ICPC-2

International Classification of Primary Care

Developed by WHO

is a classification method for primary care encounter

accession number

10-0001 (10 is the year 2010)

This number consists of the first digits of the year the patient was first seen at the facility, and the remaining digits are assigned sequentially throughout the year.

What type of care is not coveted under Medicare?

Medicare Part A & B

not covered the following services.

1. long term nursing care

2. custodial care

3. Dentures & dental care

4. eyeglasses

5. hearing aids

is the supervision of all administrative and clinical functions that contribute to the capture, management, and collection of patient service revenue.

revenue cycle management

What is "Dollars in Account Receivable"?

Money owed a healthcare facility when claims are pending

is the amount of money owed a healthcare facility after the claim has been submitted.

Revenue cycle has 4 parts what are they?

1. preclaim submission

2. claims processing

3. account receivable

4. claims/ reconciliation/ collections

Requires that the attributes and values of data be defined at the correct level of detail for the intended use of the data.

data granularity

What does it mean Medicare participation (provider) ?

provider or supplier agrees to accept assignment for all covered services provided to Medicare patient. Patient cannot be held responsible for charges in excess of the medicare fee schedule.

is a standards development organization accredited by the American National Standards Institute that addresses issues at the 7th, or application, level of healthcare systems interconnections. IT develops messaging, data content, and document standards to support the exchange of clinical info.

messagsing standards for electronic data interchange in healthcare

HL7

Daily Inpatient Census

Official count taken @ midnight is daily inpatient census.

This is the # of patients present @ the official census taking each day. Also included in the daily inpatient census are any patients who were admitted & discharged the same day.

Data set serves two purposes?

1. Identify the data elements that should be collected for each patient

2. provide uniform definitions for common terms

(the use of uniform definitions ensures that data collection from a variety of healthcare setting will share a standard definition)

ASTM

American Society Testing and Material

in designing an electronic health record, one of the best resources to use in helping to define the content of the record as well as to standardize data definitions are standards promulgated by ASTM.

The American Society for testing and Materials is an SDO (standard development organization) that develops standards for a variety of industries in the United states..

They are in charge of of developing standards related to the ehr

POMR

Problem Oriented Medical Record

the health record is better suited to serve the patient and the end user of the patient information. The key characteristic of this format is an itemized list of the patient's past and present social, psychological and health problems . Each problem is indexed with a unique number.

RAC

Recovery Audit Contractors JAN 2010 IMPLEMENTED IN THE UNITED STATES

This is a program that mandated to find and correct improper Medicare payments paid to healthcare providers collection of overpayments participating in the medicare reimbursement program

Collection of overpayments from providers

OIG

Office of Inspector General

QIO

Quality Improvement Organization

Give me an example of primary data source?

Hospital Census

Involves checking for the presence or absence of necessary reports and or signatures.

The HIM professionals review or analyze it to make sure that there are no missing reports, forms or required signatures and that all documents contain the patient's name and health record number.

Quantitative Analysis

These are financial protections to ensure that certain type s of facilities (eg., children's hospitlas) recoup all of their losses due to the differences in the APC PAYMENTS and the pre-APC payments.

Hold Harmless

What is LCDs and NCDs?

Local Coverage Determinations and National Coverage Determinations

are review policies that describe the circumstances of coverage for various types of medical treatment. They advise physicians which services Medicare considers reasonable and necessary and may indicate the need for an advance beneficiary notice. They are developed by the Centers for Medicare and Medicaid Services (CMS) and Medicare Administrative Contractors (MAC).

What is a DNFB?

Discharged not final billed or it can be called accounts not selected for billing reports

The accounts not selected for billing report is a daily report used to track the many reasons that accounts may not be ready for billing. This report is also called the discharged not final billed (DNFB) report. Accounts that have not met all facility specified criteria for billing are held and reported on this daily tracking list.

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

example to monitor timely claims processing in a hospital a summary report of "patient receivables" is generated frequently. Aged receivables can negatively affect a facility's cash flow, therefore to maintain the facility's fiscal integrity, the HIM manager must routinely analyze this report.

What is a NPI?

National Provider Identifier (NPI)

This is a 10 digit, intelligence free, numeric identifier designed to replace all prvious provider legacy numbers. This number identifies the physician universally to all payers. This number is issued to all HIPAA covered entities. It is mandatory on the CMS-1500 and UB-04 claim forms.

What is ABN?

Advance Beneficiary Notice

A statement signed by the patient when he or she is notified by the provider, prior to a service or procedure being done, that Medicare may not reimburse the provider for the service, wherein the patient indicates that he will be responsible for any charges.

HCPCS/CPT codes that appear in the hospital's chargemaster and will be included automatically on the patient's bill.

is the process of assigning a CPT/HCPCS code to a service so that the code will be automatically posted to the patient’s account via order entry.

What is "Hard Coding"

Which is mandated to find and correct improper Medicare payments paid to healthcare providers participating in the Medicare Reimbursement program.

Recovering Audit Contractor RAC

What are the four main components of "Storage and Retrieval of Medical Records"

1. Average of 50 records will be filed in an hour

2. records for the emergency dept. will be retrieved within 10 mins of request

3. Loose materials will be filed in either the record or the outguide pocket within 24 hours. of receipt in the HIM DEPT.

4. Scanned records will be avail. 24 hours of discharged.

Medical coders are on the floor of a hospital and have access to primary care provider. Medical coders shadow the patient for the duration of hospital stay, maintaining real record time.

Concurrent Coding

put food, liquids, and meds directly into the stomach

Percutaneous Endoscopic Gastrostomy (PEG)

Codes that serve as product identifiers for human drugs, currently limited to prescription drugs and a few selected over the counter products.

National Drug Codes (NDC)

group together similar diseases and procedures

What is a classification systems?

have been developed to create a list of clinical words or phrases with their meanings

Clinical Vocabularies

is a recognized system that lists preferred medical terminology.

nomenclature

What kind of index list the diagnosis code numbers?

disease index

arranged in numerical order by the patient's PROCEDURE codes CPT

Operation Index

Physican Index

Physician name or Physician Identification number

When does most facility begin counting days in account receivable at which of the following times?

Account receivable -> managed owed to facility by patient -> Payment made @ a later date by patient or third party -> claims submitted to 3rd party ins. co. -> The account receivable clock begins to tick "the date the bill drops"

What is CPOE?

Computerized Provider Order Entry System

What is Quantitative Analysis?

involves checking for the presence or absence of necessary reports and/ or signatures.

What is a Payment Status Indicators?

That are assigned to each HCPCS code and APCs play an important role in determining payment for services under the OPPS. They indicate whether a service represented by an HCPCS code is payable under the OPPS.

What is a Qualitative Analysis?

May involve checking documentation consistency, such as comparing a patients pharmacy drug profile w/medication administration record.

What is SOAP?

Subjective Objective Assessment and Plan

What is DEEDS

Data Elements for Emergency Department Systems.

Patient id data, facility and practitioner id data, payment data, arrival and first assessment data, H&P EXAM, procedure and result data, medication data and disposition and diagnosis data

What is OASIS

Outcome and Assessment Information Set (Home Health)

clinical record items, demographics & patient history, living arrangements, sensory status, integument status, respiratory status, elimination status, neuro/emotional/behavior status, ADLs, medication and equipment management

consists of data elements that represent core items for the comprehensive assessment of an adult home care patient and form the assessment for measuring patient outcomes for the purpose of outcome based quality improvement

What is UHDDS

Uniform Hospital Discharge Data Set (Acute Care )

Acute care setting

collects data on personal identification

date of birth, sex, race & ethnicity, residence (address, zip code), hospital identification, admission date, type of admission discharge date, attending physician identity, operating physician identy, and principal daignosis

What is ONC

Office of the National Coordinator of Health Information Technology

R-ADT system

Registration- Admission, Discharge, Transfer, System

What is EDMS

Electronic Data Management System

What is ARRA?

American Recovery and Reinvestment Act was signed into Law in 2009 which included significant funding for HIT

How many years does the Food and Drug Administration require research records pertaining to cancer patients be maintained?

30 years

What is ORYX?

By the Joint Commission

5 core measures are implemented to improve safety and quality of health care

What is magnetic Deguussing?

Erase a Hard Drive or Tape by degussing with magnet.

What is Accession Register

is a permanent log of all the cases entered into the database. Each number assigned is preceded by the accession year. Making it easy to access annual work loads.

A final progress note may substitute for a discharge summary in the following cases?

1. patients who are hospitalized less than 48 hours. w/problems of a minor nature

2. normal newborns

3. uncomplicated obstetrical deliveries

Information on Healthcare fraud and abuse was mandated by HIPAA & resulted in the development of?

Healthcare Integrity & Protection Data Bank

HIPDB

The number of SNF days provided under Medicare is limited to, how many days?

100 days

1-20 days benefit period

21-100 co payment $144.50

After 100 days Medicare benefits expires

What is MEDPAR?

MEDPAR (Medicare Provider Analysis & Review)

File is made up of acute care Hospital & SNF claims data for all medicare claims.

MEDPAR

1. Demographic Data on Patient

2. Data on the provider

3. Info on Medicare coverage

4. Total charges

5. MS-DRG

6. ICD-PC

7. Charges are broken down

8. PHarm charges, operating room, Physical therapy

Middle Digit Filing System

Ex. 44-37-98

* The primary unit is the middle unit (37)

44-37-98

44-secondary, 37- primary, 98- tertiary

37-file section

44- shelf #

98- Folder #

CMS requires that you maintain the patients records for?

10 yrs.

Medicare's COP condition of participant for hospitals requires that patient health records be retain at least?

The Conditions of Participation are published in the?

CMS publishes both proposed and final rules for who?

5 yrs.

Federal Register

for the Conditions of Participation for hospitals

Terminal Digit Filing System

44-37-98

98- primary unit file section

37- secondary unit shelf #

44- tertiary unit folder #

there are 100 primary #

Unit Numbering Sytem

The patient receives a unique health record number @ the time of the first encounter.

For all subsequent encounters for a particular patient, the health record # that was assigned for the first encounter is used

Unless State or Federal Laws, require longer time periods, AHIMA recommends that patient health information for minors be retained for how long?

Age of Majority plus Statute of Limitation

Health Records have two type of data?

