question

accreditation

answer

a voluntary process in which facilities agree to follow a set of standards and receive recognition for having met those standards

question

administrative simplification

answer

provisions of Health Insurance Portability and Accountability Act (HIPAA) that addressed standardization of electronic data interchange, privacy of health information, and security of health data

question

American College of Surgeons (ACS)

answer

a professional organization founded in 1913 to "improve the quality of care for the surgical patient by setting high standards for surgical education and practice" (ACS, 2003, p.1); in the early twentieth century, the ACS established a hospital standardization program that was the forerunner of today's accreditation organizations

question

American Recovery and Reinvestment Act (ARRA)

answer

Also known as the "Stimulus Act" or the "Recovery Act", ARRA was enacted in 2009; its main purpose was to create jobs and stimulate economic growth; however, it contains many provisions for health care, including billions of dollars for health information technology; Title XIII of ARRA is Health Information Technology for Economic and Clinical Health (HITECH) that addresses many of the health information and technology requirements, including privacy

question

business associate (BA)

answer

partner or contractor performing a job or service on behalf of a covered entity; the original HIPAA legislation required covered entities to have a business associate

question

capitation

answer

a method of payment for health care in which the health care provider receives a monthly payment based on the number of persons the provider has agreed to treat, regardless of the number of persons actually treated or the amount of service rendered

question

Centers for Medicare & Medicaid Services

answer

a federal agency within the Department of Health and Human Services; its main focus is to administer the Medicare and Medicaid programs

question

Children's Health Insurance Program (CHIP)

answer

allows states to offer health insurance plans for children, up to age 19, who are not already insured; CHIP affords families who earn too much to qualify for Medicaid an opportunity to obtain health insurance for their children

question

clinical documentation improvement (CDI) program

answer

a locally implemented program focused upon improving the quality of clinical documentation to "facilitate an accurate representation of health care services through complete and accurate reporting of diagnosis and procedures"; accurate clinical documentation can positively affect reimbursement, severity of illness and mortality risk assessment, and reporting of quality an pay-for-performance measures

question

covered entity (CE)

answer

under HIPAA, a health plan, a health care clearinghouse, or any health care provider that transmits health information in electronic form

question

deemed status

answer

the status of a health care provider that is deemed to meet federal Conditions of Participation by virtue of accreditation by a federally approved voluntary accrediting organization. the health care provider's accreditation satisfies the COP & routine surveys by the state agency are unnecessary

question

electronic health record (EHR)

answer

a system in which a health care provider maintains individual patient health records electronically; fully developed EHRs include capabilities such as generating clinical alerts and reminders and providing readily available decision support

question

fee-for-service

answer

a method of payment for health care in which the health care provider charges and is paid for each item of service provided

question

Flexner Report

answer

a report published in 1910, examining the state of medical education in the US and Canada; the Flexnor Report resulted in sweeping changes in the way North American physicians were educated

question

health information exchange (HIE)

answer

a process defined as "the electronic movement of health-related information among organizations according to nationally recognized standards (contrast with HIE organization)

question

health information technology (HIT)

answer

electronic health records and related information systems to manage health care processes; the major focus of the HITECH Act of 2009 is to promote adoption of HIT in an effort to improve the quality, efficiency, and safety of health care delivery while reducing costs and minimizing medical errors

question

Health Information Technology for Economic and Clinical Health (HITECH)

answer

The Health Information Technology for Economic and Clinical Health (HITECH) Act was enacted as part of the American Recovery and Reinvestment Act of 2009 to promote the adoption and meaningful use of health information technology; amends HIPAA privacy and security rules by introducing additional privacy regulations, breach notification rules, and stiffer civil and criminal penalties for security violations

question

Health Insurance Portability and Accountability Act of 1996 (HIPAA)

answer

provisions include the portability of health care benefits, prevention of fraud and abuse in health care, and simplification of the electronic interchange of health care data, while improving the privacy and security of health information

question

health record banking

answer

a concept analogous to online financial banking, where the patient controls access to the health record "account"; deposits and withdrawals may be made by authorized individuals; an alternative to a personal health record (PHR), while achieving similar goals

question

HIE organization

answer

an entity that "oversees and governs the exchange of health-related information among organizations according to nationally recognized standards"; often used synonymously with regional health information organization (RHIO), which focuses more on HIE within a specific region; contrast with health information exchange, which is a process rather than an entity

question

Hill-Burton Act

answer

the "Hospital Survey and Construction Act" enacted by Congress in 1946; this legislation provided federal money to determine the need for more hospitals and to pay for their construction

question

Hospital Inpatient Quality Reporting (IQR)

answer

a national quality initiative implemented by CMS. requires hospitals to submit data for certain quality measures, which are made publicly available to consumers via the Hospital Compare Web site. program participation is voluntary. hospitals that do not participate receive a reduced Medicare Annual Payment Update.

