ahima rhit exam prep (a)

Abbreviated Injury Scale (AIS)

A set of numbers used in a trauma registry to indicate the nature and severity of injuries by body system


Shortened forms of words or phrases; in healthcare,when there is more than one meaning for an approved abbreviation, only one meaning should be used or the context in which the abbreviation is to be used should be identified

ABC Codes

A terminology created by Alternative Link that describes alternative medicine, nursing, and other integrative healthcare interventions


Services in medicine that deviate from what is typical in comparison to the national norm

Ability (achievement) tests

Tests used to assess the skills an individual already possesses; Also called performance tests

Abnormal Involuntary Movement Scale (AIMS)

A standardized form that can be used in facilities to document involuntary movements


The expulsion or extraction of all (complete) or any part (incomplete) of the placenta or membranes, without an identifiable fetus or with a live-born infant or a stillborn infant weighing less than 500 grams

Absolute frequency

The number of times that a score of value occurs in a data set


Brief summary of the major parts of a research study


1. The process of extracting information from a document to create a brief summary of 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


Provider, supplier, and practitioner practices that are inconsistent with accepted sound fiscal, business, or medical practices that directly or indirectly may result in unnecessary costs to the program, improper payment, services that fail to meet professionally recognized standards of care or are medically unnecessary, or services that directly or indirectly result in adverse patient outcomes or delays in appropriate diagnosis or treatment


Coding errors that occur without intent to defraud the government

Accept assignment

A term used to refer to a provider's or a supplier's acceptance of the allowed charges (from a fee schedule) as payment in full for services or materials provided

Acceptance testing

Final review during EHR implementation to ensure that all tests have been performed and all issues have been resolved; usually triggers the final payment for the system and when a maintenance contract becomes effective

Acceptance theory of authority

A management theory based on the principle that employees have the freedom to choose whether they will follow managerial directions


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

Access control

1. A computer software program designed to prevent unauthorized use of an information resource 2. The process of designing, implementing, and monitoring a system for guaranteeing that only individuals who have a legitimate need are allowed to view or amend specific data sets

Access control grid

A tabular representation of the levels of authorization granted to users of a computer system's information and resources

Access control system

A system that defines who has access to what information in a computer system and specifies each user's rights and/or restrictions with respect to that information

Accession number

A number assigned to each case as it is entered in a cancer registry

Accession registry

A list of cases in a cancer registry in the order in which they were entered


Those mishaps, misfortunes, mistakes, events, or occurrences that can happen during the normal daily routines and activities in the long-term care setting


In business, the practice whereby one party in a conflict or disagreement gives in to the other party as a temporary solution


A subdivision of assets, liabilities, and equities in an organization's financial management system


1. The state of being liable for a specific activity 2. All information is attributable to its source (person or device)


Required to answer to a supervisor for performance results

Accountable Care Organization (ACO)

An organization of healthcare providers accountable for the quality, cost, and overall care of Medicare beneficiaries who are assigned and enrolled in the traditional fee-for-service program


1. The process of collecting, recording, and reporting an organization's financial data 2. A list of all disclosures made of a patient's health information

Accounting entity

The business structure, including the activities and records to be maintained for the preparation of an individual organization's financial statements

Accounting of disclosures

HIPAA requirement to list, upon patient request, all disclosures that meet the criteria. Currently, this does not require accounting for disclosures for treatment, payment, and healthcare operations (TPO), but under ARRA this changes to include these disclosures; awaiting final regulations

Accounting period

The entire process of identifying and recording a transaction and ultimately reporting it as part of an organization's financial statement

Accounting rate of return

The projected annual cash inflows, minus any applicable depreciation, divided by the initial investment

Accounts Not Selected for Billing Report

A daily financial report used to track the many reasons why accounts may not be ready for billing

Accounts payable (A/P)

Records of the payments owed by an organization to other entities

Accounts receivable (A/R)

1. Records of the payments owed to the organization by outside entities such as third-party payers and patients 2. Department in a healthcare facility that manages the accounts owed to the facility by customers who have received services but whose payment is made at a later date


1. A voluntary process of institutional or organizational review in which a quasi-independent body created for this purpose periodically evaluates the quality of the entity's work against preestablished written criteria 2. A determination by an accrediting body that an eligible organization, network, program, group, or individual complies with applicable standards 3. The act of granting approval to a healthcare organization based on whether the organization has met a set of voluntary standards developed by an accreditation agency

Accreditation Association for Ambulatory Health Care (AAAHC)

A professional organization that offers accreditation programs for ambulatory and outpatient organizations such as single-specialty and multispecialty group practices, ambulatory surgery centers, college/university health services, and community health centers

Accreditation Commission for Health Care (ACHC)

An organization that provides quality standards and accreditation programs for home health and other healthcare organizations

Accreditation organization

A professional organization that establishes the standards against which healthcare organizations are measured and conducts periodic assessments of the performance of individual healthcare organizations

Accreditation standards

Preestablished statements of the criteria against which the performance of participating healthcare organizations will be assessed during a voluntary accreditation

Accredited Standards Committee X12 (ASC X12)