1. clinical- patients health condition, diagnosis, procedures

2. Administrative- Demographic, financial info, consent & authorization

What is a Case Finding

is a method used to identify the patients who have been seen or treated in the facility for the particular disease or conditions of interest to the registry.

example is reviewing of disease indexes, pathology reports, and radiation therapy reports are part of this.

What is the BBA

BBA (Balance Budget Act 1997)

Healthcare fraud & abuse issues, especially as they related to penalties. The circumstances under which civil penalties are applied were based on the BBA.

What is SNOMED?

SNOMED (Systematized Nomenclature of Human and Veterinary Medicine International)

Mapping clinical concepts with standard descriptive terms.

SNOMED CT- is a codingsystem, controlled vocabulary, classifications system, clinical reference terminology and the thesaurus

SNOMED CT core terminology offers a consistent language for capturing, sharing and aggregating health data across specialties and sites of care.

What are the 4 primary elements that should be calculated and tracked to access clinical documentation improvement (CDI) progam?

1. record review rate

2. query rate

3. query response rate

4. query agreement rate.

Medicare Part A coverage is measured in "benefit periods"

Inpatient hospital care is usually limited to 90 days during each benefit period. Benefit period begins on the day of admission and ends when the beneficiary has been out of hte hospital for 60 days in a row, including the da of discharge.

What type of billing form used in a physician office?

What type of billing form used in a hospital

screen 837P/ cms 1500 form

Cms-1450 (UB-04)

what is UACDS?

Uniform Ambulatory Care Data Set

Focus on outpatient data collection "reason for encounter"

The reason for keeping the same demographic data elements is to make it easier to compare data for inpatients and ambulatory patients in the same facility as well as among different facilities

Data Comprehensiveness

refers specifically to the presence of all required data elements!

Data collection for transplant registries

1. demographic data

2. patient's diagnosis

3. patient's status codes regarding medical urgency

4 patients functional status

5. previous transplantation

6 histocompatibiity of donor and recipients tissues.

The health insurance portability and accountability act (HIPPA) requires the rentention of health insurance claims and accounting records for a minimum of _______ years, unless state law specifies a longer period

6yrs.

HEDIS

Healthcare Effectiveness Data Information Set

is sponsored by National Committee for Quality Assurance (NCQA)

is a set of standard performance measures designed to provide healthcare purchasers & consumers with the information they need to compare the performance of managed healthcare plan.

measure of access (at least one visit ot a provider within 3 years

measures of quality (cholesterol screenings)

measures of member satisfaction (cost per month)

the data set designed to organize data for public release about the outcomes of care

OPPS

Outpatient Prospective Payment System

The federal gov. pays for hospital outpatient services on a rate-per service according to APC.

HCPCS identifies and group the services within each APC

surgical procedures, radiology including radiation therapy, clinic visits (E/M), ER visits, partial hospitalization, chemotherapy, preventive services & screening exam, dialysis, vaccines, splints, certain implantable items

SOAP

S= subjective, which records what the patient states is the problem

O= Objective, which records what the practitioner identifies through the history, physical exam and diagnostic test

A= assessment, which combines the subjective and objective into a conclusion

P= Plan, or waht approach is going to be taken to resolve the problem

What are the type of hospitals are excluded from the Medicare Inpatient Prospective Payment System?

1. psychiartri & rehabilitation hospital

2. long term care hospital 25 days or more

3. chidren's hospital

4. cancer hospital

5. critical access hospital

6. religious non medical healthcare institution

true or false?

hospital census is it a primary data source

true

HOME HEALTH CARE

a summary should be provided for the attending physician at least every _______days.

60 days

Data comprehensiveness

refers specifically to the presence of all required data elements.

POMR

Problem-Oriented Medical Record

focuses on the documentation of a logical, organized plan of clinical thought by practitioners.

The system has four parts

problem list- is a dynamic document showing titles, numbers, and dates of problems, and its serves as a table of content of the record. problems can be initial symptoms or well define diagnoses

initial plans- describe what will be done to investigate or treat each problem

progress notes- are written in a distinctive style according to the acronmy SOAP

database-was an early minimum data set (MDS)

Advanced Beneficiary Notice

Managed care a document signed by a patient accepting responsibility for paying for a test or diagnostic service which the patients primary care thinks is appropriate which Medicare may not under Medicare's reasonable and necessary "standard and therefore not pay the party performing the test.

example patient indicating whether he/she wants to receive services that Medicare probably will not pay for it.

Medicare Summary Notice

sent to patient to show how much the provider billed how much medicare reimbursed the provider, what the patient must pay to the provider.

Remittance Advice

Sent to provider to explain payments may be 3rd party.

coordination of benefits

the electronic transmission of claims and/ or payments info from a healthcare provider to a heatlh plan for the purpose of determining relative payment responsibilities.

MS-DRG

MS-DRG assignment way of classifying patients the basis of diagnosis

Medicare paid most hospital for inpatient hospital services

1. healthcare encounter is first classified into one of 25 major diagnostic categories

2. the principal diagnosis determines the MDC assignment (major diagnostic category)

*the principal diagnosis the condition established AFTER STUDY to have resulted in the inpatient admission.

MDS

MINIMUM DATA SET (takes direction form the NCVHS national committee on vital health statistics)

example: skilled nursing facility

minimum data set items

identi & background info, cognitive patterns, communication/hearing patterns, vision patterns, mood & behavior patterns, psychosocial well being, continence in past 14 days, physical functioning& structural problems, disease diagnoses, health condition, oral/nutritional, oral/dental, skin condition, activity pursuit, medication, special treatment

MDS data are reported directly to the Centers for Medicare and Medicaid Services and must conform to agency standards.

MDS part two

Skilled Nursing Facility reimbursement rates are paid according to RUG

MDS is also used as a data collection placement at the appropriate level of care

MDS used as a data collection tool to classify medicare residents into RUGS

RUG-resource utilization groups a system used in the PPS for skilled nursing faciity hospital swing bed program and in many state medicaid case mix payment systems.

peripheral

is an external object that provides input and output for the computer

relational database

stores data in a predefined tables that contains rows and columns, similar to a spreadsheet. They are currency, real #s, integers, and strings (characters of data)

Covered Entities (CE)

are health plans, healthcare , clearing house, healthcare providers who electronically transmit any health info such as billing/payments for services or ins. coverage.

Privacy Act of 1974

applies to the federal gov

right to "Request Restriction" of PHI

An individual can request that a Covered Entity (CE) restrict the uses and disclosures of PHI to carry out treatment, payment or healthcare operations. ARRA requires that requested restrictions can be compiled with the disclosure would be made to a health plan for payment or operations purposes and the individual had paid for the healthcare service or item completely out of pocket.

de identified Information

health info from which all names and other identifying descriptors have been removed to protect the privacy of the patients, family members and healthcare providers who were involved in the case

BCP (Business Continuity Plan) is also called what?

Contingency & Disaster Planning

includes policies and procedures to help the business continue operation during the unexpected shutdown or disaster

security

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

confidentiality

a legal and ethical concept that establishes the healthcare providers responsibility for protecting health records and other personal and private info from unauthorized use or disclosure

privacy

the right of a patient to control disclosure of personal info

disclosure

the act of disclosing (exposing and revelation)

minimum necessary standard

a stipulation of hte HIPAA Privacy Rule that requires healthcare facilities and other covered entities (CE) to make reasonable efforts to limit the patient identifiable information they disclose to the least amount required to accomplish the intended purpose for which the info was requested.

Chief Privacy Officer main role

in the main person for receiving complaints

requirement for privacy training

requirements for establishing privacy safeguards for handling complaints

standards for policies and procedures and changes to policies and procedures

Notification Requirements for breach of covered entities (CE) and BAs (Business Associates)

1. notified within 60 days by mail or phone

2. 500 or more has been breached --------notified ASAP and use media outlets

3. 500 or less -------notified 60 days

data mart

is a subset of a data warehouse designed for a single purpose or specialized use. used for patient satisfaction and research

topology

is the mathematical study of shape and topological space

physical topolgy

actual geometric layout of workstations

back-end speech recognition

processes dictation in the background so it is invisible to physician where the recognition process occurs after the completion of dictation by sending voice files thru a server. Back-end speech recognition lets physicians dictate as they always have: into a telephone, a portable digital voice recorder, a PDA or even directly into a PC-based EHR,"

by editing a draft report rather than having to transcribe it from scratch."

front end speech recognition

the specific use of speech recognition technology in an environment where the recognition process occurs in real tiem as dictation take place. requires physician interaction whereby the physician/radiologist views the structured text document and edits the document as it is dictated,"

E-Health

is the use of information and communicating technology for health. Treating patients, conducting research, educating the health workforce, tracking diseases and monitoring public health.

Radio frequency identification (RFID)

An automatic recognition tech that uses a device attached to an object to transmit data to a receiver and does not require direct contact.

SQL

Structured Query Language, common language used in data definition and data manipulation

is used to store an retrieve data in relational databases. gives the information system the ability to query and report on data and to insert, update and delete data from the data base.

RFI

request for information

RFP

request for propsal

DICOM

Digital Imaging Communication in Medicine

was orginally created to permit the interchange of biomedical image wave forms and related info

BC-MAR

Bar Code Medication Administration Record

identify the right of the patient, right drug to be given at the right time in the right dosage, given at the right route

EMAR

Electronic Medication Administration Record

a system designed to prevent medication errors by checking a patients medication info against his or her barcoded wristband

CPOE

clinical provider order entry

is an application that enables providers to enter medical orders into a computer system that is located within an inpatient or ambulatory setting. CPOE replaces more traditional methods of placing medication orders, including written (paper prescriptions), verbal (in person or via telephone), and fax. Most CPOE systems allow providers to electronically specify medication orders as well as laboratory, admission, radiology, referral, and procedure orders.

graphical user interface

GUI it operates on the basis of icons that represent different computer tasks and programs. It allows for keyboards to point, click and drag

machine language

the first generation of programming languages, machine language consists of ones and zeros

Computer assisted Coding (CAC)

natural language processing

digital text from online doc. stored in the originals info system. is read directly by the software which then suggests codes to match the doc.

A computer assisted coding system (CACS) is a computersoftware application that analyzes health care documents and produces appropriate medical codes for specific phrases and terms within the document.

Health information Exchange (HIE)

A plan in which health information is shared among providers.