question

Hospital Outpatient Quality Data Reporting Program (HQP QDRP)

answer

a national quality program implemented by CMS that is modeled after the hospital IQR initiative; hospitals must report data for standardized quality measures for outpatient hospital services, which are made publically available to consumers via the Hospital Compare Web site; participation is required in order to receive the full annual update to the Outpatient Prospective Payment System (OPPS) payment rate

question

ICD-10-CM

answer

United States' clinical modification of the World Health Organization's diagnostic disease classification (International Classification of Diseases, 10th Revision, Clinical Modification); effective 10/1/13, ICD-10-CM is the diagnosis code set required by HIPAA

question

ICD-10-PCS

answer

United States' procedural coding system for inpatient, acute care settings (International classification of Diseases, 10th Revision, Procedural Coding System); effective 10/1/13

question

Institute of Medicine (IM)

answer

health division of the National Academy of Sciences; it is an independent, nonprofit organization that serves as a national adviser on matters related to health improvement

question

licensure

answer

a governmental process in which a facility must meet certain regulations, set by the state, in order to provide care

question

longitudinal patient record

answer

a record documenting a patient's health status, conditions, and treatments throughout their life and across multiple facilities, providers, and health care encounters

question

meaningful use

answer

requirement in ARRA. providers must demonstrate this in relation to EHR in order to become eligible for reimbursement incentives for Medicare/Medicaid

question

Medicaid

answer

Title XIX of the 1965 Amendments to the Social Security Act, Medicaid is jointly funded by federal and state governments and provides medical assistance to lower-income individuals and families

question

Medicaid Integrity Program (MIP)

answer

a national strategy created as a result of the Deficit Reduction Act of 2005 to detect and prevent Medicaid fraud, waste, and abuse; it uses contracted reviewers to audit the accuracy of Medicaid payments made to health care providers

question

Medicare

answer

Title XVIII of the 1965 Amendments to the Social security Act, Medicare provides health benefits for Social Security recipients and other qualified individuals

question

Medicare certification

answer

process in which a state agency determines that a health care organization meets the standards set forth in the relevant Conditions of Participation or Conditions of Coverage and is therefore eligible for participation in the Medicare program

question

Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA)

answer

made significant revisions to the Medicare program by calling for the creation of Part D, e-prescribing for prescription drug plans, revision of claims processing, and a Medicare payment recovery demonstration project that ultimately resulted int eh Recovery Audit Contractor (RAC) initiative

question

National Patient Safety Goals (NPSG)

answer

program created by the Joint Commission in 2002 to help accredited health care institutions focus upon specific patient safety concerns. updated annually based upon review of literature and available databases

question

National Quality Forum (NQF)

answer

a private, nonprofit, membership organizational focused upon improving the quality of care through national goal setting, development and endorsement of performance measurement standards, and educational initiatives; NQF collaborated with CMS to develop measures for the Physician Quality Reporting Initiative (PQRI); through a contact with the US Department of Health and Human Services, NQF continues to provide support for improved quality of health care services

question

Nationwide Health Information Network (NHIN)

answer

a set of standards, services and policies that enable secure health information exchange over the Internet. provides a foundation for the exchange of health IT across diverse entities, within communities and across the country, helping to achieve the goals of the HITECH Act. enables health information to follow the consumer, be available for clinical decision making, and support appropriate use of health care information beyond direct patient care so as to improve population health

question

Office of the National Coordinator for Health Information Technology (ONC)

answer

"the principal Federal entity charged with coordination of nationwide efforts to implement and use the most advanced health information technology and the electronic exchange of health information; the position of National Coordinator was created in 2004, through an Executive Order, and legislatively mandated in the Health Information Technology for Economic and Clinical Health Act (HITECH) of 2009"

question

patient-centered medical home model

answer

a care model in which the primary care physician act as a "gatekeeper" to coordinate the patient's care across providers; it addresses preventative, acute, and chronic care needs and also provides patients with access to electronic tools such as provider-patient e-mail, online appointment scheduling applications, and electronic health record data; the Patient Protection and Affordable Care Act (PPACA or Health Reform) calls for use of the medical home model to improve health outcomes

question

Patient Protection and Affordable Care Act (PPACA or Health Reform)

answer

a federal statute that contains a number of health care provisions, most notably an expansion of Medicaid eligibility requirements; Health Reform Act also increases quality reporting requirements for health care providers

question

patient safety organizations (PSOs)

answer

"organization that can work with clinicians and health care organizations to identify, analyze, and reduce the risks and hazards associated with patient care"; Patient Safety and Quality Improvement Act of 2005 called for development of PSOs to help determine the root causes, risks, and harms of health care safety issues

question

pay-for-performance (P4P)

answer

emerging incentive-based reimbursement programs that reward or penalize providers based upon their ability to meet pre-established quality and performance targets for delivery of health care services

question

per diem

answer

per day; a per diem payment is a payment rendered to an institution based on the number of days of service provided

question

personal health record (PHR)

