HIPAA, HITECH, and Medical Records

1. 2 HIPAA, HITECH, and Medical Records

2. 2-2 Learning Outcomes When you finish this chapter, you will be able to: 2.1 Discuss the importance of medical records and documentation in the medical billing process. 2.2 Compare the intent of HIPAA and ARRA/HITECH laws. 2.3 Describe the relationship between covered entities and business associates. 2.4 Explain the purpose of the HIPAA Privacy Rule. 2.5 Briefly state the purpose of the HIPAA Security Rule. 2.6 Explain the purpose of the HITECH Breach Notification Rule.

3. 2-3 Learning Outcomes (Continued) When you finish this chapter, you will be able to: 2.7 Describe the HIPAA Electronic Health Care Transactions and Code Sets standards and the four National Identifiers. 2.8 Explain the purpose of the Health Care Fraud and Abuse Control Program and related laws. 2.9 Identify the organizations that enforce HIPAA. 2.10 Discuss the ways in which compliance plans help medical practices avoid fraud or abuse.

4. 2-4 Key Terms • clearinghouse • code set • compliance plan • covered entity (CE) • de-identified health information • designated record set (DRS) • documentation • electronic data interchange (EDI) • electronic health record (EHR) • abuse • American Recovery and Reinvestment Act (ARRA) of 2009 • audit • authorization • breach • breach notification • business associate (BA) • Centers for Medicare and Medicaid Services (CMS)

5. 2-5 Key Terms (Continued) • HIPAA Electronic Health Care Transactions and Code Sets (TCS) • HIPAA final enforcement rule • HIPAA National Identifier • HIPAA Privacy Rule • HIPAA Security Rule • HITECH Act • informed consent • malpractice • medical record • electronic medical record (EMR) • encounter • encryption • evaluation and management (E/M) • fraud • Health Care Fraud and Abuse Control Program • Health Insurance Portability and Accountability Act (HIPAA) of 1996

6. 2-6 Key Terms (Continued) • password • protected health information (PHI) • qui tam • relator • respondeat superior • subpoena • subpoena duces tecum • transaction • treatment, payment, and health care operations (TPO) • medical standards of care • minimum necessary standard • National Provider Identifier (NPI) • Notice of Privacy Practices (NPP) • Office for Civil Rights (OCR) • Office of the Inspector General (OIG)

7. 2-7 2.1 Medical Record Documentation • A patient’s medical record contains facts, findings, and observations about that patient’s health • Documentation is the recording of a patient’s health status in a medical record history • Medical standards of care—state-specified performance measures for health care delivery • Medical records and documentation act as legal documents and help physicians make accurate diagnoses • Malpractice—failure to use professional skill when giving medical services that results in injury or harm

8. 2-8 2.1 Medical Record Documentation(Continued) • Encounter—an office visit between a patient and a medical professional • Evaluation and management (E/M)—provider’s evaluation of a patient’s condition and decision on a course of treatment • Electronic health record (EHR)—computerized lifelong health care record with data from all sources • Electronic medical record (EMR)—computerized record of one physician’s encounters with a patient

9. 2-9 2.1 Medical Record Documentation(Continued) • Informed consent—process by which a patient authorizes medical treatment after a discussion with a physician

10. 2-10 2.2 Health Care Regulation: HIPAA andHITECH • The main federal government agency responsible for health care is the Centers for Medicare and Medicaid Services, also known as CMS • The foundation legislation for the privacy of patients’ health information is called the Health Insurance Portability and Accountability Act (HIPAA) of 1996 • Protects private health information, ensures coverage, uncovers fraud and abuse, and creates industry standards

11. 2-11 2.2 Health Care Regulation: HIPAA andHITECH (Continued) • American Recovery and Reinvestment Act (ARRA) of 2009—law with provisions concerning the standards for the electronic transmission of health care data • Contains the HITECH Act—law promoting the adoption and use of health information technology