Integrated Health Network

A system that combine the financial and clinical aspects of healthcare and uses a group of healthcare providers, selected on the basis of quality and cost management criteria same as Integrated delivery systems (IDS)

The right to access PHI, The privacy rule allows an individual to inspect and obtain a copy of his or her own PHI contained within a designated record set, such as health record. There are exceptions.

what is the exceptions?

psychotherapy notes- information compiled in reasonable anticipating of a civil, criminal or adminstrative action or proceeding

or PHI subject to the Clinical Laboratory Improvement Act (CLIA) are all exceptions

document destruction include what?

date of destruction

method of destruction

description of the disposed records

inclusive dates covered

a statement that the records were destroyed in the normal course of business

the signatures of the individuals supervising and witnessing the destruction

Indemnification

Another party is to compensate that party for loss or damage that has already occurred, or to guarantee through a contractual agreement to repay another party for loss or damage that occur in the future

- offered by private insurance co. that reimbursed the patient for covered services up to a specified dollar limit. It was the the responsibility of the hospital to collect the money from the patient.

Force Majeure

"Superior Force"

Unavoidable accident

in contracts it free both parties from liability

Business Continuity Plan (BCP)

to handle an unexpected computer shutdown caused by an intentional or unintentional event or during a natural disaster

Spoliation

the action of ruining or destroying something, intentional reckless or negligent

MAC

Manditory Access Control

Hot site

is a commercial disaster recovery service that allows a business to continue computer and network operations in the event of a computer or equipment disaster.

cold site

it provides office space, but the customer provides the install all the equipment needed to continue operating

PHI

PROTECTED HEALTH INFORMATION

CAPTCHA

systems may require verification that a human not a computer is accessing a website or storage portal.

A Completely Automated Public Turing Test to tell Computer and Humans Apart

Incidental uses or Disclosures

Calling out patients names in a physician office is an incidental disclosure. It is permitted as long as the info disclosed is the minimum necessary.

Privacy Incidents

is any potential or actual compromise of personally identifiable Information in a form that could be accessed by an unauthorized person.

example: hackers obtain name, ssn, date of birth

stolen thumb drive of PII, unauthorized access to personal files

technology neutral

does not require specific technologies to be used but rather provides direction on the outcome

entity authentication

is a tech designed to let one party prove the identity of another party

Right to Request Amendment of PHI (PROTECTED HEALTH INFORMATION)

60 DAYS AFTER RECEIPT BY ALLOWING IT OR DENYING IT IN WRITING

role based access

restricting system access to authorized users, are based on the roles individual users have as part of an organization. Each user is given various privileges to perform their role or function.

SSO

single sign on

is a property of access control of multiple related but independent software system. With this property a user logs in once and gain access to all systems

Also a single action of signing out terminates access to multiple software systems.

DAC

Discretionary Access Control

it grants or restricts object access via access policy determined by an objects owner group. Owner determines object access privileges.

Medicare (title XVIII of the Social SEcurity Act) was established what year?

which functions became mandatory?

1965

utilization review, the goal of the UR process was to ensure that the services provide to Medicare beneficiaries were medically necessary.

Medicare Prescription Drug Improvement and Modernization Act passed?

2003

HIPAA was established what year

Health Insurance Portability & Accountability Act 1996

The OBRA was passed what year

Omnibus Budget Reconciliation Act of 1986

which mandated the development of a prospective system for hospital-based outpatient services provided to medicare beneficiaries

Federal Register

is the official publication for all "presidential Documents"

When the gov. institutes national change those changes are published in the Federal Register

Medicare Part C is also know as?

what does it cover

Medicare Advantage

Can choose their health care providers HMO/PPO/PFFS/SNP/MSA/HMOPOS

purchase benefits for vision, hearing and dental

Medicare Part D

prescription drug benefit

WHO PUBLISHED ICD-10

1.contains significantly more codes

2. additional info related to ambulatory and managed care encounters

3. expanded injury codes

4. laterality codes

5. up to 7 digits

ICD-10 provides up to 198,000 procedure codes, enabling hospitals to collect more specific info for use in patient care, benchmarking, quality assessment, research, public health reporting, strategic planning and reimbursement

CPT radiology codes

There are three components

professional component- Describes the services of a physician who supervises the taking of an exray film and the interpretation w/report of the results

Technical component-describes the services of the person who uses the equipment, the film and other supplies

global component-combo )professional and technical)

What group work on medical necessity of admission and efficient of facility resources?

utilitzation committees

What group takes care reducing injury and financial loss?

risk management

What group acst as a liason between the governing body and medical staff

Joint Conference

What group coordinate nationwide efforts to implement and use the most advanced Health info Technology and the electronic exchange of health information

ONC

RECOMMENDED RETENTION PERIOD

what holds for 5 yrs?

what holds for 10 yrs?

what holds for permanently?

5yrs-diagnostic Images (x-ray film) adult, diagnostic images (x-ray film) minor 5 years AFTER the age of majority.

10yrs-physician index, disease index, fetal heart monitor records (10yrs after the age of majority, operative index, patient health/medical records (adults), patient health/medical records (minors)

Permanently-Master patient index, register of birth, register of deaths, register of surgical procedure

is systematic & ongoing data collection using methods that are practical, uniform, and often focus on rapid data collection rather than complete accuray, it may or may not be population based

surveillance system

it is used to classify neoplasms according to their site, behavior, morphological characteristic and how they are graded

ICD-O

The International Classification of Disease for Oncology

What are the three types of population based cancer registeries?

1. Incidence only Registries -determine cancer rates & trends in a defined population

2. cancer control Registries- combining incidence, patient care, end results reporting

3. research registries

The company's policy states that audit logs, access reports, and security incident reports should be reviewed daily. This review is known as

an information system activity review

access control what two elements would you use?

unique user identification

auto logoff

you are looking for potential problems and violations of the privacy rule. What is this security management process called?

risk assessment

A patient authorizes Park Hospital to send a copy of a discharge summary for the latest hospitalization to Flowers Hospital. The hospital uses the discharge summary in the patient's care and files it in the medical record. When Flowers Hospital receives a request for records, a copy of Park Hospital's discharge summary is sent. This is an example of

redisclosure

To prevent our network from going down, we have duplicated much of our hardware and cables. This duplication is called

redundancy

We have just identified that an employee looked up his own medical record. Which of the following actions should be taken?

Follow the incident response procedure.

The supervisors have decided to give nursing staff access to the EHR. They can add notes, view, and print. This is an example of what?

a workforce clearance procedure

The hospital has received a request for an amendment. How long does the facility have in order to accept or deny the request?

The request must be acted on within 60 days after receipt; however, the response may be extended once by 30 days, with a written statement with reason and response date.

Cindy, Tiffany, and LaShaundra are all nurses at Sandyshore Health Care. They all have access to the same functions in the information system. It is likely that this facility is using

role based access

is the attempt to acquire sensitive information such as usernames, passwords, and credit card details (and sometimes, indirectly, money) by masquerading as a trustworthy entity in an electronic communication.

Phishing

is a general term used to describe software that performs certain behaviors such as advertising, collecting personal information, or changing the configuration of your computer, generally without appropriately obtaining your consent first.

Spyware

Today is August 30, 2013. When can the training records for the HIPAA privacy training being conducted today be destroyed?

August 30, 2019

6 years

(also known as a black hat hacker) is an individual with extensive computer knowledge whose purpose is to breach or bypass internet security or gain access to software without paying royalties.

A cracker

is the use of false, defamatory claims about someone in written or printed form.

Libel

likewise denotes false statements that damage a person’s reputation, but it is committed orally or in any other transient form.

Slander

the willful giving of false testimony under oath or affirmation, before a competent tribunal, upon a point material to a legal inquiry.

perjury

Any intentional false communication, either written or spoken, that harms a person's reputation; decreases the respect, regard, or confidence in which a person is held; or inducesdisparaging, hostile, or disagreeable opinions or feelings against a person.

defamation

"the thing speaks for itself". what law term is this

Refers to situations when it's assumed that a person's injury was caused by the negligent action of another party because the accident was the sort that wouldn't occur unless someone was negligent.

res ipsa loquitur

A legal doctrine, most commonly used in tort, that holds an employer or principal legally responsible for the wrongful acts of an employee or agent, if such acts occur within the scope of the employment or agency.

respondeat superior

the doctrine that rules or principles of law on which a court rested a previous decision are authoritative in all future cases in which the facts are substantially the same.

is the doctrine meaning a lower court is bound by rulings in previous cases where all the relevant facts and law were the same as the current case.

The doctrine that the decisions of the court should stand as precedents for future guidance.

stare decisis

Written questions submitted to a party from his or her adversary to ascertain answers that are prepared in writing and signed under oath and that have relevance to the issues in alawsuit.

interrogatory

gathering evidence is what law term

discovery

he legal term for failing to obtain informed consent before performing a test or procedure on a patient ... significant risks or alternatives, you will be asked to give explicit (written) consent.

is called battery (a form of assault).

creates an unreasonable risk to one's self. The idea is that an individual has a duty to act as a reasonable person. When a person does not act this way and injury occurs, that person may be held entirely or partially responsible for the resulting injury, even though another party was involved in the accident. -

contributory megligence

"supreme law of the land"

constitution of the united states

is the electronic aspect of identifying, collecting and producing electronically stored information (ESI) in response to a request for production in a law suit or investigation. ESI includes, but is not limited to, emails, documents, presentations, databases, voicemail, audio and video files, social media, and web sites.

e-discovery

Act has been construed to immunize a church from a personal injury claim by a church member who trips and falls while exiting the church after attending services. This is an example of what?

the premise that charitable institutions could be held blameless for their negligence act is known

Charitable immunity

This type of liability was used by a woman who was injured by the health plan urologist to whom her primary care provider referred her. The health plan did check to make sure the doctor was licensed but the health plan’s background check of the doctor was cursory. The court held that the health plan had a duty to its members to make sure that its doctors were qualified and to drop any doctors from its network if the health plan found the doctor posed a foreseeable risk of harm to its members. this is an example of what type of negligence?

corporate negligence

“the failure of one rendering professional services to exercise that degree of skill and learning commonly applied under all the circumstances in the community by the average prudent reputable member of the profession with the result of injury, loss, or damage to the recipient of those services.” what type of negligence is this?

professional negligence

The concept of contributory negligence is used to characterize conduct that creates an unreasonable risk to one's self. The idea is that an individual has a duty to act as a reasonable person. When a person does not act this way and injury occurs, that person may be held entirely or partially responsible for the resulting injury, even though another party was involved in the accident. what type of negligence is this?

