Hospital Terminology

University of Mississippi Medical CenterUniversity of Mississippi Medical CenterAccess Management

Patient Access Specialists I

In Access Managementg• We are the FIRST STAGE in the Revenue Cycle.• If patient information is entered incorrectly by usIf patient information is entered incorrectly by us,

the hospital can’t get paid for services it provides.• When errors occur, valuable resources must be ,

spent recovering money lost because of OUR MISTAKE.A M t i th f d ti f th• Access Management is the foundation of the Revenue Cycle.

What to Expect…p• This module will help you prepare to be a

RESOURCEFUL Patient Access Specialist I.p• You will learn terms commonly used while

registering patients and often heard throughout the h it lhospital.

• The terms are broken down into six categories.• A quiz at the end will measure what you learned• A quiz at the end will measure what you learned.

In This Module…You’ll Learn Terms Regarding:

1 Admitting and Registering Patients1. Admitting and Registering Patients2. Patient Records and Identification3. Patient Rights and Consent Formsg4. How Patients Arrive at UMC5. Patient Status Codes6. Miscellaneous Codes

Section ISection I

This section deals with terms regarding the admission and registration f ti tof patients.

Direct Admission- An admission usually scheduled in ad ance from a doctor’s office clinic or the emergencadvance from a doctor’s office, clinic, or the emergency room. These patients usually have a room/bed reserved.

Emergency Admission- An admission necessitated by an accident or medical emergency processed through the Emergency Department.

.

Section IScheduled Admission- An admission always scheduled in

advance. It may be urgent or elective. A Direct Admission can be a Scheduled Admission but a Scheduled Admit cannot be a Direct Admit

Pre-Admit- The process of obtaining patient information and partially preparing admission forms before a patient’s arrival at the health care facility.

Section IRegistration- The process of entering personal information

into the hospital computer system to enroll a person as a patient by creating a patient record. Patients may be registered as inpatients, outpatients, or observation patients.

Observation Patients- This is a patient a doctor wants to keep an eye on for a limited amount of time. They are assigned to a bed on the nursing unit and receive care for a period of less than 24 hours. Doctors can extend the Observation period up to 48 hours if necessary. Any additional time requires a transfer to Inpatient Status.

Section IInpatient- A patient admitted into the hospital for at least one

overnight stay. Treatment can continue indefinitely.

Outpatient- A patient being treated in an office, clinic, or other ambulatory care facility typically released on day of y y yp y ytreatment. Following a procedure and 6 hours in PACU, a doctor may want to place an Outpatient in a bed to monitor for a few additional hours, or even overnight. If they meet observation criteria, they are transferred to Observation status. If condition deteriorates, they would then be transferred to Inpatient status.

Section IISection II

This section discusses methods of patient identification.

**NOTE: THESE FIRST TWO TERMS ARE EASILY CONFUSED**

Medical record number- This number is assigned to the i d i h i FIRST VISIT h h i l d ipatient during their FIRST VISIT to the hospital and it

NEVER CHANGES. This is the patient’s unique UMC ID number used to access their personal information. It is used for all subsequent admissions to the hospital Aused for all subsequent admissions to the hospital. A patient should never have two medical record numbers.

Section IIPatient Account Number- This is a unique number

identifying a SINGLE PATIENT VISIT to UMC. A new number is assigned each time the patient is admitted to ornumber is assigned each time the patient is admitted to or registered at the hospital. It is used for billing purposes. A patient may have more than one patient account number.

Patient Identification Bracelet- A plastic band with a patient identification label affixed to it worn by the patient throughout hospitalization In the obstetrics department athroughout hospitalization. In the obstetrics department, a mother and the newborn would share the same identification label affixed to their ID bracelets until the baby is assigned their own medical record numberbaby is assigned their own medical record number.

Section IIPatient Identification Labels- Self-adhesive labels used on

the patient’s identification bracelet to identify forms, requisitions, specimens, etc.

Face Sheet- A form initiated by the admitting department and y g pincluded in the inpatient medical record that contains personal and demographic information.

Advance Directives- Documents indicating a patient’s wishes in the event they become incapacitated and unable to make decisions regarding their own medical care.to make decisions regarding their own medical care.

