an injury or a short-term illness

Durable medical equipment (DME)

Medical equipment designed for long-term use in the home, including eyeglasses, hearing aids, surgical appliances and supplies, orthotics and prostheses, and bulk and cylinder oxygen (CMS 2013); Also called home medical equipment (HME)

Contraindication

Medication should not be prescribed due to another medication or condition

Self-insured plan

Method of insurance in which the employer or other association itself administers the health insurance benefits for its employees or their dependents, thereby assuming the risks for the costs of healthcare for the group (CMS 2013)

Unstructured data

Nonbinary, human-readable data

Neural networks

Nonlinear predictive models that, using a set of data that describe what a person wants to find, detect a pattern to match a particular profile through a training process involving interactive learning

Wireless on wheels (WOWs)

Notebook computers mounted on carts that can be moved through the facility by users

Gross Hospital Death Rate

Number of deaths of inpatients in period ___________________________________________ Number of discharges (including deaths) x 100

Newborn bassinet count

Number of hospital newborn bassinets, both occupied and vacant, on any given day

Diagnostic codes

Numeric or alphanumeric characters used to classify and report diseases, conditions, and injuries

Postpartum

Occurring after childbirth

Synchronous

Occurring at the same time

Bed count day

One inpatient bed, set up and staffed for use in a 24-hour time period

Medicare secondary payer

One of the edits in the outpatient and inpatient code editors that reviews claims to determine if the claim should be paid by another form of insurance, such as workers' compensation or private insurance in the event of a traffic accident

Surgical operation

One or more surgical procedures performed at one time for one patient via a common approach or for a common purpose

Bylaws

Operating documents that describe the rules and regulations under which a healthcare organization operates; See also rules and regulations

Standing orders

Orders the medical staff or an individual physician has established as routine care for a specific diagnosis or procedure

Revenue Audit Contractor

Organization contracted to detect and correct improper payments in the FFS program

Federal Physician Self-Referral Statute (Stark)

Originally a part of the Omnibus Budget Reconciliation Act of 1989, it is a law that prohibits physicians from ordering designated health services for Medicare (and to some extent Medicaid) patients from entities with which the physician, or an immediate family member, has a financial relationship (Stark Law 2013)

Third-party payment

Payments for healthcare services made by an insurance company or health agency on behalf of the insured

Principal procedure

Performed for definitive treatment rather than for diagnostic or exploratory purpose, or necessary to take care of a complication (AHA 2011)

Guarantor

Person who is responsible for paying the bill or guarantees payment for healthcare services; adult patients are often their own guarantors, but parents guarantee payments for the healthcare costs of their children

Major medical insurance

Prepaid healthcare benefits that include a high limit for most types of medical expenses and usually require a large deductible and sometimes place limits on coverage and charges (for example, room and board); Also called catastrophic coverage

Restraints and seclusion

Any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or normal access to one's body. Chemical restraints are any drug used for discipline or convenience and not required to treat medical symptoms (CMS 2013)

Term neonate

Any neonate whose birth occurs from the beginning of the first day (267th day) of the 39th week through the end of the last day of the 42nd week (294th day), following onset of the last menstrual period

Postterm neonate

Any neonate whose birth occurs from the beginning of the first day (295th day) of the 43rd week following onset of the last menstrual period

Preterm neonate

Any neonate whose birth occurs through the end of the last day of the 38th week (266th day) following onset of the last menstrual period

Covered entity (CE)

As amended by HITECH, (1) a health plan, (2) a health care clearinghouse, (3) a health care provider who transmits any health information in electronic form in connection with a transaction covered by this subchapter (45 CFR 160.103 2013)

Flexibility of approach

As amended by HITECH, a condition under the Security Rule in which a covered entity can adopt security protection measures that are appropriate for its organization (45 CFR 164.306 2013)

Subcontractor

As amended by HITECH, a person to whom a business associate delegates a function, activity, or service, other than in the capacity of a member of the workforce of such business associate (45 CFR 160.103 2013)

Reasonable cause

As amended by HITECH, an act or omission in which a covered entity or business associate knew, or by exercising reasonable diligence would have known, that the act or omission violated an administrative simplification provision, but in which the covered entity or business associated did not act with willful neglect (45 CFR 160.401 2013)

Documentation audits

Audits within the EHR that should look for completeness, timeliness, internal consistency, and other factors that have typically been evaluated in paper documentation

Countersignature

Authentication by a second provider that signifies review and evaluation of the actions and documentation, including authentication, of a first provider

Hospital-acquired condition (HAC)

CMS identified eight hospital-acquired conditions (not present on admission) as "reasonably preventable," and hospitals will not receive additional payment for cases in which one of the eight selected conditions was not present on admission; the eight originally selected conditions include: foreign object retained after surgery, air embolism, blood incompatibility, stage III and IV pressure ulcers, falls and trauma, catheter-associated urinary tract infection, vascular catheter-associated infection, and surgical site infection—mediastinitis after coronary artery bypass graft; additional conditions were added in 2010 and remain in effect: surgical site infections following certain orthopedic procedures and bariatric surgery, manifestations of poor glycemic control, and deep vein thrombosis (DVT)/pulmonary embolism (PE) following certain orthopedic procedures (CMS 2013)

Value-based purchasing (VBP)

CMS incentive plan that links payments more directly to the quality of care provided and rewards providers for delivering high-quality and efficient clinical care. It incorporates clinical process-of-care measures as well as measures from the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey on how patients view their care experiences

Category III codes

CPT codes that contain a temporary set of codes for emerging technologies, services, and procedures (AMA 2013)

Category II codes

CPT codes that describe clinical components that may be typically included in evaluation and management services or other clinical services and, therefore, do not have a relative value associated with them. May also describe results from clinical laboratory or radiology tests and other procedures, identified to address patient safety practices, or services reflecting compliance with state or federal law. The use of these codes is optional (AMA 2013)

Tertiary care

Care centered on the provision of highly specialized and technologically advanced diagnostic and therapeutic services in inpatient and outpatient hospital settings

Medical staff privileges

Categories of clinical practice privileges assigned to individual practitioners on the basis of their qualifications

Highly sensitive health information

Certain types of patient information that require special handling in regard to access, requests, uses, and disclosures due to the nature of the information

Exploding charges

Charges for items that must be reported separately but are used together, such as interventional radiology imaging and injection procedures

Data timeliness

Concept of data quality that involves whether the data is up-to-date and available within a useful time frame. Timeliness is determined by how the data are being used and their context

Operating room (OR) procedure

Procedure that the physician panel classifies as occurring in the operating room in most hospitals; presence of an OR procedure groups a case to a surgical DRG

Prior approval (authorization)

Process of obtaining approval from a healthcare insurance company before receiving healthcare services; Also called precertification

Medication reconciliation

Process that monitors and confirms that the patient receives consistent dosing across all facility transfers, such as on admission, from nursing unit to surgery, and from surgery to ICU

Telemedicine

Professional services given to a patient through an interactive telecommunications system by a practitioner at a distant site (CMS 2013); Also called telehealth

MEDPAR (Medicare Provider Analysis and Review)

Contains data from claims for services provided to beneficiaries admitted to Medicare-certified inpatient hospitals and SNFs; data set is the data contained in the billing form's fields

Coinsurance

Cost sharing in which the policy or certificate holder pays a preestablished percentage of eligible expenses after the deductible has been met; the percentage may vary by type or site of service

Evaluation and management (E/M) codes

Current Procedural Terminology codes that describe patient encounters with healthcare professionals for assessment counseling and other routine healthcare services (CMS 2010)

Secondary data source

Data derived from the primary patient record, such as an index or a database

Data accessibility

Data items that are easily obtainable and legal to access with strong protections and controls built into the process

Bitmapped data

Data made up of pixels displayed on a horizontal and vertical grid or matrix

Vital statistics

Data related to births, deaths, marriages, and fetal deaths

Outcome and Assessment Information Set (OASIS)

Data set most associated with home health care. This data set monitors patient care by identifying markers over the course of patient care.

Minimum Data Set (MDS)

Data set most associated with skilled nursing facilities (SNF) and long-term care (LTC).

HEDIS (Healthcare Effectiveness Data Information Set)

Data set used for public releases of outcomes of care

Data precision

Data values should be just large enough to support the application or process

Facility specific index

Databases established by healthcare facilities to meet their individual, specific needs for customer care or other reporting requirements. These indexes make it possible to retrieve health records in a variety of ways including by disease, physician, operation, or other data element. Prior to computerization in healthcare, these indexes were kept on cards. Today, most are compiled from databases routinely developed by the facility

Office for Civil Rights (OCR)

Department in HHS responsible for enforcing civil rights laws that prohibit discrimination on the basis of race, color, national origin, disability, age, sex, and religion by healthcare and human services entities over which OCR has jurisdiction, such as state and local social and health services agencies, and hospitals, clinics, nursing homes, or other entities receiving federal financial assistance from HHS. This office also has the authority to ensure and enforce the HIPAA Privacy and Security Rules; Responsible for investigating all alleged violations of the Privacy and Security Rules (OCR 2013)

Metadata

Descriptive data that characterize other data to create a clearer understanding of their meaning and to achieve greater reliability and quality of information. Metadata consist of both indexing terms and attributes. Data about data: for example, creation date, date sent, date received, last access date, last modification date

Material safety data sheet (MSDS)

Documentation maintained on the hazardous materials used in a healthcare organization. The documentation outlines such information as common and chemical names, family name, and product codes; risks associated with the material, including overall health risk, flammability, reactivity with other chemicals, and effects at the site of contact; descriptions of the protective equipment and clothing that should be used to handle the material; and other similar information

Legal health record (LHR)

Documents and data elements that a healthcare provider may include in response to legally permissible requests for patient information

Surgical review

Evaluation of operative and other procedures, invasive and noninvasive, using the Joint Commission guidelines

Maternal death rate (hospital based)

For a hospital, the total number of maternal deaths directly related to pregnancy for a given time period divided by the total number of obstetrical discharges for the same time period; for a community, the total number of deaths attributed to maternal conditions during a given time period in a specific geographic area divided by the total number of live births for the same time period in the same area

Diagnostic criteria

For each mental disorder listed in the DSM-IV, a set of extensive diagnostic criteria are provided that indicate what symptoms must be present as well as those symptoms that must not be present in order for a patient to meet the qualifications for a particular mental diagnosis (DMS 2013)

Point of Origin

Formerly known as Admission Type, field location 15 of the UB-04 and its electronic equivalence is a required field on all inpatient and outpatient registrations to indicate the original for the admission (CMS 2009)

Health Level 7 (HL7)

Founded in 1987, Health Level Seven International (HL7) is a not-for-profit, ANSI-accredited standards-developing organization dedicated to providing a comprehensive framework and related standards for the exchange, integration, sharing, and retrieval of electronic health information that supports clinical practice and the management, delivery, and evaluation of health services (HL7 2013)

Elements of negligence

Four basic elements must be proven in a malpractice case: failure to use due care, breach of duty, damages, and causation

Colons

In ICD-10-CM colons: are used in the Tabular List after an incomplete term which needs one or more of the modifiers following the colon to make it assignable to a given category (CDC 2013)

Crisis management plan

In disaster planning, a plan that defines the processes and controls that will be followed until the operations are fully restored

Covered condition

In healthcare reimbursement, a health condition, illness, injury, disease, or symptom for which the healthcare insurance company will pay

Reasons for encounter (RFE)

In the international classification of primary care (ICPC) system, the subjective experience by the patient of the problem or the "reason for encounter"

Late enrollee

Individual who does not enroll in a group healthcare plan at the first opportunity, but enrolls later if the plan has a general open enrollment period

Independent practitioners

Individuals working as employees of an organization, in private practice, or through a physician group who provide healthcare services without supervision or direction

Patient portal

Information system that allows patient to log in to obtain information, register, and perform other functions

Coding and abstracting systems

Information system used to assign code numbers and enter key information from the health record

Demographic information

Information used to identify an individual, such as name, address, gender, age, and other information linked to a specific person

Medicare Part A

Insurance that assists in covering inpatient care in hospitals, including critical access hospitals, and skilled nursing facilities (not custodial or long-term care). It also assists in covering hospice care and some home healthcare. Beneficiaries must meet certain conditions to get these benefits (CMS 2013); See hospitalization insurance

Workers' compensation

Insurance that employers are required to have to cover employees who get sick or injured on the job (CMS 2013)

Established Name for Active Ingredients and FDA Unique Ingredient Identifier (UNII) Codes

Interoperability standard for active ingredients in medications

Speech recognition technology

Technology that translates speech to text

Medicare severity diagnosis-related groups (MS-DRGs)

The US government's 2007 revision of the DRG system, the MS-DRG system better accounts for severity of illness and resource consumption

Great person theory

The belief that some people have natural (innate) leadership skills

Front-end processes

The billing processes associated with preregistration, prebooking, scheduling, and registration activities that collect patient demographic and insurance information, perform verification of patient insurance, and determine medical necessity

Stillbirth

The birth of a fetus, regardless of gestational age, that shows no evidence of life (such as heartbeats or respirations) after complete expulsion or extraction from the mother during childbirth

Department of Health and Human Services (HHS)

The cabinet-level federal agency, and principal agency for protecting the health of all Americans and providing essential human services, especially for those who are at least able to help themselves (HHS 2013)

