Electronic Health Record

ICD-10-CM Tabular List

21 chapters For some chapters, the body or organ system is the axis Other chapters group together conditions by etiology or nature of the disease process ICD-10-CM contains chapters for External Causes of Morbidity Previously known as E codes in ICD-9-CM Factors Influencing Health Status and Contact with Health Services Previously known as V codes in ICD-9-CM

Superbill

A bill, submitted to the insurance company, that reflects the services provided to the patient

hybrid record

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

Credentials Committee

A committee that reviews qualifications of clinicians for admitting privileges.

Master Patient Index (MPI)

A list or database created and maintained by a healthcare facility to record the name and identification number of every patient who has ever been admitted or treated in the facility

medication reconciliation

A procedure to maintain an accurate and up-to-date list of medications for all patients between all phases of health care delivery.

Server

A server is a main computer designed to provide services to a client, workstation, or desktop computers over a local area network or the Internet. Many network software programs have a server component and workstation component.

ICD-10

A system to classify and code diagnoses, symptoms, and procedures

Z codes

Abbreviation for ICD-10-CM codes that identify factors that influence health status and encounters that are not due to illness or injury. Chapter 21 contains Z codes that are used to report encounters for circumstances other than a disease or injury, such as factors influencing health status, and to describe the nature of a patient's contact with health services. There are two main types: (1) reporting visits with healthy (or ill) patients who receive services other than treatments, such as annual checkups, immunizations, and normal childbirth. This use is coded by a Z code that identifies the service, such as Z00.01 Encounter for general adult medical examination with abnormal findings; and (2) Reporting encounters in which a problem not currently affecting the patient's health status needs to be noted, such as personal and family history. For example, a person with a family history of breast cancer is at higher risk for the disease, and a Z code is assigned as an additional code for screening codes to explain the need for a test or procedure such as Z80.3 Family history of malignant neoplasm of breast. Use Z codes to show medical necessity. Z codes such as family history or a patient's previous condition help demonstrate why a service was medically necessary. A Z code can be used as EITHER a primary code for an encounter or as an additional code. It is researched in the same way as other codes, using the Alphabetic Index to point to the term's code and the Tabular List to verify it. The terms that indicate the need for Z codes, are NOT the same as other medical terms. They usually have to do with a reason for an encounter other than a disease or its complications. When found in diagnostic statements the words "contact/exposure," "contraception," "counseling," "examination," "fitting of," "follow-up," "history (of)," "screening/test," "status," "supervision (of)," or "vaccination/inoculation" often point to Z codes.

interoperability

Ability of a software program to accept, send and communicate data from its database to and from multiple vendors' software programs

Computerized provider order entry (CPOE)

Allows providers to order prescription medication, including IV therapies, laboratory tests, imaging studies, rehabilitation services, dietary requirements in the inpatient environment.

Personal Health Record (PHR)

Allows the patient access via the internet to the medical office's website to store and update personal medical information. it allows patients to make inquires of the healthcare provider regarding prescription, appointments and other concerns

Premium

Amount you pay monthly, quarterly, semiannually or annually to purchase different types of insurance

Application server provider (ASP)

An ASP enables access to an EHR via the Internet; the EHR software and database are housed and maintained by a separate company in a remote location.

electronic health record (EHR)

An EHR system is a computerized, organized collection of individual patients' healthcare information in a digital format.

Intranet

An intranet is a privately maintained computer network that provides secure accessibility to authorized people and enables sharing of software, databases and files.

Indented codes

Are listed under associated stand-alone codes

X Codes

Are smoke, fire, flames, heat, accidental exposure. Intentional harm, and assault.

Primary insurance

Because long term healthcare can be expensive, individuals and families have the option to purchase health insurance that covers a portion of the incurred medical expense. Typically, a patient will pay a monthly premium for the medical insurance policy from an insurance company which is known as the primary insurance carrier.

Consolidated Health Informatics (CHI)

CHI is a federal government initiative that promotes the adoption of health information interoperability standards for health vocabulary and messaging.

Computer on wheels (COW)/workstation on wheels (WOW)

COW or WOW is a computer placed on a mobile desk or stand so it can be moved around an office, unit, or patient room.

