Health Information Terminology (FINAL EXAM)

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1

APC

Ambulatory Payment Classification

2

CPT

Current Procedural Terminology

3

ICD-10-CM

International Classification of Diseases

10th Revision, Clinical Modification

4

DRG

Diagnosis-Related Group

5

TJC

The Joint Commission

6

PPS

Prospective Payment System

7

Describe the APC

based on ICD-10-CM codes for diagnosis and CPT codes used for reimbursement to health care in an OUTPATIENT setting

8

Describe CPT-4

listing of medical terms and codes for diagnostic and therapeutic procedures used for coding for physician reimbursement for BOTH inpatient and outpatient

aka professional fees

9

Describe ICD

description and cause of injury

10

Describe TJC

Organization that accredits hospitals and other health carre institutions in the United States

Important for Insurance Purposes

11

Describe PPS

Payment to establishment up-front for a determined amount of Medicare patient procedures (defined by Medicare and agreed upon by the health care establishment) *INPATIENT

Based on Diagnosis Related Groups (DRG)

12

Describe EMR/EHR

Electronic Health Record System; portal to access patient records, order treatments or therapy, and document care delivered to patients; allows providers to access multiple types of data about a patient

13

Describe DRG

categorizes into payment groups patients who are medically related with respect to diagnosis and treatment and statistically similar with regard to length of stay

14

According to TJC and Healthcare Facilities Accreditation Program the medical record must contain

sufficient information to identify the patient, support the diagnosis, justify the treatment, document the course and result, and promote the continuity of care among health care providers

15

According to Medicare the medical record must contain

information to justify the admission and continued hospitalization, support the diagnosis, and describe the patient's progress and response to the medication and services

16

Radiology Health Records must contain

Patient demographic information

Specific procedure requested

Ordering physician

Documentation of medical necessity

Procedure results

Dosage required for therapeutic and radionuclide procedures

Special reports documenting evaluation or treatment of a patient

17

Informed Consent

TJC required, developed by medical staff and hospital governing board, states the patient has been informed of procedure or operation to be performed to include risks involved and possible consequences

by signing the patient or patient representative indicates that he/she has been informed of and consents to the procedure or treatment

18

If the informed consent is not filed with the medical record

the medical record must indicate that an informed consent was obtained for a given procedure or treatment and indicate where the informed consent form is located

19

Non-specific Health insurance Companies require that medical records contain

sufficient information to support the diagnosis for reimbursement purposes under the diagnosis-related group (DRG) and the perspective payment system (PPS) implemented by the government in 1983

20

Performance Improvement and Quality Management

assessment of problems in quality management activities must be ongoing

21

Health Care Records are considered

legal documents

confidential

admissible as evidence in court

22

Who is responsible for informing patients of examination results?

The physician

23

What should the technologist do when asked by a patient for the results of an examination?

refer the patient to his/her physician

24

What is the generally accepted philosophy regarding the ownership of a patients medical record?

The caregiver or facility owns the record but the patient has the right to the information included in the report except wthere prohibited by law or the patient's medical condition

25

Medical images must be maintained in

a secure area with limited public access

26

What is an essential part of the healthcare record and critical to the financial viability of the institution?

proper coding