Medical Management Guide, 2009, Version 3.0 - Tricare

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Page 164Appendix C - DefinitionsVersion 3.0Medical Management GuideClinical Practice Guidelines (CPGs)Systematically developed statements to assist practitioner and patient decisions about appropriate health carefor specific clinical circumstances (Institute of Medicine, 1990). CPGs define the role of specific diagnostic andtreatment modalities in the diagnosis and management of patients. The statements contain recommendationsbased on evidence from a rigorous systematic review and synthesis of the published medical literature.Resources:Department of Health & Human Services (HHS), National Heart Lung and Blood Institute (NHLBI):http://www.nhlbi.nih.gov/guidelines/about.htm.Department of Veterans Affairs (VA): http://www.healthquality.va.gov/index.asp.National Guideline Clearinghouse (NGC): http://www.guideline.gov/index.aspx.U.S. Army Quality Management Office (QMO): https://www.qmo.amedd.army.mil/pguide.htm.Code of Federal Regulations (CFR)The codification of the general and permanent rules published in the Federal Register by the executivedepartments and agencies of the federal government. It is divided into 50 titles that represent broad areassubject to federal regulation. Each volume of the CFR is updated once each calendar year and is issued on aquarterly basis.Resources: Government Printing Office: http://www.gpoaccess.gov/CFR/.Convalescent LeaveAn authorized leave status, not chargeable to the individual, granted to active duty Uniformed Servicemembers while under medical or dental care that is part of the care and treatment prescribed for a member'srecuperation or convalescence. Convalescent leave days are not counted as occupied bed days but are countedas sick days when the convalescent leave occurs before the disposition of the patient. Convalescent leaveoccurring after disposition of the patient while en route to a new command or convalescent leave granted by aline commander after patient discharge from the hospital is not counted as occupied bed days or sick days.Resources: DoD Manual 6015.1-M, Glossary of Healthcare Terminology (January 1999):http://www.dtic.mil/whs/directives/corres/pdf/601501m.pdf. See CD-ROM Resource AppendixC-Def 1Cooperative Health Care Clinic (CHCC)In cooperative health care clinics (CHCC), health care is provided to older patients in a group setting. The CHCCconcept, which was developed under a research grant by Kaiser Permanente in Colorado in 1991, showedimprovement in patient and provider satisfaction, as well as improved quality of care and cost effectiveness.Resources:Scott, J., Gade, G., McKenzie, M., Venohr, I. Cooperative health care clinics: a group approach to individualcare. Geriatrics, May 1998, 53(5):68-70, 76-8, 81. National Center for Biotechnology Information (NCBI): http://www.ncbi.nlm.nih.gov/pubmed/9597981?dopt=Abstract.
Medical Management Guide Version 3.0 Appendix C - DefinitionsPage 165Cost-Benefit AnalysisThe process of weighing the total expected costs vs. the total expected benefits of one or more actions in orderto choose the most profitable option. This often involves monetary calculations of initial expense vs. expectedreturn. It is usually done to decide whether to make a change or to determine how well, or how poorly, aplanned action (e.g., implementation of a program) will turn out. Also known as “running the numbers.”A cost-benefit analysis finds, quantifies, and adds all the positive factors. These are the benefits. Then itidentifies, quantifies, and subtracts all the negatives, the costs. The difference between the two indicateswhether the planned action is advisable. The real trick to doing a cost benefit analysis well is making sure youinclude all the costs and all the benefits and properly quantify them.Resources:About Business Management: http://management.about.com/cs/money/a/CostBenefit.htm.Covered EntityUnder the Health Insurance Portability and Accountability Act of 1996 (HIPAA), any entity that is:• A healthcare provider that conducts certain transactions in electronic form (called here a "coveredhealthcare provider").• A healthcare clearinghouse.• A health plan.Resources:Centers for Medicare & Medicaid Services (CMS): http://www.cms.hhs.gov/HIPAAGenInfo/06_AreYouaCoveredEntity.asp.Current Procedural Terminology ® (CPT)A coding system that describes the procedures, services, or supplies provided to patients within the outpatientsetting.Current Procedural Terminology ® (CPT), 4th Edition, is a listing of descriptive terms and identifying codes forreporting medical services and procedures. The purpose of CPT is to provide a uniform language that accuratelydescribes medical, surgical, and diagnostic services, and thereby serves as an effective means for reliablenationwide communication among physicians, and other healthcare providers, patients, and third parties.Resources:American Medical Association (AMA):http://www.ama-assn.org/ama/no-index/physician-resources/3882.shtml.Custodial CareThe treatment or services, regardless of who recommends treatment or services or which such treatment orservices are provided, that a) can be rendered safely and reasonably by a person who is not medically skilled orb) is/are designed mainly to help the patient with the activities of daily living.
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Medical Management Guide, 2009, Version 3.0 - Tricare

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