In Accordance With Hipaa Guidelines The Medical Office Must
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According to HIPAA guidelines:
concerning a patient, I may use/disclose only the minimum information that is needed to perform my job duties.
HIPAA
Health Information Portability & Accountability Act
HIPAA was passed
August 21, 1996
PHI
Protected Health Information
According to HIPAA, certain categories are considered covered entities, and must abide by HIPAA rules and regulations. They include the following:
- A health plan - A health care clearing house - A health care provider who transmits any health info in electronic form (internet transmission, phone, fax)
Under HIPAA. it is recognized that incidental use and disclosure of protected health information may occur as a result of:
normal day to day operations within a healthcare facility.
PHI (Protected Health Information) includes such things as:
-name -address -phone/fax -dates (birth/death/admission/discharge) -important numbers (soc.sec., medical record#, acct. #) -email address -biometrics -full facial images -patients medical history (When in doubt, don't give info out)
HHS
Health & Human Services
Privacy Act
standards for privacy of individually identifiable health information
Covered entities must abide by HIPAA rules & regulations:
1. Health plan 2. Health care clearinghouse 3. Health care provider
PHI is not only limited to the patient, but also:
the patients relatives, employees or household members
PCP
primary care physicians
HMO
Health Maintenance Organization - requires patients to use in-network providers in order to be covered for services. Patients do not have the option to choose physicians who are not "in-network"...they would have to pay out of pocket without reimbursement.
PPO
Preferred Provider Organization - less restricted than HMO. Patients are able to choose specialists on their own without going through a "gatekeeper."
ARRA
American Recovery on Reinvestment Act of 2009 - this pays for courses to train people for billing & responsible for health record design and format.
ROI
Release of Information
HITECH Act
Health Information Technology for Economic and Clinical Health Act.
AHIOS
Association of Health Information OUtsourcing Services
RACs
Recovery audit contractors
CMS
Centers for Medicare & Medicaid Services
EMR
Electronic Medical Records
AMA
American Medical Association
CPT
Current Procedural Terminology
ICD
International Classification of Diseases - the classification used to code and classify mortality data from death certificates.
OSHA
Occupational Safety & Health Administration - the main federal agency charged with the enforcement of safety and health legislation.
HIM
Health Information Management - the practice of maintenance and care of health records by traditional (paper) & electronic means.
Release Form:
signed authorization form for all requests for information except those involving treatment, payment or healthcare operations in accordance with HIPAA guidelines.
Healthcare facility has 30 days to respond to filed complaints.
Copies of your records must be given to you within 30 days.
Subjective
chief complaint of patient, info furnished by patient
Objective
what dr observes in patient; must support subjective; this also includes vital signs (temp, blood pressure, pulse, respiration)
Assessment
pulled together info from the subjective info and physical exam and consolidates them into an assessment
Plan
anything that will be done as a consequence of the assessment
SOAP notes
Subjective Objective Assessment Plan
CC
Chief Complaint
Ethics:
the norms for conduct that distinguish between acceptable & unacceptable behavior.
TRUE
It is ok for medical office staff to fax protected health info to another dr when the patient is being referred to that physician for treatment
FALSE
As a medical staff, you have a right to view the records of a close friend
EHR
Electronic Health Record
MOSS
Medical Office Simulation Software
PCP - Primary care physician
general practitioner skilled in handling a broad range of medical problems
Confidentiality Statement
acknowledges that you have received HIPAA training and you agree that you will abide by the HIPAA privacy regulations
HMOs pay the physician a monthly fixed amount called a:
capitation
Copayment
fixed amount patient pays when services are provided
CMS 1500
standard billing document used for physician claims submitted for Medicare Part B reimbursement
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