Medical Billing, Coding, and Insurance Chapter 2
List four code sets used for encoding data elements...
1. Codes for diseases, injuries, impairments, and other health-related problems. 2. Codes for procedures or other actions taken to prevent, diagnose, treat, or manage diseases, injuries, and impairments. 3. Codes for dental services. 4. Codes for other medical services.
List exceptions to the usual release of information rules...
1. Court orders 2. Workers' compensation cases 3. Statutory reports 4. Research 5. Self-pay requests for restrictions
List 8 advantages of EHRs over paper records...
1. Immediate access to health information. 2. Computerized physician order management. 3. Clinical decision support. 4. Automated alerts and reminders. 5. Electronic communication and connectivity. 6. Patient support. 7. Administration and reporting. 8. Error reduction.
What is the basic information documented in a patient encounter?
1. Patient's name. 2. Encounter date and reason. 3. Appropriate history and physical examination. 4. Review of all tests that were ordered. 5. Diagnosis. 6. Plan of care, or notes on procedures or treatments that were given. 7. Instructions or recommendations that were given to the patient. 8. Signature of the provider who saw the patient.
What is HIPAA designed to do?
1. Protect people's private health information. 2. Ensure health insurance coverage for workers and their families when they change or lose their jobs. 3. Uncover fraud and abuse. 4Create standards for electronic transmission of healthcare transactions.
List the four types of information in a complete history and physical...
1. The chief complaint. 2. The history and physical examination. 3. The diagnosis. 4. The treatment plan.
Clearinghouse
Clearinghouses are companies that convert nonstandard transactions into standard transactions and transmits the data to health plans, and the reverse procedure.
What is the difference between an EHR and a PHR?
An EHR is a computerized record of one physician's encounters with a patient over time that are the physician's legal record of patient care. PHR's are private, secure electronic files that are created, maintained, and controlled by patients and contain data such as their current medications, health insurance information, allergies, medical test results, family medical history, and more.
Why is "backing up" important?
Backing up is critical in recovering from either a minor or major security incident that jeopardizes critical data.
Business Associates
Business associates are organizations that work for covered entities but are not themselves covered entities.
What is EIN and the format for EIN?
EIN is Employer Identification Number (tax id number) and is issued by the IRS as a HIPAA standard. The employer identifier is used when employers enroll or disenroll employees in a health plan (X12 834) or make payments to plans on behalf of their employees (X12 820).
Electronic Data Interchange
Electronic data interchange is system to system exchange of data in a standardized format.
Explain the difference between fraud and abuse...
Fraud is an intentional act of deception used to take advantage of another person. Fraudulent acts are intentional; the individual expects an illegal or unauthorized benefit to result. Abuse is an action that improperly uses another's resources. Abuse is not necessarily intentional.
List the three types of covered entities that must follow HIPAA and HITECH regulations...
Health plans, healthcare clearinghouses, and healthcare providers.
Who are covered entities? Who are not?
Healthcare organizations that are required by law to obey HIPAA regulations are called covered entities. A covered entity is an organization that electronically transmits any information that is protected under HIPAA.
Explain the term medical professional liability...
Healthcare providers are legally responsible for providing a certain level of care.
If a state statute is more stringent than a HIPAA rule, which is followed?
The tougher rules are implemented.
What is the difference between "use of PHI" and "disclosure of PHI"?
Use of PHI means sharing or analysis within the entity that holds the information. Disclosure of PHI means the release, transfer, provision of access to, or divulging of PHI outside the entity holding the information.
What must a covered entity do when a breach occurs?
A covered entity must notify affected individuals following the discovery of a breach of unsecured health information.
What is a medical record? What does it contain?
A medical record is a file containing the documentation of a patient's medical history and related information. Medical records contain documentation of patient's conditions, treatments, and tests that are created and shared by physicians and other providers to help make accurate diagnoses and to trace the course of care.
A medical record must document what four things about services?
A patient's health history, examinations, tests, and results of treatments.
Transaction
A transaction is the electronic exchange of healthcare information.
What is E&M?
Evaluation and Management is the provider's evaluation of a patient's condition and decision on a course of treatment to manage it.
What do the abbreviations HPI, PMH, and ROS stand for?
HPI- history of the present illness PMH- past medical history ROS- review of systems (the provider asks questions about the function of each body system considered appropriate to the problem)
What is a health information exchange and an example of HIE?
Health information exchange enables the sharing of health-related information among provider organizations according to nationally recognized standards. Examples of the use of an HIE include sharing patient records with physicians outside the physician's own medical group, transmitting prescriptions to pharmacies, and ordering tests from an outside lab.
What is informed consent?
Informed consent is the process by which a patient authorizes medical treatment after a discussion with a physician.
Meaningful use
Meaningful use is the utilization of certified EHR technology to improve quality, efficiency, and patient safety.
What are medical standards of care?
Medical standards of care are state-specified performance measures for the delivery of healthcare.
What is NPI and the format?
NPI stands for National Provider Identifier and is a unique ten-digit identifier assigned to each provider.
What is a notice of privacy practice?
Notice of Privacy Practices (NPP) is a description of a covered entity's principles and procedures related to the protection of patient's health information.
Who is the OIG? What is this group's main responsibility?
OIG (Office of the Inspector General) is a government agency that investigates and prosecutes fraud. This group is responsible for detecting healthcare fraud and abuse and enforcing all laws relating to them.
What does a patient authorization do?
Patient authorization allows the covered entity to release medical information.
The information contained in the patient's medical record belongs to:
Patient's medical records-the actual progress notes, reports, and other clinical materials are legal documents that belong to the provider who created them. But the provider cannot withhold the information in the records unless providing it would be detrimental to the patient's health. The information belongs to the patient.
Protected Health Information
Protected health information is individually identifiable health information transmitted or maintained by electronic media.
What does SOAP format stand for?
Subjective information from the patient, and three elements the provider enters: Objective data such as examination and/or test results Assessment of the patient's diagnosis, and Plan, the intended course of treatment, such as surgery or medication.
The main federal government agency responsible for health care is...
The Centers for Medicare and Medicaid Services
What did the NPI replace?
The NPI has replaced other identifying numbers that had been used, such as the UPIN for Medicare and the numbers that have been assigned by each payer to the provider.
What are minimum necessary standards?
The minimum necessary standard means taking reasonable safeguards to protect PHI from incidental disclosure.
Why do medical practices want to develop compliance plans?
To prevent fraud and abuse and the liability that comes with it.