answer

"an Internet-based set of tools that allows people to access and coordinate their lifelong health information and make appropriate parts of it available to those who need it"

question

Physician Quality Reporting Initiative (PQRI)

answer

voluntary, incentive-based quality reporting system for eligible professionals who report data on quality measures for covered professional services provided to Medicare beneficiaries; it was established as a requirement by the 2006 Tax Relief and Health Care Act (TRHCA) and is implemented yearly by CMS through an annual rule-making process; therefore, program requirements and measures may vary from year to year

question

prospective payment system (PPS)

answer

a payment system in which payment levels for health care services are determined before the services are rendered; in a prospective payment system, the unit of payment is not based solely on the individual services provided, but on the payment units that represent general groupings of patient encounters, hospital stays, or episodes of care

question

protected health information (PHI)

answer

individually identifiable health information

question

quality improvement organization (QIO)

answer

"private, mostly not-for-profit organizations, which are staffed by professionals, mostly doctors and other health care professionals, who are trained to review medical care and help beneficiaries with complaints about he quality of care and to implement improvements in the quality of care available throughout the spectrum of care; QIO contracts are 3 years in length"

question

Recovery Audit Contractor (RAC)

answer

a 3rd-party entity working under the direction of CMS to detect improper Medicare payments through review of providers' medical records an Medicare claims data

question

Regional Extension Center (RECs)

answer

nonprofit organizations called for by ARRA and initially funded by federal grants to provide health information technology support to providers; RECs offer technical assistance, guidance, and support to help providers become meaningful uses of certified electronic health record technology; an additional goal for the REC program is to create HIT jobs

question

regional health information organization (RHIO)

answer

"health information organization that brings together health care stakeholders within a defined geographic area and governs health information exchange among them for the purpose of improving health and care in that community"; often uses synonymously with HIE organization, which is a broader term that encompasses the use of nationally recognized standards and is not limited by geographic boundaries

question

state agency

answer

the agency of the state government responsible for administering the federal requirements for participation in Medicare and Medicaid programs; the state agency is ordinarily also charged with administering applicable licensure requirements for the state

question

telehealth

answer

"such technologies as telephones, facsimile machines, electronic mail systems, and remote patient monitoring devices which are used to collect and transmit patient data for monitoring and interpretation"

question

telemedicine

answer

the practice of medicine in which electronic signals are utilized to transmit clinical information from one site to another; generally, the patient is in a remote location from the physician, and medical information, which may include images and video, is transmitted back and forth between with 2 locations electronically

question

telesurgery

answer

the use of robotic technology to assist with or perform procedures remotely

question

Zone Program Integrity Contractor (ZPIC) program

answer

program implemented by CMS to identify and investigate malicious fraudulent claims activity within Medicare's 7 geographic regions (zones)

question

ambulatory surgery center (ASC)

answer

a setting provided for surgery on an ambulatory basis; centers usually have at least one full-time operating room and provide surgical privileges to physicians in the community

question

appointment

answer

scheduled time that a patient is to arrive at the health care facility

question

appointment system

answer

a system by which appointments are scheduled for patients

question

ASC reimbursement system

answer

a Medicare reimbursement system for ambulatory surgery in which the HCPCS codes are listed (ASC list) and reimbursed on a percentage of the outpatient prospective payment system rates

question

birth center

answer

ambulatory setting that provides labor and delivery services in uncomplicated deliveries

question

block appointment method

answer

an appointment scheduling method that assigns all patients in a large block for the same appointment time (e.g., 9 a.m. for all morning appointments), then patients are seen on a first-come, first-serves basis

question

capitation

answer

a method of reimbursement in which the phshiucian or facility receives a fix amount each month for each patient enrolled in the plan, regardless of the amount of care that the patient receives

question

certified nurse midwife (CNM)

answer

a nurse practitioner who handles pregnancy, labor, and delivery

question

color coding

answer

a system that helps prevent the misfiling of records by assigning colors to numbers or letters and displaying those colors on the record folder so that misfiled records are easily spotted by their mismatched color patterns

question

community health center

answer

an ambulatory setting developed in the 1960s to provide ambulatory care to the indigent of a particular neighborhood; subsequent legislation expanded the scope of these health centers to any medically underserved area or population

question

compliance plan

answer

a plan for ensuring that a facility/practice is compliying with all laws and regulations, including those pertaining to reimbursement under Medicare and Medicaid

question

Current Procedural Terminology (CPT)

answer

a coding system for procedures that is used extensively in ambulatory care and that forms a part of HCPCS

question

decision-support system

answer

a computerized system that assists physicians in deciding on a diagnosis or treatment

question

Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Service

answer

a program of Medicaid for children younger than 21 that ensures that these services (screening, diagnostic, and treatment) are provided and paid for whether or not they are normally included under the state's Medicaid program

question

encounter

answer

face-to-face contact between the patient and the provider

question

encounter form

answer

a form used for billing purposes that include the services the patient received, the charges, and the diagnosis and procedure codes