A committee of the American National Standards Institute (ANSI) responsible for the development and maintenance of electronic data interchange (EDI) standards for many industries. The ASC 'X12N' is the subcommittee of ASC X12 responsible for the EDI health insurance administrative transactions such as 837 Institutional Health Care Claim and 835 Professional Health Care Claim forms

Accrediting body

A professional organization that establishes the standards against which healthcare organizations are measured and conducts periodic assessment of the performance of individual healthcare organizations


The term used by Medicare regarding the process of adding new members to a health plan

Accrual accounting

A method of accounting that requires business organizations to report income in the period earned and to deduct expenses in the period incurred


The process of recording known transactions in the appropriate time period before cash payments/receipts are expected or due


The extent to which information reflects the true, correct, and exact description of the care that was delivered with respect to both content and timing

Acid-test ratio

A ratio in which the sum of cash plus short-term investments plus net current receivables is divided by total current liabilities


A form that provides a mechanism for the resident to recognize receipt of important information


American College of Obstetrics and Gynecology

Acquired immunodeficiency syndrome (AIDS)

A retroviral disease caused by infection with human immunodeficiency virus (HIV)


One healthcare entity purchase of another healthcare entity in order to acquire control of all of its assets


The use of ultraviolet light therapy in the treatment of skin diseases

Action plan

A set of initiatives that are to be undertaken to achieve a performance improvement goal

Action steps

Specific plans an organization intends to accomplish in the near future as an effort toward achieving its long-term strategic plan

Active listening

The application of effective verbal communication skills as evidenced by the listener's restatement of what the speaker said

Active membership

Individuals interested in the AHIMA purpose and willing to abide by the Code of Ethics are eligible for active membership. Active members in good standing shall be entitled to all membership privileges including the right to vote

Active record

A health record of an individual who is a currently hospitalized inpatient or an outpatient

Activities of daily living (ADL)

The basic activities of self-care, including grooming, bathing, ambulating, toileting, and eating

Activity-based budget

A budget based on activities or projects rather than on functions or departments

Activity-based costing (ABC)

An economic model that traces the costs or resources necessary for a product or customer

Activity date or status

The element in the chargemaster that indicates the most recent activity of an item


The role a user plays in a system

Actual charge

1. A physician's actual fee for service at the time an insurance claim is submitted to an insurance company, a government payer, or a health maintenance organization; may differ from the allowable charge 2. Amount provider actually bills a patient, which may differ from the allowable charge

Acute care

Medical care of a limited duration that is provided in an inpatient hospital setting to diagnose and/or treat an injury or a short-term illness

Acute care prospective payment system

The Medicare reimbursement methodology system referred to as the inpatient prospective payment system (IPPS). Hospital providers subject to the IPPS utilize the Medicare Severity-Diagnosis Related Groups (MS-DRGs) classification system, which determines payment rates


Active duty family member; a designation used under TRICARE

Ad hoc committee

A group of individuals who join together to solve a particular task or problem


A late entry added to a health record to provide additional information in conjunction with a previous entry. The late entry should be timely and bear the current date and reason for the additional information being added to the health record

Addition of entries

Changes to the health record in the form of late entries, amendments, or addenda

Add-on codes

In CPT coding, add-on codes are referred to as additional or supplemental procedures. Add-on codes are indicated with a '+' symbol and are to be reported in addition to the primary procedure code. Add-on codes are not to be reported as stand-alone codes and are exempt from use of the -51 modifier

Addressable standards

The implementation specifications of the HIPAA Security Rule that are designated 'addressable' rather than 'required'; to be in compliance with the rule, the covered entity must implement the specification as written, implement an alternative, or document that the risk for which the addressable implementation specification was provided either does not exist in the organization, or exists with a negligible probability of occurrence

Adjunct diagnostic or therapeutic unit

An organized unit of an inpatient hospital (other than an operating room, delivery room, or medical care unit) with facilities and personnel to aid physicians in the diagnosis and treatment of illnesses or injuries through the performance of diagnostic or therapeutic procedures; Also called ancillary unit

Adjusted clinical groups (ACGs)

A classification system that groups individuals according to resource requirements and reflects the clinical severity differences among the specific groups; formerly called ambulatory care groups

Adjusted historic payment base (AHPB)

The weighted average prevailing charge for a physician service applied in a locality for 1991 and adjusted to reflect payments for services with charges below the prevailing charge levels and other payment limits; determined without regard to physician specialty and reviewed and updated yearly since 1992

Adjusted hospital autopsy rate

The proportion of hospital autopsies performed following the deaths of patients whose bodies are available for autopsy


The process of writing off an unpaid balance on a patient account to make the account balance

Administrative agencies

Executive branch agencies; source of administrative law

Administrative agency tribunals

A form of alternative dispute resolution in which tribunals are created by statute or the Constitution to hear disputes arising from administrative law

Administrative controls

Policies and procedures that address the management of computer resources

Administrative data

Coded information contained in secondary records, such as billing records, describing patient identification, diagnoses, procedures, and insurance

Administrative information

Information used for administrative and healthcare operations purposes, such as billing and quality oversight

