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History types

"Generally defined by E/M services as: problem focused (chief complaint; brief history of present illness or problem); expanded problem focused (chief complaint; brief history of present illness; problem-pertinent system review); detailed (chief complaint; extended history of present illness; extended system review; pertinent past, family, and/or social history); and comprehensive (chief complaint; extended history of present illness; complete system review; complete past, family, and social history)"


A method for accomplishing an end

Medical services

"The activities relating to medical care performed by physicians, nurses, and other healthcare professional and technical personnel under the direction of a physician"

Voluntary Disclosure Program

"A program unveiled in 1998 by the OIG that encourages healthcare providers to voluntarily report fraudulent conduct affecting Medicare, Medicaid, and other federal healthcare programs"

Net income

The difference between total revenues and total expenses

Transaction standards

Standards that support the uniform format and sequence of data during transmission from one healthcare entity to another

Health insurance prospective payment system (HIPPS) code

"A five-character alphanumeric code used in the home health prospective payment system (HHPPS) and in the inpatient rehabilitation facility prospective payment system (IRF PPS). In the HHPPS, the HIPPS code is derived or computed from the home health resource group (HHRG); in the IRF PPS, the HIPPS code is derived from the case mix group and comorbidity. Reimbursement weights for each HIPSS code correspond to the levels of care provided"

New technology

"Advance in medical technology that substantially improves, relative to technologies previously available, the diagnosis or treatment of Medicare beneficiaries. Applicants for the status of new technology must submit a formal request, including a full description of the clinical applications of the technology and the results of any clinical evaluations demonstrating that the new technology represents a substantial clinical improvement, along with data to demonstrate the technology meets the high cost threshold"


"1. The vocabulary used in a language or a subject area or by a particular speaker or group of speakers 2. A collection of words or terms and their meanings for a particular domain, used in healthcare for drug terms"

"International Classification of Impairments

Disabilities, and Handicaps (ICIDH)","Published by the World Health Organization to measure the consequences of disease and divided into three classifications: impairments, disabilities, and handicaps; the precursor to ICF"


A physician licensed to practice in osteopathy (a system of medical practice that is based on the manipulation of body parts as well as other therapies)

System testing(s)

A type of testing performed by an independent organization to identify problems in information systems

Disease index

A list of diseases and conditions of patients sequenced according to the code numbers of the classification system in use


A patient's full address and zip code


Medicare",An organization under contract with the Centers for Medicare and Medicaid Services to serve as the financial agent that works with providers and the federal government to locally administer Medicare eligibility and payments

Traditional fee-for-service (FFS) reimbursement

A reimbursement method involving third-party payers who compensate providers after the healthcare services have been delivered; payment is based on specific services provided to subscribers


Any material or chemical substance subjected to analysis

Local Codes

"Also known as HCPCS Level III Codes, these codes were developed by local Medicare and/or Medicaid carriers and were eliminated December 31, 2003, to comply with HIPAA"

Years of schooling

The highest grade of schooling completed by the enrollee or patient

Image processing

"The ability of a computer to create a graphic representation of a text block, photograph, drawing, or other image and make it available throughout an information system"

Discovery process

"The pretrial stage in the litigation process during which both parties to a suit use various strategies to identify information about the case, the primary focus of which is to determine the strength of the opposing party's case"

Computers on wheels (COWs)

Term affectionately used to refer to notebook computers mounted on carts and moved with the users

Hospital inpatient autopsy

A postmortem (after death) examination performed on the body of a patient who died during an inpatient hospitalization by a hospital pathologist or a physician of the medical staff who has been delegated the responsibility

Ethical agent

An individual who promotes and supports ethical behavior

Highly active antiretroviral therapy (HAART)

A type of therapy that consists of multiple drugs commonly given to HIV-positive individuals before they develop AIDS

Medication usage review

An evaluation of medication use and medication processes

Global payment method

Method of payment in which the third party payer makes one consolidated payment to cover the services of multiple providers who are treating a single episode of care


"A new, separate company formed by a parent company whose shares are distributed to existing shareholders of the parent company in proportion to the new entity's relationship to the parent company"

Temporary budget variance

The difference between the budgeted and actual amounts of a line item that is expected to reverse itself in a subsequent period; the timing difference between the budget and the actual event


"1. The ability of a subject to view, change, or communicate with an object in a computer system 2. One of the rights protected by the Privacy Rule; an individual has a right of access to inspect and obtain a copy of his or her own PHI that is contained in a designated record set, such as a health record "

Data comparability

The standardization of vocabulary such that the meaning of a single term is the same each time the term is used in order to produce consistency in information derived from the data

Certified coding specialist-physician based (CCS-P)