question

e-prescribing

answer

a method of entering prescriptions into an electronic system that also transmits the prescription to the pharmacy to be filed

question

family numbering system

answer

a numbering system in which a family is given a number and each individual receives that number with a suffix indicating their position within family

question

family planning center

answer

an ambulatory setting that provides family planning services

question

federally qualified health center (FQHC)

answer

a nonprofit or public organization that provides or arranges for comprehensive health care services to a medically underserved area or population

question

fee for service

answer

a reimbursement system in which the payment is based on the type and amount of service provided

question

financial system

answer

a compute system that maintains information on services billed, insurance determination, payment received, and collection efforts

question

freestanding ambulatory care

answer

care provided to patients who do not stay overnight in a setting not located within a hospital

question

growth and development chart

answer

a graphic recording of a child's height and weight over time

question

Healthcare Common Procedural Coding System (HCPCS)

answer

a system used by ambulatory care facilities to code procedures and services

question

immunization record

answer

record that maintains a list of immunizations that a child has received and often indicates when additional immunizations will be required

question

incident report

answer

internal documentation of an unusual event such as a fall, incorrect medications given or taken, or some other untoward occurrence (see also occurrence report)

question

incident to

answer

services provided to patients by mid-level providers, such as nurse practitioners or physician assistants, when the physician is on site

question

industrial or occupational health center

answer

an ambulatory setting where care is provided to employees at their place of work

question

integrated format

answer

a record format in which the information is entered in chronological order

question

International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM)

answer

a classification system used by ambulatory care facilities for coding diagnoses through 9/30/13

question

International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM)

answer

a classification system used by ambulatory care facilities for coding diagnoses beginning 10/1/13

question

International Classification of Primary Care (ICPC)

answer

a coding system developed by the World Organization of National Colleges, Academies, and Academic Associations of General Practitioners/Family Physicians (WONCA); it includes chapters arranged by body systems, with components that describe the reason why the patient is being seen for care at the primary care level

question

Local Coverage Determinations (LCDs)

answer

guidance documents published by Medicare Administrative Contractors (MACs) that include information on codes that indicate medical necessity of services; these policies apply to services covered under Medicare in the region served by the contractor

question

locum tenens

answer

an arrangement by which one physician temporary works in place of another physician

question

Medicaid Integrity Program (MIP)

answer

a joint federal and state government initiative to identify fraud and abuse in the Medicaid system

question

medical home

answer

a method of providing care in which the primary care provider works with a team of health care professionals to provide care to patients using a whole-person concept

question

Medicare physician fee schedule (MPFS or PFS)

answer

a list of Medicare-covered services and their payment rates

question

mid-level provider (MLP)

answer

a health care professional whose license permits a degree of independent judgment in treating patients, generally under the supervision of a physician (ex: NP, PA, CNM); scope of practice and requirements for supervision vary by type of provider and by state

question

National Coverage Determinations (NCDs)

answer

guidance documents published by Medicare that include information on codes that indicate medical necessity of services; these policies apply to services covered under Medicare throughout the nation

question

nurse practitioner (NP)

answer

a registered nurse who has additional training and credential that allow for limited independent practice

question

occurrence report

answer

internal documentation of an unusual event such as a fall, incorrect medications given or taken, or some other untoward occurrence (see also incident report)

question

Office of the Inspector General (OIG)

answer

the office in the Department of Health and Human Services responsible for motioning compliance with reimbursement laws and regulations

question

patient identifier

answer

an item of data that identifies the patient in the health information management system, such as the patient's name or medical record number

question

patient portal

answer

a secure method of patient access to his or her own information through a facility's electronic information system

question

patient registration system

answer

a computer system that contains demographic and financial information for every patient

question

physician assistant

answer

a professional who is not a nurse but has received training to use independent judgment in treating patients

question

physician private practice

answer

a setting in which physicians practice in their own business rather than working for an organization such as a clinic or urgent care center owned or operated by others

question

physician quality reporting system

answer

a system for physicians to report quality measures to CMS

question

problem list

answer

a numbered list of the patient's problems over time that serves as a table of contents for the problem-oriented medical record

question

problem-oriented medical record (PROM) format

answer

a record format in which the parts of the record are keyed to the problem number listed on the problem list

question

program manuals for Medicare and Medicaid

answer

basis instructions for the 2 programs, developed by the centers for Medicare & Medicaid Services

question

program transmittals

answer

periodically issued by CMS to provide revision for a specific program manual

question

prospective review/precertification

answer

1 of 2 basic approaches to utilization management, prospective review determines whether services are needed before they are provided

question

public health department

answer

an organization that provides services to promote the health of the community as a whole, such as immunizations and disease screenings; usually an agency of state or local government

question

reason for visit

answer

the reason provided by the patient for why care is required

question

registration

answer

the process by which basis demographic and financial information is obtained from the patient and entered into the health information system

question

resource-based relative value scale (RBRVS)

