NHA CEHRS Study Material | Questions And Answers Latest {2024- 2025} A+ Graded |
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advanced directive (living will) - legal document that contains information about the patients treatment
choices when they are unable to make healthcare decisions
aging report - report that identifies past due patient or insurance account balances and is usually run
monthly
assignment of benefits - a patient authorization to allow health insurance payment to be made directly
to the provider of services
authorization - a document that approves disclosure of protected health information unrelated to
treatment under the HIPAA privacy rule
benchmark - a measure of performance against industry standards
business associate - a third party entity that has contact with protected health information to provide
services unrelated to treating patients
business associate agreement - a legal contract dictating a business associate to comply with protection
of protected health information under the HIPAA privacy rule
Centers for Medicare and Medicaid Services (CMS) - a federal regulated agency that is part of the
Department of Health and Human Services, administers Medicare, works with the state governments to
administer Medicaid programs, sets standards for interoperability of EHR, and overseas implementation
of federal legislation
clinical documentation improvement (CDI) - process for executing and improving and reviewing clinical
documentation to ensure that it accurately reflects and supports CPT and ICD-10-CM codes submitted
with claims for payment
compliance program - internal policies designed to prevent claim error, fraud, and abuse
, computerized provider order entry (CPOE) - use of computer system to enter prescriptions and
treatment at the point of care
covered entity - a medical or health care service, organization, agency, or individual that has protected
health information
Current Procedural Terminology (CPT) 4th edition - a coding classification system used to report
professional services and procedures provided to a patient at ambulatory care centers, medical clinics,
and other outpatient care facilities
de-identification - the process of removing personal health information accessible to providers and
other staff members with login credentials regardless of location
electronic health record (EHR) - a record of patient health care information accessible to providers and
other staff members with login credentials regardless of location
electronic medication administration record (eMAR) - an electronic record containing a patients
medication, administration times, and who administered it
encoder - software used to assign diagnosis and procedural codes
encounter form - and itemized bill for services that contains diagnosis and procedure codes and is used
by administrative staff to complete claims forms; also known as a superbill, fee slip, or charge form
encryption - converting email or other information into a code that only intended recipients can read
explanation of benefits (EOB) - a statement that shows a patient how services provided were processed
by the insurance carrier
Health Information Technology for Economic and Clinical Health (HITECH) Act - federal legislation that
expands consumer rights and protections outlined by HIPAA and sets standards for quality and use of
EHR
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