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195 Cards in this Set
- Front
- Back
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plural of /um |
/a |
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plural of /us |
/i |
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plural of /a |
/ae |
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plural of /is |
/es |
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plural of /isis |
/itid/es |
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plural of i/on |
i/a |
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plural of ax |
ac/es |
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plural of /ix |
ic/es |
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plural of /ex |
ic/es |
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plural of /yx |
yc/es |
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plural of /nx |
ng/es |
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plural of /en |
in/a |
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plural of /ma |
mat/a |
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What does glomerular refer to? |
kidneys |
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Name the meninges |
dura mater, arachnoid, pia mater |
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encephalitis |
brain inflammation |
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myelitis |
inflammation of spinal cord |
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encephalomyelitis |
brain & spinal cord inflammation |
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systemic atrophy |
neurodegenerative disease (tissue deteriorates & loses functional activity) |
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Parkinson's disease |
creates movement disorders & pathologic midbrain changes that affect involuntary muscle system |
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Huntington's disease |
chronic, progressive mental deterioration & twisting movements of face, limbs, body |
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bacterial meningitis |
meninges inflammation caused by bacterium
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Alzheimer's disease
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condition of cerebral cortex atrophy, progressive decline in intellectual & physical functions
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Amyotrophic lateral sclerosis/Lou Gehrig's disease (ALS) |
progressively causes immobilization & death results from respiratory muscle paralysis |
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secondary Parkinsonism |
similar to Parkinson's but cause by meds, another nervous system disorder or illness |
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neoplasm |
new & abnormal growth |
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malignant primary |
where neoplasm originated
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malignant secondary |
site to where neoplasm travelled to |
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Ca in situ (carcinoma in situ) |
tumor cells undergoing changes, staying at primary site |
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benign |
noncancerous growth |
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uncertain |
tumors that can't be classified as benign or malignant because has features of each |
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unspecified behavior |
tumor behavior nor histological type specified in Dx |
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How is morphology [histology] determined? |
neoplasms named & classified according to original tissue type |
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How to code contiguous neoplasms? |
classify as .8 for overlapping lesion unless combination is specifically indexed elsewhere |
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primary site |
tumor's point of origin |
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personal history |
condition no longer exists & patient not receiving treatment for it but potential recurrence exists |
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When to code family history? |
patient has family member who had particular disease increasing risk for patient to develop it |
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metastasis |
disease transfer from one organ/part to another not directly connected with it (only malignant tumors) |
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neuroendocrine tumors |
throughout nervous & endocrine systems; hormone producing cells |
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carcinoid tumor |
slow-growing cancer type that can arise in several places, usually in GI tract |
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polycythemia vera |
blood disorder; bone marrow makes too many blood cells |
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myelodysplastic syndromes |
group of diseases; bone marrow doesn't produce enough healthy blood cells
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anemia
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RBCs number below normal |
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iron-deficiency anemia |
inadequate number of healthy RBCs leads to this |
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vitamin B-12 deficiency anemia |
marked by inadequate B-12 amount to make RBC that carry blood |
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folate (folic acid) |
necessary for RBC formation & growth |
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folate-deficiency anemia cause |
lack of folic acid, results in decrease of RBCs, leading to this anemia type |
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hemolytic anemia |
not enough RBC in blood due to premature RBC destruction |
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sickle-cell anemia |
RBC abnormal crescent-shaped |
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stem cell |
earliest form of cell in bone marrow |
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thyroid gland |
endocrine gland that secretes/stores thyroid hormones |
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hyperthyroidism |
thyroid gland produces too many thyroid hormones that circulate in blood |
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diabetes mellitus |
insufficient insulin production that leads to body's inability to metabolize carbs, protein, fat |
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type 2 diabetes |
most common form; body may not make enough insulin, doesn’t respond to insulin properly, or both; older/overweight |
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type 1 diabetes |
body makes little or no insulin; must take insulin every day |
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secondary diabetes mellitus |
not from genetics/environment but from another condition/event |
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BMI |
body mass index |
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overweight BMI |
25-29.9 |
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dementia |
general loss of intellectual abilities & personality |
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use |
act of taking a substance |
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abuse |
any harmful use of a substance |
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dependence |
addiction to substance |
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remission |
patient no longer uses, abuses or is dependent on substance |
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What are ICD-10-CM's categories? |
1st three code characters; "block" of code (ex. A09)
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What do the subcategories in ICD-10-CM represent?