contributory negligence

What are the four elements of a contract?

offer

consideration

acceptance

mutuality

is a legal principle that holds an original copy of a document as superior evidence. The rule specifies that secondary evidence, such as a copy or facsimile, will be not admissible if an original document exists and can be obtained. what type of rule is this?

applies when a party wants to admit as evidence the contents of a document at trial, but that the original document is not available. In this case, the party must provide an acceptable excuse for its absence. If the document itself is not available, and the court finds the excuse provided acceptable, then the party is allowed to use secondary evidence to prove the contents of the document and have it as admissible evidence.

best evidence rule

is a specific type of request that asks the court to render the decision of a previous lower court ruling invalid. This is often filed at the beginning of a trial or appeal as a pretrial motion. It is somewhat similar to a motion to dismiss, except it asks the court to nullify a previous ruling rather than the current filing.

motion to quash

without delay or instantly. The term is used in various legal contexts, such as when a court issues an order for a writ of possession instanter, or an attorney files a motion requesting an action to be taken, and that the action be allowed immediately, among other examples.

subpoena instanter

The interaction between state law and HIPAA is complicated. In general, HIPAA preempts state law that is “contrary” to the federal rule. A provision of state law is contrary to HIPAA if:

• a covered entity would find it impossible to comply with both the state and federal law provisions
• the provision of state law would be an obstacle to the accomplishment and execution of the goals of HIPAA

Of course, there are a number of exceptions to this general rule. First, HIPAA does not preempt most state laws that relate to public health. HIPAA also preserves certain state laws related to the oversight of health plans. Finally, a contrary state law provision is not preempted if it relates to the privacy of individually identifiable health information and is “more stringent” than HIPAA. (For a list of when a law is considered more stringent than HIPAA, seebelow.)

Determining whether a state law is “contrary” to or is “more stringent” than HIPAA is complicated by the fact that the analysis must be done on a provisionby- provision basis. This approach requires a line-by-line (and sometimes a clause-by-clause) comparison. It’s easy to see how undertaking a preemption analysis can be a time-consuming and expensive process. But there are a number of ways to make the process easier.

HIPAA preemption analysis

Secondhand statements considered trustworthy for the purpose of admission as evidence in a lawsuit when repeated by a witness because they were made spontaneously and concurrently with an event.

Under the Hearsay rule, a court normally refuses to admit as evidence statements that a witness says he or she heard another person say.

res gestae

"a matter [already] judged", A rule that a final judgment on the merits by a court having jurisdiction is conclusive between the parties to a suit as to all matters that were litigated or that could have been litigated in that suit.

res judicata

wrongful conduct by a public official

• wrongdoing, misconduct, misbehavior
• specifically, the misuse of authority by a public officer – called also malpractice
• an act or instance of wrongdoing especially by a public officer under color of authority of his office

is a legal term that refers to an individual intentionally performing an act that is illegal.

malfeasance

doing a proper act in a wrongful or injurious manner

misfeasance

A failure to act when under an obligation to do so; a refusal (without sufficient excuse) to do that which it is your legal duty to do

nonfeasance

ideal consent is the same as

informed consent

involves a living, breathing witness being asked questions about the case. The deposition has two purposes: To find out what the witness knows and to preserve that witness' testimony. The intent is to allow the parties to learn all of the facts before the trial, so that no one is surprised once that witness is on the stand -

deposition

implementation specification

it is defined as REQUIRED or ADDRESSABLE

covered entities must implement all implementation specifications that are REQUIRED

Inpatient Rehabilitation Facilities (IRF) reports the HIPPS (Health Insurance Prospective Payment System) code on the claim. The HIPPS code is a five-digit CMG (Case Mix Group). Therefore, the HIPPS code for a patient with tier 1 comorbidity and a CMG of 0109 is B0109. Home Health Agencies (HHA) report the HIPPS code on the claim. The HIPPS code is a five-character alphanumeric code. The first character is the letter "H." The second, third, and fourth characters represent the HHRG (Home Health Resource Group). The fifth character represents what elements are computed or derived. Therefore, the HIPPS code for the HHRG C0F0S0 would be HAEJ1.

A HIPPS (Health Insurance Prospective Payment System) code is a five-character alphanumeric code. A HIPPS code is used by

How many major diagnostic categories are there in the MS-DRG system?

25

a program that incorporates policies and procedures for continuing business operations during a computer system shutdown; sometimes called

business continuity plan or contingency and disaster planning

Cancer hospitals can apply for and receive waivers from the Centers for Medicare and Medicaid Services (CMS) and are therefore excluded from the inpatient prospective payment system (MS-DRGs). Rehabilitation hospitals are reimbursed under the Inpatient Rehabilitation Prospective Payment System (IRF PPS). Long-term care hospitals are reimbursed under the Long-Term Care Hospital Prospective Payment System (LTCH PPS). Skilled nursing facilities are reimbursed under the Skilled Nursing Facility Prospective Payment System (SNF PPS).

The following type of hospital is considered excluded when it applies for and receives a waiver from CMS. This means that the hospital does not participate in the inpatient prospective payment system (IPPS)

cancer hospital

record-over-record method

An accuracy calcualtion method that divides the number of records where there was no change in APC and DRG assignment by the total number of cases reveiwed is considered?

an assessment of possible security threats to the organization's data

RISK ANALYSIS

A comprehensive program of activities intended to minimize the potential for injuries to occur in a facility and to anticipate and respond to ensuring liabilities for those injuries that do occur.

loss prevention and reduction, liability claims management, participating in safety and security programs

risk management

the planned, systematic review of the patients in a healthcare facility against care criteria for admission, continued stay, and discharge.

A collection of systems and processes to ensure that facilities and resources, both human and nonhuman, are used maximally and are consistent with patient care needs.

It is a process that determines whether a planned service or a patients condition warrants care in an inpatient setting.

utilization management

was mandated under the Health Care Quality Improvement Act of 1986 to provide a database of medical malpractice payments, adverse licensure actions, and certain professional review actions (such as denial of medical staff privileges) taken by healthcare entities such as hospitals against physicians, dentists, and other healthcare providers as well as private accrediting organizations and peer review organizations.

National Practitioner Data BAnk

utilization review is based on two things in an inpatient services and justification for continued stay.

intensity of service screening criteria/ severity of illness

determine whether the patients needed services could e fulfilled most efficiently in an inpatient hospital setting or safely provided on an outpatient basis

intensity of service screening criteria

determine whether the patient's level of physical impairment requires inpatient care

severity of illness screening criteria

is the process of gathering information regarding a physician's qualifications for appointment to the medical staff,

Physician credentialing

denotes those specific services and procedures that a physician is deemed qualified to provide or perform. The specific processes for physician credentialing and delineation of clinical privileges must be defined by medical staff and department bylaws, policy, rules, or regulations

2 years by law

delineation of clinical privileges

WHAT DOES PDSA

PLAN DO STUDY ACT- is a systematic series of steps for gaining valuable learning and knowledge for the continual improvement of a product or process. Also known as the Deming Wheel, or Deming Cycle, the concept and application was first introduced to Dr. Deming by his mentor, Walter Shewhart of the famous Bell Laboratories in New York.

IT IS ALSO CALL THE DEMING WHEEL OR THE DEMING CYCLE

PDSA

THIS STEP IS ? This involves identifying a goal or purpose, formulating a theory, defining success metrics and putting Into action

THIS STEP IS? in which the components of the plan are implemented, such as making a product.

THIS STEP IS ? where outcomes are monitored to test the validity of the plan for signs of progress and success, or problems and areas for improvement.

THIS STEP IS? integrating the learning generated by the entire process, which can be used to adjust the goal, change methods or even reformulate a theory altogether.

PLAN STEP

DO STEP

STUDY STEP

ACT STEP-

These four steps are repeated over and over as part of a never-ending cycle of continual improvement.

allows the team to organize similar ideas into logical groupings. Ideas that are generated in a brainstorming session may be written on stick notes and arranged on a table or posted on a board. Without talking to each other,each team member is asked to walk around the table or board look at the ideas, and place them in natural groupings that seem related or connected to each other.

affinity grouping

is a process used to develop agreement about an issue or an idea that the team considers most important. It helps the team reach consensus. Each team member ranks each idea according to importance.

nominal group technique

it is a form of nominal group technique but rate issues by marking them with a distribution of points

multivoting technique

malpractice crisis of the 1970 created what form of management?

risk managment

An inventory strategy companies employ to increase efficiency and decrease waste by receiving goods only as they are needed in the production process, thereby reducing inventory costs.

JIT (JUST IN TIME)

TRIENNIAL EXCEPTION RULE

triennial (recurring every three years)

it is a detailed review of a patient's health record for the quality of the documentation therein

quality analysis

fundamental principles of continuous performance improvement

structure of a system determines its performance

all systems demonstrate variation

improvements rely on the collectible ad analysis of data that increase knowledge

requires the commitment and support of top administration

works best when leaders and employees know and share the organizations mission, vision and values

excellent teamwork is essential, communication must be open, honest and multidirectional

success must be celebrated to encourage more success

In 1918 the hospital standardization movement was inaugurated by the AmericAN College of Surgeons (ACS). The purpose of the Hospital Standardization Program was to ?

raise the standards of surgery by establishing minimum quality standards for hospitals.

1. accurate and complete medical records

2. complete medical record- HPI, personal family social history, physical exam, clinical lab, xray, provisional or working diagnosis, pathological findings, final diagnosis, condition on discharge, follow up and in case of death, autopsy findings

What group? initiate advance safety improvements in healthcare by giving customers more information to make healthcare choices such as medical errors

Leapfrog group

is a quantitative tool (a rate ration, index, percentage) that provides an indication of an organization's performance in relation to a specified process or outcome. Monitoring selected performance measures can help an organization determine process stability or can identify improvement opportunities. Specific criteria are used to define the organization's performance measures.

performance measure

CHAMPUS turn into TRICARE

is a healthcare program for active duty servcie members

CHAMPVA

is a healthcare program for dependents and survivors of permanently and totally disabled veterans, survivors of veterans who died form service related conditions.

is used to organize and categorize information into a more usable form for decision making purposes. Information generated through the use of brainstorming or other idea generating tools is entered on the matrix and then prioritized according to predefined criteria. This allow the team to analyze the pros and cons of each idea.

decision matrix

surgical case review includes the following cases?

determination of surgical justification based on clinical indications in cases where no tissue has been removed

where there is a significant discrepancy between preoperative, postoperative and pathological diagnose

cases with serious surgical complications or surgical mortalities

What passed in 1986?

patient protection and affordable care act (PPACA)

What is PPACA

patient protection and affordable care act

liability to individuals and health facilities for any peer review process activities conducted.

under the CMS the Health Care Quality Improvement Program is to do what?

to promote the quality, effectiveness and efficiency of services to MEDICARE beneficiaries by strengthening the community of those committed to improving quality. THEY monitor and improve quality of care communicate with beneficiaries healthcare providers, and practitioners, promote informed health choices and protect beneficiaries form poor care.

what is HIPDB?

