Term
|
Definition
| abstracting the correct diagnosis codes, procedural codes, and supply codes. |
|
|
Term
AAPC
(American Academy of Professional Coders) |
|
Definition
| A national membership organization that provides credentials, education, and coding information to medical coders in all settings. Their website is https://www.aapc.com. |
|
|
Term
| CAHIIM (Commission on Accreditation for Health Informatics and Information Management Education) |
|
Definition
| CAHIIM is the accrediting organization that oversees educational programs in higher education for health information management. |
|
|
Term
| HIM (Health Information Management) |
|
Definition
| The allied health profession that is responsible for the management of all health information for healthcare given to patients. This management includes accuracy, legality, privacy, timeliness, and availability |
|
|
Term
| HIT (Health Information Technology) |
|
Definition
| The technical aspect of Health Information Management. This includes coding, data quality, abstracting, registration, auditing, storage of information, and aligning with regulations and guidelines. |
|
|
Term
| TJC - The Joint Commission |
|
Definition
| A private, not-for-profit agency that evaluates hospitals and healthcare organizations based on pre-determined standards and criteria. If standards and criteria are met, the facility is granted Joint Commission accreditation. This is an indication that the facility is meeting high standards. |
|
|
Term
| CMS (Centers for Medicare and Medicaid Services) |
|
Definition
| A department that has oversight of healthcare policy in the U.S. It also has oversight of the federal Medicare program and the federal part of the Medicaid program. This is a part of the Department of Health and Human Services of the federal government. |
|
|
Term
| AMA (American Medical Association) |
|
Definition
| The national trade membership organization for physicians. This organization also assists in legislative matters for the medical profession. |
|
|
Term
| AHA (American Hospital Association) |
|
Definition
| The national trade membership organization that services individual healthcare providers and hospital healthcare organizations. |
|
|
Term
| AHIMA (American Health Information Management Association) |
|
Definition
| A national membership organization that provides credentials, education, and coding information for health information management, health information systems, the revenue cycle, and medical coders in all settings. They also focus on specialized and new areas of the Health Information field such as risk management, clinical documentation improvement, and quality analysis. AHIMA also provides Virtual Lab tools for accredited schools such as Rasmussen College. |
|
|
Term
| HIPAA - Health Insurance Portability and Accountability Act of 1996 |
|
Definition
| Legislation implemented by the federal government to oversee privacy, fraud, abuse, continuity of health care, reduce health care costs, preexisting medical conditions, and identity theft. There are many HIPAA guidelines, especially for privacy, that all HIM and HIT employees must abide by. |
|
|
Term
| RAC (Revenue Audit Contractor) |
|
Definition
| an outside contractor hired by Medicare to audit coded accounts of patients for improper coding or billing in the Medicare program. |
|
|
Term
|
Definition
| Care given to a patient on a limited basis as an inpatient in a hospital setting. |
|
|
Term
|
Definition
| A medical diagnosis that is present as well as the principle the patient's treatment and length of stay. An example is diabetes which must be managed carefully if the patient is admitted for a COPD Exacerbation and needs steroids. Steriods impact diabetes and therefore these must be managed. |
|
|
Term
|
Definition
| The disease or condition that was present on admission to an inpatient stay was deemed to be the reason for admission after study of the entire chart. |
|
|
Term
| A procedure performed in an inpatient stay for the treatment of a condition or complication. The main procedure performed and often tied to the Principal Diagnosis. |
|
Definition
|
|
Term
|
Definition
| List of diagnosis, injuries, or conditions found in a patient's chart that impact the health and treatment of the patient |
|
|
Term
|
Definition
| Specially designed software that helps the coding specialist assign diagnostic and procedure codes in accordance with the guidelines and rules of each coding system. |
|
|
Term
| MPI (Master Patient Index) |
|
Definition
| A database created to house the patient name and identifying information for each facility. Each facility is responsible for their own MPI of every patient who has ever been admitted and treated by the facility. |
|
|
Term
| ROI (Release of Information) |
|
Definition
| An aspect of health information management which allows for the legal release of patient information to another party or to the patient. |
|
|
Term
|
Definition
| Software or forms that contain itemized lists of cost of every service and supply a facility provides for their patients. One person is normally designated to keep the charge master information up to date and accurate. |
|
|
Term
| A payment made for a surgical procedure which includes all aspects of the surgery from diagnosis through post procedural care. One payment is made which includes all aspects of the care for the diagnosis. |
|
Definition
| Global Surgery Payment System |
|
|
Term
| Software that automatically takes the codes entered by the coding specialist and organizes them into the proper DRG based on the principal diagnosis, the secondary diagnosis, the additional diagnosis, and the procedures. |
|
Definition
|
|
Term
| DRG (Diagnosis Related Group) |
|
Definition
| A formula created by the federal government (CMS) and adopted by other payers as a way to determine payment for an inpatient stay. Related diagnosis are grouped together because management and treatment would be similar or interrelated and tend to incur similar cost and length of stay. Each diagnostic related group is assigned a number which factors into the formula which determines the cost of the inpatient stay. |
|
|
Term
| Clinical Terms. This system creates standardized terminology of patient information. |
|
Definition
SNOMED - CT - Systemized Nomenclature of Medicine Clinical Terminology
Specialized coding systems used in addition to the three main coding systems of ICD 10 - CM, ICD 10 PCS, and CPT
|
|
|
Term
|
Definition
| also called National Codes and are maintained by CMS. These codes (not Level I CPT codes) are used to charge for medical services, equipment, and supplies. |
|
|
