AAAHC: Accreditation Association for Ambulatory Health Care
A professional organization that offers accreditation programs for ambulatory and outpatient organizations such as single-specialty and multi-specialty group practices, ambulatory surgery centers, college/university health services, and community health centers
AAMC: American Association of Medical Colleges
AAMT: American Association of Medical Transcription
Abstracting: 1. The practice of extracting information from a document to create a brief summary characterizing a patient's illness, treatment, and outcome. 2. The process of extracting elements of data from a source document or database and entering them into an automated system
Accreditation: 1. A voluntary process of institutional or program study review in which an organization or agency performs an external audit to determine the quality of the entity's work against pre-established standards. 2. A determination by an accrediting body that an eligible organization, network, program, group, or individual complies with applicable standards.
Acute care: Medical care of a limited duration that is provided in a an inpatient hospital setting to diagnose and/or treat an injury or a short-term illness
AHRQ: Agency for Healthcare Research and Quality The branch of the United States Public Health Service that supports general health research and distributes research findings and treatment guidelines with the goal of improving the quality, appropriateness, and effectiveness of healthcare services
AHA: American Hospital Association 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
AHIMA: American Health Information Management Association The professional membership organization for managers of health record services and healthcare information systems as well as coding services; provides accreditation, certification, and educational services
Allied health professional: A credentialed healthcare worker who is not a physician, nurse, psychologist, or pharmacist (for example, a physical therapist, dietitian, social worker, or occupational therapist)
AMA: American Medical Association The national professional membership organization for physicians that distributes scientific information to its members and the public, informs members of legislation related to health and medicine, and represents the medical profession’s interests in national legislative matters
AMIA: American Medical Information Association The membership organization composed of individuals, institutions, and corporations that develop and use information technologies in healthcare
ANA: American Nurses Association The national professional membership association of nurses that works for the improvement of health standards and the availability of healthcare services, fosters high professional standards for the nursing profession, and advances the economic and general welfare of nurses
Capitation: A method of healthcare reimbursement in which an insurance carrier prepays a physician, hospital, or other healthcare provider a fixed amount for a given population without regard to the actual number or nature of healthcare services provided to the population
Care: The management of, responsibility for, or attention to the safety and well-being of other persons in the context of healthcare settings
Career development: The process of growing or progressing within one’s profession or occupation
Caregiver: 1. Any clinical professional (physician, nurse, technologist, or therapist, for example) who provides care directly to patients 2. A nonprofessional who provides supportive assistance in a residential setting to a relative, friend, or client who is seriously ill
CARF: Commission on Accreditation of Rehabilitation Facilities A private, not-for-profit organization that develops customer-focused standards for behavioral healthcare and medical rehabilitation programs and accredits such programs on the basis of its standards
Category II Codes: Current Procedural Terminology (CPT)codes that describe services or test results that are agreed upon as contributing to positive health outcomes and high-quality patient care. They are for performance measurement, and use of these codes is optional.
Category III Codes: Current Procedural Terminology (CPT) codes that describe new and emerging technology. They may be published at any time during the year, rather than on the annual publication cycle, and can be found on the AMA Web site (www.ama-assn.org) and immediately preceding the alphabetic index in the CPT codebook.