Stand alone code

CPT code that includes a complete description of the procedure or service.

Current Procedural Terminology (CPT) codes

CPT codes are five-digit codes the AMA developed and insurance carriers and managed care companies adopted as the means for identifying common medical procedures.

CPT Appendices

CPT contains appendices located between the Medicine section and the index. Insurance specialists should carefully review these appendices to become familiar with coding changes that affect the practices annually:

Incomplete charts

Charts that are missing signatures, reports, or other required elements as outlined in either CMS Conditions for Participation for Medical Record Services or the Joint Commission accreditation guidelines for information management.

American Recovery and Reinvestment Act (ARRA)

Commonly referred to as the stimulus package or the Recovery Act, this legislation was intended to create jobs and promote investment and consumer spending during the recession in the last half of this century's first decade

discharge summary

Comprehensive outline of patient's entire hospital stay; includes condition at time of admission, admitting diagnosis, test results, treatments and patient's response, final diagnosis, and follow-up plans

continuity of care

Continuation of care smoothly from one provider to another, so that the patient receives the most benefit and no interruption in care.

CPT-4

Current Procedural Terminology, fourth edition

redundant data

Data in a database which is needlessly duplicated.

Demographics

Demographics are the statistical data of a person or population. They are typically comprised of address, phone numbers, gender, age, marital status, employment, and education. However, demographics can be very broad to include disabilities, mobility, home ownership, income, and personal preferences.

Medicare Improvement for Patients and Providers Act of 2008 (MIPPA)

Enacted by congress in 2008, this 275-page piece of legislation blocked scheduled cuts in Medicare's payments to physicians and increased benefits to low-income beneficiaries and other vulnerable area population.

Benefits of the EHR

Enhanced accessibility to clinical information, improved patient safety, enhance quality of patient care, greater efficiency and saving.

6 sections of CPT

Evaluation, Anesthesia, Surgery, Radiology, Medicine & Pathology & Laboratory.

National Committee on Vital and Health Statistics (NCVHS)

Formed in 1949 and restructured following the passage of HIPAA, the NCVHS is an advocate for uniform health data sets, particularly for underrepresented populations. This advisory committee has responsibility for providing recommendations on health information policy and standards to the Department of Health and Human Services (HHS).

Centers for Medicare & Medicaid Services (CMS)

Formerly known as the Health Care Financing Administration(HCFA), this federal agency is responsible for administering Medicare, Medicaid, the Health Insurance Portability and Accountability Act (HIPAA), and other health related programs.

ICD-10-CM Official Guidelines for Coding and Reporting

General rules, inpatient (hospital) coding guidance, and outpatient (physician office/clinic) coding guidance from the four cooperating parties (CMS advisers and participants from the AHA, AHIMA, and NCHS).

2010-EHR Certification program, major financial incentives

Government mandates and funding spurred the standardization of features in the electronic records industry

Healthcare Common Procedure Coding System (HCPCS) codes

HCPCS codes are used by HHS's Centers for Medicare & Medicaid Services (CMS) to identify medical supplies such as durable medical equipment and medical procedures. The coding of supplies ensures uniformity for billing and financial reimbursement.

Health Information Exchange (HIE)

HIE is the transmission of healthcare information electronically across organizations within a region, community or hospital system.

HIPPA

Health Insurance Portability and Accountability Act of 1996

Continuity of Care Document (CCD) Continuity of Care Records (CCR)

Healthcare provider-oriented record comprising a core set of data considered to be the most relevant summary of a patient's medical healthcare.

International Classification of Diseases (ICD) codes

ICD codes are the international standard diagnostic classification for all medical data concerning the incidence and prevalence of disease in large populations and for other health management purposes.

What is HITECH?

In 2009, Congress amended HIPAA by passing the Health Information Technology for Economic and Clinical Health (HITECH) Act. This law updated many of HIPAA's privacy and security requirements and was implemented through the HIPAA Omnibus Rule in 2013.

Facility-Based Model

In the United States, healthcare facilities are largely privately owned and operated, rather than controlled by a centralized government agency. Therefore the focus has primarily been on the need to support a national health information infrastructure and establish benchmarks for data transfer and compatibility between multiple EHR programs.