HEALTHCARE INTEGRITY AND PROTECTION DATA BANK

FEDERAL OR STATE LICENSING AND CERTIFICATION ACTIONS, INCLUDING REVOCATION, reprimands, censures, probation, suspensions, and any other loss of license, or the right to apply for or renew a license, whether by voluntary surrender, non-renewability, or otherwise

exclusions from participation in federal or state healthcare programs

any other adjudicated actions or decisions defined in the HIPDB

healthcare integrity and protection data bank

displays data points over a period of time to provide information about performance

run chart

support the collection of data that must be oriented by time.

ex. a receptionist might be asked to record the time ladder when a patient arrives at her workstation and then record again on the same time ladder when the patient is called to an exam room. IF we want to get a picture of how the receptionist work is broken up by other considerations, we might also ask her to record timing of phone calls, provider request for assistance, and the like to see how other duties had an impact on her interactions with patients.

time ladder

part of a utilization management program in which health care is reviewed as it is provided. Reviewers, usually nurses, monitor appropriateness of the care, the setting, and the progress ofdischarge plans. The ongoing review is directed at keeping costs as low as possible and maintaining effectiveness of care.

concurrent review

is a tool for analyzing relationships between two variables. One variable is plotted on the horizontal axis and the other is plotted on the vertical axis. The pattern of their intersecting points can graphically show relationship patterns.

are used to plot the points for two continuous variables that may be related to each other in some way.

example page 439 number 77

scatter diagram

Graphical representation of the sequence of steps or tasks (workflow) constituting a process,

flow process chart

allows the team to organize similar ideas into logical groupings

affinity grouping

a frequency distribution with continuous interval data (like a bar graf but the bars are all touching)

s a graphical representation of the distribution of numerical data. It is an estimate of the probability distribution of a continuous variable (quantitative variable)

histogram

quality management theorist

1. kaizen

2. Crosby

3. peters

4. deming

5. joiner

6. juran

7. armand f. Feigenbaum

8. walterr a Shewhart

1. change for better from CEO to assembly line workerbees

2. zero defects

3. in search of excellence

4.14 points (merit raises, formal evaluations and quotas established thru benchmarking

5. team work

6. consists of quality planning, quality control, and quality improvement. (triology)

7. necessity of integrating the funcitons of total quality control

8. statistical process control, reduce variation in process

s a structured communication technique, originally developed as a systematic, interactive forecasting method which relies on a panel of experts. The experts answer questionnaires in two or more rounds.

delphi process

is a useful decision-making technique. It helps you make a decision by analyzing the forces for and against a change, and it helps you communicate the reasoning behind your decision.

force field analysis

it looks like a bar chart, except that the highest ranking item is listed first, followed by the second highest, down to the lowest ranked item. ITs purpose is to display how the team ranked the problems and to allow the team to focus on those problems tat may have the biggest potential for improving the process.

pareto chart

s an approach to quality management that builds upon traditional quality assurance methods by emphasizing the organization and systems: it focuses on "process" rather than the individual; it recognizes both internal and external "customers"; it promotes the need for objective data to analyze and improve processes.

continuous quality improvements

Each time a patient is registered, a new patient number is created;multiple addmissions=multiple pateint numbers for one person

#1, #14, #18#43

serial numbering system

Patient is assigned a number the first time they are registered and are reassigned the same number all subsequent admissions and encounters; all records are filed in one folder

The same patient was admitted on three different occasions and assigned a new medical record number each time. In order to correct this situation in a unit numbering system, which medical record number should be used given the following information?

Admitted 5/04/13 Patty Miller 23-33-56

Admitted 6/05/13 P. J. Miller 25-56-88

Admitted 9/27/13 Patricia Miller 27-12-12

unit numbering system

23-33-56

groups

1. physicians services/ other health services

2. Medical supplies, orthotics and DME (durable medical equipment)

3. DIAGNOSIS CODES

4. Inpatient hospital procedures

5. Dental services

6. drugs/biologics

code set

1. HCPCS and CPT

2. HCPCS (A-V CODES)

3. ICD-10 CM, ICD-9 CM VOLS 1 &2

4. ICD-10 PCS, ICD 9 CM VOL 3

5.dental codes (HCPCS, D codes)

6. national drug classification (NDC)

Which of the following is associated with Medicare SNF prospective payment?

RUG III

is used to track for many reasons that the accounts are not ready for billing, This is also called DNFB (discharge not a final bill)

bill reporting

each service or supply item CDM is commonly referred to as a line item. this has 7 items

charge code, item description, general ledger key, revenue codes,cpt/hcpcs codes, charge and actvity date

what are the required elements of a charge description?

indemnity

reimburse patients to a certain amount.

Type I recommendation when 2% of delinquent records are due to missing history and physicals or operative reports.

The remaining choices are incorrect and defined as follows: absence of SOAP format in progress notes = the SOAP format is not a requirement of Joint Commission; missing signatures on progress notes = both signature omissions and discharge summary reports can be captured after discharge, but history and physicals should be on the chart within 24 hours of the patient's admission; missing discharge summaries = both signature omissions and discharge summary reports can be captured after discharge, but history and physicals should be on the chart within 24 hours of the patient's admission.

security rules only applies to what?

E-PHI

The three components of a security program are protecting DATA

which are ?

the privacy of data, ensuring the integrity of data, and ensuring the availiability of data

1. are computer software applications that interact with the user, other applications, and the database itself to capture and analyze data. A general-purpose is designed to allow the definition, creation, querying, update, and administration of databases.

Database management systems (DBMS)

its a type of data that is used for qualitative (what kind) rater than quantitative (how much or how many). it is also called categorical data. Example female category could be coded as "0" and male category could be coded as "1".

nominal data

this type of data is expressing rankings from lowest to highest .

example 0= no or minimal risk, 1= low risk, 2=moderate risk, 3=high risk, 4=presence of vital organ failure

ordinal data

this type of data refer to the limited number of values, typically only whole number

example medications a person is taking, the number of children in a family, or the number of records that are coded.

discrete data

this data on a quantitaitve variables assume an infinite number of possible values.

height, weight, temperature and costs or charges. whole and decimal numbers

continuous data

is the degree of agreement among repeated administrations of a diagnostic test performed by a single rater

intra-rater reliability

is the degree of agreement among raters. It gives a score of how much homogeneity, or consensus, there is in the ratings given by judges.

inter-rater reliability

can be used to describe populations. mean, median and mode are the three measures of the center of a distribution of values.

mode are used for

medians for

means for

measures of central tendency

mode are used for nominal level variables

medians for ordinal level variables

means are used for interval and ration level variables.

refers to the extent to which scores within a set vary from each other. Measures in which the scores in a set are spread out or clustered together around the mean.

range is one way to measure dispersion because it is the difference between the highest and lowest values.

Dispersion

central tendency which one is used most often

mean

the repetition of number is a data set is termed as frequency of that particular number or the variable in which that number is assigned.

example: johnny hit the ball three times, sam hit the ball 4 times. its a tally of repetition

frequency distribution

the NUMBER of inpatients TREATED during the LAST 24 HOURS

inpatient service day, daily inpatient census and daily census all mean the same thing.

this DOES NOT include NEWBORNS

ONLY FOR ADULTS/PEDIATRICS

inpatient census-The NUMBER of inpatients COUNTED at a PARTICULAR TIME (usually 11:59 pm) The 11:59 pm (midnight) Inpatient Census is the starting point for the next day.

ADMISSIONS/DISCHARGES

inpatient census

Which facilities seek Joint Commission accreditation?

hospitals, behavioral health care, long term care, home care, ambulatory care, pathology and clinical laboratory services, office based surgery practices

This is to integrate outcomes data and other performance measurement data into its accreditation processes. The goal of the initiative is to promote a comprehensive, continuous, data driven accreditation process for healthcARE facilities. Its initiative uses nationally standardized performance measures to improve the safety and quality of healthcare.

Joint Commission to link patient outcomes to accreditation.

ORYX

What are the three risk areas that are vitally important to the accuracy of the claims submissions process?

coding and billing, documentation and medical necessity for tests and procedures

What are the three areas of that are high risk billing practices?

billing for non covered services, altered claim forms, duplicate billing, misrepresentation of facts on a claim form failing to return over payments, bundling, billing for medically unnecessary services, overcoding and upcoding , billing for items or services not rendered adn false cost reports.

This outline seven steps as the hallmark of an effective program (corporate compliance program) to prevent and detect violations of law. These seven steps have become the blueprint for an effective compliance program for healthcare organization.

The U.S. Federal Sentencing Guideline

WHAT IS ANSI standard?

The American National Standards Institute is a private non-profit organization that oversees the development of voluntary consensus standards for products, services, processes, systems, and personnel in the United States.

This organization looks at issues related to the efficiency and effectiveness for the healthcare delivery system, disease protocols and guidelines for improved disease outcomes.

AHRQ (Agency for Healthcare Research and Quality)

data sets were developed for a variety of healthcare settings. Data sets for acute cae, long term care, and ambulatory care were the first to be created. What organization is involved in this?

NCHS (NATIONAL CENTER FOR HEALTH STATISTICS)

If physicians were to dictate information regarding patients they are treating in the facility, the disclosure of protected health information to the transcriptions would be considered healthcare operations and therefore, permitted under the HIPAA Privacy Rule.

true

If physicins, who are separate covered entities, are dictating information on their private patients, however, it would be necessary for physicians to OBTAIN a Business associate agreement with the facility.

it is permitted by the Privacy Rule for one covered entity to be a business associate for another covered entity.

true

what is the responsibility of a middle manager?

developing, implementing, and revising the organization's policies and procedures under the direction of executive managers

what is the responsibility of executive managers?

executing the organizational plans developed at the board and executive levels, providing the operational information that executives need to develop meaningful plans for the the organizations future

position descriptions outline the work and qualifications required by the job, performance standards establish expectations for how well the job will be done and how much work will be accomplished, written policies and procedures explaining staffing requirements and scheduling assist the supervisor in being fair and objective and help the staff understand the rules.

staffing tools

what organization is continually monitoring and improving the quality of care provided?

