CHAP Health Information Management Flashcards

Which CPT code range covers Evaluation and Management (E/M) services?

Answer: 99202–99499

E/M services are coded in the range 99202–99499 in the CPT coding system, covering office visits, hospital care, consultations, and other patient evaluation services.

What is the purpose of a 'deficiency analysis' in health information management?

Answer: To identify missing or incomplete documentation in health records

Deficiency analysis (also called chart completion) reviews health records to identify missing, incomplete, or unsigned documentation that must be completed per policy or regulatory requirements.

What does the HIPAA Security Rule specifically protect?

Answer: Electronic Protected Health Information (ePHI)

The HIPAA Security Rule establishes standards to protect electronic Protected Health Information (ePHI) — PHI that is created, received, maintained, or transmitted in electronic form.

In health information management, what is a 'master patient index' (MPI)?

Answer: A database that uniquely identifies each patient and links their records across the organization

The MPI is a database that assigns a unique identifier to each patient and links all their records across an organization, ensuring accurate patient identification and record matching.

Which federal act established meaningful use requirements to promote the adoption of electronic health records?

Answer: HITECH Act

The Health Information Technology for Economic and Clinical Health (HITECH) Act established the Medicare and Medicaid EHR Incentive Programs (meaningful use) to promote EHR adoption.

What is the standard retention period for adult patient medical records under most US state laws?

Answer: 10 years

Most US states require medical records for adult patients to be retained for a minimum of 10 years from the date of last treatment, though requirements vary by state.