Administrative information systems

A category of healthcare information systems that supports human resources management, financial management, executive decision support, and other business-related functions

Administrative law

A body of rules and regulations developed by various administrative entities empowered by Congress; falls under the umbrella of public law

Administrative law judge

A hearings officer who conducts appeal conflicts between providers of services, or beneficiaries, and Medicare contractors

Administrative management theory

A subdivision of classical management theory that emphasizes the total organization rather than the individual worker and delineates the major management functions

Administrative provisions

Documented, formal practices to manage data security measures throughout the healthcare organization

Administrative safeguards

Administrative actions such as policies and procedures and documentation retention to manage the selection, development, implementation, and maintenance of security measures to protect electronic protected health information and manage the conduct of the covered entity's or business associate's workforce in relation to the protection of that information

Administrative services

Business-related services provided by an insurance organization to self-insured employers or other parties according to an administrative services only contract (for example, actuarial support, benefit plan design, claims processing, data recovery and analysis, employee benefits communication, financial advice, medical care conversions, stop-loss coverage, and other services as requested)

Administrative services only (ASO) contract

An agreement between an employer and an insurance organization to administer the employer's self-insured health plan

Administrative simplification

A term referring to the Health Insurance Portability and Accountability Act (HIPAA) provisions which include standards for transactions and code sets that are used to exchange health data, standard identifiers for use on transactions, and privacy and security standards to protect personal health information. HIPAA included these administrative simplification provisions in order to improve the efficiency and effectiveness of the healthcare system.


The condition of being admitted into evidence in a court of law

Admission agreement

A legal contract signed by the resident that specifies the long-term care facility's responsibilities and fees for providing healthcare and other services

Admission date

The date the patient was admitted for inpatient care, outpatient service, or start of care. In the inpatient hospital setting, the admission date is the hospital's formal acceptance of a patient who is to receive healthcare services while receiving room, board, and continuous nursing services

Admissions and readmissions processing policy

A policy that provides the guidelines that are required when a resident is admitted or readmitted to the facility

Admission-discharge-transfer (ADT)

The name given to software systems used in healthcare facilities that register and track patients from admission through discharge including transfers; usually interfaced with other systems used throughout a facility such as an electronic health record or lab information system

Admission type

The required classification used to indicate the priority of an admission/visit required for submitting claims using the electronic 837I format or the equivalent CMS-1450 claim form

Admission utilization review

A review of planned services (intensity of service) and/or a patient's condition (severity of illness) to determine whether care must be delivered in an acute-care setting

Admitting diagnosis

A provisional description of the reason why a patient requires care in an inpatient hospital setting


The decision to purchase, implement, and utilize an information system such as the EHR

Adult day care

Group or individual therapeutic services provided during the daytime hours to persons outside their homes; usually provided for individuals with geriatric or psychiatric illnesses

Adult health questionnaire

See patient history questionnaire

Adult learning

Self-directed inquiry aided by the resources of an instructor, colleagues/fellow students, and educational materials

Advance beneficiary notice (ABN)

A statement signed by the patient when he or she is notified by the provider, prior to a service or procedure being done, that Medicare may not reimburse the provider for the service, wherein the patient indicates that he will be responsible for any charges

Advanced decision support

Automated clinical practice guidelines that are built in to electronic health record systems and designed to support clinical decision making

Advance directive

A legal, written document that describes the patient's preferences regarding future healthcare or stipulates the person who is authorized to make medical decisions in the event the patient is incapable of communicating his or her preferences

Advanced practice registered nurse (APRN)

The term being increasingly used by legislative and governing bodies to describe the collection of registered nurses that practice in the extended role beyond the normal role of basic registered nursing

Adverse action

A term used to refer to an action taken against a practitioner's clinical privileges or medical staff membership in a healthcare organization; Also called licensure disciplinary action

Adverse drug event

A patient injury resulting from a medication, either because of a pharmacological reaction to a normal dose, or because of a preventable adverse reaction to a drug resulting from an error

Adverse drug reaction (ADR)

Unintended, undesirable, or unexpected effects of prescribed medications or of medication errors that require discontinuing a medication or modifying the dose, require initial or prolonged hospitalization, result in disability, require treatment with a prescription medication, result in cognitive deteriororation or impairment, are life threatening, result in death, or result in congenital anomalies

Adverse patient occurrences (APOs)

Occurrences such as admission for adverse results of outpatient management, readmission for complications, incomplete management of problems on previous hospitalization, or unplanned removal, injury, or repair of an organ or structure during surgery; covered entities must have a system for concurrent or retrospective identification through medical chart-based review according to objective screening criteria

Adverse selection

A situation in which individuals who are sicker than the general population are attracted to a health insurance plan, with adverse effects on the plan's costs

Affiliated covered entity

Legally separate covered entities, affiliated by common ownership or control; for purposes of the Privacy Rule, these legally separate entities may refer to themselves as a single covered entity

Affinity diagram

A graphic tool used to organize and prioritize ideas after a brainstorming session

Affinity grouping

A technique for organizing similar ideas together in natural groupings


Healthcare services that are provided to a patient after a period of hospitalization or rehabilitation and are administered with the objective of improving or restoring health to the degree that aftercare is no longer needed