The Joint Commission since the mid 1950s

a statement that describes general guidelines that direct behavior or direct and constrain decision making in the organization. It is developed at both the institutional land departmental levels. should be consistent within the organization. They must be developed in accordance with applicable laws and reflect actual practice.

policy

What is DRA?

The Deficit Reduction Act of 2005 was enacted in 2006. is a significant from a compliance perspective because it has transformed the nature of compliance program from voluntary to mandatory.

is the process which ensures that a set of people are following a given set of rules. The rules are referred to as the ___________ standard or_________benchmark

Compliance management

compliance, compliance

What is the Joint Commission compliance, the rate of records completed?

30 days or days specified in medical staff bylaws must be computed. Remember the Average days are not the same as the rate of records delinquent.

what organization is this?

is a private, nonprofit organization that establishes guidelines and standards for the operation and management of healthcare facilities to ensure the quality and safety of care. IT operates voluntary accreditation programs for hospitals, non hospital based psychiatric and substance abuse organizations, long term care organization, home care organizations, ambulatory care organizations, and organization based pathology and clinical laboratory services.

if you are accredited is a s a condition of licensure and receiving medicaid and medicare reimbursement.

inspection every 3 yrs.

The Joint Commission

Medicare Conditions of Participation (COP), Which medical facility must follow teh rule and regulations for participating in the Medicare of COP?

HOSPITALS, HOME HEATLH AGENCIES AMBULATORY SURGICAL CENTERS AND HOSPICES.

What do you call this?

it is a performance expectations and structures or processes that must be in place for an organization to provide safe, high-quality care, treatment and services. This knowledge pertaining directly to the health record and documentation in the record are critical for HIM professionals working in an accredited facility.

Elements of Performance (EPs)

the creation of the National Practitioner DAta Bank was mandated by

Health Care Quality Improvement Act

when is the only time when a individual is not granted to their PHI?

When a licensed healthcare professional has determined that access to PHI would likely endanger the life or safety of the individual

what is HIPAA?

Health Insurance Portability and Accountability Act -1996

Includes health record security and privacy, right ot access their health records, right to amendment to the information in their records and add information

developed privacy standard to protect health information and security standards for electronic health care information

written contingency plan

how many clicks can you do for a radial button?

how many clicks can you do for a check off button?

ONE

many

Looking at the Payment determinations and audit of cost reports is what program that looks at that to make sure it is done right?

The Medicare Integrity Program 113-36 law to battle fraud and abuse .

what are three steps to medical necessity and utilization review that is required?

clinical review, peer review and appeals consideration.

what does the OIG do?

The Officer of Inspector General does an investigations, audits, and evaluations related to healthcare fraud

qui tam practices

whistle blowers

exceptions to the Federal Anti-Kickback Statute that allow legitimate business arrangements and are nto subject to prosecution are?

safe harbors

what is this?

are activities that are not subject to prosecution adn protect the organization from civil or criminal penalties.

safe harbor

accrediting bodies such as the Joint Commission can survey facilities for compliance with the Medicare Conditions of Participation for Hospitals instead of the government is called

deemed status.

Joint Commission uses what method for on-site survey?

what does it mean?

tracer methodology

it incorporates the use of the priority focus process (PFP) review, follows the experience of care through the organization's entire healthcare process, and allows the surveyor to identify performance issues.

What are the goals for a case management?

continuity of care, cost effectiveness, quality and appropriate utilization.

what is ABN?

Advance Beneficiary Notice

should be provided to a patient when a service is not considered medically necessary, indicating that Medicare might not pay and that the patient may be responsible for the entire charge.

when the RAC has determined the incorrect payment has been made to a hospital, what will the RAC do?

demand letter is sent out to the provider. which includes the providers identification, reason for the review, lsit of claims, reasons for any denials and amount of over payment for each claim.

the demand letter is the same as denial letter

The top bar is teh general system life cycle

the bottom bar is the information system life cycle

the one with the ??????? is implementation.

is the act of comparing one's performance to high quality performers. The purpose of this comparison is to identify how high quality performers are able to achieve better performance and incorporate what works best into your way of doing things.

benchmarking

compares performance between functional areas or departments within an organzation

internal benchmarking

is used to close the gap between an organization's performance and that of other organizations. Sometimes called performance benchmarking.

external benchmarking

Sunset Beach Clinic allows patients to communicate by e-mail to ask questions regarding their treatment and request appointment changes. E-mails and text messages are

considered health care business records and are subject to the same regulations as records created in face-to-face patient encounters.

Fred is recovering nicely, so he asks Dr. Jones if he can go home for the weekend. Dr. Jones approves a two-night leave of absence (LOA). Chances are Fred is a patient in

a long-term care facility; his LOA will decrease the month's total inpatient service days.

The discharge diagnosis for this inpatient encounter is rule out myocardial infarction. The coder would assign

a code for a myocardial infarction.

When a diagnosis is preceded by the phrase "rule out" in the inpatient setting, the condition is coded as though it is confirmed.

is the most basic of the decision support tools. The alternatives are compared with one another by various criteria.

consistent criteria are used to evaluate the alternatives/vendors.

example the decision makers in the HIM dept. have decided to use the ________ ______ _______ to select coding software.

decision grid or matrix.

This form of evaluation is which supervisor, peers and staff contribute to this performance evaluation

360 degree evaluation

You are conducting an educational session on benchmarking. You tell your audience that the key to benchmarking is to use the comparison to

improve your department's processes.

What federal legislation passed in 1986 confers liability to individuals and health facilities for any peer review process activites conducted?

patient protection and affordable care act.

that the discussions, deliberations records and proceedings of medical staff committees having responsibility for the evaluation and improvement of quality are kept confidential nd are not subject to disclosure outside the medical staffr process

no under state laws, records of medical review committees are not subject to introduction into evidence.

peer review protection

are errors in medical care that are clearly identifiable, preventable, and serious in their consequences for patients. Things shouldnt have happen in the first place. example infant abduction, shouldnt have happen because of policies have been in placed.

never event

Medicare physician payment system of "customary, prevailing, and reasonable (CRP) has changed to what?

Medicare Physician Fee Schedule

patient cannot be held responsible for charges in excess of the Medicare fee schedule.

balancing billing

is a statement sent to the provider to explain payments made by third party

remittance advice

prospective payment system used to reimburse the "hospital" for outpatient surgery is ?

APC- AMBULATORY PAYMENT CLASSIFICATION

The prospective payment used to reimburse a "free-standing surgery center" for outpatient surgery is

ASC- AMBULATORY SURGICAL CENTER

The prospective payment system used to reimburse the "physician" for outpatient surgery is

RBRVS.

Inpatient Rehabilitation Facilities (IRF) reports the HIPPS (Health Insurance Prospective Payment System) code on the claim. The HIPPS code is a five-digit CMG (Case Mix Group). Therefore, the HIPPS code for a patient with tier 1 comorbidity and a CMG of 0109 is B0109. Home Health Agencies (HHA) report the HIPPS code on the claim. The HIPPS code is a five-character alphanumeric code. The first character is the letter "H." The second, third, and fourth characters represent the HHRG (Home Health Resource Group). The fifth character represents what elements are computed or derived. Therefore, the HIPPS code for the HHRG C0F0S0 would be HAEJ1.

What is the federal fiscal year?

October 1st through September 30 of the next year.

-the volume of services and their expense do not affect reimbursement

-means paying a fixed amount per member per month

-involves a group of physicians or an individual physician

this means capitation

This documents published by the Office of Inspector General (OIG) every year. It details the OIG's focus for Medicare fraud and abuse for that year. It gives health care providers an indication of general and specific areas that are targeted for review. It can be found on the internet on CMS WEB site.

The OIG'S Workplan

This number identifies the physician universally to all payers. This number identifies the physician universally to all payers. This number is issued to all HIPAA covered entities. It is mandatory on the CMS-1500 and UB-04 CLAIMS forms.

National Provider Identifier (NPI)

1. What codes are involved with Inpatient Psychiatric Facilities (IPF)?

2. the following coding system is/are utilized in the MS-DRG prospective payment methodologies?

1. icd-9 cm codes

2. ICD-9-CM codes

CMS identified HAC hospital acquired conditions. the importance of the HAC payment provision is that the hospital

HAC- EXAMPLES OBJECTS RETAINED AFTER SURGERY, BLOOD INCOMPATIBILITY, CATHETER ASSOCIATED URINARY TRACKT INFECTION.

will not receive additional payment for these conditions when they are not present on admission.

under Medicare a beneficiary has _____ _____ days.

the patient has a total of 60 lifetime reserve days

lifetime reserve days are usually reserved for use during the patient's final (terminal) hospital stay.

lifetime reserve days re not renewable, meaning once a patient uses all of their lifetime reserve days, the patient is responsible for the total charges.

this is under medicare part A inpatient stay.

lifetime resevre days.

who uses the PAI -patient assessment Instrument to classify patients into case mix groups

inpatient rehabilitation facilities.

, in healthcare, is the difference between what hospitals bill and what they receive in payment from third party payers, most commonly government programs; also known as contractual adjustment.

CONTRACTUAL ALLOWANCE

CMS assigns one _______to each APC and each________code.

payment status indicator, HCPCS

under the acute inpatient prospective payment system (PPS), A predetermined rate based on the MS-DRG (HOW MANY CASES) is assigned to each case is used to reimburse hospitals for inpatient are provided to Medicare and Tricare beneficiaries.

one case per inpatient hospitalization

When health care providers are found guilty under any of the civil false claims statutes, the Office of Inspector
General is responsible for negotiating these settlements and the provider is placed under a

Corporate Integrity Agreement

Regarding hospital emergency department and hospital outpatient evaluation and management CPT code assignment are done by?

each facility is accountable for developing and implementing its own methodology

issue lump-sum payments to providers to compensate them for all the healthcare services delivered to a patient for a specific illness and /or over a specific period of time

health plans that used________reimbursement methods issue lump sum payments to providers to compensate them for all the health care services delivered to a patient for a specific illness and or over a specific period of time.

episode of care

some services are performed by a nonphysician practitioner (such as a physician Assistant) these services are an integral yet incidental component of a physicians treatment. a physician must have personally performed an initial visit and must remain actively involved in the continuing care. Medicare requires direct supervision for these services to be billed.

incident to billing

P274 IN BOOK AND QUESTION 107 IN PRG LOOK AT

relives the coding unit of repetitive coding that does not require documentation analysis.

contains information about healthcare services and transactions provided to a patient. Its primary purpose is to allow the provider to accurately charge routine services and supplies to the patient.