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etiology, anatomical site, severity of condition |
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What is the extension in ICD-10-CM? |
7th code character |
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What is an initial encounter? |
first visit for current condition |
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subsequent encounter |
any visit after first for current condition
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sequela |
complications/conditions that arise as direct result of an injury/illness that no longer exists |
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place-holder |
allows for future expansion without disturbing 7th character |
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What do brackets [ ] signify? |
tabular list: synonyms, alternative wording, explanatory phrases; index: identify manifestations |
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manifestation |
condition caused by another illness |
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What are parenthesis ( ) used for? |
index/tabular list: enclose supplementary words that may/may not be present in statement of disease |
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What is colon : used for? |
tabular list: rarely used; may be used after incomplete term that requires adjective/descriptor |
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NEC |
not elsewhere classifiable; info in medical record provides detail for which specific code does not exist |
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NOS |
not otherwise specified; medical record info not enough to assign more specific code |
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code also |
no sequencing direction |
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Dx words not to code |
suspicion of, probable, likely |
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How to code unconfirmed/uncertain Dx? |
code only signs & symptoms |
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Acute & chronic conditions exist. Sequence? |
acute first then chronic |
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combination code |
one code, classifies 2 Dx |
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How to code left/right sides if no code for both? |
code left/right separately if both affected |
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coexisting condition - sequence |
principal Dx first then coexisting condition (ex. principal Dx - chronic arthritis, coexisting condition - sore throat) |
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What is the function of the GI system? |
extract nutrients & get rid of waste |
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an/o |
anus |
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append/o |
appendix |
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bucc/o |
cheek |
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cholecyst/o |
gallbladder |
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col/o |
colon, large intestine |
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colon/o |
colon |
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dent/i |
tooth |
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duoden/o |
duodenum |
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enter/o |
small intestine |
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esophag/o |
esophagus |
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faci/o |
face |
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gastr/o |
stomach |
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gloss/o |
tongue |
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hepat/o |
liver |
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ile/o |
ilium
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jejun/o |
jejunum |
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lapar/o |
abdomen |
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mandibul/o |
lower jaw, mandible |
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or/o |
mouth |
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pancreat/o |
pancreas |
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rect/o |
rectum |
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stomat/o |
mouth |
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BE |
barium enema |
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BM |
bowel movement |
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BRBPR |
bight red blood per rectum |
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GB |
gallbladder |
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GERD |
gastroesophageal reflux disease |
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GI |
gastrointestinal |
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HBV |
hepatitis B virus |
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IBD |
irritable bowel disease |
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LFTs |
liver function tests |
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n.p.o. |
nothing by mouth |
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PUD |
peptic ulcer disease |
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endocrine system function |
send messages to body via hormones, organs respond with chemicals of their own |
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major gland types |
endocrine, exocrine |
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exocrine glands |
gland secretions carried to surface (ex. sweat glands) |
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endocrine glands |
gland secretions discharged into bloodstream |
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aden/o |
gland |
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adren/o |
adrenal glands |
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adrenal/o |
adrenal glands |
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crin/o |
secrete |
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gluc/o |
sugar |
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glyc/o |
sugar |
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gonad/o |
sex glands |
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home/o |
sameness |
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hormon/o |
hormone |
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insulin/o |
insulin |
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myx/o |
mucus |
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parathyroid/o |
parathyroid gland |
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pituitar/o |
pituitary gland |
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somat/o |
body |
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thyr/o |
thyroid gland |
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thyroid/o |
thyroid gland |
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toc/o |
child birth |
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toxic/o |
poison |
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BMR |
basal metabolic rate |
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DI |
diabetes insipidus |
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DM |
diabetes mellitus |
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FBG |
fasting blood glucose |
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FBS |
fasting blood sugar |
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GH |
growth hormone |
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IDDM |