"An AHIMA credential awarded to individuals who have demonstrated coding expertise in physician-based settings, such as group practices, by passing a certification examination"

Data consistency

"The extent to which the healthcare data is valid, accurate, usable and has integrity, so that each end user has a consistent view of the data"

Network provider

A physician or another healthcare professional who is a member of a managed care network

Systems analysis and design

A performance improvement methodology that can be applied to any type of system

Clean claim

A completed insurance claim form that contains all the required information (without any missing information) so that it can be processed and paid promptly

Group practice without walls (GPWW)

A type of managed care contract that allows physicians to maintain their own offices and share administrative services

Risk prevention

One component of a successful risk management program

System implementation

The third phase of the systems development life cycle

Strategic goals

Long-term objectives set by an organization to improve its operations

Project deliverables

The tangible end results of a project

Medical savings account (MSA) plans

"Plans that provide benefits after a single, high deductible has been met whereby Medicare makes an annual deposit to the MSA and the beneficiary is expected to use the money in the MSA to pay for medical expenses below the annual deductible"


Former name of Medicare Advantage (Part C)


The machines and media used in an information system


The application of technology to managing health information

Randomized clinical trial (RCT)

A special type of clinical trial in which the researchers follow strict rules to randomly assign patients to groups

Long-term assets

"Assets whose value to the organization extends beyond one fiscal year, for example, buildings, land, and equipment are long-term assets"


The action taken to eliminate the balance of a bill after the bill has been submitted and partial payment has been made or payment has been denied and all avenues of collecting the payment have been exhausted

Request for proposal (RFP)

A type of business correspondence asking for very specific product and contract information that is often sent to a narrow list of vendors that have been preselected after a review of requests for information during the design phase of the systems development life cycle

Preoperative anesthesia evaluation

An assessment performed by an anesthesiologist to collect information on a patient's medical history and current physical and emotional condition that will become the basis of the anesthesia plan for the surgery to be performed

National provider file (NPF)

"A file developed by the Centers for Medicare and Medicaid Services that includes all healthcare providers, including nonphysicians, and sites of care"

Essential Medical Data Set (EMDS)

A recommended data set designed to create a health history for an individual patient treated in an emergency service


A medication with no active ingredients

Newborn autopsy rate

The number of autopsies performed on newborns who died during a given time period divided by the total number of newborns who died during the same time period

Judge-made law

Unwritten law originating from court decisions where no applicable statute exists

Applications and data criticality analysis

"A covered entity's formal assessment of the sensitivity, vulnerabilities, and security of its programs and the information it generates, receives, manipulates, stores, and/or transmits"

Healthcare informatics

The field of information science concerned with the management of all aspects of health data and information through the application of computers and computer technologies


The ability of different information systems and software applications to communicate and exchange data

Aging of accounts

"The practice of counting the days, generally in thirty-day increments, from the time a bill was sent to the payer to the current day"


The first stage of Lewin's change process in which people are presented with disconcerting information to motivate them to change

No man's land

The zone in the palmar or volar surface of the hand between the distal palmar crease (the crease in the palm closest to the fingers) and the middle of the middle phalanx (middle finger)

Leader-member relations

"A situation in contingency theory describing how well the leader is liked, respected, and followed"

Midnight rule

A Medicare regulation that states the day preceding a leave of absence becomes a nonbillable day for Medicare purposes when a Part A beneficiary takes a leave of absence and is not present in the skilled nursing facility at midnight

Clinical Care Classification (CCC)

"Two interrelated taxonomies, the CCC of Nursing Diagnoses and Outcomes and the CCC of Nursing Interventions and Actions, that provide a standardized framework for documenting patient care in hospitals, home health agencies, ambulatory care clinics, and other healthcare settings"


The period immediately following childbirth

Behavioral healthcare information

"Information related to treatment for conditions such as mental disorders, mental retardation, and other developmental disabilities"

Object request broker (ORB)

The messenger at the heart of the object-oriented framework that acts as a relay station between client and server

Affinity grouping

A technique for organizing similar ideas together in natural groupings



Transaction-processing system

"A computer-based information system that keeps track of an organization's business transactions through inputs (for example, transaction data such as admissions, discharges, and transfers in a hospital) and outputs (for example, census reports and bills)"


"The quality of being in a constant, continuous state. (ASTM 2005 3.1.11)"

Occurrence report

A structured data collection tool that risk managers use to gather information about potentially compensable events

Organizational pull model

A model in which the organization views information systems technology as the means to enable people in the organization to work more efficiently and effectively

Institute of Electrical and Electronics Engineers Standards Association (IEEE-SA)

An activity of the IEEE that develops standards in a broad-range of industries including healthcare