Charge description master

ensure that each piece of data can only mean one thing

example "patient"

data dictionary

a list of recommended data elements with uniform definitions that are relevant for a particular use.

data set

an individual fact or measurement that is the smallest unique subset of a database

example age gender, insurance co., and blood pressure are all data elements concerning a patient.

data element

healthcare data sets have two purpose what are they?

identify the data elements for each patient and provide uniform definitons for common terms.

it is a request from a clinical area to check out a health record. It can be paper or electronic format. the information contained on a ______usually includes patient's name, health record number, date of the request, date and time needed, name of the requestor and location for delivery.

requisition

information standards that provide clear descriptors of data elements to be included in computer based patient record systems.They specify the type of data to be collected in each data field and the attributes adn values of each data field all of which are captured in data dictionaries.

structure and content

Which database from the National Health Care Survey that uses the patient health record as a data source?

National Ambulatory Medical Care Survey

this is a data base that collects a sample of hospital based and freestanding ambulatory surgery centers. Data include patient demographic characteristics, source of payments, information on anesthesia, the diagnoses and the surgical and nonsurgical procedures on patient visits of hospital based and freestanding ambulatory surgery centers.

National Survey of Ambulatory Surgery

Medicare claims for Part A services and hospital based Medicare Part B services are submitted to a designated what?

Medicare administrative contractor (MAC). MACs are replacing the claims payment contractors known as fiscal intermediaries.

refers to accounts that show money owed by the patient and that the healthcare facility has defined as uncollectable. When multiple, extensive attempts have been made to collect, but no money has been paid, these charges are written off as bed debt.

determined by the facility to be uncollectible

Bad debt

Medicare part B covers what?

physician services, outpatient care and homehealth

The outpatient prospective payment system (OPPS) was first implemented for services furnished on or after August 1, 2000. Under the OPPS, the federal government pays for hospital outpatient services on a rate per service basis that varies according to the ambulatory payment classification (APC) group to which the service is assigned. The healthcare Common Procedural Coding System (HCPCS) identifies and groups the services within each APC group.

what are some of the services?

. Services included under APCs are as follows: surgical procedures, radiology, clinical visits, emergency room visits, partial hospitalization services for the mentally ill, chemotherapy, preventative services and screening exams, dialysis for other than ESRD, vaccines, splints, casts, antigens, and certain implantable items.

The plans reimburses patients up to a specified amount.

These plans were offered by private insurance companies that reimbursed (or indemnified) the patient for covered services up to a specified dollar limit. It was then the responsibility of the hospital to collect the money from the patient.

Indemnity plans

is defined as a condition present at the time the order for inpatient admission occurs.-conditions that develop during an outpatient encounter, including the emergency department, observation or outpatient surgery, are considered as present on admission. An indicator is assigned to principal and secondary diagnoses and the external cause of injury codes based on physicians documentation.

POA-present on admission

Medical record information may be exempt from the __________requirements if the requests for information meets the test of being an unwarranted invasion of personal privacy.

example: the information is generated from federally funded research conducted by a private health care organization.

Freedom of Information Act

sworn verbal testimony you are asked to provide

deposition

The extent to which the HIPAA privacy rule may regulate an individual's rights of access is not meant to preeempt other existing federal laws and regulations This means that if an individual's rights of access????.

this means that an individual's right of access are greater under another applicable federal law, the individual should be afforded the greater access.

A written authorization from the patient releasing copies of his or her medical records is required

give examples

the patients attorney

a physician requesting copies from another physician

an insurance company

According to AHIMA's Position on Transmission of Health Information, the health information manager should engage in all of the following to ensure that information is properly sent facsimile transmission give me some characteristics of sending it facsimile transmission?

what is one thing you should never do when faxing medical doc.?

to preprogram into the machine the number of destination sites

encrypt the data if public channels are used for electronic transmittal

ask the sender to contact the recipient prior to and after transmission.

you should never ever do a follow up by sending the original record by mail.

medicla records stays at the medical facilities all times only when the courts ask it.

Under traditional rules of evidence, a medical/health record is considered______________ and is _______________into evidence

hearsay, inadmissible

what healthcare systems have to comply with the requirements of the Freedom of Information Act?

Veterans hsopital

is a law that gives you the right to accessinformation from the federal government. It is often described as the law that keeps citizens in the know about their government.

is a federal law that allows for the full or partial disclosure of previously unreleased information and documents controlled by the United States government.

The Freedom of Information Act (FOIA)

each service or supply item in the CDM is commonly referred to as a line item. Each line item typically has at a mimimum the following seven elements, charge code, item description, general ledger key, revenue code, cpt/hcpcs code, charge, and activity date. The codes used in a charge description MASTER IS LEVELS 1 AND II of HCPCS.

Relieves the coding unit of repetitive coding that does not require documentation analysis.

charge description master

In analyzing the reason for the changes in hospital’s Medicare case mix index over time, the analyst should start with which of the following levels of details?

MS-DRG triples, pairs, and singles

Diagnostic service provided to a Medicare beneficiary by the admitting hospital, or by an entitiy wholly owned or wholly operated by the hospital,within three days prior to and including the day of admission are considered to be inpatient services and included in the inpatient payment

what is excluded in the 3 day window?

. The following services are NOT subject to the three day payment window rule and are excluded from the inpatient payment; hospice, home health, skilled nursing service ambulance, or maintenance renal dialysis services with three day of admission

what are several types of hospitals are excluded from medicare acute inpatient prospective payment system.

Psychiatric & rehabilitation hospitals, long term care hospitals, children’s hospitals, cancer hospitals and critical access hospitals

Patient ttransfer between two ipps hospitals

A type 1 transfer is when a patient is discharged from an acute IPPS hospital (Community Hospital in this case) and is admitted to another acute IPPS hospital (big Medical Center) on the same day. Payment is altered for the transferring hospital and is based on a per diem rate methodology. The transferring facility receives double the perdiem rate for the first day plus the per diem rate for each day thereafter for the patient LOS. The receiving facility receives the full PPS payment rate for the case.

Inpatient Prospective Payment System (IPPS)- EXCLUDES WHAT FACILITIES

EXCLUDES PSYCHIATRIC, LONG TERM CARE AND REHABILITATION

IS the total dollar amount that the healthcare insurance policy will pay for the policyholder and each covered dependent for covered healthcare services during a specified period, such as a year or lifetime.

Overarching limitation or maximum dollar plan limit

medicare part B covers?

covers physician services, outpatient care and home health

HOW MANY DAYS WILL MEDICARE COVER FOR SNF?

100 DAYS

medicare part A begins on the day of admission and ends when the beneficiary has been out of the hospital for 60 days in a row. Including the day of discharge.

Benefit Period

When the patient is issued a different number for each admission or encounter for care and the records of past episodes of care are bought forward to be filed under the last number issued.

serial-unit number system

written documents that assist an organization in achieving its objectives and carring out its mission statement are known as

strategic plans.

There is a clear flow of authority from superior to subordinate throughout the orgnization

scalar or chain of command principle.

under the Americans with Disabilities Act (ADA), prior to employment, it is illegal to require a

physical exam

, this bill was signed into law by President Franklin Roosevelt on July 5, 1935. It established the National Labor Relations Board and addressed relations between unions and employers in the private sector.

Wagner Act

performance appraisal should occur

on a periodic basis

refers to the principle that a subordinate should have one and only one superior to whom he or she is directly responsible. That means, on a hierarchic tree, there should be only one in the absolute command.

unity of command

your job description states that as Assistant Directo of the HIM Department, you will supervise day to day operations for the record processing, transcription, and release of information areas.

What principle of management is described

span of control

Maslow's Hierarchy

self actualization-

esteem

love/belonging

safety (financial/health security)

physiological

are tools that present metrics from a variety of quality aspects in one concise report. They may present measures of clinical quality (such as infection rates), financial quality, volume, and patient satisfaction. The indicators provide snapshot of all areas of quality to give leaders and communities of interest an overall perspective of the service the organization is providing. They are like dashboards on a car it is a reports of process measures that help leaders know what is currently going on so that they can plan strategically where they want to go next.

Dashboards

What are the following Joint Commission core measure criteria sets

Heart failure, acute myocardial infarction and pneumonia

(NOT DIABETES MELLITUS)

A Joint Commission-accredited organization must review its formulary annually to ensure a medication’s continued

continued Efficacy and safety

Problems in patient care and other areas of the healthcare organization are usually symptoms inherent in a

System is a collection of parts that interact with each other to form an interdependent whole.

system

is a collection of parts that interact with each other to form an interdependent whole.

system

The National Patient Safety Goals have effectively mandated all healthcare organizations examine care processes that have a potential for error and can cause injure to patients. The NPSGs include

identifying patients correctly, improving staff communication, using medicines safely, preventing infection, checking patient medicines, preventing patients from falling, preventing bed sores and identifying patient safety risks.

The scope of performance improvement measurements that help identify important areas of service used by a healthcare organization are

volume, risk, problem prone outcomes.

this type of performance measure focuses on a process that leads to a certain outcome, meaning that a scientific or experiential basis must exist for believing that the process, when executed appropriately as designed will increase the probability of achieving the desired outcome.

process measure

a standard of performance or best practice for a particular process or outcome

Benchmarking

The Joint Commission’s quality improvement activities for health record documentation include all except which of the following core performance measures for hospitals

Acute myocardial infarction, hypertension, pregnancy and related conditions are core performance measures for hospitals.

Seizure disorders is not part of the core performance measures for hospitals

displays data points over a period of time or provide information about performance. The measured points of a process are plotted on a graph at regular time intervals to help team members see whether there are substantial changes in the numbers over time.

run chart

is a structured data tool that risk managers used to gather information about potentially compensable events. Also called an incident report. Effective occurrence reports carefully structure the collection of data, information and facts in a relatively simple format.