answer

a reimbursement system used by Medicare Part B to reimburse physicians; it is based on the relative value of the services provided

question

retrospective review

answer

1 of 2 basic approaches to utilization management, retrospective review examines care after it has been given, to identify inappropriate care and provide feedback to the caregiver

question

return-to-work physical

answer

a physical done before an employee may return to the job after an injury or illness

question

rural health clinic (RHC)

answer

health care clinic that, in addition to physician services, utilizes mid-level providers such as PAs and NPs, and that is located in an underserved rural area

question

source-oriented format

answer

a record format in which the information is organized according to the source of the information, such as laboratory, nursing, etc

question

standard scheduling

answer

a method in which appointments are scheduled continuously throughout the day, with appointment times at specific intervals (e.g: every 15 minutes)

question

superbill

answer

a form used for billing purposes that includes the services the patient received, the charges, and diagnosis and procedure codes

question

terminal digit filing

answer

a filing system in which records are filed first by the last 2 digits of their numbers, allowing files to expand evenly

question

university health center

answer

an ambulatory setting in which care is provided to university staff and students

question

urgent care center

answer

an ambulatory care setting in which patients are seen on a walk-in basis without appointments; these centers provide service for longer hours than do must private physician practices

question

walk-ins

answer

patients who arrive without an appointment or who receive an appointment at the last minute

question

ambulatory payment classifications (APCs)

answer

groupings of outpatient services (based on the HCPCS code assigned) that determine the payment the hospital receives under the Hospital Outpatient Prospective Payment Systems (HOPPS)

question

ambulatory surgery

answer

(also called "same-day" surgery) surgery in which it is planned that the patient will arrive at the facility, have surgery, recover from any anesthesia, and be ready for discharge in a single day, thus avoiding an overnight stay in the health care facility

question

American Recovery and Reinvestment Act (ARRA)

answer

a federal law that, among other things, created an incentive program for health care providers to utilize EHRs for improved patient care

question

chargemaster or charge description master (CDM)

answer

a computer file that contains a list of the Healthcare Common Procedural Coding System codes and associated charges for services provided to hospital patients

question

clinic outpatient

answer

an outpatient treated in an organized clinic of the hospital, in which hospital staff evaluate the patient and manage the patient's care

question

common working file

answer

a file maintained on each Medicare beneficiary in one of the 9 regional databases; this file contains claims history information from both Part A and Part B claims and data on utilization patterns of Medicare beneficiaries

question

discounting

answer

reducing the payment for additional procedures or ambulatory patient groups so that these other items are not paid at the full rate, as they would be if they had been the only services performed in a given encounter

question

Emergency Medical Treatment and Active Labor Act (EMTALA)

answer

a federal law that imposes a legal duty on hospitals to screen and stabilize, if necessary, any patient who arrives int eh emergency department; the purpose of EMTALA is to prevent the "dumping" of patients who may not be able to pay for emergency department services

question

emergency outpatient

answer

an outpatient evaluated and treated in the emergency department of the hospital

question

fiscal intermediary (FI)

answer

before the implementation of MACs, an organization with a contract with CMS to process and pay Part A Medicare claims

question

hospital inpatient

answer

an individual receiving health care services as well as room and board and continuous nursing care in a hospital and where patients generally stay overnight

question

hospital outpatient

answer

a hospital patient who receives care at the hospital but who is not admitted as a patient

question

Hospital Inpatient Prospective Payment System (HIPPS or IPPS)

answer

Medicare's payment system for hospital inpatient services; the basic unit of payment in the IPPS is the Medicare Severity Diagnosis Related Group (MS-DRG)

question

Hospital Outpatient Prospective Payment System (HOPPS or OPPS)

answer

Medicare's payment system for hospital outpatient services; the basic unit of payment is the ambulatory payment classification (APC) of each service provided

question

hospitalist

answer

"a physician who specializes in inpatient medicine"

question

Medicare Administrative Contractor (MAC)

answer

an organization that has contracted with CMS to process Medicare claims. they replaced fiscal intermediaries and Medicare carriers

question

Medicare carrier

answer

before the implementation of MACs, an organization having a contract with the CMS to process and pay Part B Medicare claims

question

Medicare Severity Diagnosis Related Groups (MS-DRGs)

answer

groupings of inpatient services (based on the diagnosis, expected resource consumption, and other characteristics) that determine the payment the hospital receives under the Hospital Inpatient Prospective Payment System (HIPPS)

question

observation services

answer

"services furnished by a hospital on the hospital's premises, including use of a bed and periodic monitoring by a hospital's nursing or other staff, which are reasonable and necessary to evaluate an outpatient's condition or determine the need for a possible admission to the hospital as an inpatient

question

partial hospitalization program (PHP)

answer

an intensive treatment program in which patients receive services for part of each day; these patients would otherwise require inpatient psychiatric care

question

potentially compensable event (PCE)

answer

an occurrence that may result in litigation against the health care provider or that may require health care provider to financially compensate an injured party