Word-processing services

Companies outside the healthcare facility that specialize in the deciphering and typing of medical dictation

Amendment request

"The right of individuals to ask that a covered entity amend their health records, as provided in Section 164.526 of the Privacy Rule "

Late entry

An addition to the health record when a pertinent entry was missed or was not written in a timely manner

Executive dashboard

An information management system providing decision makers with regularly updated information on an organization's key strategic measures

Storage management software

"Software used to manage the SAN, keep track of where data are stored, and move older data to less expensive, but still accessible, storage locations"

Risk factor reduction

The reduction of risk in the pool of members

Security pyramid

A graphic representation of security measures in which each depends on the one below it

Role playing

A training method in which participants are required to respond to specific problems they may actually encounter in their jobs

Health information services department

The department in a healthcare organization that is responsible for maintaining patient care records in accordance with external and internal rules and regulations

Medical informatics professionals

Individuals who work in the field of medical informatics

Center for Drug Evaluation and Research (CDER) Data Standards Manual

A compilation of standardized nomenclature monographs for sharing information regarding manufactured drug dosage forms

Episode-of-care (EOC) reimbursement

A category of payments made as lump sums to providers for all healthcare services delivered to a patient for a specific illness and/or over a specified time period; also called bundled payments because they include multiple services and may include multiple providers of care

Data Elements for Emergency Department Systems (DEEDS)

A data set designed to support the uniform collection of information in hospital-based emergency departments

Operational plan

The short-term objectives set by an organization to improve its methods of doing business and achieve its planned outcomes

Universal personal identifier

A unique numerical identifier for each citizen in the United States

Creditable coverage

Prior healthcare coverage that is taken into account to determine the allowable length of preexisting condition exclusion periods (for individuals entering group health plan coverage)

Analysis session

The process of mining a data segment

Medically needy option

An option in the Medicaid program that allows states to extend eligibility to persons who would be eligible for Medicaid under one of the mandatory or optional groups but whose income and/or resources fall above the eligibility level set by their state


"A role in organizational innovation in which an idea is challenged, compared to stringent criteria, and tested against reality"

Digital dictation

A process in which vocal sounds are converted to bits and stored on computer for random access

Hospital-based outpatient care

"A subset of ambulatory care that utilizes a hospital's staff, equipment, and resources to render preventive and/or corrective healthcare services"

Out-of-pocket expenses

"Healthcare costs paid by the insured (for example, deductibles, copayments, and coinsurance) after which the insurer pays a percentage (often 80 or 100 percent) of covered expenses"

Parents and children

A name for exploding charges wherein the parent is the item that explodes into other items and appears on the bill


Something that stimulates or encourages an individual to work harder

Generally accepted accounting principles (GAAP)

"An accepted set of accounting principles; or standards, and recognized procedures central to financial accounting and reporting"

Hospital inpatient

"A patient who is provided with room, board, and continuous general nursing services in an area of an acute care facility where patients generally stay at least overnight"

Arden syntax

A standard language for encoding medical knowledge representation for use in clinical decision support systems

Inpatient rehabilitation facility PPS (IRFPPS)

Utilizes the patient assessment instrument to assign patients to case-mix groups according to their clinical situation and resource requirements

Performance measure/measurement system

System designed to improve performance by providing feedback on whether goals have been met


"A set of activities designed to familiarize new employees with their jobs, the organization, and its work culture"


A type of research instrument with which the members of the population being studied are asked questions and respond orally

Job procedure

"A structured, action-oriented list of sequential steps involved in carrying out a specific task or solving a problem"

Purchase order

"A paper document or electronic screen on which all details of an intended purchase are reported, including authorizations"

Operation index

"A list of the operations and surgical procedures performed in a healthcare facility, which is sequenced according to the code numbers of the classification system in use"

Civilian Health and Medical Program - Uniformed Services (CHAMPUS)

"A federal program providing supplementary civilian-sector hospital and medical services beyond that which is available in military treatment facilities to military dependents, retirees and their dependents, and certain others"


A measure of central tendency that is determined by calculating the arithmetic average of the observations in a frequency distribution

Ambulatory care organization

"A healthcare provider or facility that offers preventive, diagnostic, therapeutic, and rehabilitative services to individuals not classified as inpatients or residents"


The amount of effort and materials needed to produce project deliverables

Civil law

"The branch of law involving court actions among private parties, corporations, government bodies, or other organizations, typically for the recovery of private rights with compensation usually being monetary"

Discharge status

"The disposition of the patient at discharge (that is, left against medical advice, discharged to home, transferred to skilled nursing facility, or died)"

Computer virus

A software program that attacks computer systems with the intention of damaging or destroying files