Against medical advice (AMA)

The discharge status of patients who leave a hospital after signing a form that releases the hospital from any responsibility or who leave a hospital without notifying hospital personnel

Age Discrimination in Employment Act (1967)

Federal legislation that prohibits employment discrimination against persons between the ages of 40 and 70 and restricts mandatory retirement requirements except where age is a bona fide occupational qualification

Agency for Healthcare Research and Quality (AHRQ)

The branch of the US 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

Agenda for Change

An initiative undertaken by the Joint Commission that focused on changing the emphasis of the accreditation process from structure to outcomes

Aggregate data

Data extracted from individual health records and combined to form de-identified information about groups of patients that can be compared and analyzed

Aggregate information system

The combining of various data sets in order to compile overview or summary statistics

Aging of accounts

The practice of counting the days, generally in 30-day increments, from the time a bill was sent to the payer to the current day

AHA Coding Clinic for HCPCS

The official coding advice resource for coding information on HCPCS CPT codes for hospital providers and certain HCPCS level II codes for hospitals, physicians, and other healthcare professionals

AHIMA Standards of Ethical Coding

The American Health Information Management Association's principles of professional conduct for coding professionals involved in diagnostic and/or procedural coding or other health record data abstraction


A type of warning that is generated by an automated medical device


A software-generated warning that is based on a set of clinical rules built in to a healthcare information system


A procedure for solving a mathematical problem in a finite number of steps, which frequently involves repetition of an operation

Algorithmic translation

A process that involves the use of algorithms to translate or map clinical nomenclatures among each other or to map natural language to a clinical nomenclature or vice versa


A name added to, or substituted for, the proper name of a person; an assumed name

Alias policy

A policy that is implemented when resident confidentiality is required by the resident, family, or responsible party

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)

Allowable charge

Average or maximum amount a third-party payer will reimburse providers for a service

All patient diagnosis-related groups (AP-DRGs)

A case-mix system developed by 3M and used in a number of state reimbursement systems to classify non-Medicare discharges for reimbursement purposes

All patient refined diagnosis-related groups (APR-DRGs)

An expansion of the inpatient classification system that includes four distinct subclasses (minor, moderate, major, and extreme) based on the severity of the patient's illness


See average length of stay

Alphabetic filing system

A system of health record identification and storage that uses the patient's last name as the first component of identification and his or her first name and middle name or initial for further definition

Alphanumeric filing system

A system of health record identification and storage that uses a combination of alphabetic letters (usually the first two letters of the patient's last name) and numbers to identify individual records


Modifying the natural anatomic structure of a body part without affecting the function of the body part. The principal purpose of this procedure is to improve the patient's appearance

Alternative delivery system (ADS)

A type of healthcare delivery system in which health services are provided in settings such as skilled and intermediary facilities, hospice programs, nonacute outpatient programs, and home health programs, which are more cost-effective than in the inpatient setting

Alternative hypothesis

A hypothesis that states that there is an association between independent and dependent variables

Alternative Link

The original developer of the ABC codes

Ambulatory care

Preventive or corrective healthcare services provided on a nonresident basis in a provider's office, clinic setting, or hospital outpatient setting

Ambulatory care information system

A type of information system designed specifically for use and support in ambulatory care settings

Ambulatory care organization

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

Ambulatory Care Quality Alliance

An organization consisting of a broad base of healthcare professionals who work collaboratively to improve healthcare quality and patient safety through performance measurement, data aggregation, and reporting in the ambulatory care setting

Ambulatory payment classification (APC)

Hospital outpatient prospective payment system (OPPS). The classification is a resource-based reimbursement system. The payment unit is the ambulatory payment classification group (APC group)

Ambulatory payment classification group (APC group)

Basic unit of the ambulatory payment classification (APC) system. Within a group, the diagnoses and procedures are similar in terms of resources used, complexity of illness, and conditions represented. A single payment is made for the outpatient services provided. APC groups are based on HCPCS/CPT codes. A single visit can result in multiple APC groups. APC groups consist of five types of service- significant procedures, surgical services, medical visits, ancillary services, and partial hospitalization. The APC group was formerly known as the ambulatory visit group (AVG) and ambulatory patient group (APG)

Ambulatory payment classification (APC) relative weight

A number reflecting the expected resource consumption of cases associated with each APC, relative to the average of all APCs, that is used in determining payment under the Medicare hospital outpatient prospective payment system (OPPS)

Ambulatory payment classification (APC) system

The Medicare reimbursement methodology system referred to as the hospital outpatient prospective payment system (OPPS). Hospital providers subject to the OPPS utilize the ambulatory payment classification (APC) system, which determines payment rates

Ambulatory surgery center (ASC) payment rate

The Medicare ASC reimbursement methodology system referred to as the ambulatory surgery center (ASC) payment system. The ASC payment system is based on the ambulatory payment classifications (APCs) utilized under the hospital OPPS

Ambulatory surgery center or ambulatory surgical center (ASC)