Centers for Disease Control and Prevention (CDC): A group of federal agencies that oversee health promotion and disease control and prevention activities in the United States
Centers for Medicare and Medicaid Services (CMS): The division of the Department of Health and Human Services that is responsible for developing healthcare policy in the United States and for administering the Medicare program and the federal portion of the Medicaid program; called the Health Care Financing Administration (HCFA) prior to 2001
Certification: 1. The process by which a duly authorized body evaluates and recognizes an individual, institution, or educational program as meeting predetermined requirements 2. An evaluation performed to establish the extent to which a particular computer system, network design, or application implementation meets a pre-specified set of requirements
Certified coding specialist (CCS): An AHIMA credential awarded to individuals who have demonstrated skill in classifying medical data from patient records, generally in the hospital setting, by passing a certification examination
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
Certified medical transcriptionist (CMT): A certification that is granted upon successful completion of an examination
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
Civilian Health and Medical Program—Veterans Administration (CHAMPVA): The federal healthcare benefits program for dependents of veterans rated by the Veterans Administration as having a total and permanent disability, for survivors of veterans who died from VA-rated service-connected conditions or who were rated permanently and totally disabled at the time of death from a VA-rated service-connected condition, and for survivors of persons who died in the line of duty
Classification system: 1. A system for grouping similar diseases and procedures and organizing related information for easy retrieval 2. A system for assigning numeric or alphanumeric code numbers to represent specific diseases and/or procedures
Clinical coding: The process of assigning numeric or alphanumeric classifications to diagnostic and procedural statements
Clinical terminology: A set of standardized terms and their synonyms that can be mapped to broader classifications. See nomenclature
Coded data: Data that are translated into a standard nomenclature of classification so that they may be aggregated, analyzed, and compared
Coder: A person assigned solely to the function of coding
Coding: Process of assigning a number to a data element
Coding Clinic: A publication issued quarterly by the American Hospital Association and approved by the Centers for Medicare and Medicaid Services to give coding advice and direction for ICD-9-CM
Coding specialist: The healthcare worker responsible for assigning numeric or alphanumeric codes to diagnostic or procedural statements
Commission on Accreditation for Health Informatics and Information Management Education (CAHIIM): The accrediting organization for degree-granting programs in health informatics and information management. CAHIIM serves the public interest by establishing quality standards for the educational preparation of future health information management (HIM) professionals
Compliance: 1. The process of establishing an organizational culture that promotes the prevention, detection, and resolution of instances of conduct that do not conform to federal, state, or private payer healthcare program requirements or the healthcare organization’s business policies 2. The act of adhering to official requirements
Confidentiality: A legal and ethical concept that establishes the healthcare provider’s responsibility for protecting health records and other personal and private information from unauthorized use or disclosure
Continuing education: A type of training that enables employees to remain current in the knowledge base of their profession
Cooperating parties for ICD-9-CM: A group of organizations (the American Health Information Management Association, the American Hospital Association, the Centers for Medicare and Medicaid Services, and the National Center for Health Statistics) that collaborates in the development and maintenance of the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM)
Correct Coding Initiative (CCI): A national initiative designed to improve the accuracy of Part B claims processed by Medicare carriers
CPT Level I: Current Procedural Terminology codes that constitute first level of the HCPCS coding system
CPT Level II: Current Procedural Terminology codes that are applicable to selected physician and non-physician services, durable medical goods, drugs, and supplies
Curriculum: A prescribed course of study in an educational program
Data administrator: An emerging role responsible for managing the less technical aspects of data, including data quality and security
Database administrator: The individual responsible for the technical aspects of designing and managing databases
Delinquent Record: Incomplete record that has not been finished within a specified established timeframe
Department of Health and Human Services ((D)HHS): The cabinet-level federal agency that oversees all of the health- and human-services–related activities of the federal government and administers federal regulations
Diagnosis: A word or phrase used by a physician to identify a disease from which an individual patient suffers or a condition for which the patient needs, seeks, or receives medical care
Diagnosis-related group (DRG): A unit of case-mix classification adopted by the federal government and some other payers as a prospective payment mechanism for hospital inpatients in which diseases are placed into groups because related diseases and treatments tend to consume similar amounts of healthcare resources and incur similar amounts of cost; in the Medicare and Medicaid programs, one of more than 500 diagnostic classifications in which cases demonstrate similar resource consumption and length-of-stay patterns
Diagnostic codes: Numeric or alphanumeric characters used to classify and report diseases, conditions, and injuries
Disease management: A more expansive view of case management in which patients with the highest risk of incurring high-cost interventions are targeted for standardizing and managing care throughout integrated delivery systems 2. A program focused on preventing exacerbations of chronic diseases and on promoting healthier life styles for patients and clients with chronic diseases
Disease registry: A centralized collection of data used to improve the quality of care and measure the effectiveness of a particular aspect of healthcare delivery
Documentation: The recording of pertinent healthcare findings, interventions, and responses to treatment as a business record and form of communication among caregivers
Academic Pathways
Overview of AHIMA