CCA (AHIMA) flashcards

32 cards. Read the term and the definition here. The deck at the top of this page is optional.

Authentication of health record entries

Verification that an entry was made by the person who claims authorship, using a unique written or electronic signature that cannot be shared, so the author can be held accountable.

History and physical timing

CMS requires hospitals to complete and document the history and physical within 24 hours after inpatient admission, or within 30 days before admission if it is updated on admission.

Late entry addendum

A correction or addition made after the original note is authenticated; it must be dated, timed, and signed when written, while the original entry remains unchanged and legible.

Discharge summary elements

The discharge summary documents the reason for admission, significant findings, procedures performed, condition at discharge, and discharge instructions or plan of care.

Verbal order authentication

A verbal or telephone order must be documented when received and then authenticated by the responsible practitioner within the timeframe set by medical staff bylaws or state law, commonly 24 hours.

Medical necessity documentation

Clinical documentation must justify the services reported and support the diagnoses and procedures coded; when it does not, payers may deny the claim as not medically necessary.

Health record retention

Retention periods are set by state law, facility policy, and payer contracts; Medicare requires records supporting claims and cost reports to be retained at least five years.

Excludes1 note

An ICD-10-CM note indicating two conditions are mutually exclusive and cannot be coded together; only the condition documented as the reason for the encounter is reported.

Principal diagnosis

For inpatient coding, the condition established after study to be chiefly responsible for occasioning the admission, sequenced first on the inpatient claim.

First-listed diagnosis

For outpatient coding, the diagnosis, symptom, or reason for the encounter chiefly responsible for the visit, sequenced first on the claim.

ICD-10-PCS structure

Seven alphanumeric characters with no decimal point, where each position has its own meaning: section, body system, root operation, body part, approach, device, and qualifier.

Modifier 25

Appended to an evaluation and management code when a significant, separately identifiable E/M service is performed on the same day as a procedure by the same physician.

Present on admission indicator

A claim flag showing a condition was present when the inpatient admission order was written; required on inpatient claims and excluded from hospital-acquired condition payment when marked Y.

Provider query

A formal communication to the physician when documentation is ambiguous, incomplete, or conflicting, requesting clarification that supports accurate code assignment without leading the respondent.

Nominal data

Data that classify observations into named categories with no inherent order or ranking; examples include sex, race, blood type, and discharge disposition.

Ratio data

The highest level of measurement: equal intervals plus a true zero, so meaningful ratios can be computed; weight, length of stay in days, and pulse are examples.

Median

The middle value in an ordered data set; with an even count it is the mean of the two middle values, and it is preferred when data are skewed.

UHDDS

The Uniform Hospital Discharge Data Set defines the minimum core data elements collected on every inpatient discharge, including patient demographics, diagnoses, procedures, and expected payer.

Hospital occupancy rate

Total inpatient service days divided by the product of bed count and the number of days in the period, multiplied by 100; a standard measure of capacity use.

Case mix index

The sum of the relative weights of all DRGs paid in a period divided by the number of discharges; higher values indicate patients requiring more resources.

Minimum necessary standard

A HIPAA requirement that uses and disclosures of protected health information be limited to the least amount reasonably needed to accomplish the intended purpose.

Breach notification timeframe

Covered entities must notify affected individuals without unreasonable delay and no later than 60 days after discovery; breaches affecting 500 or more people require immediate notice to HHS.

MS-DRG assignment

Inpatient groups are assigned from the principal diagnosis, performed procedures, secondary diagnoses acting as complications or comorbidities, discharge disposition, and patient age and sex.

Stark Law

A federal physician self-referral prohibition: physicians may not refer Medicare patients for designated health services to entities with which they or immediate family members have a financial relationship, absent an exception.

Anti-Kickback Statute

A federal criminal law prohibiting knowingly offering, paying, soliciting, or receiving remuneration to induce referrals of items or services payable by federal health care programs.

Advance Beneficiary Notice

A notice a provider gives a Medicare beneficiary when a service is expected to be denied as not medically necessary, allowing the patient to accept financial liability.

Master patient index

An enterprise-wide database that assigns a unique identifier to each patient and links encounters, enabling accurate record retrieval and detection of duplicate or overlapping records.

Role-based access control

A security method that grants system permissions according to a user's job function, so staff see only the patient information needed for their assigned duties.

Recovery point objective

The maximum acceptable amount of data loss, measured in time, that an organization will tolerate after a disruption; it drives how frequently backups are taken.

Health information exchange

The electronic movement of health-related data among organizations according to national standards, letting clinicians access patient information across separate systems and care settings.

Computer-assisted coding

Software that applies natural language processing to clinical text and suggests ICD, CPT, or HCPCS codes; a trained coder must review and validate every suggestion before final assignment.

X12 837 claim

The ASC X12N electronic transaction standard used to submit health care claims; 837P is used by professionals, 837I by institutional providers, and 835 returns the remittance advice.