Under Medicare, an outpatient surgical facility that has its own national identifier; is a separate entity with respect to its licensure, accreditation, governance, professional supervision, administrative functions, clinical services, recordkeeping, and financial and accounting systems; has as its sole purpose the provision of services in connection with surgical procedures that do not require inpatient hospitalization; and meets the conditions and requirements set forth in the Medicare Conditions of Participation

Ambulatory surgical center (ASC) list

The Medicare ASC list which indicates procedures that are covered and paid if performed in the ASC setting

Ambulatory surgical center (ASC) services

ASC diagnostic and therapeutic procedures which can be safely performed outside a hospital setting


Alteration of health information by modification, correction, addition, or deletion

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

American Academy of Professional Coders (AAPC)

The American Academy of Professional Coders provides certified credentials to medical coders in physician offices, hospital outpatient facilities, ambulatory surgical centers, and in payer organizations

American Accreditation Healthcare Commission/URAC

A healthcare quality improvement organization that offers managed care organizations, as well as other organizations, accreditation to validate quality healthcare, and provides education and measurement programs

American Association for Accreditation of Ambulatory Surgery Facilities (AAAASF)

An organization that provides an accreditation program to ensure the quality and safety of medical and surgical care provided in ambulatory surgery facilities

American Association of Health Plans (AAHP)

The trade organization for health maintenance organizations, preferred provider organizations, and other network-based health plans created by the merger of the Group Health Association of America and the American Managed Care and Review Association

American Association of Medical Record Librarians (AAMRL)

The name adopted by the Association of Record Librarians of North America in 1944; precursor of the American Health Information Management Association

American Association of Preferred Provider Organizations (AAPPO)

A national association composed of preferred provider organizations (PPOs) and affiliate organizations, which advocates for consumer awareness of their healthcare benefits and advocates for greater access, choice, and flexibility

American College of Healthcare Executives (ACHE)

The national professional organization of healthcare administrators that provides certification services for its members and promotes excellence in the field

American College of Obstetricians and Gynecologists (ACOG)

The professional association of medical doctors specializing in obstetrics and gynecology

American College of Radiology-National Electrical Manufacturers Association (ACR-NEMA)

The professional organizations (ACR) and trade associations (NEMA) that work collaboratively to develop digital imaging standards

American College of Surgeons (ACS)

The scientific and educational association of surgeons formed to improve the quality of surgical care by setting high standards for surgical education and practice

American College of Surgeons Commission on Cancer

The organization that approves cancer-related programs, including cancer registries and trauma centers

American Correctional Association (ACA)

An organization that provides education, training, correctional certification, and accreditation for correctional healthcare organizations

American Dental Association (ADA)

A professional dental association dedicated to the public's oral health, ethics, science, and professional advancement

American Health Information Community (AHIC)

A public-private federal advisory committee associated with the Office of the National Coordinator that makes recommendations to the secretary on how to accelerate adoption of interoperable electronic health information technology

American Health Information Management Association (AHIMA)

The professional membership organization for managers of health record services and healthcare information systems as well as coding services; provides accreditation, advocacy, certification, and educational services

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

American Medical Association (AMA)

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; maintains and publishes the Current Procedural Terminology (CPT) coding system

American Medical Informatics Association (AMIA)

A professional association for individuals, institutions, and corporations that promotes the development and use of medical informatics for patient care, teaching, research, and healthcare administration

American Medical Record Association (AMRA)

The name adopted by the American Association of Medical Record Librarians in 1970; precursor of the American Health Information Management Association

American National Standards Institute (ANSI)

An organization that governs standards in many aspects of public and private business; developer of the Health Information Technology Standards Panel

American Nurses Association (ANA)

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

American Occupational Therapy Association (AOTA)

The nationally recognized professional association of more than 40,000 occupational therapists, occupational therapy assistants, and students of occupational therapy

American Osteopathic Association (AOA)

The professional association of osteopathic physicians, surgeons, and graduates of approved colleges of osteopathic medicine that inspects and accredits osteopathic colleges and hospitals

American Physical Therapy Association (APTA)

The national professional organization whose goal is to foster advancements in physical therapy practice, research, and education

American Psychiatric Association (APA)

The international professional association of psychiatrists and related medical specialists that works to ensure humane care and effective treatment for all persons with mental disorders, including mental retardation and substance-related disorders

American Psychological Association (APA)

The professional organization that aims to advance psychology as a science and profession and promotes health, education, and human welfare

American Recovery and Reinvestment Act of 2009 (ARRA)

An economic stimulus package enacted by the 111th United States Congress in February 2009; signed into law by President Obama on February 17, 2009; an unprecedented effort to jumpstart the economy, create/save millions of jobs, and put a down payment on addressing long-neglected challenges; an extraordinary response to a crisis unlike any since the Great Depression; includes measures to modernize our nation's infrastructure, enhance energy independence, expand educational opportunities, preserve and improve affordable healthcare, provide tax relief, and protect those in greatest need; Also called Recovery Act; Stimulus

American Society for Healthcare Risk Management (ASHRM)

The professional society for healthcare risk management professionals that is affiliated with the American Hospital Association and provides educational tools and networking opportunities for its members

American Society for Quality (ASQ)