Occurrence report

What is CDM?

charge description master

what are the seven elements within the CDM?

CHARGE CODE

ITEM DESCRIPTION

GENERAL LEDGER (G/L) KEY

REVENUE CODE

INSURANCE CODE MAPPING (CODE A, CODE B, CODE C, CODE D)

CHARGES

ACTIVITY DATE

is the numerical identification of the service or supply.it links the item to a particular dept. for revenue tracking, budget analysis, and cost accounting reasons.

Each item has a unique number with a prefix that indicates the department number (the number assigned to a specific ancillary department)

charge code

is the two or three digit number that assigns each item to a particular section of the general ledger in the healthcare facility's accounting section.

Reports can be generated from this information to include statistics related to volume in terms of numbers, dollars, and payer types.

general ledger

it totals all items and their charges for printing on the UB-92/UB-04.

This is printed on the UB-04 claim form to represent the cost center.

Revenue codes

This information is used because it provides a uniform system of identifying procedures, services, or supplies. Multiple columns can e available for various financial classes.

HCPCS code

This information provides a narrative name of the services provided. This information should be presented in a clear and concise manner. When possible, the narratives from the HCPCS/CPT book should be utilized.

item/service description

The Unified Medical Language System (UMLS) is a project sponsored by the

National Library of Medicine

modifer 26 is

professional component

An encoder that prompts the coder to answer a series of questions and choices based on the documentation in the medical record is called a(n)

logic based encoder

The Healthcare Cost and Utilization Project (HCUP) consists of a set of databases that include data on inpatients whose care is paid for by third-party payers. HCUP is an initiative of the

Agency for Healthcare Research and Quality

According to the American Medical Association, medical decision making is measured by all of the following except the

risk of complications

amount of complexity of data reviewed

number of diagnosis or management options

In general, all three key components (history, physical examination, and medical decision making) for the E/M codes in CPT should be met or exceeded when

a new patient is seen at the office

Which of the following is expected to enable hospitals to collect more specific information for use in patient care, benchmarking, quality assessment, research, public health reporting, strategic planning, and reimbursement?

ICD-10-CM

The abstract completed on the patients in your hospital contains the following items: patient demographics; prehospital interventions; vital signs on admission; procedures and treatment prior to hospitalization; transport modality; and injury severity score. The hospital uses these data for its

TRAUMA REGISTRY

The nursing staff would most likely use which of the following to facilitate aggregation of data for comparison at local, regional, national, and international levels?

ABC CODES

According to the UHDDS, a procedure that is surgical in nature, carries a procedural or anesthetic risk, or requires special training is defined as a

SIGNIFICANT PROCEDURE

A list or collection of clinical words or phrases with their meanings is a

CLINICAL VOCABULARY

it is a process must be used by HIE organizations to identify any patient for whom data are to be exchange. This algorithm uses sophisticated probability equations to identify patients.

Identity matching algorithm

is an essential first step in adopting new IS technology. Strategic information systems planning is the process of identifying and assigning priorities to the various upgrades and changes that might be made in an organization’s IS.

Planning Phase

- is usually initiated by the submission of a project requisition or request from a department for the development, modification or purchase of an information system. The request typically includes an overview of the system purpose, desired functions, anticipated benefits and costs

Analysis Phase

specifies the functions of the system and provides the design or blueprint of the proposed system. It describes the systems hows. How do the users interact with the system? How do the data identified for the IS relate to each other? HOw do the pieces of the system interact with each other? How will this system be programmed?

Design Phase

is a complex undertaking and includes the development of the computer programs, testing of the system and development of system documentation, user training and system conversion.

Implementation Phase

ensure both the short and long term success of the information system. System backups, software upgrades, equipment maintenance and replacement, ongoing user training and assistance and disaster recovery

Maintenance and Evaluation Phase

clinical data warehouse

CDW

Data design system

DDS

KEY MANAGEMENT SERVICES

KMS

MANAGEMENT INFORMATION SYSTEM

is supported by transaction processing system (TPS) data to help middle managers make decisions about their department’s objectives. MISs are usually specialized and designed to support a particular area of the business. In a health information management (HIM) MIS, for example, input data might include admission, discharge, and transfer data, and data on the number of dictated reports, coded records, filed records and incomplete records. Examples of the outputs would include structured reports production schedules, and productivity analysis so that the HIM director can make management decisions.

MIS

is a special kind of database that manages data from different source systems in the hospital or other provider settings, including direct entry of discrete data by the clinician. CDRs can process discrete data from various ancillary systems such as laboratory pharmacy, and radiology systems. They also can store and make accessible paper document images and clinical images such as those from PACS (picture archiving and communication system)

CDR

involves thoroughly reviewing the vendors proposal, conductin product demonstrations, visiting sites where the product is already installed, calling references and investigating the vendors business practices. The organization must be assured that not only will the ehr function as expected,

but that the vendor will do a good job implementing it, provide appropriate support when there are problems keep it current and remain in business.

Due diligence

data msut be available continuously. An EHR should have server redundancy. This mean that as data are entered and processed by one server, they are entered and processed simultaneously by a second server. Should the primary server crash, the system should be designed to “fail over” to the second server and can continue processing as if at least from the user’s point of view, nothing had happened.

REDUNDANT SERVERS

To effectively transmit healthcare data between a provider and payer, both parties must adhere to electronic data interchange standards.

X12N

it is the exchange, integration, sharing, and retrieving of electronic health information that supports patient care. The HL7 standard allows exchange of data between common systems that make up the EHR such as radiology, laboratory, pharmacy, and other systems. This is a family of standards that aid the exchange of data among hospital systems and more recently physician practices and other types of provider systems.

Health Level Seven (HL7)

the introduction of an electronic health record should trigger a review of the organization’s retention schedule with an eye toward enabling a realistic retention schedule for electronic data. Another element of the retention schedule should be the retention of metadata, including both audit logs and the data about data that supports the data dictionary. It is also important to keep a record of all changes made to templates, cds rules and other customization to the EHR.

Retention schedule

DUAL CORE

- ONE VENDOR PRIMARILY SUPPLIES THE FIINANCIAL AND ADMINISTRAIVE APPLICATIONS AND ANOTHER VENDOR PRIMARILY SUPPLIES THE CLINICAL APPLICATIONS.

when a hospital uses many different vendors to support its information system needs, the information technology strategy being used is called the best of breed

Best of breed

operates in the systems of Medicare administrative contractors (MAC) and provides a series of flags that can affect APC payments because it identifies coding errors in claims. It provides a series of flags that can affect APC payments because it identifies coding errors in claims.

OCE -

A CODING PROFESSIONL MAY ASSUME A CAUSE AND EFFECT RELATIONSHIP BETWEEN HYPERTENSION AND WHICH OF THE FOLLOWING COMPLICATIONS?

Hypertension and chronic kidney disease

- are designated and defined as all conditions that coexist at the time of admission, that develop subsequently, or that affect the treatment received or the length of stay (LOS) . Diagnoses are to be excluded that related to an earlier episode that has no bearing on the current hospital stay.

Other diagnoses

- is the practice of using multiple codes that describe individual components of a procedure rather than an appropriate single code that describes all steps of the procedure performed. Or you can say it is a billing practice in which providers use multiple procedure code for a group of procedures instead of the appropriate combination code.

UNBUNDLING

)- to prohibit unbundling of procedures. which most providers have built into their claims software) explain what procedures and services cannot be billed together on the same day of service for a patient. The mutually exclusive edit applies to improbable or impossible combinations of codes. They look at services that cannot reasonably be billed together. Improper coding leading to inappropriate payment for Part B Medicare claims

NICCI edits national Correct Coding initiative

is a condition that existed at admission and is thought to increase the patient stay at least one day for approximately 75% of the patients. Diabetes existed at the time of admission.

comorbid condition

is defined as a condition present at the time the order for inpatient admission occurs –conditions that develop during an outpatient encounter, including the emergency department, observation or outpatient surgery, are considered as present on admission. A POA indicator is assigned to principal and secondary diagnoses and the external cause of injury codes.

present on admission

An accuracy calculation method that divides the number of records where there was no change in APC or DRG assignment by the total number of cases reviewed is considered.

record over record method

The hospital acquired conditions provision of the Medicare PPS is an example of which type of value based purchasing system?

paying for value

to promote efficiency in resource use while providing high quality care. To achieve this goal CMS as a first step established the hospital acquired conditions provision in the acute care inpatient setting.

paying for value

catheter associated urinary tract infections pressure ulcers, serious preventable event- object left in surgery, air embolism, blood incompatibility, vascular catheter associated infections, mediastinitis after CABG, falls and fractures, dislocations, intracranial injury, crushing injuries and burns.

The fiscal year 2009 hospital acquired conditions provision list includes

Which of the following is true about a primary key in a database table?

Usually a unique number

Does not change in value

Uniquely identifies each row in a table.

is a knowledge system built from a set of rules applied to specific problems. It can take the place of a human expert when it comes to problem solving. The system simulates the reasoning process of human experts in certain well defined areas. Uses artificial intelligence techniques to capture the knowledge of human experts and to translate and store it in a knowledge base.

Expert System

HEALTH INFORMATICS medical /health device communication standards enable communicate between medical, health care and wellness devices and with external computer systems. They provide automatic and detailed electronic data capture of client-related and vital signs information and of device operational data.

IEEE-1073

refers to the number of subordinates a supervisor has.

Span of control

refers to the principle that a subordinate should have one and only one superior to whom he or she is directly responsible.

unity of command

exists in an organization when all or most decisions and orders come from a centralized source, usually the members from the top levels of the organizational structure.

example: you are the assistant director of the HIM department, you will supervise day to day operations for the record processing, transcription, and release of information areas.

centralized authority

Use the following statistics from Utah Home Health to calculate the absenteeism rate.

A. 0.44% B. 5.68% C.5.8% D. 0.568%

25 total work days lost X 100= 2500

20 X 22 = 440

2500/440= 5.68%

5.68%

Kari works 40 hours per week at Rio Grande Radiology, which pays time and a half for overtime and double time for holidays. During the past week, Kari took six hours of unpaid personal leave and worked an eight hour holiday. How many hours will Kari be paid?

40hrs-6 unpaid leave=34

double time 8X2=16

34+ 8=42