question

referred hospital outpatient

answer

an outpatient who is referred to the hospital for specific services, such as laboratory or radiology examinations; the hospital is responsible only for providing the diagnostic or therapeutic services requested, while the referring physician is responsible for evaluating and managing the patient's care

question

resident

answer

primarily a licensed physician, dentist, or podiatrist who participates in an approved graduate medical education program

question

revenue codes

answer

used on the UB-04 to indicate the general nature of the services provided

question

status indicator

answer

an alphabetic character that indicates the type of each APC and whether or how that APC is paid under the Hospital Outpatient Prospective Payment System (OPPS)

question

Uniform Ambulatory Care Data Set (UACDS)

answer

a 16-item data set approved by the National Committee on Vital and Health Statistics (NCVHS); one of the first attempts to standardize ambulatory data collection efforts

question

Uniform Hospital Discharge Data Set (UHDDS)

answer

standard data elements to be collected from individual inpatient records; the UHDDS data definitions are important for correct reporting of inpatient data

question

American Correctional Association

answer

a professionals association of correctional administrators, wardens, superintendents, and other individuals and institutions that promotes improved correctional standards and studies causes of crime and juvenile delinquents as well as methods of crime control and prevention, offering voluntary accreditation for all components of adult and juvenile corrections

question

American Correctional Health Services Association (ACHSA)

answer

a professional association of health care providers, individuals, and organizations interested in improving the quality of correctional health services

question

American Public Health Association (APHA)

answer

a professional association of health care workers, administrators, epidemiologists, planners, community and mental health specialists, and interested individuals who seek to protect and promote personal, mental, and environmental health through promulgation of standards, establishment of uniform practices and procedures, and research

question

Bureau of Citizenship and Immigration Services (USCIS)

answer

a division of the Department of Homeland Security responsible for the immigration service functions that were formerly performed by the Immigration and Naturalization Service (INS)

question

Bureau of Immigration and customs Enforcement (ICE)

answer

a division of the Department of Homeland Security responsible for the border and security functions of the former Immigration and Naturalization Service (INS)

question

Certified Correctional Health Professional Program (CCHP)

answer

a certification program for health care professionals working in corrections, administered by the National Commission on Correctional Health Care

question

Correctional Cer6tification Program (CCP)

answer

a certification program offered by the American Correctional Association to correctional officers, correctional staff, staff nurses, and nurse managers working in corrections

question

Department of Corrections (DOC)

answer

a division of state government responsible fro the operation of prisons

question

detainee

answer

a person held in custody awaiting trial or disposition

question

Division of Immigration Health Services (DIHS)

answer

an organizational component of ICE responsible for providing health care services to individuals placed in ICE custody

question

Federal Bureau of Prisons (FBP)

answer

a division of the US Department of Justice responsible for the administrator and operation of federal correctional facilities, including penitentiaries, prison camps, and metropolitan correctional centers

question

grievance process

answer

a formal, administrative process whereby inmates may file complaints against a correctional facility for review by a panel; institutional policies, and sometimes state statutes, determine time frames for the review process, decisions, and appeals

question

health services director (HSD)

answer

an individual responsible for the administration and operations of health services within a prison system or DOC

question

hybrid covered entity

answer

an organization whose activities include both covered and noncovered functions under HIPAA

question

inmate

answer

a person confined to a correctional institution such as a prison

question

inmate self-pay or copayment

answer

the practice of requiring inmates to pay a (small) feel for predetermined, nonemergency medical treatments

question

jail

answer

an institution administered by local units of government (i.e., cities or counties) with the authority to detain adults for a period of 48 hours or longer and to confine adults convicted of misdemeanors whose sentence does not exceed 1 year

question

juvenile detention facility

answer

a facility operated by a unit of government for the confinement of individuals under 18 years of age

question

National Commission on Correctional Health Care (NCCHC)

answer

a national association that offers voluntary accreditation of the health services in correctional facilities

question

prisons

answer

facilities operated by a unit of the state or federal government for the confinement of adults convicted of a felony whose sentence exceeds 1 year

question

telemedicine/telehealth

answer

the application of technology where a video camera, a high-speed line, and monitoring and imaging equipment are installed at both a correctional facility and a medical facility; the telehealth equipment is linked either by high-speed communication lines, computer networks, or satellite hookups, thus allowing videoconferencing and digital images to be transmitted and received by either site

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chronic kidney disease (CKD)

answer

a gradual loss of kidney function classified into 5 stages, with mild loss of kidney function in the early stages and severe or total loss in the later stages; in the final stage (stage 5) the individual's kidneys are no longer able to perform the job of excreting the body's wastes or promoting homeostasis, and the patient requires dialysis or kidney transplant

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Clinical Performance Measures (CPM) Project

answer

an ongoing project of CMS, implemented through the ESRD networks, to measure and report the quality of renal dialysis services provided under the Medicare program