A quality improvement organization whose members' interests are related to statistical process control, quality cost measurement and control, total quality management, failure analysis, and zero defects

American Society for Testing and Materials (ASTM)

A national organization whose purpose is to establish standards on materials, products, systems, and services

American Society for Testing and Materials Committee E31 (ASTM E31)-Healthcare Informatics

A committee within the American Society for Testing and Materials that creates standards on the content, structure, and functionality of electronic health record systems, health information confidentiality policies and procedures, health data security, and the exchange of information across clinical systems, such as laboratory devices with information systems

American Society for Testing and Materials Standard E1384 (ASTM E1384)-Standard Guide for Description of Content and Structure of an Automated Primary Record of Care

A standard that identifies the basic information to be included in electronic health records and requires the information to be organized into categories

American Standard Code for Information Interchange (ASCII)

Electronic code that represents text, which makes it possible to transfer data from one computer to another

Americans with Disabilities Act (ADA) of 1990

Federal legislation which ensures equal opportunity for and elimination of discrimination against persons with disabilities

America's Health Insurance Plans (AHIP)

A national trade association representing companies providing health benefits to Americans; formerly known as the Health Insurance Association of America (HIAA)


Data or information that is not represented in an encoded, computer-readable format


Review of health record for proper documentation and adherence to regulatory and accreditation standards

Analysis of discharged health records policy

A policy that outlines steps to be taken to process discharged resident records

Analysis phase

The first phase of the systems development life cycle during which the scope of the project is defined, project goals are identified, current systems are evaluated, and user needs are identified

Analysis session

The process of mining a data segment


Any material or chemical substance subjected to analysis

Anatomical modifiers

Two-digit CPT codes that provide information about the exact body location of procedures, such as -LT, Left side, and -TA, Left great toe

Ancillary packaging

The inclusion of routinely performed support services in the reimbursement classification of a healthcare procedure or service

Ancillary services

1. Tests and procedures ordered by a physician to provide information for use in patient diagnosis or treatment 2. Professional healthcare services such as radiology, laboratory, or physical therapy

Ancillary service visit

The appearance of an outpatient in a unit of a hospital or outpatient facility to receive services, tests, or procedures; ordinarily not counted as an encounter for healthcare services

Ancillary systems

Electronic systems that generate clinical information (such as laboratory information systems, radiology information systems, pharmacy information systems, and so on)

Ancillary unit

See adjunct diagnostic or therapeutic unit

Androgynous leadership

Leadership in which cultural stereotyped masculine and feminine styles are integrated into a more effective hybrid style

Anesthesia death rate

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

Anesthesia report

The report that notes any preoperative medication and response to it, the anesthesia administered with dose and method of administration, the duration of administration, the patient's vital signs while under anesthesia, and any additional products given the patient during a procedure

Anesthetic risk

The risk of harm resulting from the administration of anesthetic agents


Extending or moving forward

Antipsychotic Dyskinesia Identification System

One of several standardized forms for assessing and documenting abnormal movements (of face, eyes, mouth/tongue, or body) that may occur in the course of treatment with some psychotropic medications; See also discus monitoring form

Antipsychotic medications

Drugs that are used in the management of psychotic conditions, bipolar disorders, or major depression with psychotic features

Any and all records

A phrase frequently used by attorneys in the discovery phase of a legal proceeding. Subpoena-based requests containing this phrase may create a situation where the record custodian or provider's legal counsel can work to limit the records disclosed to those defined by a particular healthcare entity's legal health record. Typically, this is only during a subpoena phase, unless the information is legally privileged or similarly protected; the discovery phase of litigation probably can be used to request any and all relevant materials

APC grouper

Software programs that help coders determine the appropriate ambulatory payment classification for an outpatient encounter


1. A request for reconsideration of a denial of coverage or rejection of claim decision 2. The next stage in the litigation process after a court has rendered a verdict; must be based on alleged errors or disputes of law rather than errors of fact

Appellate court

Courts that hear appeals on final judgments of the state trial courts or federal trial courts


The operation that results in adding information to documentation already in existence

Application controls

Security strategies, such as password management, included in application software and computer programs

Application programming interface (API)

A set of definitions of the ways in which one piece of computer software communicates with another or a programmer makes requests of the operating system or another application; operates outside the realm of the direct user interface

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

Application service provider (ASP)

A third-party service company that delivers, manages, and remotely hosts standardized applications software via a network through an outsourcing contract based on fixed, monthly usage, or transaction-based pricing

Applied artificial intelligence

An area of computer science that deals with algorithms and computer systems that exhibit the characteristics commonly associated with human intelligence

Applied healthcare informatics

Automated information systems applied to healthcare delivery business and workflow processes, including the diagnosis, therapy, and systems of managing health data and information within the healthcare setting

Applied research

A type of research that focuses on the use of scientific theories to improve actual practice, as in medical research applied to the treatment of patients

Appreciative inquiry

An organizational development technique in which successful practices are identified and expanded throughout the organization

Aptitude tests

Tests that assess an individual's general ability to learn a new skill

AQA Alliance

A broad-based coalition of physicians, consumers, purchasers, health insurance plans, and others who are committed to effectively and efficiently improve performance measurement, data aggregation, and reporting in the ambulatory care setting


