CCA (AHIMA) key terms

The complete set of clinical, administrative, and financial documentation created during a patient's contact with a health care organization, kept to support care decisions, legal needs, and billing.

The process of verifying that an entry in the record was made or approved by the person named as its author, typically through a handwritten or electronic signature with date and time.

A late entry added to a health record to supply missing details or clarify earlier documentation; it carries the date it was written and never alters or removes the original entry.

A legal document prepared while a patient is still able to decide, stating preferences for future medical treatment or naming another person to make those decisions.

A patient's voluntary agreement to a test or treatment after being told its purpose, risks, benefits, and alternatives, documented in the record before the service is performed.

A schedule shaped by law, regulation, and facility policy that states how long each type of health record must be kept before it may be lawfully destroyed.

The controlled process of disclosing patient information to a requesting party only after confirming that a valid patient authorization or a legal permission applies.

The classification system used in the United States to assign codes to diagnoses, symptoms, and reasons for visits on both inpatient and outpatient claims.

A procedure classification used only for inpatient hospital reporting in the United States, built from seven-character codes describing body system, root operation, body part, approach, and device.

A code set maintained by the American Medical Association that describes medical services and procedures and is used mainly for physician and outpatient facility billing.

A national code set covering supplies, drugs, durable medical equipment, and services not described by CPT, reported on claims sent to Medicare and other payers.

The condition established after study to be chiefly responsible for the patient's admission to the hospital, reported as the first-listed diagnosis on an inpatient claim.

A flag showing whether a condition was already present when an inpatient stay began, used to separate hospital-acquired complications from conditions that arrived with the patient.

A written or electronic request asking the provider to clarify, add, or confirm documentation needed for accurate code assignment, worded so it does not lead the provider to a desired answer.

A short code appended to a procedure or service code that adds detail, such as which side of the body was treated or why a service was repeated or reduced.

Payer edit tables that pair codes which normally should not be billed together, flagging the combination as bundled unless a valid override modifier and supporting documentation exist.

A category of CPT codes describing visits and similar services in which a clinician evaluates and manages a patient's condition, selected by the documented level of service.

A prospective payment category Medicare uses for inpatient hospital stays, grouping patients with similar clinical conditions and similar expected resource use into one fixed payment amount.

The facility's internal listing that pairs every billable item and service with its charge amount and revenue code, kept current by the organization.

An organized set of policies, training, monitoring, and reporting channels a health care organization adopts to prevent, find, and fix violations of billing, coding, and privacy rules.

A federal law imposing civil liability, including treble damages, on anyone who knowingly submits or causes the submission of a false or fraudulent claim to a government payer.

A federal criminal law that forbids offering, paying, soliciting, or receiving anything of value to induce referrals for items or services paid by federal health care programs.

Federal regulation governing how covered entities may use and disclose protected health information and setting patient rights, including access to and amendment of their records.

The HIPAA principle that a covered entity should use, disclose, or request only the amount of protected health information needed to accomplish the intended purpose.

A facility-wide database that assigns one unique identifier to each patient and links all of that person's encounters, helping prevent duplicate and overlapping records.

A reference that defines each data element captured in a system, including its name, format, permitted values, source, and the meaning of the element.

The degree to which health information is complete, accurate, timely, and consistent, and is defined and captured the same way every time it is reported.

Information first collected for another purpose, such as patient care or claim payment, that is later reused for research, quality measurement, or planning.

A measure of the average severity and resource intensity of a hospital's inpatient population, calculated from assigned DRG weights and used in payment and comparison.

Comparing an organization's own performance measures or coded data against external standards, peer facilities, or prior results in order to find gaps and improve.

A digital, longitudinal record of a patient's health information that is created, stored, and shared across care settings, with functions such as order entry and results reporting.

A computer application that lets clinicians enter orders for medications, laboratory tests, and other services electronically, replacing handwritten orders and reducing transcription errors.

Automated tools built into health information systems that present alerts, reminders, guidelines, or reference material to clinicians at the moment a care decision is being made.

A security method that gives each user only the system permissions their job requires, limiting viewing and editing of health information to a need-to-know basis.

The electronic movement of health information among separate organizations, allowing providers in different settings to share patient data while care is being delivered.

The process of converting data into a coded form that can be read only with the correct key, used to protect health information stored on devices or sent over networks.