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Consolidated Renal Operations in a Web-enabled Network (CROWNWeb)

answer

CMS Internet-based software application that is the required method by which dialysis facilities submit data about patients and facility operations

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continuous ambulatory peritoneal dialysis (CAPD)

answer

a form of peritoneal dialysis in which the patient is able to dialyze him/herself 3 to 4 times per day without special assistance and with a minimum amount of equipment

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continuous cycling peritoneal dialysis (CCPD)

answer

a form of peritoneal dialysis in which the patient uses a cycler machine to dialyze once a day for 9 to 10 hours, generally while sleeping

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dialysate

answer

a solution used to filter products across a semipermeable membrane by the process of diffusion; waste products filter into the dialysate from the blood, while certain other products, such as bicarbonates, filter into the blood from the dialysate

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dialysis

answer

"the process of artificially removing metabolic end products and water across a semipermeable membrane by diffusion" (McAfee, 1987); the 2 most common types of dialysis are hemodialysis and peritoneal dialysis

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dialysis facility

answer

"an entity that provides (1) outpatient maintenance dialysis services, or (2) home dialysis training and support services, or (3) both; a dialysis facility may be an independent or hospital-based unit...or a self-care dialysis unit that furnishes only self-dialysis services"(Conditions for Coverage, 2008, 20476)

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end-stage renal disease (ESRD)

answer

is stage 5 of chronic kidney disease; at this stage the patient has irreversible renal failure with little or no kidney function; when a patient is in end-stage renal disease, he/she requires either dialysis or a kidney transplant to maintain life

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erythropoietin stimulating agent (ESA)

answer

stimulates the bone marrow to make red blood cells and is used to treat and prevent anemia, a common complication of chronic kidney disease in patients on dialysis

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ESRD networks

answer

18 organizations that have contracted with the centers for Medicare & Medicaid Services (CMS) to assess the quality of care rendered to ESRD patients and to collect and analyze ESRD data

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hemodialysis (HD)

answer

cleansing of the blood as it circulates through an artificial kidney machine outside the patient's body

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Kt/V

answer

a means of measuring the adequacy of dialysis (i.e., a way to determine whether the patient is dialyzing long enough or often enough to remove sufficient waste and excess fluid from the body); target Kt/V values in the Conditions for Coverage are 1.2 for hemodialysis and a weekly Kt/V of at least 1.7 for peritoneal dialysis

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peritoneal dialysis (PD)

answer

filling of the patient's abdominal cavity with a solution (dialysate); the semipermeable membrane across which the products diffuse is the patient's own peritoneal membrane; the fluid containing the wastes is later withdrawn from the peritoneal cavity

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quality assessment and performance improvement (QAPI)

answer

The Conditions for Coverage require each dialysis facility to adopt a data-driven performance improvement program that utilizes indicators of performance measures associated with improved health outcomes and with the identification and reduction of medical errors

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Renal Management Information system (REMIS)

answer

a system that determines Medicare coverage periods for ESRD patients and serves as the primary mechanism to store and access information in the ESRD Program Management and Medical Information System (PMMIS) Database; REMIS tracks the ESRD patient population for both Medicare and non-Medicare patients

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renal replacement therapy (RRT)

answer

a treatment that replaces kidney function; the treatment may be some type of dialysis or it may be kidney transplantation

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validation survey

answer

a survey conducted by a regional office of the CMS to determine whether the surveys being conducted by state agencies (or other groups) are appropriately assessing the facility's operations

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Accountable Care Organizations (ACOs)

answer

"a local entity and a related set of providers, including at least primary care physicians, specialists, and hospitals, that can be held accountable for the cost and quality of care delivered to a defined subset of traditional Medicare program beneficiaries or other defined populations, such as commercial health plan subscribers. The primary ways the entity would be held accountable for its performance are through changes in traditional Medicare provider payment featuring financial rewards for good performance based on comprehensive quality and spending measurement and monitoring" (Devers and Berenson, 2009, pp. 1-2)

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bed day

answer

an inpatient service received by one member for one 24-hour period

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capitation

answer

payment of a fixed dollar amount to a provider for each patient assigned to that provider, regardless of the amount of care the patient receives

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Clinical Laboratory Improvement Amendments of 1988 (CLIA)

answer

federal legislation that provides for regulation of all clinical laboratories, including those operated in HMOs and physician practices within managed care networks

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coinsurance

answer

the amount of expense that is the responsibility of the insured under an indemnity insurance policy, usually 20%

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concurrent review

answer

verifying medical necessity of tests and procedures ordered during an inpatient hospitalization

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coordination of benefits (COB)

answer

determining which insurance is the primary payer and ensuring that no more than 100% of the charges are paid to the provider and/or reimbursed to the patient

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copayment

answer

a flat-rate payment, such as $10 per visit, made by the covered individual for a specific service at the time of the service

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credentialing

answer

a process of review to approve a provider who applies to participate in a health plan