Section IIISection IIIThis section discusses patients’ rights concerning health care and the

f th t i d i i t tiforms they must sign during registration.

HIPAA- Stands for the Health Insurance Portability and Accountability Act of 1996 A major component of HIPAAAccountability Act of 1996. A major component of HIPAA addresses the privacy of individuals’ health information by establishing a nation-wide federal standard concerning the PRIVACY OF HEALTH INFORMATION and how it can be used and disclosed. This federal standard will generally preempt all state privacy laws except for those establishing stronger protections. The HIPAA privacy laws became effective on April 14, 2003.

Section IIIEMTALA St d f th E M di l T t tEMTALA – Stands for the Emergency Medical Treatment

and Active Labor Act. It governs when and how a patient may be REFUSED TREATMENT, or transferred from one hospital to another when in unstable condition. “Refusal pof treatment,” broadly interpreted means the potential of refusal based on financial conditions or ability to pay.

Medicare Rights Form – This important message form must be signed and dated by all Medicare patients. This informs Medicare patients of their rights to services and discharge.

Section IIINotification of Consent of Medical Treatment – This form

AUTHORIZES THE HOSPITAL TO DO MANY THINGS and must be signed and dated by the patients on EACH VISIT. It is required to be scanned into the system by the registering PAS.

This form:A h i h h i l l i i f i h• Authorizes the hospital to release patient information when necessary

• Authorizes the insurance company to reimburse hospital for services provided to the patient

• Is a financial agreement between the patient and hospitalIs a financial agreement between the patient and hospital • Is an official notice that the patient is liable for coinsurance • Gives consent to treat patient• Explains how x-rays are retained and destroyedExplains how x rays are retained and destroyed• Informs patients of their responsibility to secure their valuables.

Section IIINotification of Privacy Practices (NPP) – This form, which

must be signed and dated by the patient describes how medical i f i b h i b d d di l d dinformation about the patient may be used and disclosed, and how patients can gain access to the information. The notice has to be SIGNED AND DATED ONLY ONCE, pending the Patient Access Specialist enters into the system that aPatient Access Specialist enters into the system that a signature has been obtained. This is part of the HIPPA Act. The PAS is required to scan NPP into the system.

Section IVSection IV

This section explains the different ways patients arrive to the hospital and how they should be classifiedand how they should be classified.

Ambulatory - patient walked in.

Air Transport – patient brought in by helicopter.

Wheel Chair – patient arrived in their privately owned wheelchair.

Section IVGround Ambulance – patient arrived by ambulance

but was not on a stretcher.

Carried – patient was physically carried in by someone not affiliated with UMC.

Stretcher ti t i d b b l dStretcher – patient arrived by ambulance and was on a stretcher.

Section VSection V

This section presents eleven different patient status codes and their meanings.

Patient Status Codes and MeaningsInpatient Status CodesIA – Inpatient ActiveIP Inpatient Pre AdmitIP – Inpatient Pre-AdmitID – Inpatient DischargeIC – Inpatient Complete

Section VPatient Status Codes and MeaningsOutpatient Status CodespOA – Outpatient ActiveOP – Outpatient Pre-RegisteredOD Outpatient Discharge (NOTE: Monthly Account)OD – Outpatient Discharge (NOTE: Monthly Account)OC – Outpatient Complete (Not an Active Code)ET – Emergency ActiveEA – Emergency Discharge (NOTE EA instead of ED)EC – Emergency Complete (Not an Active Code)

Section VI• The following slides present an exhaustive list of codes

used throughout the hospital.

• You do not need to know all of them.

• Naturally you will become familiar with codes common to your area.

• For the quiz, you must know that this list can always be accessed by using the Help Screen. To access, place the cursor where the code is needed and hit “Shift + F12 ”cursor where the code is needed and hit Shift + F12.