International Classification of Diseases, Tenth Revision, Procedure Coding System (ICD-10-PCS)

The coding classification system that will replace ICD-9-CM, Volume 3, on October 1, 2014. ICD-10-PCS has 16 sections and contains significantly more procedure codes than ICD-9-CM, providing the ability to code procedures with a greater level of specificity (CMS 2013)

International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM)

The coding classification system that will replace ICD-9-CM, Volumes 1 and 2, on October 1, 2014. ICD-10-CM is the United States' clinical modification of the WHO's ICD-10. ICD-10-CM has a total of 21 chapters and contains significantly more codes than ICD-9-CM, providing the ability to code with a greater level of specificity (CDC 2013)

Progress notes

The documentation of a patient's care, treatment, and therapeutic response, which is entered into the health record by each of the clinical professionals involved in a patient's care, including nurses, physicians, therapists, and social workers

Data accuracy

The extent to which data are free of identifiable errors

Data currency

The extent to which data are up-to-date; a datum value is up-to-date if it is current for a specific point in time. It is outdated if it was current at some preceding time yet incorrect at a later time

Data validity

The extent to which data have been verified to be accurate

Data availability

The extent to which healthcare data are accessible whenever and wherever they are needed

Data relevancy

The extent to which healthcare-related data are useful for the purposes for which they were collected

Data confidentiality

The extent to which personal health information is kept private

Data consistency

The extent to which the healthcare data are reliable and the same across applications Data content standard: Clear guidelines for the acceptable values for specified data fields. These standards make it possible to exchange health information using electronic networks

Family and Medical Leave Act of 1993 (FMLA)

The federal legislation that allows full-time employees time off from work (up to 12 weeks) to care for themselves or their family members with the assurance of an equivalent position upon return to work (Public Law 103-3 1993)

Omnibus Budget Reconciliation Act (OBRA) of 1989

The federal legislation that mandated important changes in the payment rules for Medicare physicians; specifically, the legislation that requires nursing facilities to conduct regular patient assessments for Medicare and Medicaid beneficiaries (Public Law 101-239 1989)

Tax Equity and Fiscal Responsibility Act of 1982 (TEFRA)

The federal legislation that modified Medicare's retrospective reimbursement system for inpatient hospital stays by requiring implementation of diagnosis-related groups and the acute care prospective payment system (Public Law 97-248 1982)

Social Security Act of 1935

The federal legislation that originally established the Social Security program as well as unemployment compensation and support for mothers and children; amended in 1965 to create the Medicare and Medicaid programs (Ch 531, 49 Stat. 620 1935)

Security Rule

The federal regulations created to implement the security requirements of HIPAA

Technical interoperability

The interoperability achieved through application of message format standards

Transformational leadership

The leadership of a visionary who strives to change an organization

Duty to warn

The legal obligation of a health professional to disclose information to warn an intended victim when a patient threatens to harm an individually identifiable victim and the psychiatrist or mental health provider believes that the patient is likely to harm the individual

Data granularity

The level of detail at which the attributes and values of healthcare data are defined

Computerized internal fee schedule

The listing of the codes and associated fees maintained in the practice's computer system, along with the additional data fields necessary for completing the CMS-1500 claim form

Maximum allowable charges

The maximum charges allowed for a service rendered

Security

The means to control access and protect information from accidental or intentional disclosure to unauthorized persons and from unauthorized alteration, destruction, or loss

Clinician/physician web portals

The media for providing physician/clinician access to the provider organization's multiple sources of data from any network-connected device

Emergency and trauma care

The medical-surgical care provided to individuals whose injuries or illnesses require urgent care to address conditions that could be life threatening or disabling if not treated immediately

Systematized Nomenclature of Medicine Clinical Terminology (SNOMED CT)

The most comprehensive, multilingual clinical healthcare terminology in the world. SNOMED CT contributes to the improvement of patient care by underpinning the development of electronic health records that record clinical information in ways that enable meaning-based retrieval (IHTSDO 2013)

International Classification of Diseases, Tenth Revision (ICD-10)

The most recent revision of the disease classification system developed and used by the WHO to track morbidity and mortality information worldwide (WHO 2013)

Transfer of records

The movement of a record from one medium to another (for example, from paper to microfilm or to an optical imaging system) or to another records custodian

American Medical Association (AMA)

The national professional membership organization for physicians that distributes scientific information to its members and the public, informs members of legislation related to health and medicine, and represents the medical profession's interests in national legislative matters; maintains and publishes the CPT coding system (AMA 2013)

Newborn autopsy rate

The number of autopsies performed on newborns who died during a given time period divided by the total number of newborns who died during the same time period

Bed capacity

The number of beds that a facility has been designed and constructed to house

Infant mortality rate

The number of deaths of individuals under one year of age during a given time period divided by the number of live births reported for the same time period

Neonatal mortality rate

The number of deaths of infants under 28 days of age during a given time period divided by the total number of births for the same time period

Postneonatal mortality rate

The number of deaths of persons aged 28 days up to, but not including, one year during a given time period divided by the number of live births for the same time period

Hospital-acquired infection rate

The number of hospital-acquired infections for a given time period divided by the total number of inpatient discharges for the same time period

Hospital death rate

The number of inpatient deaths for a given period of time divided by the total number of live discharges and deaths for the same time period

Gross death rate

The number of inpatient deaths that occurred during a given time period divided by the total number of inpatient discharges, including deaths, for the same time period

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

Inpatient daily census

The number of inpatients present at census-taking time each day, plus any inpatients who were both admitted and discharged after the previous day's census-taking time

Crude birth rate

The number of live births divided by the population at risk

Newborn death rate

The number of newborns who died divided by the total number of newborns, both alive and dead; Also called newborn mortality rate

Code of Federal Regulations (CFR)

The official collection of legislative and regulatory guidelines mandated by final rules published in the Federal Register (CMS 2013)

Association of American Medical Colleges (AAMC)

The organization established in 1876 to standardize the curriculum for medical schools in the United States and to promote the licensure of physicians (AAMC 2013)

Retrospective review

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

Puerperal

The period immediately following childbirth

Neonatal period

The period of an infant's life from the hour of birth through the first 27 days, 23 hours, and 59 minutes of life

Eligibility period

The period of time following the eligibility date (usually 31 days) during which a member of an insured group may apply for insurance without evidence of insurability

Custodian of health records

The person designated as responsible for the operational functions of the development and maintenance of the health record and who may certify through affidavit or testimony the normal business practices used to create and maintain the record

History and physical (H and P)

The pertinent information about the patient, including chief complaint, past and present illnesses, family history, social history, and review of body systems

Point of care (POC)

The place or location where the physician administers services to the patient

Upcoding

The practice of assigning diagnostic or procedural codes that represent higher payment rates than the codes that actually reflect the services provided to patients; See overcoding

Overcoding

The practice of assigning more codes than needed to describe a patient's condition. Some instances of overcoding may be contrary to the guidance provided in the Official Coding Guidelines

Prognosis

The probable outcome of an illness, including the likelihood of improvement or deterioration in the severity of the illness, the likelihood for recurrence, and the patient's probable life expectancy

Clinical Documentation Improvement (CDI)

The process an organization undertakes that will improve clinical specificity and documentation that will allow coders to assign more concise disease classification codes

Hospital Outpatient Prospective Payment System (HOPPS)

The reimbursement system created by the Balanced Budget Act of 1997 for hospital outpatient services rendered to Medicare beneficiaries; maintained by the Centers for Medicare and Medicaid Services (CMS 2013)

Redisclosure

The release, transfer, provision of access to, or divulging in any other manner of patient health information that was generated by an external source to others outside of the organization and its workforce members

Data quality

The reliability and effectiveness of data for its intended uses in operations, decision making, and planning; See also data integrity

Consultation

The response by one healthcare professional to another healthcare professional's request to provide recommendations or opinions regarding the care of a particular patient or resident

Return on assets (ROA)

The return on a company's investment, or earnings, after taxes divided by total assets

Medication Five Rights

The right drug, in the right dose, through the right route, at the right time, and to the right patient

American College of Surgeons (ACS)

The scientific and educational association of surgeons formed to improve the quality of surgical care by setting high standards for surgical education and practice (ACS 2013) American Dental Association (ADA): A professional dental association dedicated to the public's oral health, ethics, science, and professional advancement (ADA 2013)

Chief nursing officer (CNO)

The senior manager (usually a registered nurse with advanced education and extensive experience) responsible for administering patient care services

Chief information officer (CIO)

The senior manager responsible for the overall management of information resources in an organization

Critical path or critical pathway

The sequence of tasks that determine the project finish date;

For-profit organization

The tax status assigned to business entities that are owned by one or more individuals or organizations and that earn revenues in excess of expenditures that are subsequently paid out to the owners or stockholders

Inpatient discharge

The termination of hospitalization through the formal release of an inpatient from a hospital; See also discharge status

Root operation

The third character of an ICD-10-PCS code that defines the objective of the procedure

Hospital autopsy rate

The total number of autopsies performed by a hospital pathologist for a given time period divided by the number of deaths of hospital patients (inpatients and outpatients) whose bodies were available for autopsy for the same time period

Proportionate mortality ratio (PMR)

The total number of deaths due to a specific cause during a given time period divided by the total number of deaths due to all causes

Crude death rate

The total number of deaths in a given population for a given period of time divided by the estimated population for the same period of time

Length of stay (LOS)

The total number of patient days for an inpatient episode, calculated by subtracting the date of admission from the date of discharge

Eighty-five/fifteen (85/15) rule

The total quality management assumption that 85 percent of the problems that occur are related to faults in the system rather than to worker performance

Assignment of benefits

The transfer of one's interest or policy benefits to another party; typically the payment of medical benefits directly to a provider of care

Implied consent

The type of permission that is inferred when a patient voluntarily submits to treatment

Attending physician identification

The unique national identification number assigned to the clinician of record at discharge who is responsible for the inpatient discharge summary (NCVHS 1996)

Discharge date (inpatient)

The year, month, and day that an inpatient was formally released from the hospital and room, board, and continuous nursing services were terminated

Drug Listing Act of 1972

This act amended the Federal Food, Drug, and Cosmetic Act so that drug establishments that are engaged in the manufacturing, preparation, propagation, compounding, or processing of a drug are required to register their establishments and list all of their commercially marketed drug products with the Food and Drug Administration (FDA) (Public Law 92-387 1972)

Average Length of Stay (ALOS)

Total length of stay (discharge days) _____________________________________ Total discharges (including deaths)

Percentage of Occupancy

Total service days for period ____________________________ Total bed count days in the period x 100

Average Daily Census (ADC)

Total service days for the unit for the period ____________________________________________ Total number of days in the period

Trauma registry software

Tracks patients with traumatic injuries from the initial trauma treatment to death

Indemnity health insurance

Traditional, fee-for-service healthcare plan in which the policyholder pays a monthly premium and a percentage of the usual, customary, and reasonable healthcare costs and the patient can select the provider

Speech-language therapy (SLP)

Treatment to regain and strengthen speech skills (CMS 2013)

Calendar year (CY)

Twelve-month period (year) that begins January 1 and ends December 31

Anatomical modifiers

Two-digit CPT codes that provide information about the exact body location of procedures, such as -LT, Left side, and -TA, Left great toe

Implied contract

Type of agreement between physician and patient that is created by actions

Retrospective payment system

Type of fee-for-service reimbursement in which providers receive recompense after health services have been rendered; Also called retrospective payment method

Self-pay

Type of fee-for-service reimbursement in which the patients or their guarantors pay a specific amount for each service received

Case-based payment

Type of prospective payment method in which the third-party payer reimburses the provider a fixed, preestablished payment for each case

Usual, customary, and reasonable (UCR)

Type of retrospective fee-for-service payment method in which the third-party payer pays for fees that are usual, customary, and reasonable, wherein "usual" is usual for the individual provider's practice; "customary" means customary for the community; and "reasonable" is reasonable for the situation

Medical examiner

Typically a physician with pathology training given the responsibility by a government, such as a county or state, for investigating suspicious deaths

Defective authorization

Under HIPAA, an authorization is not valid, if the document submitted has any of the following defects: (i) The expiration date has passed or the expiration event is known by the covered entity to have occurred; (ii) The authorization has not been filled out completely, with respect to an element described in section 164.508(c); (iii) The authorization is known by the covered entity to have been revoked; (iv) The authorization violates any paragraph in 164.508; (v) Any information in the authorization is known by the covered entity to be false (45 CFR 164.508 2013)

Covered professional services

Under HITECH incentives, specific to the Medicare program, are those services furnished by an eligible provider, which is based on services defined in the Medicare fee schedule (42 CFR 495.100 2012)

Medicaid eligible provider (EP)

Under HITECH specific to the Medicaid program, the Medicaid professional eligible for an EHR incentive payment is limited to the a physician, a dentist, a certified nurse-midwife, a nurse practitioner, a physician assistant practicing in a federally qualified health center (FQHC) or a rural health (RHC). In addition, to qualify for an EHR incentive payment, a Medicaid EP must (1) have a minimum 30 percent patient volume attributable to individuals enrolled in a Medicaid program; (2) have a minimum 20 percent patient volume attributable to individuals enrolled in a Medicaid program, and be a pediatrician; (3) practice predominantly in a FQHC or RHC and have a minimum 30 percent patient volume attributable to needy individuals (42 CFR 495.304 2012)