A proceeding in which disputes are submitted to a third party or a panel of experts outside the judicial trial system


The configuration, structure, and relationships of hardware (the machinery of the computer including input/output devices, storage devices, and so on) in an information system

Archival database

A historical copy of a database that is saved at a particular point in time. It is used to recover and/or restore the information in the database

Archive file

A file in a collection of files reserved for later research or verification for the purposes of security, legal processes, and/or backup

Arden syntax

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

Area of excellence

A describable skill, competence, or capability that a department or company cultivates to a level of proficiency

Arithmetic mean length of stay (AMLOS)

The average length of stay for all patients

Artificial intelligence (AI)

High-level information technologies used in developing machines that imitate human qualities such as learning and reasoning

Artificial neural network (ANN)

A computational technique based on artificial intelligence and machine learning in which the structure and operation are inspired by the properties and operation of the human brain


Accredited Standards Committee, Electronic Data Interchange; See Accredited Standards Committee X12 (ASC X12)


A computer program that translates assembly language instructions into machine language

Assembly language

A second-generation computer programming language that uses simple phrases rather than the complex series of switches used in machine language


The systematic collection and review of information pertaining to an individual who wants to receive healthcare services or enter a healthcare setting

Assessment completion date

According to the Centers for Medicare and Medicaid Services' instructions, the date by which a Minimum Data Set for Long-Term Care must be completed; that is, within 14 days of admission to a long-term care facility

Assessment final completion date

The date (within 32 days of the assessment's final completion date) on which the Centers for Medicare and Medicaid requires Minimum Data Set for Long-Term Care assessments to be electronically submitted to the facility's state Minimum Data Set for Long-Term Care database

Assessment indicator code

A component of the code used for Medicare billing by long-term care facilities

Assessment locking

A term that refers to the Centers for Medicare and Medicaid Services' requirement that long-term care facilities must encode Minimum Data Set assessments in a computerized file and edit the data items for compliance with data specifications

Assessment reference date (ARD)

The date that sets the designated end point of resident observation for all staff participating in the assessment


The human, financial, and physical resources of an organization


An agreement between a physician and CMS whereby a physician or supplier agrees to accept the Medicare-approved amount as payment in full for services or supplies provided under Part B. Medicare pays the physician or supplier 80 percent of the approved amount after the annual $100 deductible has been met; the beneficiary pays the remaining 20 percent

Assignment of benefits

The transfer of one's interest or policy benefits to another party; typically the payment of medical benefits directly to a provider of care

Assisted living

A type of freestanding long-term care facility where residents receive necessary medical services but retain a degree of independence

Association for Healthcare Documentation Integrity (AHDI)

Formerly the American Association for Medical Transcription (AAMT), the AHDI has a model curriculum for formal educational programs that includes the study of medical terminology, anatomy and physiology, medical science, operative procedures, instruments, supplies, laboratory values, reference use and research techniques, and English grammar

Association of American Medical Colleges (AAMC)

The organization established in 1876 to standardize the curriculum for medical schools in the United States and to promote the licensure of physicians

Association of Clinical Documentation Improvement Specialists (ACDIS)

Formed in 2007 as a community in which clinical documentation improvement professionals could communicate resources and strategies to implement successful programs and achieve professional growth

Association of Record Librarians of North America (ARLNA)

Organization formed 10 years after the beginning of the hospital standardization movement whose original objective was to elevate the standards of clinical recordkeeping in hospitals, dispensaries, and other healthcare facilities; precursor of the American Health Information Management Association

Association rule analysis (rule induction)

The process of extracting useful if/then rules from data based on statistical significance; See also rule induction

Assumption coding

The practice of assigning codes on the basis of clinical signs, symptoms, test findings, or treatments without supporting physician documentation


Undetermined aspects of a project that are considered to be true (for example, assuming that project team members have the right skill set to perform their duties)

ASTM International

Formerly known as the American Society for Testing and Materials, a system of standards developed primarily for various EHR management processes

ASTM Standard E1384-02a

Standard that identifies the content and structure for EHRs, covering all types of healthcare services, including acute-care hospitals, ambulatory care, skilled nursing facilities, home healthcare, and specialty environments


Occurring at different times

Asynchronous transfer mode (ATM)

A topology for transmitting data across large wide-area networks

Atlas System

A severity-of-illness system commonly used in the United States and Canada

At risk contract

A type of managed care contract between Medicare and a payer or a payer and a provider according to which patients receive care during the entire term of the contract even if actual costs exceed the payment established by the agreement

Attending physician

The physician primarily responsible for the care and treatment of a patient

Attending physician identification

The unique national identification number assigned to the clinician of record at discharge who is responsible for the inpatient discharge summary

Attending Physician Statement (APS)

The standardized insurance claim form created in 1958 by the Health Insurance Association of America and the American Medical Association; See also COMB-1 form


The act of applying an electronic signature to the content showing authorship and legal responsibility for a particular unit of information

Attorney-client privilege

An understanding that protects communication between client and attorney

Attorney in fact

Agent authorized by an individual to make certain decisions, such as healthcare determinations, according to a directive written by the individual