Health Information Technology for Economic and Clinical Health (HITECH) Act

It was initiated by Congress to stimulate and increase the use of electronic health records by independent physician and hospital over a five-year period.

Office of the National Coordinator for Health Information Technology (ONC)

Its purpose is to serve as a resource for the entire health system, support the adoption of HIT, and promote a nationwide health information exchange.

Barriers to the EHR

Lack of standards, unknown costs and return on investment, difficulties operating EHR systems, significant changes in clinical/clerical processes, lack of trust and safety

Tabular List

Numerical Listing of diseases and injuries

legacy system

Older information systems that are often incompatible with other systems, technologies, and ways of conducting business. Incompatible legacy systems can be a major roadblock to turning data into information, and they can inhibit firm agility, holding back operational and strategic initiatives.

Medicare Part A

Part of the federally funded Medicare insurance program that covers hospitals, skilled nursing facilities, home health agencies and other non-ambulatory services.

Medicare Part B

Part of the federally funded Medicare insurance program that covers medical providers' supervision, outpatient hospital care, diagnostic tests, ambulance services, and other ambulatory services.

Health Insurance Portability and Accountability Act (HIPAA)

Passed by Congress in 1996, this legal act enforces standards for electronic patient health, administrative, and financial data.

New Patient

Patient who has not been seen by the primary physician or other health professional with the same specialty in the same practice within the last three years

CPT Appendix A

Provides a complete list of modifiers and their descriptions. Modifiers are written as two-digit codes that follow the main CPT codes.

Protected health information (PHI)

Regulated under HIPAA, PHI includes any information (past, present, or future) about health status, provision of healthcare (including mental health), and payment for healthcare that can be linked to a specific individual.

Secondary insurance

Secondary health insurance is an insurance policy that pays for some of the patient's medical expenses that primary health insurance does not pay, for example, the deductible and co-payments.

Deductible

Specified amount of money that the insured must pay for covered medical expenses before the insurance policy begins to pay; usually annual amount per individual or family

Conditions of Participation

Standards developed by the Department of Health and Human Services (DHHS) that a facility must comply with in order to participate in the Medicare and Medicaid programs.

Structured data

Structured data is information organized in a format so it is identifiable, storable, retrievable, and analyzable in a computer system. Conversely, unstructured data is unidentifiable and not stored in a database (e.g., free text).

CPT Appendix B

Summary of Additions, Deletions, and Revisions

SNOMED-CT

Systematized Nomenclature of Medicine Clinical Terminology

Electronic Medical Record (EMR)

Term for medical software that lacks a full range of higher-end functionalities to store, access, and use patient medical information. EMRs are not interoperable

Certification Commission for Health Information Technology (CCHIT)

The Certification Commission's mission was to accelerate the adoption of health information technology by creating an efficient, credible, and sustainable product certification program.

E-prescribing

The use of computerized tools usually embedded in an EHR program, to create and sign prescriptions for medicines, thereby replacing handwritten prescriptions. Electronic are sent to pharmacies over the internet via a clearinghouse.

Telehealth services

These services use electronic and communication technology to deliver medical information and services over large and small distances through a standard telephone line.

Institute of Medicine (IOM)

This independent, nonprofit organization works outside the government to provide unbiased and authoritative medical advice to decision makers and the public.

Template

This is an electronic document predesigned with a set format and structure. It serves as a model for a letter, fax, report, or note that a user then completes with patient-specific information.

Return on investment (ROI)

This measures expressed as a percentage is the amount earned from a company's total purchase or investment, calculated by dividing the total capital into earnings or financial benefits.

End-to-end solution

This software industry term suggests the vendor of an application program can provide all the hardware and software components to meet the client's requirement and that no other supplier need be involved.

Encrypting

To be transmitted securely, computer data are changed from their original form, making the data unintelligible to unauthorized parties, and then decrypted back into their original form for use by the receiving entity.