Patient volume

Under HITECH, specific to the Medicaid program, means the minimum participation threshold (42 CFR 495.302 2012)

Resection

Under ICD-10-PCS, a root operation that involves cutting out or off, without replacement, all of a body part (CMS 2013). Includes all of a body part or any subdivision of a body part that has its own body part value in ICD-10-PCS

Reposition

Under ICD-10-PCS, a root operation that involves moving to its normal location or other suitable location all or a portion of a body part (CMS 2013)

Restriction

Under ICD-10-PCS, a root operation that involves partially closing an orifice or the lumen of a tubular body part (CMS 2013)

Extraction

Under ICD-10-PCS, a root operation that involves pulling or stripping out or off all or a portion of a body part by the use of force (CMS 2013)

Repair

Under ICD-10-PCS, a root operation that involves restoring, to the extent possible, a body part to its normal anatomical structure and function (CMS 2013)

Extirpation

Under ICD-10-PCS, a root operation that involves taking or cutting out solid matter from a body part (CMS 2013)

Removal

Under ICD-10-PCS, a root operation that involves taking out or off a device from a body part (CMS 2013)

Dictation system

Used by physicians and transcription staff to dictate various medical reports such as the operative report, history and physical, and the discharge summary

Face sheet

Usually the first page of the health record, which contains patient identification, demographics, date of admission, insurance coverage or payment source, referral information, hospital stay dates, physician information, and discharge information, as well as the name of the responsible party, emergency and additional contacts, and the resident's diagnoses

Denial

When a bill has been returned unpaid for any of several reasons (for example, sending the bill to the wrong insurance company, patient not having current coverage, inaccurate coding, lack of medical necessity, and so on)

Electronic prescribing (e-Rx)

When a prescription is written from the personal digital assistant and an electronic fax or an actual electronic data interchange transaction is generated that transmits the prescription directly to the retail pharmacy's information system

Trait approach

Proposes that leaders possess a collection of traits or qualities that distinguish them from nonleaders

Data exchange standards

Protocols that help ensure that data transmitted from one system to another remain comparable

Standard treatment protocols (STPs)

Protocols that identify the specific service units necessary to produce a given product (patient)

Accounting of disclosures

Providing the patient, upon request, with a listing of all disclosures of his/her health information, both internally and externally.

Balanced Budget Act (BBA) of 1997

Public Law 105-33 enacted by Congress on August 5, 1997, that mandated a number of additions, deletions, and revisions to the original Medicare and Medicaid legislation; the legislation that added penalties for healthcare fraud and abuse to the Medicare and Medicaid programs and also affected the hospital outpatient prospective payment system (HOPPS) and programs of all-inclusive care for elderly (PACE) (Public Law 105-33 1997)

Cancer registry

Records maintained by many states for the purpose of tracking the incidence (new cases) of cancer; Also called tumor registry

Global package

Refers to the payment policy of bundling payment for the various services associated with a surgery into a single payment covering professional services for preoperative care, the surgery itself, and postoperative care

Transactional leadership

Refers to the role of the manager who strives to create an efficient workplace by balancing task accomplishment with interpersonal satisfaction

Scorecards

Reports of outcomes measures to help leaders know what they have accomplished; Also called dashboards

Dashboards

Reports of process measures to help leaders follow progress to assist with strategic planning; Also called scorecards

Medicare administrative contractor (MAC)

Required by section 911 of the Medicare Prescription Drug, Improvement and Modernization Act of 2003, CMS is completing the process of awarding Medicare claims processing contracts through competitive procedures resulting in replacing its current claims payment contractors, fiscal intermediaries and carriers, with new contract entities called MACs.

Variable costs

Resources expended that vary with the activity of the organization, for example, medication expenses vary with patient volume

Health savings accounts (HSAs)

Savings accounts designed to help people save for future medical and retiree health costs on a tax-fee basis; part of the 2003 Medicare bill; Also called medical savings accounts

External cause of injury code

See E code

Occupancy percent/ratio

See bed occupancy ratio

Data analyst

See health data analyst

Institutional death rate

See net death rate

Surgical death rate

See postoperative death rate

Retrospective payment method

See retrospective payment system

Data silos

Separate repositories of data that do not communicate with each other

Respiratory therapy (RT)

Services provided by a qualified professional for the assessment, treatment, and monitoring of patients with deficiencies or abnormalities of pulmonary function

Residential care

Services, including board and lodging, provided in a protective environment but with minimal supervision to residents who are not in an acute phase of illness and would be capable of self-preservation during an emergency

Transfusion reactions

Signs, symptoms, or conditions suffered by a patient as the result of the administration of an incompatible transfusion

Covered service (expense)

Specific healthcare charges that an insurer will consider for payment under the terms of a health insurance policy; See benefit

Unbilled

Specific report that lists patient encounters that have ended but for whom a final bill has not been prepared

Back-end speech recognition (BESR)

Specific use of SRT in an environment where the recognition process occurs after the completion of dictation by sending voice files through a server

Conditions for Coverage

Standards applied to facilities that choose to participate in federal government reimbursement programs such as Medicare and Medicaid (CMS 2013); See also Conditions of Participation

Good Samaritan statute

State law or statute that protects healthcare providers from liability for not obtaining informed consent before rendering care to adults or minors at the scene of an emergency or accident

Tort laws

State legislation that applies to civil cases dealing with wrongful conduct or injuries

Evidence of insurability

Statement or proof of a health status necessary to obtain healthcare insurance, especially private healthcare insurance

Provider portal

System that enables providers to enter orders—based on organizational policy—as if they were in the hospital

Electronic record management (ERM)

Systems that capture data from print files and other report-formatted digital documents, such as e-mail, e-fax, instant messages, web pages, digital dictation, and speech recognition and stores them for subsequent viewing; Also called computer output to laser disk (COLD) technology

Team charter

A document that explains the issues the team was initiated to address, describes the team's goal or vision, and lists the initial members of the team and their respective departments

Trigger

A documented response that alerts a skilled nursing facility resident assessment instrument assessor to the fact that further research is needed to clarify an assessment

Resident care facility

A facility that provides accommodations, supervision, and personal care services for those who are dependent on services of others due to age or physical or mental impairment

Intermediate care facility

A facility that provides health-related care and services to individuals who do not require the degree of care or treatment that a hospital or a skilled nursing facility provides but who still require medical care and services because of their physical or mental condition

Consolidated billing/bundling

A feature of the prospective payment system established by the Balanced Budget Act of 1997 for home health services provided to Medicare beneficiaries that requires the home health provider that developed the patient's plan of care to assume Medicare billing responsibility for all of the home health services the patient receives to carry out the plan

Centers for Disease Control and Prevention (CDC)

A federal agency dedicated to protecting health and promoting quality of life through the prevention and control of disease, injury, and disability. Committed to programs that reduce the health and economic consequences of the leading causes of death and disability, thereby ensuring a long, productive, healthy life for all people (CDC 2013)

Health Care and Education Reconciliation Act of 2010 (P.L. 111-152) (HCERA)

A federal law enacted by Congress through reconciliation in order to make changes to the Patient Protection and Affordable Care Act. HCERA was signed into law by President Barack Obama on March 30, 2010 (Public Law 111-152 2010); Also called HR 4872

Affordable Care Act

A federal statute that was signed into law on March 23, 2010. Along with the Health Care and Education Reconciliation Act of 2010 (signed into law on March 30, 2010), the act is the product of the healthcare reform agenda of the Democratic 111th Congress and the Obama administration (PPACA 2010); Also called Patient Protection and Affordable Care Act (PPACA)

Medicare

A federally funded health program established in 1965 to assist with the medical care costs of Americans 65 years of age and older as well as other individuals entitled to Social Security benefits owing to their disabilities (CMS 2013)

Minimum Data Set for Long-Term Care Version 2.0 (MDS 2.0)

A federally mandated standard assessment form that Medicare- and Medicaid-certified nursing facilities must use to collect demographic and clinical data on nursing home residents; includes screening, clinical, and functional status elements

Bioethics

A field of study that applies ethical principles to decisions that affect the lives of humans, such as whether to approve or deny access to health information

Informatics

A field of study that focuses on the use of technology to improve access to, and utilization of, information

Chargemaster

A financial management form that contains information about the organization's charges for the healthcare services it provides to patients; Also called charge description master (CDM)

Undercoding

A form of incomplete documentation that results when diagnoses or procedures that should be coded are not assigned

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

Interagency transfer form

A form that contains sufficient information about a patient to provide continuity of care during transfer or discharge

Credential

A formal agreement granting an individual permission to practice in a profession, usually conferred by a national professional organization dedicated to a specific area of healthcare practice; or the accordance of permission by a healthcare organization to a licensed, independent practitioner (physician, nurse practitioner, or other professional) to practice in a specific area of specialty within that organization.

Structured query language (SQL)

A fourth-generation computer language that includes both DDL and DML components and is used to create and manipulate relational databases

Major drug class

A general therapeutic or pharmacological classification scheme for prescription drug products reported to the Food and Drug Administration under the provisions of the Drug Listing Act

Recovery audit contractor (RAC)

A governmental program whose goal is to identify improper payments made on claims of healthcare services provided to Medicare beneficiaries. Improper payments may be overpayments or underpayments

State Health Information Exchange Cooperative Agreement Program

A grant program that supports states or state designated entities (SDEs) in establishing HIE services among healthcare providers and hospitals in their regions

eHealth Exchange

A group of federal agencies and non-federal organizations that came together under a common mission and purpose to improve patient care, streamline disability benefit claims, and improve public health reporting through secure, trusted, and interoperable health information exchange.

Pre-existing condition

A health problem a person has before the date that a new insurance policy starts (CMS 2013)

Serial filing system

A health record identification system in which a patient receives sequential unique numerical identifiers for each encounter with, or admission to, a healthcare facility

Extended care facility

A healthcare facility licensed by applicable state or local law to offer room and board, skilled nursing by a full-time registered nurse, intermediate care, or a combination of levels on a 24-hour basis over a long period of time

Inpatient long-term care hospital (LTCH)

A healthcare facility that has an average length of stay greater than 25 days, with patients classified into distinct diagnosis groups called

Inpatient psychiatric facility (IPF)

A healthcare facility that offers psychiatric medical care on an inpatient basis

Inpatient rehabilitation facility (IRF)

A healthcare facility that specializes in providing services to patients who have suffered a disabling illness or injury in an effort to help them achieve or maintain their optimal level of functioning, self-care, and independence

Long-term care facility

A healthcare organization that provides medical, nursing, rehabilitation, and subacute care services to residents who need continual supervision or assistance

Managed fee-for-service reimbursement

A healthcare plan that implements utilization controls (prospective and retrospective review of healthcare services) for reimbursement under traditional fee-for-service insurance plans

Insured

A holder of a health insurance policy; See certificate holder; member; policyholder; subscriber

Patient advocate

A hospital employee whose job is to speak on a patient's behalf and help get any information or services needed (CMS 2013)

Hospital outpatient

A hospital patient who receives services in one or more of a hospital's facilities when he or she is not currently an inpatient or a home care patient

Psychiatric hospital

A hospital that provides diagnostic and treatment services to patients with mental or behavioral disorders

Contingency model of leadership

A leadership theory based on the idea that the success of task- or relationship-oriented leadership depends on leader-member relationships, task structure, and position power

Living will

A legal document, also known as a medical directive, that states a patient's wishes regarding life support in certain circumstances, usually when death is imminent (CMS 2013)

Durable power of attorney for healthcare decisions (DPOA-HCD)

A legal instrument through which a principal appoints an agent to make healthcare decisions on the principal's behalf in the event the principal becomes incapacitated

Advance directive

A legal, written document that describes the patient's preferences regarding future healthcare or stipulates the person who is authorized to make medical decisions in the event the patient is incapable of communicating his or her preferences

Outpatient visit

A patient's visit to one or more units located in the ambulatory services area (clinic or physician's office) of an acute care hospital in which an overnight stay does not occur

Skilled nursing facility prospective payment system (SNF PPS)

A per-diem reimbursement system implemented in July 1998 for costs (routine, ancillary, and capital) associated with covered skilled nursing facility services furnished to Medicare Part A beneficiaries

Continued-stay utilization review

A periodic review conducted during a hospital stay to determine whether the patient continues to need acute care services

Longitudinal health record

A permanent, coordinated patient record of significant information listed in chronological order and maintained across time, ideally from birth to death

Any and all records

A phrase frequently used by attorneys in the discovery phase of a legal proceeding. Subpoena-based requests containing this phrase may create a situation where the record custodian or provider's legal counsel can work to limit the records disclosed to those defined by a particular healthcare entity's legal health record.