Attributable risk (AR)

A measure of the impact of a disease on a population (for example, measuring additional risk of illness as a result of exposure to a risk factor)


1. Data elements within an entity that become the column or field names when the entity relationship diagram is implemented as a relational database 2. Properties or characteristics of concepts; used in SNOMED CT to characterize and define concepts


See mortality


A learning technique in which participants in different locations can learn together via telephone lines while listening to a presenter and looking at handouts or books


1. A function that allows retrospective reconstruction of events, including who executed the events in question, why, and what changes were made as a result 2. To conduct an independent review of electronic system records and activities in order to test the adequacy and effectiveness of data security and data integrity procedures and to ensure compliance with established policies and procedures; See also external review


The ability to do a methodical examination and verification of all information activities such as entering and accessing

Audit controls

The mechanisms that record and examine activity in information systems

Audit log

A chronological record of electronic system(s) activities that enables the reconstruction, review, and examination of the sequence of events surrounding or leading to each event and/or transaction from its beginning to end. Includes who performed what event and when it occurred

Audit reduction tool

Used to review the audit trail and compare it to facility-specific criteria and eliminate routine entries such as the periodic back-ups

Audit trail

1. A chronological set of computerized records that provides evidence of information system activity (log-ins and log-outs, file accesses) used to determine security violations 2. A record that shows who has accessed a computer system, when it was accessed, and what operations were performed; See also audit log


The performance of internal and/or external reviews (audits) to identify variations from established baselines (for example, review of outpatient coding as compared with CMS outpatient coding guidelines)


Confirm by signing

Authenticated evidence

Evidence that appears to be relevant and has been shown to have a baseline authenticity or trustworthiness


1. The process of identifying the source of health record entries by attaching a handwritten signature, the author's initials, or an electronic signature 2. Proof of authorship that ensures, as much as possible, that log-ins and messages from a user originate from an authorized source


The genuineness of a record, that it is what it purports to be; information is authentic if proven to be immune from tampering and corruption


Person(s) who is (are) responsible and accountable for the health information creation, content, accuracy, and completeness for each documented event or health record entry


The right to make decisions and take actions necessary to carry out assigned tasks


1. The granting of permission to disclose confidential information; as defined in terms of the HIPAA Privacy Rule, an individual's formal, written permission to use or disclose his or her personally identifiable health information for purposes other than treatment, payment, or healthcare operations 2. A patient's consent to the disclosure of protected health information (PHI); the form by which a patient gives consent to release of information

Authorization management

The process of protecting the security and privacy of the confidential data in a database

Authorization to disclose information

An authorization that allows the healthcare facility to verbally disclose or send health information to other organizations; See also authorization


The origination or creation of recorded information attributed to a specific individual or entity acting at a particular time


1. A procedure that allows dictated reports to be considered automatically signed unless the health information management department is notified of needed revisions within a certain time limit 2. A process by which the failure of an author to review and affirmatively either approve or disapprove an entry within a specified time period results in authentication


The process of extracting and translating dictated and then transcribed free-text data (or dictated and then computer-generated discrete data) into ICD-9-CM and CPT evaluation and management codes for billing and coding purposes

Autodialing system

A method used to automatically call and remind patients of upcoming appointments

Automated clearinghouse (ACH)

An electronic network for the processing of financial transactions

Automated code assignment

Uses data that have been entered into a computer to automatically assign codes; uses natural language processing (NLP) technology-algorithmic (rules-based) or statistical-to read the data contained in a CPR

Automated codebook encoder

A type of encoder that mimics the codebook

Automated forms processing technology

Technology that allows users to electronically enter data into online digital forms and electronically extract data from online digital forms for data collection or manipulation; See also e-forms technology

Automatic log-off

A security procedure that ends a computer session after a predetermined period of inactivity


A core ethical principle centered on the individual's right to self-determination that includes respect for the individual; in clinical applications, the patient's right to determine what does or does not happen to him or her in terms of healthcare


The postmortem examinations of the organs and tissues of a body to determine the cause of death or pathological conditions

Autopsy rate

The proportion or percentage of deaths in a healthcare organization that are followed by the performance of autopsy

Autopsy report

Written documentation of the findings from a postmortem pathological examination


The accessibility for continuous use of data

Available for hospital autopsy

A situation in which the required conditions have been met to allow an autopsy to be performed on a hospital patient who has died


The value obtained by dividing the sum of a set of numbers by the number of values

Average daily census

The mean number of hospital inpatients present in the hospital each day for a given period of time

Average duration of hospitalization

See average length of stay

Average length of stay (ALOS)

The mean length of stay for hospital inpatients discharged during a given period of time

Average payment rate (APR)

The amount of money the Centers for Medicare and Medicaid could pay a health maintenance organization for services rendered to Medicare recipients under a risk contract

Average record delinquency rate

The monthly average number of discharges divided by the monthly average number of delinquent records

Average wholesale price (AWP)

The price commonly used when negotiating pharmacy contracts


In business, a situation where two parties in conflict ignore that conflict

Awareness training

Training designed to help individuals understand and respond to information technology concerns