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credentials verification organization (CVO)

answer

an organization that contracts with a managed care organization or other health care organization to provide credential verification services for physicians and other clinicians seeking clinical privileges

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deductible

answer

the amount of expenses the insureds must pay each year from their own pockets before the plan will reimburse them

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dependent

answer

the spouse or child of the primary insurance recipient

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Diagnosis Related Groups (DRGs)

answer

basis of the inpatient prospective payment system used by Medicare to reimburse acute care facilities; also used in some MCO contracts

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discharge planning

answer

arranging post-discharge services for patients prior to discharge to provide continuity of care and aid in recuperation

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eligibility

answer

whether a person is able to receive benefits under an insurance policy

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encounter

answer

contact between a patient and a provider who is responsible for the assessment and evaluation of the patient at a specific contact, exercising independent judgment

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Flexible Spending Account (FSA)

answer

tax-free money an employee sets aside to use during a specified period for health care expenses

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gatekeeper

answer

the primary care provider who coordinates all of the patient's health care and decides what, if any, additional care is required

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group model HMO

answer

a model in which the HMO has an exclusive contract with a multispecialty medical group that provides all physician services and contracts with other facilities as necessary to provide comprehensive services; Kaiser Permanente is a successful example of this model; in general, the group model is uncommon.

question

health maintenance organization (HMO)

answer

a business entity that either provides or arranges for health services for a covered population after prepayment of a fixed premium

question

Health Reimbursement Arrangement (HRA)

answer

is a mechanism by which an employer funds an account for its employees to pay for otherwise unreimbursed health care expenses

question

Health Savings Account (HSA)

answer

an account set up by an employee with pretax income that is also not taxed when the employee withdraws from the account at the end of the benefit year roll over to the next year, withdrawals for nonmedical expenses are subject to income tax and a 10% penalty

question

Hierarchical Condition Categories (HCGs)

answer

disease groupings based on ICD codes from both inpatient admissions and outpatient visits in Medicare Advantage organizations, HCCs are used to risk-adjust Medicare payments to MCOs

question

indemnity insurance

answer

traditional health insurance in which the insured is reimbursed for expenses after the care has been given

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independent practice association (IPA) model

answer

an HMO model that was developed primarily as a way for the solo practice physician to participate in the managed care market

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integrated delivery systems/network (IDS/N)

answer

a group of facilities contracted together to provide the comprehensive set of services that any patient may need; they are owned, leased, or grouped together by long-term contracts and are recognized by the public as a combined operating entity

question

managed care organization (MCO)

answer

an organization that provides comprehensive health services, coordinated through a primary care provider who acts as a gatekeeper, after the patient formally enrolls in the organization

question

managed indemnity plans

answer

indemnity insurance plans that do not limit the insured's choice of health care providers but do include cost-control measures such as preauthorization of expensive tests, surgical procedures, and inpatient hospitalization

question

Medicare Advantage

answer

a program by which eligible Medicare beneficiaries may choose to receive their health care through a qualified managed care plan, which in turn receives capitation payments from Medicare for each enrollee

question

mixed model HMO

answer

an HMO that operates within 2 or more different types of organizational structures to provide flexibility to members

question

member

answer

an individual who is enrolled in a managed care organization

question

National Committee for Quality Assurance (NCQA)

answer

an accreditation association that accredits managed care organizations and related services; their accreditation programs include health plan accreditation, wellness and health promotion, managed behavioral health care organizations, new health plans, and disease management

question

network model HMO

answer

an HMO that contracts with multiple physician groups, hospitals, and other facilities to provide a comprehensive health care package

question

panel

answer

the group of patients who have chosen a particular provider as their primary care provider

question

per diem

answer

a reimbursement methodology where the payment is based on the number of days of care

question

preadmission certification

answer

review and approval of the medical necessity of inpatient care prior to the patient's admission

question

preauthorization

answer

review and prior approval for payment of a health care service

question

preferred provider organization (PPO)

answer

an insurance entity that contracts with providers to create a preferred network; the insured population is allowed to use any provider, but using network providers results in a lesser cost to the patient

question

Principal In-Patient Diagnostic Cost Groups (PIP-DCGs)

answer

the first risk adjustment model that Medicare used to adjust capitation payments made to Part C plans, based largely on the principal diagnoses of hospitalized enrollees; PIP-DCGs were replaced by HCCs in 2004

question

referral

answer

an authorization to receive from a specific health provider a specific health services that will be paid for by the HMO

question

staff model HMO

answer

the most tightly organized HMO structure; the HMO entity owns the facilities and arranges for health care through employed physicians, who are allowed to see only the particular HMO's patients

question

subscriber

answer

primary recipient of the insurance benefit

question

URAC

answer

an independent, nonprofit organization offering accreditation, education, and measurement programs; URAC's Health Plan standards are appropriate for HMOs and other integrated health plans; its Health Network accreditation does not include utilization management and is better suited for PPO accreditation

Comparative Health Information Management Chapters 1-6 Midterm Practice – Flashcards

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