insulin dependent diabetes mellitus (type 1 diabetes) |
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IGF |
insulin-like growth factors |
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NIDDM |
non-insulin dependent diabetes mellitus |
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PRL |
prolactin |
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PTH |
parathyroid hormone |
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TFT |
thyroid function test |
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TSH |
thyroid stimulating hormone |
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subpoena |
issued by court requiring person named to appear in court/supply requested documents or both; can authorize legal release of medical records |
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arbitration |
court of law alternative; cheaper & usually resolves issues quicker than court system; disputing parties meet with arbitrator who makes ruling |
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nonbinding arbitration |
ruling is suggestion from objective person |
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binding arbitration |
ruling is final & must be obeyed |
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testimony |
sworn witness/expert statement while on witness stand in court; lie = perjury charge |
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RACs |
recovery audit contractors recover overpayments for Medicare & Medicaid |
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punitive damages |
damages collected by insurance when fraud discovered; punish defendant & deter him from repeating; can far exceed compensatory charges (ex. 5 times fraud amount) |
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insurance audit |
thorough review by insurance of claim & related documentation; records searched for inconsistencies & alterations |
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compensatory damages |
damages collected by insurance when fraud discovered; damages collected = fraud amount |
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compliance plans |
used by healthcare providers; identify, investigate & prevent fraud violations in healthcare services |
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FCA |
federal false claims act; basis for prosecution of healthcare fraud & abuse claims; prohibits anyone from committing fraud |
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fraud |
inaccurate info used to wrongfully gain compensation |
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willful neglect |
intentional failure/reckless indifference to comply with administrative simplification provision violated |
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resolution agreement |
used by Office for Civil Rights to resolve violation complaint of breached info; contract signed where covered entity agrees to perform certain obligations (ex. staff training for 3 years) |
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OCR |
Office for Civil Rights; enforces privacy & security rules by investigating & educating |
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unsecured protected health information |
info not encrypted |
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breach |
violation of a standard |
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encryption |
electronic info translated into coded form, cannot be understood without decryption equipment |
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security rule |
establishes national set of security standards for electronic health info; does not apply to PHI transmitted orally/in writing; protects & allows for access to ePHI |
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minimum necessary |
limits unnecessary/inappropriate access to & disclosure of PHI |
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authorization |
required for any use/disclosure of PHI not being used for treatment, payment & healthcare operations (TPO) |
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TPO |
treatment, payment & healthcare operations |
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consent |
written permission |
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notice of privacy practices |
form defining how provider can use PHI |
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protected health information (PHI) |
individually identifiable info held/transmitted by covered entity or its business associate in any form (written, paper, electronic)
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HIPAA Privacy Rule |
sets national standards for use & disclosure of PHI; protects PHI |
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electronic data interchange (EDI) |
info transferred electronically in standard format between trading partners (insurance & provider) |
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transaction & code sets standards |
outline format & codes used for electronic transmissions |
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electronic transaction
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transmitted via electronic medium (ex. internet) |
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transaction |
electronic exchange involving info transfer between two parties for specific purpose |
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business associate |
person who assists in activity involving use of individually identifiable health info (ex. independent medical transcriptionist) |
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covered entities |
health plans, healthcare clearing houses, healthcare providers who transmit health info in electronic form; follow HIPAA regulations; healthcare professionals part of covered entity's workforce also covered entity |
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administrative simplification compliance act |
sets national standards for privacy, security, unique identifiers, transactions & code sets |
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what ASCA stands for |
administrative simplification compliance act |
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titles |
HIPAA sections |
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HITECH |
health information technology for economic & clinical health act; promotes adoption & meaningful use of health information technology |
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accountability |
to increase healthcare system effectiveness while protecting health data integrity, confidentiality & availability, as well as preventing fraud & abuse |
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portability |
to ensure continuation of health insurance coverage for workers & families during times of job loss/change |
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HIPAA |
health insurance portability and accountability act; objectives are portability & accountability |
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code of ethics |
document outlining ethical guidelines; lists behaviors & efforts members/employers expected to uphold |
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medical ethics |
include confidentiality, accuracy, integrity, completeness & proper storage of medical records; involves guarding against fraud & misleading claims |
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confidential |
something kept secret |
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civil money penalties |
willful neglect punishment |
