RHIT VOCAB

Commission on Accreditation of Rehabilitation Facilities A private, not-for-profit organization that develops customer-focused standards for behavioral healthcare and medical rehabilitation programs and accredits such programs on the basis of its standards

Current Procedural Terminology (CPT)codes that describe services or test results that are agreed upon as contributing to positive health outcomes and high-quality patient care. They are for performance measurement, and use of these codes is optional

Current Procedural Terminology (CPT) codes that describe new and emerging technology. They may be published at any time during the year, rather than on the annual publication cycle, and can be found on the AMA Web site (www.ama-assn.org) and immediately preceding the alphabetic index in the CPT codebook

A group of federal agencies that oversee health promotion and disease control and prevention activities in the United States

The division of the Department of Health and Human Services that is responsible for developing healthcare policy in the United States and for administering the Medicare program and the federal portion of the Medicaid program; called the Health Care Financing Administration (HCFA) prior to 2001

1. The process by which a duly authorized body evaluates and recognizes an individual, institution, or educational program as meeting predetermined requirements
2. An evaluation performed to establish the extent to which a particular computer system, network design, or application implementation meets a pre-specified set of requirements

A federal program providing supplementary civilian-sector hospital and medical services beyond that which is available in military treatment facilities to military dependents, retirees and their dependents, and certain others

The federal healthcare benefits program for dependents of veterans rated by the Veterans Administration as having a total and permanent disability, for survivors of veterans who died from VA-rated service-connected conditions or who were rated permanently and totally disabled at the time of death from a VA-rated service-connected condition, and for survivors of persons who died in the line of duty

1. A system for grouping similar diseases and procedures and organizing related information for easy retrieval
2. A system for assigning numeric or alphanumeric code numbers to represent specific diseases and/or procedures

The process of assigning numeric or alphanumeric classifications to diagnostic and procedural statements

A set of standardized terms and their synonyms that can be mapped to broader classifications

Data that are translated into a standard nomenclature of classification so that they may be aggregated, analyzed, and compared

Process of assigning a number to a data element

1. The process of establishing an organizational culture that promotes the prevention, detection, and resolution of instances of conduct that do not conform to federal, state, or private payer healthcare program requirements or the healthcare organization’s business policies 2. The act of adhering to official requirements

A legal and ethical concept that establishes the healthcare provider’s responsibility for protecting health records and other personal and private information from unauthorized use or disclosure

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

Current Procedural Terminology codes that constitute first level of the HCPCS coding system

Current Procedural Terminology codes that are applicable to selected physician and non-physician services, durable medical goods, drugs, and supplies

Incomplete record that has not been finished within a specified established timeframe

RecordThe cabinet-level federal agency that oversees all of the health- and human-services–related activities of the federal government and administers federal regulations

A word or phrase used by a physician to identify a disease from which an individual patient suffers or a condition for which the patient needs, seeks, or receives medical care

A unit of case-mix classification adopted by the federal government and some other payers as a prospective payment mechanism for hospital inpatients in which diseases are placed into groups because related diseases and treatments tend to consume similar amounts of healthcare resources and incur similar amounts of cost; in the Medicare and Medicaid programs, one of more than 500 diagnostic classifications in which cases demonstrate similar resource consumption and length-of-stay patterns

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

A more expansive view of case management in which patients with the highest risk of incurring high-cost interventions are targeted for standardizing and managing care throughout integrated delivery systems 2. A program focused on preventing exacerbations of chronic diseases and on promoting healthier life styles for patients and clients with chronic diseases

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

The recording of pertinent healthcare findings, interventions, and responses to treatment as a business record and form of communication among caregivers

1. Any clinical professional (physician, nurse, technologist, or therapist, for example) who provides care directly to patients
2. A nonprofessional who provides supportive assistance in a residential setting to a relative, friend, or client who is seriously ill

The management of, responsibility for, or attention to the safety and well-being of other persons in the context of healthcare settings

A method of healthcare reimbursement in which an insurance carrier prepays a physician, hospital, or other healthcare provider a fixed amount for a given population without regard to the actual number or nature of healthcare services provided to the population

The national professional membership organization for physicians that distributes scientific information to its members and the public, informs members of legislation related to health and medicine, and represents the medical profession’s interests in national legislative matters

Agency for Healthcare Research and Quality The branch of the United States Public Health Service that supports general health research and distributes research findings and treatment guidelines with the goal of improving the quality, appropriateness, and effectiveness of healthcare services

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

1. A voluntary process of institutional or program study review in which an organization or agency performs an external audit to determine the quality of the entity's work against pre-established standards.
2. A determination by an accrediting body that an eligible organization, network, program, group, or individual complies with applicable standards.