Disability

A physical or mental condition that either temporarily or permanently renders a person unable to do the work for which he or she is qualified and educated

Osteopath

A physician licensed to practice in osteopathy (a system of medical practice that is based on the manipulation of body parts as well as other therapies)

Physician's orders

A physician's written or verbal instructions to the other caregivers involved in a patient's care

Disaster planning

A plan for protecting electronic protected health information (ePHI) in the event of a disaster that limits or eliminates access to facilities and ePHI

Downtime procedure policy

A policy that focuses on sustaining business function during short interruptions that do not exceed the threshold that would be classified as disasters; Also called contingency plan

Incomplete records policy

A policy that outlines how physicians are notified of records missing documentation or signatures

Records retention policy

A policy that specifies the length of time that health records are kept as required by law and operational needs

Hospital inpatient autopsy

A postmortem (after death) examination performed on the body of a patient who died during an inpatient hospitalization by a hospital pathologist or a physician of the medical staff who has been delegated the responsibility

Hospital autopsy

A postmortem (after death) examination performed on the body of a person who has at some time been a hospital patient by a hospital pathologist or a physician of the medical staff who has been delegated the responsibility; See hospital inpatient autopsy

Solo practice

A practice in which the physician is self-employed and legally the sole owner

Significant procedure

A procedure that is surgical in nature or carries a procedural or an anesthetic risk or requires specialized training

Inductive reasoning

A process of creating conclusions based on a limited number of observations

Compliance plan

A process that helps an organization, such as a hospital, accomplish its goal of providing high-quality medical care and efficiently operating a business under various laws and regulations

Cost-benefit analysis

A process that uses quantitative techniques to evaluate and measure the benefit of providing products or services compared to the cost of providing them

Collective bargaining

A process through which a contract is negotiated that sets forth the relationship between the employees and the healthcare organization

General Equivalence Mappings (GEMs)

A program created to facilitate the translation between ICD-9-CM and ICD-10-CM/PCS (CMS 2010)

Clinical Documentation Improvement Plan

A program in which specialists concurrently review health records for incomplete documentation, prompting clinical staff to clarify ambiguity which allows coders to assign more concise disease classification codes

Quota sampling

A sampling technique where the population is first segmented into mutually exclusive subgroups, just as in stratified sampling, and then judgment is used to select the subjects or units from each segment based on a specified proportion

Judgment sampling

A sampling technique where the researcher relies on his or her own judgment to select the subjects based on relevant expertise

Convenience sampling

A sampling technique where the selection of units from the population is based on easy availability or accessibility

Patient history questionnaire

A series of structured questions to be answered by patients to provide information to clinicians about their past and current health status; Also called adult health questionnaire

Pediatric service

A service that provides diagnostic and therapeutic services for patients at age of minority

Available for hospital autopsy

A situation in which the required conditions have been met to allow an autopsy to be performed on a hospital patient who has died

Statute of limitations

A specific time frame allowed by a statute or law for bringing litigation

Occasion of service

A specified identifiable service involved in the care of a patient that is not an encounter (for example, a lab test ordered during an encounter)

Outcomes and Assessment Information Set (OASIS)

A standard core assessment data tool developed to measure the outcomes of adult patients receiving home health services under the Medicare and Medicaid programs (CMS 2013)

HL7 EHR Functional Model

A standard developed by HL7 that details the specifications for an electronic health record

Electronic data interchange (EDI)

A standard transmission format using strings of data for business information communicated among the computer systems of independent organizations (CMS 2013)

Certificate of need (CON)

A state-directed program that requires healthcare facilities to submit detailed plans and justifications for the purchase of new equipment, new buildings, or new service offerings that cost in excess of a certain amount

Explanation of benefits (EOB)

A statement issued to the insured and the healthcare provider by an insurer to explain the services provided, amounts billed, and payments made by a health plan. See payer remittance report

Code of ethics

A statement of ethical principles regarding business practices and professional behavior

Full-time equivalent (FTE)

A statistic representing the number of full-time employees as calculated by the reported number of hours worked by all employees, including part-time and temporary, during a specific time period

Central tendency

A statistical term referring to the center of the distribution; an average or middle value

Geometric mean length of stay (GMLOS)

A statistically adjusted value of all cases of a given Medicare severity diagnosis-related group (MS-DRG), allowing for the outliers, transfer cases, and negative outlier cases that would normally skew that data; used to compute hospital reimbursement for transfer cases

Purposive sampling

A strategy of qualitative research in which researchers use their expertise to select representative units and unrepresentative units to capture a wide array of perspectives

Partial hospitalization

A structured program of active treatment for psychiatric care that is more intense than the care a patient receives in a doctor or therapist's office (CMS 2013)

Job procedure

A structured, action-oriented list of sequential steps involved in carrying out a specific task or solving a problem

Single-blinded study

A study design in which (typically) the investigator but not the subject knows the identity of the treatment and control groups

Cohort study

A study, followed over time, in which a group of subjects is identified as having one or more characteristics in common

Administrative management theory

A subdivision of classical management theory that emphasizes the total organization rather than the individual worker and delineates the major management functions

Discharge summary

A summary of the resident's stay at a healthcare facility that is used along with the postdischarge plan of care to provide continuity of care upon discharge from the facility

Infection control

A system for the prevention of communicable diseases that concentrates on protecting healthcare workers and patients against exposure to disease-causing organisms and promotes compliance with applicable legal requirements through early identification of potential sources of contamination and implementation of policies and procedures that limit the spread of disease

Healthcare provider cost report information system (HCRIS)

A system of Medicare cost report files containing information on provider characteristics, utilization data, and cost and charge data by cost center

Terminal-digit filing system

A system of health record identification and filing in which the last digit or group of digits (terminal digits) in the health record number determines file placement

Numeric filing system

A system of health record identification and storage in which records are arranged consecutively in ascending numerical order according to the health record number

Source-oriented health record format

A system of health record organization in which information is arranged according to the patient care department that provided the care

Pay for quality (P4Q)

A type of incentive to improve the quality of clinical outcomes using the electronic health record that could result in additional reimbursement or eligibility for grants or other subsidies to support further HIT efforts

Per patient per month (PPPM)

A type of managed care arrangement by which providers are paid a fixed fee in exchange for supplying all of the healthcare services an enrollee needs for a specified period of time (usually one month but sometimes one year); See per member per month (PMPM)

At risk contract

A type of managed care contract that provides a set fee for the care a patient is expected to receive throughout the life of the contract. Should the actual costs exceed the agreed upon contract fee, the patient continues to receive care through the end of the contract

Palliative care

A type of medical care designed to relieve the patient's pain and suffering without attempting to cure the underlying disease

Prospective payment system (PPS)

A type of reimbursement system that is based on preset payment levels rather than actual charges billed after the service has been provided; specifically, one of several Medicare reimbursement systems based on predetermined payment rates or periods and linked to the anticipated intensity of services delivered as well as the beneficiary's condition

Severity of illness (SI or SOI)

A type of supportive documentation reflecting objective clinical indicators of a patient illness (essentially the patient is sick enough to be at an identified level of care) and referring to the extent of physiologic decompensation or organ system loss of function

Long-term care

A variety of services that help people with health or personal needs and activities of daily living over a period of time. Long-term care can be provided in the home, in the community, or in various types of facilities, including nursing homes and assisted living facilities (CMS 2013)

Flextime

A work schedule that gives employees some choice in the pattern of their work hours, usually around a core of midday hours

Referral

A written approval from the primary care doctor for the patient to see a specialist (CMS 2013)

Universal protocol

A written checklist developed by the Joint Commission to prevent errors that can occur when physicians perform the wrong procedure, for example

Corrective action plan (CAP)

A written plan of action to be taken in response to identified issues or citations from an accrediting or licensing body

Consumer-directed (driven) healthcare plan (CDHP)

Managed care organization characterized by influencing patients and clients to select cost-efficient healthcare through the provision of information about health benefit packages and through financial incentives

Temporary privileges

Privileges granted for a limited time period to a licensed, independent practitioner on the basis of recommendations made by the appropriate clinical department or the president of the medical staff

Respite care

Temporary or periodic care provided in a nursing home, assisted living residence, or other type of long-term care program so that the usual caregiver can rest or take some time off (CMS 2013)

Computers on wheels (COWs)

Term affectionately used to refer to notebook computers mounted on carts and moved with the users

Diagnostic and Statistical Manual of Mental Disorders, Fourth Revision, Text Revision (DSM-IV-TR)

The 2004 text revision of the Diagnostic and Statistical Manual of Mental Disorders, Fourth Revision, with updated clinical terms, but very few coding changes (APA 2013)

Case-mix groups (CMGs)

The 97 function-related groups into which inpatient rehabilitation facility discharges are classified on the basis of the patient's level of impairment, age, comorbidities, functional ability, and other factors

American Academy of Professional Coders (AAPC)

The American Academy of Professional Coders provides certified credentials to medical coders in physician offices, hospital outpatient facilities, ambulatory surgical centers, and in payer organizations (AAPC 2013)

AHIMA Standards of Ethical Coding

The American Health Information Management Association's principles of professional conduct for coding professionals involved in diagnostic or procedural coding or other health record data abstraction

Morbidity

The state of being diseased (including illness, injury, or deviation from normal health); the number of sick persons or cases of disease in relation to a specific population

Medicare nonparticipation

The status with the Medicare program in which the provider has not signed a participation agreement and does not accept the Medicare allowable fee as payment in full, with the result that the payment goes directly to the patient and the patient must pay the bill up to Medicare's limiting charge of 115% of the approved amount

Fee schedule

A complete listing of fees used by health plans to pay doctors or other providers (CMS 2013)

Job description

A detailed list of a job's duties, reporting relationships, working conditions, and responsibilities; Also called position description

Notifiable disease

A disease that must be reported to a government agency so that regular, frequent, and timely information on individual cases can be used to prevent and control future cases of the disease

Documentation paradigm

A disease-specific format developed by the individual provider for the purpose of establishing standard clinical documentation forms

Statement of work (SOW)

A document that defines the scope and goals of a specific project; Also called project charter

Normalization

1. A formal process applied to relational database design to determine which variables should be grouped in a table in order to reduce data redundancy 2. Conversion of various representational forms to standard expressions so those with the same meaning will be recognized as synonymous by computer software in a data search

Liability

1. A legal obligation or responsibility that may have financial repercussions if not fulfilled 2. An amount owed by an individual or organization to another individual or organization

Informed consent

1. A legal term referring to a patient's right to make his or her own treatment decisions based on the knowledge of the treatment to be administered or the procedure to be performed 2. An individual's voluntary agreement to participate in research or to undergo a diagnostic, therapeutic, or preventive medical procedure

Continuous quality improvement (CQI)

1. A management philosophy that emphasizes the importance of knowing and meeting customer expectations, reducing variation within processes, and relying on data to build knowledge for process improvement 2. A component of total quality management (TQM) that emphasizes ongoing performance assessment and improvement planning

Consent

1. A patient's acknowledgement that he or she understands a proposed intervention, including that intervention's risks, benefits, and alternatives 2. The document signed by the patient that indicates agreement that protected health information (PHI) can be disclosed

Episode of care

1. A period of relatively continuous medical care performed by healthcare professionals in relation to a particular clinical problem or situation 2. One or more healthcare services given by a provider during a specific period of relatively continuous care in relation to a particular health or medical problem or situation 3. In home health, all home care services and nonroutine medical supplies delivered to a patient during a 60-day period; the episode of care is the unit of payment under the home health prospective payment system (HHPPS)

Third-party administrator

1. An entity required to make or responsible for making payment on behalf of a group health plan 2. A business associate that performs claims administration and related business functions for a self-insured entity (CMS 2013)

Health record

1. Information relating to the physical or mental health or condition of an individual, as made by or on behalf of a health professional in connection with the care ascribed that individual 2. A medical record, health record, or medical chart that is a systematic documentation of a patient's medical history and care

Health Care Quality Improvement Act (HCQIA)

A 1986 act that requires facilities to report professional review actions on physicians, dentists, and other facility-based practitioners to the National Practitioner Data Bank (NPDB) (Public Law 99-660 1986)

Operation Restore Trust

A 1995 joint effort of the Department of HHS, OIG, CMS, and AOA to target fraud and abuse among healthcare providers; based on the two-year findings of the project HHS expanded all fraud and abuse prevention activities

Data analysis

A body of methods that help to describe facts, detect patterns, develop explanations, and test hypotheses. It is used in all the sciences. It is used in business, in administration, and in policy (Levine and Roos 2002)

Institute of Medicine (IOM)

A branch of the National Academy of Sciences whose goal is to advance and distribute scientific knowledge with the mission of improving human health (IOM 2013)

Behavioral healthcare

A broad array of psychiatric services provided in acute, long-term, and ambulatory care settings; includes treatment of mental disorders, chemical dependency, mental retardation, and developmental disabilities, as well as cognitive rehabilitation services

Postdischarge plan of care (from long-term care facility)

A care plan used to help a resident discharged from the long-term care facility to adapt to his or her new living arrangement

All patient diagnosis-related groups (AP-DRGs)

A case-mix system developed by 3M and used in a number of state reimbursement systems to classify non-Medicare discharges for reimbursement purposes

Bundled payments

A category of payments made as lump sums to providers for all healthcare services delivered to a patient for a specific illness or over a specified time; a relatively continuous period in relation to a particular clinical problem or situation; they include multiple services and may include multiple providers of care; See also episode-of-care reimbursement

Intrahospital transfer

A change in medical care unit, medical staff unit, or responsible physician during hospitalization

History of present illness (HPI)

A chronological description of the development of the patient's present illness from the first sign or symptom or from the previous encounter to the present

Subpoena

A command to appear at a certain time and place to give testimony on a certain matter; Also called subpoena ad testificandum

Coding compliance plan

A component of an HIM compliance plan or a corporate compliance plan modeling the OIG Program Guidance for Hospitals and the OIG Supplemental Compliance Program Guidance for Hospitals that focuses on the unique regulations and guidelines with which coding professionals must comply