Section VIALG ADULT ALLERGY AIR AIR-AMBULANCE

DRM DERMATOLOGY DIG DIGESTIVE DZ

AEA AMBULATORY EVALANE ANESTHESIOLOGY ACR CARDIOLOGY CVS CARDIOVASCULAR

DER DURANT ER MED DMD DURANT MEDICINE DPE DURANT PEDS ER DPM DURANT PEDS MEDCVS CARDIOVASCULAR

LAB CLINICAL LAB RMD CRC MEDICINE RNU CRC NEUROLOGY

DPM DURANT PEDS MEDENT EAR,NOSE,THROAT EFT EMERGENCY FAST

TRACKRNU CRC NEUROLOGY

DEN DENTISTRY

TRACK EMR EMERGENCY

ROOM

Section VIEND ENDOCRINE AFM FAMILY MEDICINE

NCU NEONATAL NEP NEPHROLOGY

NUR GEN NEWBORN GER GERONTOLOGY GAM GROUND

AMBULANCE

NEU NEUROLOGY NSU NEUROSURGERY OB OBSTETRICS

/INPATIENTAMBULANCE GYT GYN TUMOR GYN GYNECOLOGY HPC HEMATOLOGY

/INPATIENT OOB OBSTETRICS

/OUTPATONC ONCOLOGY HPC HEMATOLOGY

IFD INFECTIOUS DZ REH INPATIENT REHAB MED MEDICINE

OHN OPHTHALMOLOGY DOS ORAL DENTISTRY ORT ORTHOPEDICSNOB OUTBORN

Section VIPTH PATHOLOGY VAN PAVL ANESTHESIA

VNE PAVL NEUROLOGY VOB PAVL OBSTETRICS

VEN PAVL EAR, NOSE, THROAT

VEM PAVL EMERGENCY MED

VOT PAVL OCCUPATIONAL

VOP PAVL OPHTHAL VOR PAVL ORTHMED

VFM PAVL FAMILY MED VGY PAVL GYN VLB PAVL

VOR PAVL ORTH VPA PAVL PATHOLOGY VPE PAVL PEDIATRICS VPT PAVL PHYSICAL

LABORATORY VMD PAVL MEDICINE VNS PAVL NEURO

SURGERY

VPT PAVL PHYSICALTHERAPY

VPM PAVL PREVENT MED VPY PAVL PSYCHIATRY

SURGERYVRA PAVL RADIOLOGY

Section VIVRD PAVL RADIOLOGY VSU PAVL SURGERY

PET PEDS E N T PER PEDS EMERGENCY

VPR EDIATRIC RESP THER

PAD PEDS ADOLESCENT PAL PEDS ALLERGY

PED PEDS ENDOCRINE PFM PEDS FAMILY MED PSU PEDS GEN SURG PHP PEDSPAL PEDS ALLERGY

PAN PEDS ANESTHESIO PCRP PEDS CARDIOLOGY PCV PEDS CARDIOVAS

PHP PEDS HEMATOLOGY

PID PEDS INFECT DZ PMD PEDS MEDICINEPCV PEDS CARDIOVAS

PLB PEDS CLINIC LAB PDN PEDS DENTISTRY PDR PEDS

PMD PEDS MEDICINE PNE PEDS

NEPHROLOGY PNU PEDS NEUROLOGY

DERMATOLOGYPDG PEDS DIGEST DZ

PNS PEDS NEUROSURG PON PEDS ONCOLOGY

Section VIPOH PEDS OPHTHALMOL POS PEDS ORAL DENT POR PEDS ORTHOPEDIC

PUR PEDS UROLOGY APS PLASTIC SURGERY PSY PSYCHIATRYPOR PEDS ORTHOPEDIC

PPH PEDS PATHOLOGY PPS PEDS PLASTIC

SURGERY

PSY PSYCHIATRY PUL PULMONARY RON RADIATION

ONCOLOGYPPY PEDS PSYCHIATRY PPU PEDS PULMONARY PGX PEDS RADIOLOGY PEH PEDS REHAB

GIX RADIOLOGY RHU RHEUMATOLOGY SUR SURGERY

PEH PEDS REHAB PRH PEDS RHEUMATOLO PTC PEDS THORACIC PTP PEDS TRANSPLANT

THC THORACIC TPT TRANSPLANT TRA TRAUMA URO UROLOGY

PTR PEDS TRAUMA URO UROLOGY VAS VASCULAR SURG