1. The practice of extracting information from a document to create a brief summary characterizing a patient's illness, treatment, and outcome.
2. The process of extracting elements of data from a source document or database and entering them into an automated system

A computerized record of health information and associated processes

The process of transforming text into an unintelligible string of characters that can be transmitted via communications media with a high degree of security and then decrypted when it reaches a secure destination

Specialty software used to help the coder assign diagnosis and procedure codes

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

An information system designed to combine financial and clinical information for use in the management of business affairs of a healthcare organization; See executive decision support system

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

A list of healthcare services and procedures (usually CPT/HCPCS codes) and the charges associated with them developed by a third-party payer to represent the approved payment levels for a given insurance plan; also called table of allowances

A computer software program that automatically assigns prospective payment groups on the basis of clinical codes

A classification system that identifies healthcare procedures, equipment, and supplies for claim submission purposes; the three levels are as follows: I, Current Procedural Terminology codes, developed by the AMA; II, codes for equipment, supplies, and services not covered by Current Procedural Terminology codes as well as modifiers that can be used with all levels of codes, developed by CMS; and III (eliminated December 31, 2003 to comply with HIPAA), local codes developed by regional Medicare Part B carriers and used to report physicians’ services and supplies to Medicare for reimbursement

The field of study that focuses on health information, its structure, acquisition, and use

Certain activities undertaken by or on behalf of, a covered entity, including those involved with quality assessment, performance improvement, peer review, clinical training, underwriting, legal services, compliance, and business management functions

A provider of diagnostic, medical, and surgical care as well as the services or supplies related to the health of an individual and any other person or organization that issues reimbursement claims or is paid for healthcare in the normal course of business

An allied health profession that is responsible for ensuring the availability, accuracy, and protection of the clinical information that is needed to deliver healthcare services and to make appropriate healthcare-related decisions

The federal legislation directed at improving access, affordability and continuity of health coverage, controlling fraud and abuse in healthcare, reducing costs, and ensuring the security and privacy of health information The act limits exclusion for preexisting medical conditions, prohibits insurance companies from denying coverage to individuals or businesses on the basis of health status, and guarantees availability of health insurance to small employers

Entity that combines the provision of healthcare insurance and the delivery of healthcare services, characterized by: (1) organized healthcare delivery system to a geographic area, (2) set of basic and supplemental health maintenance and treatment services, (3) voluntarily enrolled members, and (4) predetermined fixed, periodic prepayments for members’ coverage

A paper- or computer-based tool for collecting and storing information about the healthcare services provided to a patient in a single healthcare facility; also called a patient record, medical record, resident record, or client record, depending on the healthcare setting

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

An umbrella term that refers to the medical and nonmedical services provided to patients and their families in their places of residence

A healthcare entity that has an organized medical staff and permanent facilities that include inpatient beds and continuous medical/nursing services and that provides diagnostic and therapeutic services for patients as well as overnight accommodations and nutritional services

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

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

A group of healthcare organizations that collectively provides a full range of coordinated healthcare services ranging from simple preventative care to complex surgical care

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

A database protocol developed by the Regenstrief Institute for Health Care aimed at standardizing laboratory and clinical codes for use in clinical care, outcomes management, and research

The legal authority or formal permission from authorities to carry on certain activities that by law or regulation require such permission (applicable to institutions as well as individuals)

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

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

A private, not-for-profit organization that evaluates and accredits hospitals and other healthcare organizations on the basis of predefined performance standards

The newest revision of the disease classification system developed and used by the World Health Organization to track morbidity and mortality information worldwide (not yet adopted by the United States)