DSM-IV-TR Classification

"A listing of psychiatric disorders that includes corresponding ICD-9-CM codes (i.e. 315.31, Expressive Language Disorder)"

Indicator measurement system

An indicator-based monitoring system developed by The Joint Commission for accredited organizations and meant to provide hospitals with information on their performance

Unique physician identification number (UPIN)

A unique numerical identifier created by the Centers for Medicare and Medicaid Services for use by physicians who bill for services provided to Medicare patients

Nosocomial infection

An infection acquired by a patient while receiving care or services in a healthcare organization

Supervised learning

Any learning technique that has as its purpose to classify or predict attributes of objects or individuals


A program that directs the hardware components of a computer system to perform the tasks required


The portion of an organization's profit that is distributed to its investors

Short-stay patient

A patient admitted to the hospital for an intended stay of less than twenty-four hours and who is considered an outpatient and not included in inpatient hospital census statistics

Workgroup on Electronic Data Interchange (WEDI)

A subgroup of Accreditation Standards Committee X12 that has been involved in developing electronic data interchange standards for billing transactions

Anesthesia death rate

The ratio of deaths caused by anesthetic agents to the number of anesthesias administered during a specified period of time

Secondary diagnosis

A statement of those conditions coexisting during a hospital episode that affect the treatment received or the length of stay

Pro forma

An estimate

System catalog

An integrated data dictionary (which is a component of a database management system) that generally contains information on data tables and relationships in addition to data definitions

Project network

The relationship between tasks in a project that determines the overall finish date

Health information exchange (HIE)

A plan in which health information is shared among providers

Clinic cases

Patient encounters that take place on an outpatient basis in a clinic within a teaching environment

Preexisting condition

"Any injury, disease, or physical condition occurring prior to an arbitrary date before the insured's enrollment date of coverage, medical advice, diagnosis, care, or treatment was recommended or received; Healthcare coverage may be denied for a period of time for a pre-existing condition, but the Health Insurance Portability and Accountability Act constrains the use of exclusions for pre-existing conditions and establishes requirements exclusions for pre-existing conditions must satisfy"


A set of columns or a collection of related data items in a table


A specific description of the services or deliverable goods to be provided as the result of a business process

Equal Pay Act of 1963 (EPA)

The federal legislation that requires equal pay for men and women who perform substantially the same work

Continuous speech technology

A computer technology that automatically translates voice patterns into written language in real time. Sometimes called continuous speech recognition

Singleton ambulatory patient groups

"An ambulatory patient group assigned to a patient claim that, after consolidation of significant procedures and packaging of ancillaries, is part of a visit with no remaining multiple significant procedures"

Transfer record

"A review of the patient's acute stay along with current status, discharge and transfer orders, and any additional instructions that accompanies the patient when he or she is transferred to another facility"

Security management

"The oversight of facilities, equipment, and other resources, including human resources and technology, to reduce the possibility of harm to or theft of these assets of an organization"

Capital budget process

A four-stage process organizations follow to determine what capital projects to include in the budget

Developmental disability

"A mental or physical limitation affecting major life activities, arising before adulthood, and usually lasting throughout life"

Discovery request

A petition for discovery

Health Care Quality Improvement Program (HCQIP)

"A quality initiative begun in 1992 by the Health Care Financing Administration and implemented by peer review organizations that uses patterns of care analysis and collaboration with practitioners, beneficiaries, providers, plans, and other purchasers of healthcare services to develop scientifically based quality indicators and to identify and implement opportunities for healthcare improvement"

Population-based registry

"A type of registry that includes information from more than one facility in a specific geopolitical area, such as a state or region"

American Hospital Association (AHA)

"The national trade organization that provides education, conducts research, and represents the hospital industry's interests in national legislative matters; membership includes individual healthcare organizations as well as individual healthcare professionals working in specialized areas of hospitals, such as risk management; one of the four Cooperating Parties on policy development for the use of ICD-9-CM"

Mohs' micrographic surgery

"A type of surgery performed to remove complex or ill-defined skin cancer, requiring a single physician to act in two integrated, but separate and distinct, capacities: surgeon and pathologist"

Community health information network (CHIN)

"An integrated collection of computer and telecommunications capabilities that facilitates communications of patient, clinical, and payment information among multiple providers, payers, employers, and related healthcare entities within a community"

Request for information (RFI)

A written communication often sent to a comprehensive list of vendors during the design phase of the systems development life cycle to ask for general product information

Continuing medical education (CME)

"Activities such as accredited sponsorship, nonaccredited sponsorship, medical teaching, publications that advance medical care and other learning experiences, proof of which is required for a physician to maintain certification"