By Dava Stewart
If you do any research or reading about the regulations surrounding medical records, you will likely find yourself swimming in visual alphabet soup. Essentially, you are combining the acronyms and jargon of three, separate professions: software, healthcare, and government. It’s bound to get confusing.
Here are some of the most common acronyms you will find, along with what they mean and why you should know them.
HHS — The United States Department of Health and Human Services. This government entity is responsible for overseeing a host of programs designed to protect the health and well being of millions of citizens. In addition to Medicare and Medicaid, HHS oversees regulations, such as HIPAA and HITECH, among others.
HIPAA — Health Information Portability and Accountability Act. This may be the acronym that rules all others. This law, originally enacted in 1996, originally protected the healthcare coverage of workers (and their families) when they lost or changed jobs. In the time since, HIPAA has been expanded to address patients’ privacy and the responsibility of care providers, insurance companies, and others to keep patient information secure.
HITECH — Health Information Technology for Economic and Clinical Health. This law was part of the 2009 American Recovery and Reinvestment Act and was designed to promote adoption and meaningful use of health information technology by offering various, staggered incentives to certain healthcare providers.
OIG — Office of the Inspector General. This department within HHS is responsible for enforcing regulations and is “dedicated to combating fraud, waste and abuse and to improving the efficiency of HHS programs,” according to the website. If a chiropractic office is investigated at the federal level, the OIG will carry out the investigation.
EHR — Electronic Health Records. “EHR” usually refers to the software where electronic health records are kept/maintained. HITECH encourages the use of EHRs through incentives, but there are also security concerns that should always be addressed.
SOAP Notes — Subjective Objective Assessment Plan Notes. Practitioners take notes based on what the patient reports, what they observe, how they assess the patient’s condition, and how they plan to carry out treatment. Most EHR systems have a template for SOAP notes, and many practitioners make the mistake of copying and pasting notes from one chart to the next, which is an almost sure-fire way to trigger an audit.
ICD — International Classification of Diseases. This set of codes is published by the World Health Organization (WHO) and is used for billing purposes. Care providers submit codes for services rendered to insurance companies, who then, in theory, remit payment. In the U.S., ICD-9 is the standard, although ICD-10 has been available for a number of years. Audits can be triggered due to overuse of certain billing codes.
These are just a few of the many acronyms that DCs encounter on a regular basis. A thorough understanding of both what the codes mean, as well as how a practice can be impacted by them, is vital to running a healthy business.