Breast Imaging Reporting and Data System Atlas (BI-RADS®)

A comprehensive guide providing standardized breast imaging terminology, and a report organization, assessment structure, and a classification system for mammography, ultrasound, and MRI of the breast (ACR 2013)

Current Procedural Terminology (CPT®)

A comprehensive, descriptive list of terms and associated numeric and alphanumeric codes used for reporting diagnostic and therapeutic procedures and other medical services performed by physicians; published and updated annually by the American Medical Association (AMA 2013)

Incidence rate

A computation that compares the number of new cases of a specific disease for a given time period to the population at risk for the disease during the same time period

MS-DRG grouper

A computer program that assigns inpatient cases to Medicare severity diagnosis-related groups and determines the Medicare reimbursement rate

Decision support system (DSS)

A computer-based system that gathers data from a variety of sources and assists in providing structure to the data by using various analytical models and visual tools in order to facilitate and improve the ultimate outcome in decision-making tasks associated with nonroutine and nonrepetitive problems

Present on admission (POA)

A condition present at the time of inpatient admission (CMS 2013)

Extreme immaturity

A condition referring to a newborn with a birth weight of fewer than 1,000 grams or gestation of fewer than 28 completed weeks

Role-based access control (RBAC)

A control system in which access decisions are based on the roles of individual users as part of an organization

Uniform Hospital Discharge Data Set (UHDDS)

A core set of data elements adopted by the US Department of Health, Education, and Welfare in 1974 that are collected by hospitals on all discharges and all discharge abstract systems

Default judgment

A court ruling against a defendant in a lawsuit who fails to answer a summons for a court appearance

Allied health professional

A credentialed healthcare worker who is not a physician, nurse, psychologist, or pharmacist (for example, a physical therapist, dietitian, social worker, or occupational therapist)

Template-based entry

A cross between free text and structured data entry. The user is able to pick and choose data that are entered frequently, thus requiring the entry of data that change from patient to patient

Uniform Ambulatory Care Data Set (UACDS)

A data set developed by the National Committee on Vital and Health Statistics consisting of a minimum set of patient- or client-specific data elements to be collected in ambulatory care settings

Nursing Management Minimum Data Set (NMMDS)

A data set that supports description, analysis, and comparisons of nursing care and nursing resources in the context of complex healthcare outcomes; designed to complement the clinical patient-oriented data designated in the nursing minimum data set (NMDS)

Data warehouse

A database that makes it possible to access data from multiple databases and combine the results into a single query and reporting interface; See clinical data warehouse; clinical repository

Normative decision model

A decision tree developed by Vroom-Yetton to determine when to make decisions independently or collaboratively or by delegation

Data dictionary

A descriptive list of the names, definitions, and attributes of data elements to be collected in an information system or database whose purpose is to standardize definitions and ensure consistent use

Healthcare Common Procedure Coding System (HCPCS)

A medical code set that identifies healthcare procedures, equipment, and supplies for claim submission purposes. It has been selected for use in the HIPAA transactions. HCPCS Level I contains numeric CPT codes which are maintained by the AMA. HCPCS Level II contains alphanumeric codes used to identify various items and services that are not included in the CPT medical code set. These are maintained by HCFA, the BCBSA, and the HIAA. HCPCS Level III contains alphanumeric codes that are assigned by Medicaid state agencies to identify additional items and services not included in levels I or II. These are usually called "local codes", and must have "W," "X," "Y," or "Z" in the first position. HCPCS Procedure Modifier Codes can be used with all three levels, with the WA-ZY range used for locally assigned procedure modifiers (CMS 2013)

College of American Pathologists (CAP)

A medical specialty organization of board-certified pathologists that owns and holds the copyright to SNOMED CT® (CAP 2013)

Per case

A method of billing in which services are charged on the basis of the total service being rendered rather than by each component of the service (for example, charging for transplantation services when the organ has been procured, the transplant has been made, and aftercare has been rendered)

Self-reported health status

A method of measuring health status in which a person rates his or her own general health, for example, by using a five category classification: excellent, very good, good, fair, or poor

Fee-for-service (FFS) reimbursement

A method of reimbursement through which providers retrospectively receive payment based on either billed charges for services provided or on annually updated fee schedules; Also called fee-for-service basis Fetal autopsy rate: The number of autopsies performed on intermediate and late fetal deaths for a given time period divided by the total number of intermediate and late fetal deaths for the same time period

Chronological order

A method of sequencing the health record according to time where the most recent document is found at the end of the health record

Hay method of job evaluation

A modification of the point method of job evaluation that numerically measures the levels of three major compensable factors: know-how, problem-solving ability, and accountability; Also called Hay Guide Chart/Profile Method of Job Evaluation

Claim status codes

A national administrative code set, identified in X12 277 Claims Status Notification transactions, that identifies the status of healthcare claims (CMS 2013)

Claim adjustment reason codes

A national administrative code set, used in X12 835 and X12 837 Claim Payment and Remittance Advice and Claims Transactions, that identifies the reasons for any differences or adjustments between the original provider charge for a claim or service and the payer's payment for it (CMS 2013)

Correct Coding Initiative (CCI)

A national initiative designed to improve the accuracy of Part B claims processed by Medicare carriers (CMS 2013)

Diagnostic and Statistical Manual of Mental Disorders, Fourth Revision (DSM-IV)

A nomenclature developed by the American Psychiatric Association to standardize the diagnostic process for patients with psychiatric disorders, which includes codes that correspond to ICD-9-CM codes; most recent version is fourth edition (text revision), or DSM-IV-TR, published in 2000 (APA 2013)

National Cancer Registrars Association (NCRA)

A not-for-profit association representing cancer registry professionals and Certified Tumor Registrars (CTR). The primary focus is education and certification with the goal to ensure all cancer registry professionals have the required knowledge to be superior in their field (NCRA 2013)

Hospital newborn inpatient

A patient born in the hospital at the beginning of the current inpatient hospitalization

Capitated patient

A patient enrolled in a managed care program that pays a fixed monthly payment to the patient's identified primary care provider

Clinic outpatient

A patient who is admitted to a clinical service of a clinic or hospital for diagnosis or treatment on an ambulatory basis

Hospital inpatient

A patient who is provided with room, board, and continuous general nursing services in an area of an acute care facility where patients generally stay at least overnight

Outpatient

A patient who receives ambulatory care services in a hospital-based clinic or department

Home health agency (HHA)

A program or organization that provides a blend of home-based medical and social services to homebound patients and their families for the purpose of promoting, maintaining, or restoring health or of minimizing the effects of illness, injury, or disability; these services include skilled nursing care, physical therapy, occupational therapy, speech therapy, and personal care by home health aides

Health Care Quality Improvement Program (HCQIP)

A program that supports the mission of CMS to assure healthcare security for beneficiaries. The mission of HCQIP is to promote the quality, effectiveness, and efficiency of services to Medicare beneficiaries by strengthening the community of those committed to improving quality; monitoring and improving quality of care; communicating with beneficiaries and healthcare providers, practitioners, and plans to promote informed health choices; protecting beneficiaries from poor care; and strengthening the infrastructure (CMS 2013)

Voluntary Disclosure Program

A program unveiled in 1998 by OIG that encourages healthcare providers to voluntarily report fraudulent conduct affecting Medicare, Medicaid, and other federal healthcare programs

Provider-based entity

A provider of healthcare services, a rural health clinic, or a federally qualified health clinic, as defined in section 405-2401 of the Code of Federal Regulations, that is either created or acquired by a main provider for the purpose of furnishing healthcare services under the name, ownership, and administrative and financial control of the main provider, in accordance with the provisions of the proposed rule (42 CFR 413.65 2009)

Semicolon

A punctuation mark [;] placed after a procedure description within a CPT code set to avoid repeating common information

Incident report

A quality or performance management tool used to collect data and information about potentially compensable events (events that may result in death or serious injury); See also occurrence report

Critical performance measures

A quantitative tool used to assess the importance of clinical, financial, and utilization aspects in relation to a healthcare provider's outcomes

Maternal mortality rate (community based)

A rate that measures the deaths associated with pregnancy for a specific community for a specific period of time

Mortality rate

A rate that measures the risk of death for the cause under study in a defined population during a given time period

Meaningful Use (MU)

A regulation that was issued by CMS on July 28, 2010, outlining an incentive program for professionals (EPs), eligible hospitals, and CAHs participating in Medicare and Medicaid programs that adopt and successfully demonstrate meaningful use of certified EHR technology

Traditional fee-for-service (FFS) reimbursement

A reimbursement method involving third-party payers who compensate providers after the healthcare services have been delivered; payment is based on specific services provided to subscribers

Balance billing

A reimbursement method that allows providers to bill patients for charges in excess of the amount paid by the patients' health plan or other third-party payer (not allowed under Medicare or Medicaid)

Per-diem reimbursement

A reimbursement system based on a set payment for all of the services provided to a patient on one day rather than on the basis of actual charges

Positive relationship

A relationship in which the effect moves in the same direction; Also called direct relationship

Negative relationship

A relationship in which the effects move in opposite directions; Also called inverse relationship

One-to-one relationship

A relationship that exists when an instance of an entity is associated with only one instance of another entity, and vice versa

One-to-many relationship

A relationship that exists when one instance of an entity is associated with multiple instances of another entity

Claim

A request for payment for services, benefits, or costs by a hospital, physician or other provider that is submitted for reimbursement to the healthcare insurance plan by either the insured party or by the provider

Motion for summary judgment

A request made by the defendant in a civil case to have the case ruled in his or her favor based on the assertion that the plaintiff has no genuine issue to be tried

Retrospective utilization review

A review of records some time after the patient's discharge or date of service to determine any of several issues, including the quality or appropriateness of the care provided

Qualitative analysis

A review of the health record to ensure that standards are met and to determine the adequacy of entries documenting the quality of care

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

Integrated delivery system (IDS)

A system that combines the financial and clinical aspects of healthcare and uses a group of healthcare providers, selected on the basis of quality and cost management criteria, to furnish comprehensive health services across the continuum of care; See integrated provider organization

Data type

A technical category of data (text, numbers, currency, date, memo, and link data) that a field in a database can contain

Root-cause analysis

A technique used in performance improvement initiatives to discover the underlying causes of a problem. Analysis of a sentinel event from all aspects (human, procedural, machinery, material) to identify how each contributed to the occurrence of the event and to develop new systems that will prevent recurrence

Natural language processing (NLP)

A technology that converts human language (structured or unstructured) into data that can be translated then manipulated by computer systems; branch of artificial intelligence

Telehealth

A telecommunications system that links healthcare organizations and patients from diverse geographic locations and transmits text and images for (medical) consultation and treatment; Also called telemedicine

Plan of care (POC)

A term referring to Medicare home health services for homebound beneficiaries that must be delivered under a plan established by a physician

Scope of work

A term used in project management. A document that sets forth requirements for performance of work to achieve the project objectives

Document control number (DCN)

A term used to refer to the number assigned to a claim when received for processing, facilitating ease of search on the part of the CMS

Patient Care Data Set (PCDS)

A terminology of patient problems, patient care goals, and patient care orders that represents and captures clinical data for inclusion in patient care information systems

Complete master census

A total census for a facility showing the names and locations of patients present in the hospital at a particular point in time

Healthcare information system (HIS)

A transactional system used in healthcare organizations (for example, patient admitting, accounting, and receivables); See hospital information system

Occupational therapy (OT)

A treatment that uses constructive activities to help restore a resident's ability to carry out needed activities of daily living and improves or maintains functional ability

Excludes 2

A type 2 Excludes note represents "not included here." An Excludes 2 note indicates that the condition excluded is not a part of the condition represented by the code, but a patient may have both conditions at the same time (CDC 2013)

Medical malpractice

A type of action in which the plaintiff must demonstrate that a healthcare provider-patient relationship existed at the time of the alleged wrongful act

Operational budget

A type of budget that allocates and controls resources to meet an organization's goals and objectives for the fiscal year

Registered health information technician (RHIT®)

A type of certification granted after completion of an AHIMA-accredited two-year program in health information management and a credentialing examination

Concurrent coding

A type of coding that takes place while the patient is still in the hospital and receiving care

Ordinal data

A type of data that represents values or observations that can be ranked or ordered

Object-oriented database (OODB)

A type of database that uses commands that act as small, self-contained instructional units (objects) that may be combined in various ways

Recovery room record

A type of health record documentation used by nurses to document the patient's reaction to anesthesia and condition after surgery; Also called recovery room report

Structured data entry

A type of healthcare data documentation about an individual using a controlled vocabulary rather than narrative text; Also called discrete data

Alternative delivery system (ADS)

A type of healthcare delivery system in which health services are provided in settings such as skilled and intermediary facilities, hospice programs, nonacute outpatient programs, and home health programs, which are more cost-effective than in the inpatient setting

Court-ordered warrant (bench warrant)

An authorization issued by a court for the attachment or arrest of a person either in the case of contempt or where an indictment has been found or to bring in a witness who does not obey a subpoena

Personal health record (PHR)

An electronic or paper health record maintained and updated by an individual for himself or herself; a tool that individuals can use to collect, track, and share past and current information about their health or the health of someone in their care

Data comprehensiveness

All required data items are included. Ensures that the entire scope of the data is collected with intentional limitations documented