Eligible professional (EP)

To participate in the HITECH Act incentive program for meaningful use (MU) on an ONC-certified EHR program, an EP qualifying under Medicare must be a doctor of either medicine, osteopathy, dental surgery, dental medicine, podiatry, optometry, or chiropractic. Individuals qualifying under the Medicaid program must be a doctor of medicine or osteopathy, nurse practitioner, certified nurse-midwife, dentist, or qualifying physician assistant.

National Provider Identifier (NPI)

Unique 10-digit code for providers required by HIPAA.

Distribution-Based Model

Universal healthcare is the concept of a government-organized healthcare system.HealthConnect was a healthcare management strategy initiated by the Australian government

procedure code

a code assigned to a particular medical service or procedure

Drug formulary

a database of approved medications in drug therapy categories that includes information on the medications' preparation, safety, effectiveness, and cost.

computer-based patient record (CPR)

a lifetime patient record that includes all information from all specialities, including dentistry and psychiatry. the record is available to all providers nationally and potentially internationally

established patient

a patient who has been seen by a provider in the practice in the same specialty within three years

HIPPA compliance

a plan set in place at the facility that tells how the facility will safeguard pt. info and privacy. *all new employees must sig they have beed trained in this area.

modifier

a two-digit character that is appended to a CPT code to report special circumstances involved with a procedure or service

Joint Commission

an independent, not-for-profit organization that evaluates and accredits healthcare organizations

Health Level Seven (HL7)

an international computer language by which various healthcare systems can communicate. HL7 is currently the selected standard for interfacing clinical data between software programs in most institutions.

Regional Extension Centers (RECs)

currently assist primary healthcare clinicians in becoming proficient and meaningful EHR users

HCPCS codes

descriptive terms with letters or numbers or both used to report medical services and procedures for reimbursement. Provides a uniform language to describe medical, surgical, and diagnostic services. HCPCS codes are used to report procedures and services to government and private health insurance programs, and reimbursement is based on the codes reported

encounter form

financial record source document used by providers and other personnel to record treated diagnoses and services rendered to the patient during the current encounter

Health Information Technology Regional Extension Centers (HITRC)

gathers information on effective practices in EHR adoption, meaningful use and provider support for 62 REC's across the country.

Mid-1990s

governmental insurance agencies such as Medicare and Medicaid offered medical providers financial incentives to implement electronic PMS programs and levied penalities on them for noncompliance.

Meaningful use (MU)

healthcare providers' use of certified EHR technology in ways that can be measured significantly in quality (e.g., e-prescribing) and in quantity (e.g., set percentage of patients). By demonstrating MU with an ONC-certified EHR program, providers then can receive stimulus money, as set up through the HITECH Act of 2009

inpatient

inpatient is a person who is admitted to the hospital and stays overnight or for an indeterminate amount of time, usually several days or weeks.

Best Practice Guidelines

methods that have consistently shown superior results and are used as a benchmark or standard until improvement are discovered or developed

History and Physical (H&P)

must be completed within 24 hours after admission and no more than 30 days before, if within 30 days it should include an updated entry reflecting any changes, also called interval history, H&P should be completed before any procedure even if less than 24 hours after admission

Alphabetic Index

one of 2 ways diagnoses are listed in the ICD-10. They appear in alphabetical order with their corresponding diagnosis code

patient portals

online applications that are designed to allow patients access to storage of some of their medical records and allow communication with their healthcare providers across the internet.

outpatient

outpatient is a person who is not hospitalized for 24 hours or more but may visit a hospital, a medical clinic, or other healthcare facility for diagnosis or treatment.

Copayment (copay)

provision in an insurance policy that requires the policyholder or patient to pay a specified dollar amount to a health care provider for each visit or medical service received

In the CPT-4 Index, what will you find indented underneath main terms?

subterms

Computerized provider order entry (CPOE)

the process of communicating a clinician's instructions for patient treatment over a computer network to departments within a hospital or testing facilities outside the patient setting.

Point of Care

the time and place the healthcare provider gives the patient medical care.

meaningful use

the use of certified electronic health record technology to achieve health and efficiency goals, with a financial incentive from Medicare and Medicaid

practice management systems (PMSs).

this type of software program manages, among other things, financial transactions, both charges and payments, and the billing of insurance claims and patient statements.