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15 Cards in this Set

  • Front
  • Back
ABUSE
Actions that improperly use another person's resources
AUDIT
A formanl examination of a physician's accounting or patient medical records
AUTHORIZATION
Document signed by a patient that permits the release of particular medical information under specific stated conditions
BUSINESS ASSOCIATE
A person or organization that performs a function or activity for a covered entity but is not part of its work force
(CMS) CENTERS FOR MEDICARE AND MEDICAID SERVICES
Federal agency within the Department of Health and Human Services (HHS) that runs medicare, medicaid, clinical laboratories and other government health programs
CHIEF COMPLAINT (CC)
A patients description of the symptoms or other reasons for seeking medical care from a provider
CLEARINGHOUSE
A company that converts, for a fee, nonstandard data formats into HIPAA standard transactions and transmits the data to health palns; or also handles the reverse process, changing the HIPAA formatted transactions from health plans into nonstandard formats for providers
CODE SET
Alphabetic and/or numeric representations for data
COVERED ENTITY
(CE)
Under HIPAA, a health plan, clearinghouse, or provider that transmits any health information in electronic form in connection with a HIPAA transaction
DE-IDENTIFIED HEALTH INFORMATION
Medical data from which individual identifiers have been removed; also known as a redacted or blinded record
DESIGNATED RECORD SET
(DRS)
A covered entity's records that contain Protected Health Information (PHI)
DOCUMENTATION
The systematic, logical, and consistent recording of a patient's health status, history, examinations, tests, results of treatment and observations- in chronological order in a patient medical record
ELECTRONIC MEDICAL RECORD
(EMR)
Creation and/ or maintenance of a patient medical records in electronic form, such as computer files
ENCOUNTER
An office visit between a patient and a medical professional
EVALUATION ANS MANAGEMENT
(E/M )
Procedure codes that cover physicians' services performed to determine that optimum course for a patients care.
(listed in the E/M section of the CPT)