Electronic health record (EHR)

An electronic record of health-related information on an individual that conforms to nationally recognized interoperability standards and that can be created, managed, and consulted by authorized clinicians and staff across more than one healthcare organization; Also called computer-based health record; computer-based patient record

Per member per month (PMPM)

Amount of money paid monthly for each individual enrolled in a capitation-based health insurance plan; See per patient per month

Premium

Amount of money that a policyholder or certificate holder must periodically pay an insurer in return for healthcare coverage

Chart conversion

An EHR implementation activity in which data from the paper chart are converted into electronic form

Context-based access control

An access control system which limits users to accessing information not only in accordance with their identity and role, but to the location and time in which they are accessing the information

Employee Retirement Income Security Act of 1974 (ERISA)

An act that sets minimum standards for most voluntarily established pension and health plans in private industry to provide protection for individuals in these plans (Public Law 93-406 1974)

Inpatient admission

An acute care facility's formal acceptance of a patient who is to be provided with room, board, and continuous nursing service in an area of the facility where patients generally stay at least overnight

Late entry

An addition to the health record when a pertinent entry was missed or was not written in a timely manner

Institutional Review Board (IRB)

An administrative body that provides review, oversight, guidance, and approval for research projects carried out by employees serving as researchers, regardless of the location of the research (such as a university or private research agency); responsible for protecting the rights and welfare of the human subjects involved in the research. IRB oversight is mandatory for federally funded research projects

Urgent admission

An admission in which the patient requires immediate attention for care and treatment of a physical or psychiatric problem. Generally, the patient is admitted to the first available, suitable accommodation

Nondisclosure agreement

An agreement relating to the confidentiality and privacy of patient information employees may be required to sign as a condition of employment

Grace period

An amount of time beyond a due date during which a payment may be made without incurring penalties; in healthcare, the specific time (usually 31 days) following the premium due date during which insurance remains in effect and a policyholder may pay the premium without penalty or loss of benefits

Public health

An area of healthcare that deals with the health of populations in geopolitical areas, such as states and counties

RAI (Resident Assessment Instrument)

An assessment instrument used in skilled nursing facilities (SNF) and long-term care (LTC).

Preoperative anesthesia evaluation

An assessment performed by an anesthesiologist to collect information on a patient's medical history and current physical and emotional condition that will become the basis of the anesthesia plan for the surgery to be performed

Deficiency analysis

An audit process designed to ensure that all services billed have been documented in the health record

Standard of care

An established set of clinical decisions and actions taken by clinicians and other representatives of healthcare organizations in accordance with state and federal laws, regulations, and guidelines; codes of ethics published by professional associations or societies; regulations for accreditation published by accreditation agencies; usual and common practice of equivalent clinicians or organizations in a geographical region

Readiness assessment

An evaluation of a healthcare organization's infrastructure to identify and capture information on what must be addressed and where to apply resources in preparation for change such as an EHR implementation or ICD-10 transition

Concurrent utilization review

An evaluation of the medical necessity, quality, and cost-effectiveness of a hospital admission and ongoing patient care at or during the time that services are rendered

Potentially compensable event (PCE)

An event (for example, an injury, accident, or medical error) that may result in financial liability for a healthcare organization, for example, an injury, accident, or medical error

Waiver of privilege

An exception to physician-patient privilege that occurs when a party claims damages for a mental or physical injury; the party thereby waives his or her right to confidentiality to the extent that it is necessary to determine whether the mental or physical injury is due to another cause

All patient refined diagnosis-related groups (APR-DRGs)

An expansion of the inpatient classification system that includes four distinct subclasses (minor, moderate, major, and extreme) based on the severity of the patient's illness

House of Delegates

An important component of the volunteer structure of the American Health Information Management Association that conducts the official business of the organization and functions as its legislative body

Shift differential

An increased wage paid to employees who work less desirable shifts, such as evenings, nights, or weekends

The Joint Commission

An independent, not-for-profit organization, the Joint Commission accredits and certifies more than 20,000 healthcare organizations and programs in the United States. Joint Commission accreditation and certification is recognized nationwide as a symbol of quality that reflects an organization's commitment to meeting certain performance standards (Joint Commission 2013)

Enterprise master patient index (EMPI)

An index that provides access to multiple repositories of information from overlapping patient populations that are maintained in separate systems and databases

Licensed practitioner

An individual at any level of professional specialization who requires a public license or certification to engage in patient care

Third-party payer

An insurance company (for example, Blue Cross/Blue Shield) or healthcare program (for example, Medicare) that pays or reimburses healthcare providers (second party) or patients (first party) for the delivery of medical services

Court order

An official direction issued by a court judge and requiring or forbidding specific parties to perform specific actions

Medicare Part B

An optional and supplemental portion of Medicare that beneficiaries pay a monthly premium for. Part B assists coverage with doctors' services and outpatient care. It also covers some other medical services that Part A does not cover, such as some of the services of physical and occupational therapists, and some home healthcare. Part B pays for these covered services and supplies when they are medically necessary (CMS 2013); See also supplemental medical insurance

National Association for Healthcare Quality (NAHQ)

An organization devoted to advancing the profession of healthcare quality improvement through its accreditation program (NAHQ 2013)

Group practice

An organization of physicians who share office space and administrative support services to achieve economies of scale; often a clinic or ambulatory care center

Insurer

An organization that pays healthcare expenses on behalf of its enrollees; See third-party payer

Provider network organization

An organization that performs prospective, concurrent, and retrospective reviews of healthcare services provided to its enrollees

Data audit

An organizational procedure for monitoring the quality of data by analyzing reports for anomalies, inaccuracies, and missing data

Hospital outpatient care unit

An organized unit of a hospital that provides facilities and medical services exclusively or primarily to patients who are generally ambulatory and who do not currently require or are not currently receiving services as an inpatient of the hospital

Referred outpatient

An outpatient who is provided special diagnostic or therapeutic services by a hospital on an ambulatory basis but whose medical care remains the responsibility of the referring physician

Business associate agreement (BAA)

As amended by HITECH, a contract between the covered entity and a business associate must establish the permitted and required uses and disclosures of protected health information by the business associate and provides specific content requirements of the agreement. The contract may not authorize the business associate to use or further disclose the information in a manner that would violate the requirements of HIPAA, and requires termination of the contract if the covered entity or business associate are aware of noncompliant activities of the other (45 CFR 164.504 2013)

Breach notification

As amended by HITECH, a covered entity shall, following the discovery of a breach of unsecured protected health information, notify each individual whose unsecured protected health information has been, or is reasonably believed by the covered entity to have been, accessed, acquired, used, or disclosed as a result of such breach (45 CFR 164.404 2013)

Notice of privacy practices

As amended by HITECH, a statement (mandated by the HIPAA Privacy Rule) issued by a healthcare organization that informs individuals of the uses and disclosures of patient-identifiable health information that may be made by the organization, as well as the individual's rights and the organization's legal duties with respect to that information (45 CFR 164.520 2013)

Direct treatment relationship

As amended by HITECH, a treatment relationship between an individual and a health care provider that is not an indirect treatment relationship (45 CFR 164.501 2013)

Low-birth-weight neonate

Any newborn baby, regardless of gestational age, whose birth weight is less than 2,500 grams

Discharge diagnosis

Any one of the diagnoses recorded after all the data accumulated during the course of a patient's hospitalization or other circumscribed episode of medical care have been studied

Surgical procedure

Any single, separate, systematic process upon or within the body that can be complete in itself; is normally performed by a physician, dentist, or other licensed practitioner; can be performed either with or without instruments; and is performed to restore disunited or deficient parts, remove diseased or injured tissues, extract foreign matter, assist in obstetrical delivery, or aid in diagnosis

Group health plan

As amended by HITECH, an employee welfare benefit plan (as defined in section 3(1) of the Employee Retirement Income and Security Act of 1974 (ERISA), 29 U.S.C. 1002(1)), including insured and self-insured plans, to the extent that the plan provides medical care (as defined in section 2791(a)(2) of the Public Health Service Act (PHS Act), 42 U.S.C. 300gg-91(a)(2)), including items and services paid for as medical care, to employees or their dependents directly or through insurance, reimbursement, or otherwise, that: has 50 or more participants (as defined in section 3(7) of ERISA, 29 U.S.C. 1002(7)); or (2) is administered by an entity other than the employer that established and maintains the plan (45 CFR 160.103 2013)

Willful neglect

As amended by HITECH, conscious, intentional failure or reckless indifference to the obligation to comply with the administrative simplification provision violated (45 CFR 160.401 2013)

Protected health information (PHI)

As amended by HITECH, individually identifiable health information: (1) Except as provided in paragraph (2) of this definition, that is: (i) transmitted by electronic media; (ii) maintained in electronic media; or (iii) transmitted or maintained in any other form or medium. (2) Protected health information excludes individually identifiable health information: (i) in education records covered by the Family Educational Rights and Privacy Act, as amended, 20 U.S.C. 1232g; (ii) in records described at 20 U.S.C. 1232g(a)(4)(B)(iv); (iii) in employment records held by a covered entity in its role as employer; and (iv) regarding a person who has been deceased for more than 50 years (45 CFR 160.103 2013)

Individually identifiable health information

As amended by HITECH, information that is a subset of health information, including demographic information collected from an individual, and: (1) is created or received by a health care provider, health plan, employer, or health care clearinghouse; and (2) relates to the past, present, or future physical or mental health or condition of an individual; the provision of health care to an individual; or the past, present, or future payment for the provision of health care to an individual; and (i) that identifies the individual; or (ii) with respect to which there is a reasonable basis to believe the information can be used to identify the individual (45 CFR 160.103 2013)

Electronic Protected Health Information (ePHI)

As amended by HITECH, means information that comes within paragraphs (1)(i) or (1)(ii) of this definition of protected health information as specified in this section which is (1)(i) information transmitted by electronic media, and (1)(ii) information maintained in electronic media (45 CFR 160.103 2013)

Reasonable diligence

As amended by HITECH, means the business care and prudence expected from a person seeking to satisfy a legal requirement under similar circumstances (45 CFR 160.401 2013)

Psychotherapy notes

As amended by HITECH, notes recorded (in any medium) by a health care provider who is a mental health professional documenting or analyzing the contents of conversation during a private counseling session or a group, joint, or family counseling session and that are separated from the rest of the individual's medical record. Psychotherapy notes exclude medication prescription and monitoring, counseling session start and stop times, the modalities and frequencies of treatment furnished, results of clinical tests, and any summary of the following items: diagnosis, functional status, the treatment plan, symptoms, prognosis, and progress to date (45 CFR 164.501 2013)

Unsecured personal health information (PHI)

As amended by HITECH, protected health information that is not rendered unusable, unreadable, or indecipherable to unauthorized persons through the use of a technology or methodology specified by the secretary in the guidance issued under section 13402(h)(2) of Public Law 111-05 (45 CFR 164.402 2013)

Genetic information

As amended by HITECH, refers to health information pertaining to individual genetic tests, genetic tests of family members of the individual, manifestations of a disease in family members, including any fetus carried by the individual or family member who is a pregnant woman, and any embryo legally held by an individual or family member utilizing an assisted reproductive technology (45 CFR 160.103 2013)

Physical safeguards

As amended by HITECH, security rule measures such as locking doors to safeguard data and various media from unauthorized access and exposures;, including facility access controls, workstation use, workstation security, and device and media controls (45 CFR 164.310 2013)

Technical safeguards

As amended by HITECH, the Security Rule means the technology and the policy and procedures for its use that protect electronic protected health information and control access to it (45 CFR 164.304 2013)

Disclosure

As amended by HITECH, the release, transfer, provision of access to, or divulging in any manner of information outside the entity holding the information (45 CFR 160.103 2013)

Covered functions

As amended by HITECH, those functions of a covered entity the performance of which makes the entity a health plan, health care provider, or health care clearinghouse (45 CFR 164.103 2009)

Data aggregation

As amended by HITECH, with respect to protected health information created or received by a business associate in its capacity as the business associate of a covered entity, the combining of such protected health information by the business associate with the protected health information received by the business associate in its capacity as a business associate of another covered entity, to permit data analyses that relate to the health care operations of the respective covered entities (45 CFR 164.501 2013)

Designated record set

As amended by HITECH: (1) A group of records maintained by or for a covered entity that is: (i) The medical records and billing records about individuals maintained by or for a covered health care provider; (ii) The enrollment, payment, claims adjudication, and case or medical management record systems maintained by or for a health plan; or (iii) Used, in whole or in part, by or for the covered entity to make decisions about individuals

Ambulatory payment classification group (APC group)

Basic unit of the ambulatory payment classification (APC) system. Within a group, the diagnoses and procedures are similar in terms of resources used, complexity of illness, and conditions represented. A single payment is made for the outpatient services provided. APC groups are based on HCPCS/CPT codes. A single visit can result in multiple APC groups. APC groups consist of five types of service: significant procedures, surgical services, medical visits, ancillary services, and partial hospitalization. The APC group was formerly known as the ambulatory visit group (AVG) and ambulatory patient group (APG)

Reimbursement

Compensation or repayment for healthcare services

Not otherwise specified (NOS)

In ICD-10-CM this abbreviation is the equivalent of unspecified (CDC 2013)

Compliance officer

Designated individual who monitors the compliance process at a healthcare facility

