RHIA cheat sheet

Information governance (IG) is an enterprise-wide framework of accountabilities, policies, processes, and standards governing the creation, use, retention, and disposition of information.

AHIMA's eight IG principles: accountability, transparency, integrity, protection, compliance, availability, retention, and disposition.

Information lifecycle: capture/creation, maintenance and use, disclosure/access, retention, and destruction; retention and disposition decisions are made at the designated end of the lifecycle, not ad hoc.

Common data quality dimensions: accuracy, completeness, consistency, timeliness, validity, granularity, precision, accessibility, and relevancy.

Designated record set (45 CFR 164.501) is the group of medical, billing, and other records used in whole or part to make decisions about individuals; it defines the scope of individual access and amendment rights.

The legal health record is the subset of information the organization designates as its official business record of care; it is what is disclosed to requesters and must be defined in policy.

Medicare Conditions of Participation (42 CFR 482.24) require hospitals to retain records in accordance with state law but for no less than 5 years.

Data governance assigns decision rights and accountability through data owners and data stewards; IG is broader and also spans privacy, security, compliance, retention, and analytics enablement.

Master patient index integrity requires one unique identifier per patient; duplicate and overlay errors are tracked as a data quality metric because they affect patient safety and claims.

Uses and disclosures for treatment, payment, and health care operations (TPO) require no authorization; uses and disclosures not permitted by the Privacy Rule require a valid authorization.

The minimum necessary standard applies to most uses, disclosures, and requests, but not to disclosures to or requests by a provider for treatment, disclosures to the individual, or disclosures made under a valid authorization.

Disclosures required by the Privacy Rule include disclosures to the individual and to HHS for compliance investigation; other disclosures, such as mandated public health reporting, are permitted when required by law.

Valid authorization elements: description of the PHI, who may disclose, who may receive, purpose, expiration date or event, signature and date, right to revoke, right to refuse to sign, and a redisclosure statement.

Breach notification: individuals must be notified without unreasonable delay and no later than 60 days after discovery; HHS is notified concurrently for breaches affecting 500 or more individuals, with media notice when 500 or more reside in a state or jurisdiction.

An accounting of disclosures covers the 6 years preceding the request and excludes disclosures for TPO, disclosures to the individual, and disclosures made under a valid authorization.

Right of access: the covered entity must act within 30 days of the request and may take one 30-day extension with written notice; fees are limited to reasonable, cost-based amounts or a permitted flat fee.

Preemption: HIPAA establishes a federal floor; a state law that is stricter or affords greater privacy protection generally controls over the contrary HIPAA provision.

De-identification uses either Safe Harbor (removal of 18 specified identifiers) or Expert Determination by a qualified statistician; psychotherapy notes and 42 CFR Part 2 substance use disorder records require separate, specific consent.

Levels of measurement: nominal (unordered categories), ordinal (rank order), interval (equal intervals, no true zero), and ratio (true zero, all arithmetic operations valid).

Central tendency: the mean suits interval/ratio data but is sensitive to outliers; the median suits ordinal or skewed data; the mode is the only measure valid for nominal data.

Rate = (number of events divided by population at risk) multiplied by a constant; incidence counts new cases during a period, while prevalence counts all existing cases at a point or over a period.

Sensitivity = TP / (TP + FN); specificity = TN / (TN + FP); positive predictive value = TP / (TP + FP); negative predictive value = TN / (TN + FN).

Chart selection: bar chart for categorical comparisons, line chart for trends over time, histogram for distribution shape, scatterplot for correlation, pie chart only for a few parts of a whole.

A data warehouse is an integrated, subject-oriented, time-variant, nonvolatile repository; a data mart is a subset serving one business area; a data lake holds raw structured and unstructured data.

Interoperability standards: HL7 v2 for messaging, CDA for clinical documents, FHIR for application programming interfaces; terminology via SNOMED CT, LOINC, ICD-10-CM/PCS, CPT, and RxNorm.

Sampling methods include simple random, stratified, systematic, cluster, and convenience; a p-value below 0.05 is commonly used as the threshold for statistical significance, which differs from clinical importance.

Revenue cycle phases: pre-service (scheduling, eligibility verification, prior authorization), service (charge capture, documentation, coding, clinical documentation integrity), and post-service (claims submission, denial management, collections).

Claim forms: CMS-1500 for professional claims; UB-04/CMS-1450 for institutional claims.

Coding systems: ICD-10-CM for diagnoses, ICD-10-PCS for inpatient procedures, and CPT or HCPCS Level II for outpatient services, procedures, and supplies.

Payment systems: inpatient stays are paid under the IPPS by MS-DRG; hospital outpatient services are paid under OPPS by APC; case mix index = sum of DRG relative weights divided by total discharges.

Days in accounts receivable = total accounts receivable divided by average daily charges (or net revenue); it is a primary measure of liquidity and collection efficiency.

Net collection rate = payments divided by (gross charges minus contractual allowances); clean claim rate = clean claims divided by total claims submitted.

DNFB (discharged, not final billed) counts accounts that cannot be billed because coding, documentation, or abstracting is incomplete, and is a leading cause of revenue delay.

Medical necessity denials are appealed with supporting documentation; an Advance Beneficiary Notice must be issued before a Medicare beneficiary receives a service expected to be non-covered so the patient accepts financial responsibility.

The 3-day payment window (72-hour rule) bundles outpatient services furnished within 3 days before an inpatient admission (1 day for non-IPPS hospitals) into the inpatient claim unless a documented exception applies.

Management functions: planning, organizing, staffing, directing, controlling, and evaluating; budgeting and variance analysis are control activities.

Leadership styles: autocratic, democratic/participative, laissez-faire, transactional (reward and exchange), transformational (vision and inspiration), situational, and servant.

Motivation theories: Maslow (hierarchy of needs), Herzberg (hygiene factors versus motivators), McGregor (Theory X versus Theory Y), and McClelland (achievement, affiliation, power).

Team development (Tuckman): forming, storming, norming, performing, and adjourning.

Change models: Lewin (unfreeze, change, refreeze) and Kotter's eight steps, beginning with creating urgency and ending with anchoring change in the culture.

Conflict modes (Thomas-Kilmann): competing, collaborating, compromising, avoiding, and accommodating; collaborating pursues a win-win outcome when both concerns are high.

Staffing math: 1 FTE = 2,080 paid hours per year; productivity = worked hours divided by units of service; hours per patient day = productive hours divided by patient days.

Strategic planning: SWOT environmental scan, then mission and vision, SMART goals, action plans, and evaluation; root cause analysis investigates sentinel events, and just culture distinguishes human error from at-risk and reckless behavior.