CEHRS flashcards

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

Medical record retention

HIPAA requires retention of compliance documentation for six years, but state law sets medical record retention and often requires longer periods; always follow the stricter, longer requirement.

Late entry documentation

A late entry is added after the original note and must be labeled 'late entry,' include the actual date and time of entry, and reference the date of service.

Record correction method

Draw a single line through the error, write the correct information, and add initials, date, and time; never erase, use white-out, or delete original text.

Audit trail purpose

An audit trail records who accessed or changed a record and when, supporting security investigations, compliance reviews, and legal discovery; it must be protected and retained.

Concurrent audit

A concurrent audit reviews documentation while the patient is still receiving care, allowing immediate correction and education before the claim is billed.

Retrospective audit

A retrospective audit reviews closed records after billing or discharge to measure documentation accuracy, coding compliance, and identify trends requiring provider education.

Legal hold on records

A legal hold suspends routine destruction of records relevant to litigation or investigation; destruction must stop until counsel releases the hold in writing.

HIPAA authorization elements

A valid authorization identifies the patient, recipient, purpose, expiration, and right to revoke, and is signed and dated by the patient or personal representative.

Treatment payment operations

TPO permits use or disclosure of protected health information without authorization for treatment, payment, and health care operations, subject to minimum necessary rules.

Breach notification deadline

Covered entities must notify affected individuals without unreasonable delay and no later than 60 days after discovery; HHS notification follows the same 60-day standard.

Psychotherapy notes protection

Psychotherapy notes require a separate, specific authorization for disclosure and are excluded from general treatment, payment, and operations disclosures under HIPAA.

Accounting of disclosures

Patients may request a list of disclosures of their health information for the prior six years, excluding disclosures for treatment, payment, and health care operations.

Patient right to access

Patients may request copies of their record; the covered entity must act within 30 days and may take one 30-day extension with written notice.

42 CFR Part 2

Federal rules protect substance use disorder treatment records more strictly than HIPAA, requiring patient consent for most disclosures and prohibiting redisclosure without consent.

Modifier 25

Modifier 25 indicates a significant, separately identifiable evaluation and management service was performed on the same day as a procedure by the same provider.

NCCI edit

National Correct Coding Initiative edits identify code pairs that should not be billed together; a modifier may override only when the services are genuinely distinct.

CMS-1500 form

The CMS-1500 is the standard paper claim form for professional services, including physician and non-institutional billing, submitted to Medicare and other payers.

UB-04 claim form

The UB-04 is the standard institutional claim form used by hospitals and facilities to bill inpatient, outpatient, and other facility services.

Medical necessity requirement

Billed services must be reasonable and necessary for diagnosing or treating the patient's condition; documentation must support the code and level of service.

Coinsurance versus copay

A copayment is a fixed dollar amount per service, while coinsurance is a percentage of the allowed amount that the patient pays after the deductible.

Subscriber versus patient

The subscriber is the person who holds the insurance policy; the patient may be the subscriber or a dependent, and the relationship must be reported accurately.

Coordination of benefits

COB rules determine which health plan pays first when a patient has multiple coverages; the primary plan pays, and the secondary may cover remaining costs.

Birthday rule

For dependent children covered by both parents, the plan of the parent whose birthday falls earlier in the calendar year is primary under common COB rules.

Eligibility transaction 270

The 270 health care eligibility benefit inquiry and 271 response are electronic transactions used to verify a patient's coverage before services are rendered.

NPI characteristics

A National Provider Identifier is a unique 10-digit number assigned to health care providers for standard electronic transactions; it contains no embedded intelligence.

Guarantor responsibility

The guarantor is the person financially responsible for the patient's account, often the subscriber or parent, and receives billing statements.

HL7 standard

Health Level Seven is a messaging standard used to exchange clinical and administrative data between health information systems, such as admissions and results.

FHIR standard

Fast Healthcare Interoperability Resources is a modern HL7 standard using web APIs to exchange discrete health data between systems and applications.

Continuity of Care Document

The CCD is an electronic summary of a patient's health information, including medications, allergies, problems, and results, used to support care transitions.

Clinical decision support

CDS provides clinicians with alerts, reminders, order sets, and evidence-based guidance at the point of care to improve safety and quality.

Role-based access control

RBAC grants system permissions based on job duties, ensuring staff access only the patient information needed for their role, supporting minimum necessary compliance.

Promoting Interoperability

The CMS program formerly called Meaningful Use incentivizes eligible professionals and hospitals to use certified EHR technology and exchange health information.