Magnetic resonance image (MRI): The generation of a powerful magnetic field that surrounds the patient, creating computer-interpreted radio frequency imaging
Managed care: 1. Payment method in which the third party payer has implemented some provisions to control the costs of healthcare while maintaining quality care 2. Systematic merger of clinical, financial, and administrative processes to manage access, cost, and quality of healthcare
Managed care organization (MCO): A type of healthcare organization that delivers medical care and manages all aspects of the care or the payment for care by limiting providers of care, discounting payment to providers of care, and/or limiting access to care
Master patient index (MPI): A list or database created and maintained by a healthcare facility to record the name and identification number of every patient who has ever been admitted or treated in the facility
Medicaid: An entitlement program that oversees medical assistance for individuals and families with low incomes and limited resources; jointly funded between state and federal governments
Medical informatics: A field of information science concerned with the management of data and information used to diagnose, treat, cure, and prevent disease through the application of computers and computer technologies
Medical record: See health record
Medical record administrator: See health information management professional
Medical record technician: See health information management professional
Medical transcription: The conversion of verbal medical reports dictated by healthcare providers into written form for inclusion in patients’ health records
Medicare: A federally-funded health program established in 1965 to assist with the medical care costs of Americans sixty-five years of age and older as well as other individuals entitled to Social Security benefits owing to their disabilities
National Association of Healthcare Quality (NAHQ): An organization devoted to advancing the profession of healthcare quality improvement through its accreditation program
National Centers for Health Statistics (NCHS): The federal agency responsible for collecting and disseminating information on health services utilization and the health status of the population in the United States
National Committee for Quality Assurance (NCQA): A private not-for-profit accreditation organization whose mission is to evaluate and report on the quality of managed care organizations in the United States
Network: 1. A type of information technology that connects different computers and computer systems so that they can share information 2. Physicians, hospitals, and other providers who provide healthcare services to members of a managed care organization; providers may be associated through formal or informal contracts and agreements
Network administrators: The individuals involved in installing, configuring, managing, monitoring, and maintaining network computer applications and responsible for supporting the network infrastructure and controlling user access
Nomenclature: A recognized system of terms used in a science or art that follows preestablished naming conventions; a disease nomenclature is a listing of the proper name for each disease entity with its specific code number
North American Association of Central Cancer Registries (NAACCR): A national organization that certifies state, population-based cancer registries
Nosology: The branch of medical science that deals with classification systems
Nurse practitioner (NP): A healthcare professional authorized to provide basic primary healthcare, diagnosing and treating common acute illnesses and injuries
Occupational therapy (OT): A treatment that uses constructive activities to help restore the resident’s ability to carry out needed activities of daily living and improves or maintains functional ability
Optimization: The process of thoroughly reviewing the health record to identify all procedures performed and services rendered by the physician; must be accurately and completely coded to ensure optimum reimbursement
Outpatient code editor (OCE): A software program linked to the Correct Coding Initiative that applies a set of logical rules to determine whether various combinations of codes are correct and appropriately represent the services provided
Outpatient coder: An individual responsible for assigning ICD-9-CM and CPT/HCPCS codes to ambulatory surgery or emergency department cases
Patient Self-Determination Act (PSDA): The federal legislation that requires healthcare facilities to provide written information on the patient’s right to issue advance directives and to accept or refuse medical treatment
Per diem: Type of prospective payment method in which the third party payer reimburses the provider a fixed rate for each day a covered member is hospitalized
Performance measure: A quantitative tool used to assess the clinical, financial, and utilization aspects of a healthcare provider’s outcomes or processes
Personal health record (PHR): An electronic or paper health record maintained and updated by an individual for himself or herself
Physical therapy (PT): The field of study that focuses on physical functioning of the resident on a physician-prescribed basis
Physician assistant (PA): A healthcare professional licensed to practice medicine with physician supervision
Physician care group (PCG): Type of outpatient prospective payment method for physician services in which patients are classified into similar, homogenous categories
Pre-existing condition: Disease, illness, ailment, or other condition (whether physical or mental) for which, within a specified period 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
Primary care physician (PCP): 1. Physician who provides, supervises, and coordinates the healthcare of a member and who manages referrals to other healthcare providers and utilization of healthcare services both inside and outside a managed care plan 2. The physician who makes the initial diagnosis of a patient’s medical condition; See primary care provider
Principal diagnosis: The disease or condition that was present on admission, was the principal reason for admission, and received treatment or evaluation during the hospital stay or visit
Principal procedure: The procedure performed for the definitive treatment of a condition (as opposed to a procedure performed for diagnostic or exploratory purposes) or for care of a complication
Privacy Act of 1974: The legislation that gave individuals some control over information collected about them by the federal government
Privacy and security standards: Standards that ensure the confidentiality and integrity of patient-identifiable information
Privilege: The professional relationship between patients and specific groups of caregivers that affects the patient’s health record and its contents as evidence; the services or procedures, based on training and experience, that an individual physician is qualified to perform; a right granted to a user, program, or process that allows access to certain files or data in a system
Procedures and services (outpatient): All medical procedures and services of any type (including history, physical examination, laboratory, x-ray or radiograph, and others) that are performed pertinent to the patient’s reasons for the encounter, all therapeutic services performed at the time of the encounter, and all preventive services and procedures performed at the time of the encounter
Prospective payment: A method of determining reimbursement based on predetermined factors, not individual services
Prospective payment system (PPS): A type of reimbursement system that is based on preset payment levels rather than actual charges billed after the service has been provided; specifically, one of several Medicare reimbursement systems based on predetermined payment rates or periods and linked to the anticipated intensity of services delivered as well as the beneficiary’s condition
Protected health information (PHI): Under HIPAA, all individually identifiable information, whether oral or recorded in any form or medium, that is created or received by a healthcare provider or any other entity subject to HIPAA requirements
Public health: An area of healthcare that deals with the health of populations in geopolitical areas, such as states and counties
Academic Pathways
Overview of AHIMA