RHIT STUDY GUIDE!! WHITE BOARD NOTES| WITH 100% VERIFIED SOLUTIONS

RHIT STUDY GUIDE!! WHITE BOARD NOTES| WITH 100% VERIFIED SOLUTIONS Policies- - ANSWER -Principles describing how a department or organization will handle a specific situation or evaluate a specific process. They are clear simple statements of how an HIM department will conduct it's services. Procedures- - ANSWER -Once policies are in place, procedures will define the processes by which the policies are put into action. Procedures are written documents that describe the steps involved in performing a specific function. OIG Workplan- - ANSWER -Provides information on new and ongoing reviews or audits each year. National Practitioner Data Bank- - ANSWER -Provide a database of medical malpractice payments, adverse licensure actions and certain professional review actions taken by healthcare entities. Benchmarking- - ANSWER -Compares organization standards against external organizations. Red Flag Rule- - ANSWER -Used as triggers to alert organizations of potential identity theft. Average length of Stay- - ANSWER -25 days or less Fraud- - ANSWER -Intentionally executes or attempts to execute a scheme to obtain money or any healthcare benefit program. Compliance Officer- - ANSWER -Checks the written standards of conduct, policies, procedures, and audits that address the areas of potential fraud. Chief Privacy Officer- - ANSWER -Responsible for privacy practices within the organization, performs privacy risk assessments, overseeing privacy training. Office of Inspector General OIG- - ANSWER -Office in the federal government working to combat fraud, waste and abuse to improve the efficiency of HHS programs. Medical Necessity- - ANSWER -The determination that the services provided will benefit the patient and are needed. Health Insurance Portability and Accountability Act (HIPAA)- - ANSWER United States legislation enacted to control fraud and abuse in healthcare, reduce healthcare costs, provides data privacy and security provisions for safeguarding medical information. Data Dictionary- - ANSWER -A listing of all the data elements within a specific system that defines each individual data element, standard input of the data element and specific data length. Living Will- - ANSWER -Written statement detailing a person's desires regarding their medical treatment in circumstances in which they're no longer able to express informed consent, especially an advance directive Secondary Data - ANSWER -Secondary Data- Data derived from the primary patient record such as an index, registry or database for things such as research and quality patient safety. Cancer Registry- - ANSWER -Records maintained by many states for the purpose of tracking the incidence new cases of cancer. Administrative Safeguards- - ANSWER -Include policies and procedures that address the management of computer resources. Master Patient Index MPI- - ANSWER -Most common patient- identifying directory. Anti-kickback Statute- - ANSWER -Dictates that physicians can't receive money or other benefits for referring patients to a healthcare facility. Noncustodial Parents rights to Medical Records- - ANSWER -By law, a parent not granted custody of a minor child has the same right as the custodial patent to the child's academic, medical, hospital or other health records, unless otherwise order by the courts. Audit Trail- . - ANSWER -A coding compliance manager reviewing tool that identifies when a user logs in and out, what he or she does, and more Physician Advisor/Champion- - ANSWER -Well-respected physician who can informally help physician community adapt to and ultimately adopt health IT. Is the communicator between CDI and actual physician. POA INDICATIORS- - ANSWER -Y N U W Y- - ANSWER -Diagnosis was present at time of inpatient admission N- - ANSWER -Diagnosis was not present at time of inpatient admission U- - ANSWER -Documentation insufficient to determine if the condition was present at the time of inpatient admission. W- - ANSWER -Clinically undetermined. Provider unable to clinically determine whether the condition was present at the time of inpatient admission Query- . - ANSWER -Communication tool for CDI staff to communicate with providers to obtain clinical clarification, provide a documentation alert, get documentation clarification or ask questions regarding documentation Clinical Documentation Improvement- - ANSWER -The process an organization undertakes that will improve clinical specificity and documentation that will allow coders to assign more concise disease classification codes.