medical necessity
treatment that is in accordance with generally accepted medical practice
electronic medical record
computerized record of one physicians encounters with a patient over time
health information technology
using computers and electronic communications to manage medical information. ex: sharing pt records with physicians outside the physicians own medical group, transmitting Rx to phamramcy’s and ordering tests from an outside labs.
revenue cycle management
oversight of the activities associated with a patient encounter to ensure that the provider receives full payment for services
nationally recognized designation that acknowledges that an individual has mastered a standard body of knowledge and meets certain competencies
patient examination
an examination of a person’s body in order to determine his or her state of health
pay for performance (P4P)
provision of financial incentives to physicians who provide evidence-based treatments to their patients
federal act that provides financial incentives for adoption of electronic health records
practice management program
program used to perform admin. and financial functions in a medical office
electronic health record
computerized lifelong health care record with data from all sources
are practice management programs designed to manage patients clinical records?
what do integrated PM/EHR programs do?
increase patient safety, improve quality of care and reduce operating costs
is the ambulatory care medical record a log of a patients hospitalizations?
no, ambulatory is for outpatients not overnight stays
can medical records be used to protect physicians from accusations of malpractice?
yes, because all documentation regarding the care and treatment of a patient will be in the records and can be used as a legal document.
when are the patients eligibility for insurance benefits verified?
during the second step of the medical documentation and billing cycle
what program is used to monitor the status of claims that have been sent out to health plans?
practice management programs
who maintains personal health records?
the patient
who maintains EHR’s?
the physician
what is the federal law that protects patient’s private health information, ensures coverage during job changes, and uncovers fraud and abuse?
should diagnosis’ be included in medical office records for patients?
what are some of the concerns when implementing an EHR in a physicians practice?
1. changes to the practice’s workflow
2. cost
3. the inability to share information due to lack of clinical standards
what is the purpose of managing the revenue cycle?
cash flow
what are practice management programs used for?
to manage payments from payers electronically
what type of health record contains information that may be entered by a number of physicians and other providers?
accounts receivable
electronic medical record
health Information exchange
health information technology
national health information network – is a set of standard services and policies that enable the secure exchange of health information over the internet.
practice management
revenue cycle management
list the 10 steps in the medical documentation cycle.
1. preregister patient
2. establish financial responsibility
3. check in patient
4. review coding compliance
5. billing
6. check out patient
7. prepare and transmit claims
8. monitor payer adjudication
9. generate patient statements
10. follow up on patient payments and collections
health informatics
knowledge required to optimize the acquisition, storage, retrieval, and use of information in health and biomedicine
Physician quality reporting initiative (PQRI)
a medicare program that gives bonuses to physicians when they use treatment plans and clinical guidelines that are based on scientific evidence
meaningful use
the utilization of certified EHR to improve quality, efficiency, and patient safety in the health care system
integrated PM/EHR programs
programs that share and exchange demographic information, appointment schedules, and clinical data
medical record
a chronological health care record that includes information that the patient provides, such as medical Hx, as well as the physician’s assessment, Dx and TP
continuity of care
coordination of care received by a patient over time and across multiple health care providers
medical malpractice
the provision of medical services at a less than acceptable level of professional skill that results in injury or harm to a patient
diagnosis code
a code that represents the physicians determination of a patients primary illness
procedure code
a code that represents the particular service, treatment, or test provided by a physician
data wharehouse
a collection of data that includes all areas of an organizations operations
data mining
the process of analyzing large amounts of data to discover patterns or knowledge
record retention schedule
a plan for the management of records that lists types of records and indicates how long they should be kept
must retention schedules comply with state and federal laws?
how long are physician’s required to maintain medical records?
for 7 years, some states including Hawaii require them to be maintained for 25 years
how long should laboratory pathology tests be retained for?
10 years
what are the medical billers responsibilities?