Six Sigma

Disciplined and data-driven methodology for getting rid of defects in any process

Minimum Data Set 3.0 (MDS)

Document created when OBRA required CMS to develop an assessment instrument to standardize the collection of SNF patient data; the MDS is the minimum core of defined and categorized patient assessment data that serves as the basis for documentation and reimbursement in an SNF (CMS 2013)

Subjective, objective, assessment, plan (SOAP)

Documentation method that refers to how each progress note contains documentation relative to subjective observations, objective observations, assessments, and plans

Counterclaim

In a court of law, a countersuit

National Institutes of Health (NIH)

Federal agency of HHS that is the primary agency for conducting and reporting medical research; NIH investigates the prevention, causes, and treatments for diseases (NIH 2013)

Omnibus Budget Reconciliation Act (OBRA) of 1987

Federal legislation passed in 1987 that required the Health Care Financing Administration (renamed the Centers for Medicare and Medicaid Services) to develop an assessment instrument (resident assessment instrument) to standardize the collection of patient data from skilled nursing facilities (Public Law 100-203 1987)

Workers' Adjustment and Retraining Notification (WARN) Act

Federal legislation that requires employers to give employees a 60-day notice in advance of covered plant closings and covered mass layoffs (Public Law 100-379 1988)

Americans with Disabilities Act (ADA) of 1990

Federal legislation which ensures equal opportunity for and elimination of discrimination against persons with disabilities (Public Law 110-325 2008)

Postoperative anesthesia record

Health record documentation that contains information on any unusual events or complications that occurred during surgery as well as information on the patient's condition at the conclusion of surgery and after recovery from anesthesia

Intraoperative anesthesia record

Health record documentation that describes the entire surgical process from the time the operation began until the patient left the operating room

Transfusion record

Health record documentation that includes information on the type and amount of blood products a patient received, the source of the blood products, and the patient's reaction to them

Labor and delivery record

Health record documentation that takes the place of an operative report for patients who give birth in the obstetrics department of an acute care hospital

Out-of-pocket

Healthcare costs that a patient must pay out of pocket because they are not covered by Medicare or other insurance (CMS 2013)

Disproportionate share hospital (DSH)

Healthcare organizations that meet governmental criteria for percentages of indigent patients. Hospital with an unequally (disproportionately) large share of low-income patients. Federal payments to these hospitals are increased to adjust for the financial burden

Evidence-based medicine

Healthcare services based on clinical methods that have been thoroughly tested through controlled, peer-reviewed biomedical studies

Teaching hospital

Hospital engaged in an approved graduate medical education residency program in medicine, osteopathy, dentistry, or podiatry

Sole-community hospital

Hospital that, by reason of factors such as isolated location, weather conditions, travel conditions, or absence of other hospitals (as determined by the Secretary of the HHS), is the sole source of patient hospital services reasonably available to individuals in a geographical area who are entitled to benefits

Swing beds

Hospital-based acute care beds that may be used flexibly to serve as acute or skilled nursing care

Chief information security officer (CISO)

IT leadership role responsible for overseeing the development, implementation, and enforcement of a healthcare organization's security program; role has grown as a direct result of the HIPAA security regulations

Chief information technology officer (CITO)

IT leadership role that guides an organization's decisions related to technical architecture and evaluates the latest technology developments and their applicability or potential use in the organization

Injury (harm)

In a negligence lawsuit, one of four elements, which may be economic (hospital expenses and loss of wages) and noneconomic (pain and suffering), that must be proved to be successful

Data normalization

In a relational database, it is the process of organizing data to minimize redundancy

Placeholder character

In ICD-10-CM "X" is used as a placeholder at certain codes to allow for future expansion (CDC 2013)

Character, 7th

In ICD-10-CM certain categories have applicable 7th characters. The character is required for all codes within the category, or as notes in the Tabular List instruct. If a code that requires a 7th character is not 7 characters, a placeholder "X" must be used to fill in the empty character (CDC 2013)

Not elsewhere classifiable (NEC)

In ICD-10-CM this abbreviation in the Alphabetic Index represents "other specified" when a specific code is not available for a condition (CDC 2013)

Hospital live birth

In an inpatient facility, the complete expulsion or extraction of a product of human conception from the mother, regardless of the duration of pregnancy, which, after such expulsion or extraction, breathes or shows any other evidence of life, such as beating of the heart, pulsation of the umbilical cord, or definite movement of voluntary muscles

Iatrogenic

Induced inadvertently by a physician or surgeon or by medical treatment or diagnostic procedures

Long-term care diagnosis related group (LTC-DRG)

Inpatient classification that categorizes patients who are similar in terms of diagnoses and treatments, age, resources used, and lengths of stay. Under the prospective payment system (PPS), hospitals are paid a set fee for treating patients in a single DRG category, regardless of the actual cost of care for the individual. LTC-DRGs are exactly the same as the DRGs for the inpatient prospective payment system (IPPS). See also diagnosis related group (DRG)

Office of Inspector General (OIG)

Mandated by Public Law 95-452 (as amended) to protect the integrity of HHS programs, as well as the health and welfare of the beneficiaries of those programs. The OIG has a responsibility to report both to the Secretary and to the Congress program and management problems and recommendations to correct them. The OIG's duties are carried out through a nationwide network of audits, investigations, inspections, and other mission-related functions performed by OIG components (OIG 2013)

Qualified Medicare beneficiaries (QMBs)

Medicare beneficiaries who have resources at or below twice the standard allowed under the Social Security Income program and incomes at or below 100 percent of the federal poverty level (CMS 2013)

Medicare Part D

Medicare drug benefit created by the Medicare Modernization Act of 2003 (MMA) that offers outpatient drug coverage to beneficiaries for an additional premium. Starting January 1, 2006, new Medicare prescription drug coverage became available to everyone with Medicare. This coverage assists in lowering prescription drug costs and protect against higher costs in the future (CMS 2013)

Prepartum

Occurring prior to childbirth

Limited data set

PHI that excludes direct identifiers of the individual and the individual's relatives, employers, or household members but still does not deidentify the information

Patient-identifiable data

Personal information that can be linked to a specific patient, such as age, gender, date of birth, and address

Capital assets

Physical assets with an estimated useful life of more than one year; See fixed assets; property, plant, and equipment (PPE)

Medical savings account (MSA) plans

Plans that provide benefits after a single, high deductible has been met whereby Medicare makes an annual deposit to the MSA and the beneficiary is expected to use the money in the MSA to pay for medical expenses below the annual deductible

Centers for Medicare and Medicaid Services (CMS)

The Department of Health and Human Services agency responsible for Medicare and parts of Medicaid. CMS is responsible for the oversight of HIPAA administrative simplification transaction and code sets, health identifiers, and security standards. CMS also maintains the HCPCS medical code set and the Medicare Remittance Advice Remark Codes administrative code set (CMS 2013)

Supplemental medical insurance (SMI)

The Medicare program that pays for a portion of the costs of physicians' services, outpatient hospital services, and other related medical and health services for voluntarily insured and disabled individuals (CMS 2013)

Outpatient prospective payment system (OPPS)

The Medicare prospective payment system used for hospital-based outpatient services and procedures that is predicated on the assignment of ambulatory payment classifications

Acute-care prospective payment system

The Medicare reimbursement methodology system referred to as the inpatient prospective payment system (IPPS). Hospital providers subject to the IPPS utilize the Medicare severity diagnosis-related groups (MS-DRGs) classification system, which determines payment rates (CMS 2012)

Mitigation

The Privacy Rule requires covered entities to lessen, as much as possible, harmful effects that result from the wrongful use and disclosure of protected health information. Possible courses of action may include an apology; disciplinary action against the responsible employee or employees (although such results will not be able to be shared with the wronged individual); repair of the process that resulted in the breach; payment of a bill or financial loss that resulted from the infraction; or gestures of goodwill and good public relations, such as a gift certificate, that may assuage the individual (45 CFR 164.530 2009)

World Health Organization (WHO)

The United Nations specialized agency created to ensure the attainment by all peoples of the highest possible levels of health; responsible for a number of international classifications, including ICD-10 and ICF (WHO 2013)

Early fetal death

The death of a product of human conception that is fewer than 20 weeks of gestation and 500 grams or less in weight before its complete expulsion or extraction from the mother

Information governance (IG)

The accountability framework and decision rights to achieve enterprise information management (EIM). IG is the responsibility of executive leadership for developing and driving the IG strategy throughout the organization. IG encompasses both data governance (DG) and information technology governance (ITG)

Copy/Paste Functionality

The act of copying text within the electronic health record, copying of text from an outside document and pasting it into the EHR or pasting it to a new location with the record, in which the original text is not removed from the record

Rebill

The act of resubmitting a corrected bill to the payer after it has been rejected

Charge reconciliation

The act of reviewing charges entered for claims submission by the charge entry process. Ensures that all services, procedures, and supplies are available and pass to the claim form

Conditions of Participation

The administrative and operational guidelines and regulations under which facilities are allowed to take part in the Medicare and Medicaid programs; published by the Centers for Medicare and Medicaid Services, a federal agency under the Department of Health and Human Services (CMS 2013); See also Conditions for Coverage

Average payment rate (APR)

The amount of money the Centers for Medicare and Medicaid could pay a health maintenance organization for services rendered to Medicare recipients under a risk contract

Reasonable and customary charges (R and C)

The amounts charged by healthcare providers consistent with charges from similar providers for identical or similar services in a given locale; See also usual, customary, and reasonable

Shift rotation

The assignment of employees to different periods of service to provide coverage, as needed

Clinical privileges

The authorization granted by a healthcare organization's governing board to a member of the medical staff that enables the physician to provide patient services in the organization within specific practice limits

Direct obstetric death

The death of a woman resulting from obstetric complications of the pregnancy state, labor, or puerperium; from interventions, omissions, or treatment; or from a chain of events resulting from any of the events listed

Indirect obstetric death

The death of a woman that resulted from a previously existing disease (or a disease that developed during pregnancy, labor, or the puerperium) that was not due to obstetric causes, although the physiologic effects of pregnancy were partially responsible for the death

Maternal death

The death of any woman, from any cause, related to or aggravated by pregnancy or its management (regardless of duration or site of pregnancy), but not from accidental or incidental causes

Bed turnover rate

The average number of times a bed changes occupants during a given period of time

Case-mix index (CMI)

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

Activities of daily living (ADL)

The basic activities of self-care, including grooming, bathing, ambulating, toileting, and eating

Sixty-day episode payment

The basic unit of payment under the home health prospective payment system that covers a beneficiary for 60 days regardless of the number of days furnished unless the beneficiary elects to transfer, has a significant change in condition, or is discharged and then returns to the same agency within the 60-day episode

Interoperability

The capability of different information systems and software applications to communicate and exchange data

Critical care

The care of critically ill patients in a medical emergency requiring the constant attention of the physician

Home health prospective payment system (HHPPS)

The case mix reimbursement system developed by the Centers for Medicare and Medicaid Services in 2008, to cover home health services, including therapy visits and different resource costs provided to Medicare beneficiaries (CMS 2013)

Quality

The degree or grade of excellence of goods or services, including, in healthcare, meeting expectations for outcomes of care

Budget cycle

The complete process of financial planning, operations, and control for a fiscal year; overlaps multiple fiscal years; Also called budget calendar

Many-to-many relationship

The concept (occurring only in a conceptual model) that multiple instances of an entity may be associated with multiple instances of another entity

Performance improvement (PI)

The continuous study and adaptation of a healthcare organization's functions and processes to increase the likelihood of achieving desired outcomes

Cost-sharing

The cost for medical care that patients pay for themselves, like a copayment, coinsurance, or deductible (CMS 2013)

Per-diem rate

The cost per day derived by dividing total costs by the number of inpatient care days

Information life cycle

The cycle of gathering, recording, processing, storing, sharing, transmitting, retrieving, and deleting information

Date of service (DOS)

The date a test, procedure, or service was rendered

Data

The dates, numbers, images, symbols, letters, and words that represent basic facts and observations about people, processes, measurements, and conditions

Infant death

The death of a live-born infant at any time from the moment of birth to the end of the first year of life (364 days, 23 hours, 59 minutes from the moment of birth)

Postneonatal death

The death of a live-born infant from 28 days to the end of the first year of life (364 days, 23 hours, 59 minutes from the moment of birth)

Neonatal death

The death of a live-born infant within the first 27 days, 23 hours, and 59 minutes following the moment of birth

Fetal death

The death of a product of human conception before its complete expulsion or extraction from the mother regardless of the duration of the pregnancy; See stillbirth

Intermediate fetal death

The death of a product of human conception before its complete expulsion or extraction from the mother that is 20 complete weeks of gestation (but less than 28 weeks) and weighs 501 to 1,000 grams

Late fetal death

The death of a product of human conception that is 28 weeks or more of gestation and weighs 1,001 grams or more before its complete expulsion or extraction from the mother

Against medical advice (AMA)

The discharge status of patients who leave a hospital prior to the recommended discharge date given by the physician

Discharge status

The disposition of the patient at discharge (that is, left against medical advice, discharged to home, transferred to skilled nursing facility, or died)

Strategic plan

The document in which the leadership of a healthcare organization identifies the organization's overall mission, vision, and goals to help set the long-term direction of the organization as a business entity

