NHA CEHRS STUDY GUIDE
2024/2025
advanced directive (living will) - CORRECT ANSWER legal document that
contains information about the patients treatment choices when they are unable to
make healthcare decisions
aging report - CORRECT ANSWER report that identifies past due patient or
insurance account balances and is usually run monthly
assignment of benefits - CORRECT ANSWER a patient authorization to allow
health insurance payment to be made directly to the provider of services
authorization - CORRECT ANSWER a document that approves disclosure of
protected health information unrelated to treatment under the HIPAA privacy rule
benchmark - CORRECT ANSWER a measure of performance against industry
standards
business associate - CORRECT ANSWER a third party entity that has contact
with protected health information to provide services unrelated to treating patients
,business associate agreement - CORRECT ANSWER 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) - CORRECT ANSWER 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) - CORRECT ANSWER 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 - CORRECT ANSWER internal policies designed to
prevent claim error, fraud, and abuse
computerized provider order entry (CPOE) - CORRECT ANSWER use of
computer system to enter prescriptions and treatment at the point of care
covered entity - CORRECT ANSWER a medical or health care service,
organization, agency, or individual that has protected health information
, Current Procedural Terminology (CPT) 4th edition - CORRECT ANSWER 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 - CORRECT ANSWER the process of removing personal health
information accessible to providers and other staff members with login credentials
regardless of location
electronic health record (EHR) - CORRECT ANSWER 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) - CORRECT ANSWER an
electronic record containing a patients medication, administration times, and who
administered it
encoder - CORRECT ANSWER software used to assign diagnosis and
procedural codes
encounter form - CORRECT ANSWER 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
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