1. verify pt insurance info and eligibility
2. collect payments
3. maintain up to date info about a health plans billing guidelines
4. follow federal, state, and local regulations on maintaining the confidentiality of information about patients
5. abstracting info from patients records for accurate billing
6. billing health plans and patients
7. assist pts with insurance info
8. processing payments
9. maintaining financial records
10. updating forms and computer systems the practice uses for pt info. and health care claims processing
what are the eight facts that are documented in the medical record for an ambulatory patient encounter?
1. patients name
2. encounter date and reason
3. appropriate history and physical examination
4. review of all tests that were ordered
5. diagnosis
6. plan of care, or notes on procedures or treatments that were given
7. instructions or recommendations that were given to the patient
8. signature of the provider who saw the patient
what are the four functions of a PMP that relate to manageing claims?
1. creating electronic claims
2. monitoring clims status electronically
3. receiving notification of electronic payments
4. handling electronic payments
what are the responisbilities of the clinical staff?
provide treatment for patients
what are the responibilities of the administrative staff?
they manage the business aspects of health care, they work behind the scenes in a medical office and do not provide medical treatment or testing.
what its the goal of HIE?
facilitate access to clinical information for the purpose of providing quality care to patients.
what are the 8 core functions of the EHR?
1. Health Info & data element – pt demographic info
2. results management – access to current & past labs & tests results
3. order mgt – ability to send, receive & store orders for medications, tests and other services
4. decision support
5. electronic communication & conncectivitiy – ability for health plans/providers to access info
6. patient support
7. administrative processes – procedure codes and Dx codes enterd by physician in the EHR are transmitted electronically to PMP where coding specialist reviews them
8. reporting & population management
Electronic Funds Transfer (EFT)
electronic payments sent directly to the providers bank
the info needed to create a claim is found on what 2 documents?
patient information form and encounter form
when then payer receives the claim, it goes through a series of steps designed to determine whether the claim should be paid.
how is the A/R information important to a practice?
helps practice decide whether to buy or lease new equipment, adopt new technology, expand to a larger office, add staff etc.
Medicare Improvements for Patients and Providers Act 2008 – provides financial incentives to practioners who use e-prescribing, it enables them to transmit Rx electronically to a patients pharmacy
what does e-prescribing eliminate?
RX errors caused by illegible handwriting and electronically checks for drug interactions and allergies
MIPAA requires e-prescribing by what year? If providers fail to do so, what happens?
2011. They reduce payments to providers who fail to e-prescribe
what year did George W. Bush recommend greater use of IT in health care? And by what year should EHR be established by?
2004 and 2014
REC – regional extensions centers
offer information, guidance, training and support services to PCP who are in the process of making the transition to an EHR system.
integrated PM/EHR program
can share and exchange demographic info., appointment schedules and clinical data, so info does not have to be entered twice, once in PMP and secondly in EHR.
what are the benefits of integrated PM/EHR programs?
increases pt safety, improves the quality of pt care and reduces operating costs.
encounter AKA visit?
the meeting of the patient and the physician or other medical professional for the purpose of providing health care.
preventative care
care to keep diseases from occurring or to enable early detection and treatment. ex: routine physical, immunizations, screening tests and behavioral counseling.
acute care
provided for illnesses with sudden onset that are time limited – not expected to continue for more than a few days or weeks, such as the recovery for a broken bone.
chronic illness
Must be treated over the long term. On-going medical treatment for a lengthy period of time, in many cases for a life time. ex: heart disease, diabetes, asthma, AIDS.
Personal Health information (PHR)
are private, secure electronic files that are created, maintained and owned by the patient
what do PHR’s contain?
current medicines and dosages, Health information, immunization records, allergies, medical test results, past surgeries, and family medical history.
compliance officer
often the physician or practice manager – investigates and resolves all compliance issues pertaining to coding, billing, documentation and reimbursement.
is the administrative staff soley responsible for collecting payment for services?
NO – all personnel both admin. and clinical play key roles. each must commuincate critical information to other staff members for reimbursement to occur.

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