Board of directors

The elected or appointed group of officials who bear ultimate responsibility for the successful operation of a healthcare organization; Also called board of governors; board of trustees

Health information exchange (HIE)

The exchange of health information electronically between providers and others with the same level of interoperability, such as labs and pharmacies

National Centers for Health Statistics (NCHS)

The federal agency responsible for collecting and disseminating information on health services utilization and the health status of the population in the United States; developed the clinical modification to the International Classification of Diseases, Ninth Revision (ICD-9) and is responsible for updating the diagnosis portion of the ICD-9-CM (NCHS 2013)

Food and Drug Administration (FDA)

The federal agency responsible for controlling the sale and use of pharmaceuticals, biological products, medical devices, food, cosmetics, and products that emit radiation, including the licensing of medications for human use (FDA 2013); See Federal Food, Drug and Cosmetic Act

Securities and Exchange Commission (SEC)

The federal agency that regulates all public and some private transactions involving the ownership and debt of organizations (SEC 2013)

Freedom of Information Act (FOIA)

The federal law established in 1967, amended in 1986, that is applicable only to federal agencies, through which individuals can seek access to information without the authorization of the person to whom the information applies (Public Law 99-570 1986)

Consolidated Omnibus Budget Reconciliation Act of 1986 (COBRA)

The federal law requiring every hospital that participates in Medicare and has an emergency room to treat any patient in an emergency condition or active labor, whether or not the patient is covered by Medicare and regardless of the patient's ability to pay; COBRA also requires employers to provide continuation benefits to specified workers and families who have been terminated but previously had healthcare insurance benefits (Public Law 99-272 1986)

Health Insurance Portability and Accountability Act of 1996 (HIPAA)

The federal legislation enacted to provide continuity of health coverage, control fraud and abuse in healthcare, reduce healthcare costs, and guarantee the security and privacy of health information; limits exclusion for pre-existing medical conditions, prohibits discrimination against employees and dependents based on health status, guarantees availability of health insurance to small employers, and guarantees renewability of insurance to all employees regardless of size; requires covered entities (most healthcare providers and organizations) to transmit healthcare claims in a specific format and to develop, implement, and comply with the standards of the Privacy Rule and the Security Rule; and mandates that covered entities apply for and utilize national identifiers in HIPAA transactions (Public Law 104-191 1996); Also called the Kassebaum-Kennedy Law

Patient Self-Determination Act (PSDA)

The federal legislation, passed through an Amendment to the Omnibus Budget Reconciliation Act of 1990, that requires healthcare facilities to provide written information on the patient's right to issue advance directives and to accept or refuse medical treatment

Privacy Rule

The federal regulations created to implement the privacy requirements of the simplification subtitle of the Health Insurance Portability and Accountability Act of 1996; effective in 2002; afforded patients certain rights to and about their protected health information

Physical therapy (PT)

The field of study that focuses on physical functioning of the resident on a physician-prescribed basis

Blue Cross and Blue Shield (BC/BS)

The first prepaid healthcare plans in the United States; Blue Shield plans traditionally cover hospital care and Blue Cross plans cover physicians' services

Unfreezing

The first stage of Lewin's change process in which people are presented with disconcerting information to motivate them to change

Location or address of encounter

The full address and nine-digit zip code for the location at which outpatient care was received from the healthcare practitioner of record

Health record ownership

The generally accepted principle that individual health records are maintained and owned by the healthcare organization that creates them but that patients have certain rights of control over the release of patient-identifiable (confidential) information

Information management

The generation, collection, organization, validation, analysis, storage, and integration of data as well as the dissemination, communication, presentation, utilization, transmission, and safeguarding of the information

Authenticity

The genuineness of a record, that it is what it purports to be; information is authentic if proven to be immune from tampering and corruption

Plaintiff

The group or person who initiates a civil lawsuit

Secondary insurer

The insurance carrier that pays benefits after the primary payer has determined and paid its obligation

Primary insurer (payer)

The insurance company responsible for making the first payment on a claim; See also secondary insurer

Data comparability

The standardization of vocabulary such that the meaning of a single term is the same each time the term is used in order to produce consistency in information derived from the data

Nosocomial infection rate

The number of hospital-acquired infections for a given time period divided by the total number of inpatient discharges for the same time period

Postoperative infection rate

The number of infections that occur in clean surgical cases for a given time period divided by the total number of operations within the same time period

Gross autopsy rate

The number of inpatient autopsies conducted during a given time period divided by the total number of inpatient deaths for the same time period

Bed count

The number of inpatient beds set up and staffed for use on a given day; Also called bed complement

Source of admission

The point from which a patient enters a healthcare organization, including physician referral, clinic referral, health maintenance organization referral, transfer from a hospital, transfer from a skilled nursing facility, transfer from another healthcare facility, emergency department referral, court or law enforcement referral, and delivery of newborns

Duplicate billing

The practice of submitting more than one claim for the same item or service

Unbundling

The practice of using multiple codes to bill for the various individual steps in a single procedure rather than using a single code that includes all of the steps of the comprehensive procedure

Job evaluation

The process of applying predefined compensable factors to jobs to determine their relative worth

Coding

The process of assigning numeric or alphanumeric representations to clinical documentation

Record reconciliation

The process of assuring that all the records of discharged patients have been received by the HIM department for processing

Data cleaning

The process of checking internal consistency and duplication as well as identifying outliers and missing data; Also called data cleansing; data scrubbing

Transcription

The process of deciphering and typing medical dictation

Data modeling

The process of determining the users' information needs and identifying relationships among the data

Utilization review (UR)

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

Deductive reasoning

The process of developing conclusions based on generalizations

Release of information (ROI)

The process of disclosing patient-identifiable information from the health record to another party

Data mining

The process of extracting and analyzing large volumes of data from a database for the purpose of identifying hidden and sometimes subtle relationships or patterns and using those relationships to predict behaviors

Computer-assisted coding (CAC)

The process of extracting and translating dictated and then transcribed free-text data (or dictated and then computer-generated discrete data) into ICD-9-CM and CPT evaluation and management codes for billing and coding purposes

Risk analysis

The process of identifying possible security threats to the organization's data and identifying which risks should be proactively addressed and which risks are lower in priority; Also called risk assessment

Multidisciplinary care pathways

The process of integrating each healthcare professional's standards of care to provide better treatment for each patient

Data security

The process of keeping data, both in transit and at rest, safe from unauthorized access, alteration, or destruction

Ethical decision making

The process of requiring everyone to consider the perspectives of others, even when they do not agree with them

Systematic sampling

The process of selecting a sample of subjects for a study by drawing every nth unit on a list

Stratified random sampling

The process of selecting the same percentages of subjects for a study sample as they exist in the subgroups (strata) of the population

Version control

The process whereby a healthcare facility ensures that only the most current version of a patient's health record is available for viewing, updating, and so forth

Expressed consent

The spoken or written permission granted by a patient to a healthcare provider that allows the provider to perform medical or surgical services

Patient Protection and Affordable Care Act (PPACA)

The product of the healthcare reform agenda of the Democratic 111th Congress and the Obama administration. The act is designed at increasing the rate of health insurance coverage for Americans and reducing the overall costs of healthcare (Public Law 111-148 2010)

American Health Information Management Association (AHIMA)

The professional membership organization for managers of health record services and healthcare information systems as well as coding services; provides accreditation, advocacy, certification, and educational services

American Psychological Association (APA)

The professional organization that aims to advance psychology as a science and profession and promotes health, education, and human welfare (APA 2013)

Bed occupancy ratio

The proportion of beds occupied, defined as the ratio of inpatient service days to bed count days during a specified period of time

Adjusted hospital autopsy rate

The proportion of hospital autopsies performed following the deaths of patients whose bodies are available for autopsy

Death rate

The proportion of inpatient hospitalizations that end in death

American Recovery and Reinvestment Act of 2009 (ARRA)

The purposes of this act include the following: 1) To preserve and create jobs and promote economic recovery. (2) To assist those most impacted by the recession. (3) To provide investments needed to increase economic efficiency by spurring technological advances in science and health. (4) To invest in transportation, environmental protection, and other infrastructure that will provide long-term economic benefits. (5) To stabilize state and local government budgets, in order to minimize and avoid reductions in essential services and counterproductive state and local tax increases (ARRA 2009); Also called Recovery Act; Stimulus

Continuum of care

The range of healthcare services provided to patients, from routine ambulatory care to intensive acute care; the emphasis is on treating individual patients at the level of care required by their course of treatment with the assurance of communication between caregivers

Infection rate

The ratio of all infections to the number of discharges, including deaths

Anesthesia death rate

The ratio of deaths caused by anesthetic agents to the number of anesthesias administered during a specified period of time

Postoperative death rate

The ratio of deaths within 10 days after surgery to the total number of operations performed during a specified period of time

Net autopsy rate

The ratio of inpatient autopsies compared to inpatient deaths calculated by dividing the total number of inpatient autopsies performed by the hospital pathologist for a given time period by the total number of inpatient deaths minus unautopsied coroners' or medical examiners' cases for the same time period

Syntax

The rules and conventions that one needs to know or follow in order to validly record information, or interpret previously recorded information, for a specific purpose. Such rules and conventions may be either explicit or implicit (CMS 2013)

Data analytics

The science of examining raw data with the purpose of drawing conclusions about that information. It includes data mining, machine language, development of models, and statistical measurements. Analytics can be descriptive, predictive, or prescriptive

Net death rate

The total number of inpatient deaths minus the number of deaths that occurred less than 48 hours after admission for a given time period divided by the total number of inpatient discharges minus the number of deaths that occurred less than 48 hours after admission for the same time period

Inpatient bed occupancy rate

The total number of inpatient service days for a given time period divided by the total number of inpatient bed count days for the same time period; Also called percentage of occupancy

Personal/unique identifier

The unique name or numeric identifier that sets apart information for an individual person for research and administrative purposes

Customary, prevailing and reasonable (CPR) charge payment method

Type of retrospective fee-for-service payment method used by Medicare until 1992 to determine payment amounts for physician services, in which the third-party payer pays for fees that are customary, prevailing, and reasonable

Common ownership

Under HIPAA, Subpart A of this section, exists if an entity or entities possess an ownership or equity interest of five (5) percent or more in another entity (45 CFR 164.103 2009)

Acute-care hospital

Under HITECH specific to the Medicaid program, a health care facility (1) where the average length of patient stay is 25 days or fewer; and (2) with a CMS certification number (previously known as the Medicare provider number) that has the last four digits in the series 0001-0879 or 1300-1399 (42 CFR 495.302 2012)

Medicaid eligible hospital

Under HITECH specific to the Medicaid program, to be eligible for an EHR incentive payment for each year for which the eligible hospital seeks an EHR incentive payment, the eligible hospital must meet the following criteria: (1) An acute care hospital must have at least a 10 percent Medicaid patient volume for each year for which the hospital seeks an EHR incentive payment. (2) A children's hospital is exempt from meeting a patient volume threshold (42 CFR 495.304 2012)

Qualifying hospital

Under HITECH specific to the Medicare program, an eligible hospital that is a meaningful EHR user for the EHR reporting period applicable to a payment or payment adjustment year (42 CFR 495.100 2012)

EHR reporting period

Under HITECH, except with respect to payment adjustment years, refers to the initial continuous 90-day period within the calendar year an eligible hospital or provider demonstrates meaningful use of a certified EHR technology. Subsequent reporting years are full calendar years in which the provider demonstrates meaningful use of a certified EHR technology (42 CFR 495.4 2012)

Qualifying critical access hospital (CAH)

Under HITECH, specific to the Medicare program, a CAH that is a meaningful EHR user for the EHR reporting period applicable to a payment year or payment adjustment year in which a cost reporting period begins (42 CFR 495.100 2012)

Eligible hospital

Under HITECH, specific to the Medicare program, a hospital subject to the prospective payment system specified in 412.1(a)(1) of this chapter, excluding those hospitals specified in 412.23 and 412.25 (42 CFR 495.100 2012)

Eligible professional (EP)

Under HITECH, specific to the Medicare program, means a physician as defined in section 1861(r) of the Act, which includes, with certain limitations, all of the following types of professionals: 1) a doctor of medicine or osteopathy, (2) a doctor of dental surgery or medicine, (3) a doctor of podiatric medicine, (4) a doctor of optometry, (5) a chiropractor (45 CFR 495.100 2012)

Breach of security

Under HITECH, with respect to unsecured PHR, identifiable health information of an individual in a PHR, acquisition of such information without the authorization of the individual.

Excludes 1

Under ICD-10-CM, a type 1 Excludes note is a pure excludes note. It means "not coded here." An Excludes 1 note indicates that the code excluded should never be used at the same time as the code above the note (CDC 2013)

Reattachment

Under ICD-10-PCS, a root operation that involves putting back in or on all or a portion of a separated body part to its normal location or other suitable location (CMS 2013)

Replacement

Under ICD-10-PCS, a root operation that involves putting in or on biological or synthetic material that physically takes the place or function of all or a portion of a body part (CMS 2013)

Major diagnostic category (MDC)

Under diagnosis-related groups (DRGs), one of 25 categories based on single or multiple organ systems into which all diseases and disorders relating to that system are classified

Food and drug interactions

Unexpected conditions that result from the physiologic incompatibility of therapeutic drugs and food consumed by a patient

Statutory law

Written law established by federal and state legislatures; Also called legislative law