Classification system of patients based on the International Classification of Diseases, clinical modification codes for diagnoses, current procedural terminology evaluation and management codes, and procedure codes, age, sex, and visit deposition used for reimbursement for health care provided in the hospital outpatient setting.
Comprehensive listing of medical terms and codes for the uniform designation of diagnostic and therapeutic procedures; used in the United States for coding for physician reimbursement and hospital outpatient and ambulatory surgical procedures
System that categorizes into payment group patients who are medically related with respect to diagnosis and treatment and statistically similar with regard to length of stay
Electronic health record system generally considered as the portal through which climates access a patient's health record, order treatments or therapy, & document care delievered to patients; allows providers to gather multiple types of data about a patient (clinical, financial, administrative, & research)
An accreditation program "authorized by the Centers for Medicare & Medicaid Services to survey" all hospitals and many other types of health care settings
Term used to encompass both registered health information administrators and registered health information technicians as individuals with either of these credentials who hold a variety of positions within the health information management profession
Federal legislation passed to improve the efficiency & effectiveness of the health care system; components that affect health info. include privacy, security, & the establishment of standards and requirements for the electronic transmission of certain health info.
Permanent or long-lasting documentation of all patient care info. that applies to individual patients
The classification system used in the United States to report morbidity & mortality info. until Sept 30, 2015
The classification system that replaced ICD-9-CM Volumes 1/2 on Oct 1, 2015. This classification system is used for diagnosis coding in all health care setting in the United States.
A classification system used in the United States for reporting of inpatient hospital procedures. Replaces the ICD-9-CM Vol.3 procedures codes on Oct 1, 2015.
Organization that accredits and certifies health care organizations & other programs in the US.
Process by which the quality of the care & services provided to patients within a health care facility is monitored & evaluated
System for Medicare patients by which a predetermined level of reimbursement is established before services are provided
Professionals who posses the expertise to develop, implement, and/or manage individual, aggregate, & public health care data in support of patient safety & privacy, as well as the confidentiality & security of health info
Professionals who are technical experts in health data collection, analysis, monitoring, maintenance, & reporting activities in accordance with established data-quality principles, legal & regulatory standards, & professional best practice guidelines
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