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Insurance Billing

Insurance Billing YCST Chapter Four Terms and Abbreviations

CC Chief complaint or complication/comorbidity
Dx Diagnosis
ED or ER Emergency department or Emergency room
EHR Electronic Health Record
EMR Electronic Medical Record
FH Family history
HIM Health Information Management
HPI History of Present Illness
ICU Intensive Care Unit
LLQ Left lower quadrant
LUQ Left upper quadrant
MDM Medical Decision Making
NP New patient
PCP Primary Care Physician
PE or PX Physical Examination
PFSH Past family and social history
PH Past history
RCU Respiratory care unit
RLQ Right lower quadrant
R/O Rule out
ROS Review of Systems
RUQ Right upper quadrant
SH Social history
SOAP Subjective, objective, assessment, plan
WNL Within normal limits
What is a medical condition that runs a short but relatively severe course? Acute
What is a patient's statement describing symptoms, problems, or conditions as the reason for seeking health care services from a physician? Chief complaint
What is a medical condition persisting over a long period of time? Chronic
What is an ongoing condition that exists along with the condition for which the patient is receiving treatment? Comorbidity
What is the provision of similar services to the same patient by more than one physician on the same day? Concurrent care
What are services rendered by a physician whose opinion or advice is requested by another physician or agency in the evaluation or treatment of a patient's illness or suspected problem? Consultation
Who is a provider whose opinion or advice about evaluation or management of a specific problem is requested by another physician? Consulting physician
What is it when a physican sees a patient who has received treatment for a condition and is referred by the previous doctor for treatment of the same condition? Continuity of care
What is a chronologic detailed recording of pertinent facts and observations about a patient's health as seen in chart notes and medical reports? Documentation
What is a patient record that is created using a computer with software? EHR
Who is an individual who has received professional services within the past three years from the physician or another physician of the same specialty who belongs to the same group practice? Established patient
What is the performance of services and procedures that are consistent with the diagnosis in accordance with standards of good medical practice, performed at the proper level, and provided in the most appropriate setting? Medical necessity
Who is an individual who has not received any professional services from the physician or another physician of the same specialty who belongs to the same group practice within the past three years? New patient
Who is the physician ordering nonphysician services for a patient when an insurance claim is submitted by a nonphysiian supplier of services? Ordering physician
Who is a physician who oversees the care of patients in a managed health care plan and refers patients to see specialists for services as needed? PCP
What is the process of going over financial documents before billing is submitted to the insurance company to determine documentation deficiencies and errors? Prospective review
What is the transfer of the total or specific care of a patient from one physician to another? Referral
Who is a physician who sends the patient for testing or treatment noted on the insurance claim when it is submitted by the physicain performing the service? Referring physician
What is the process of going over financial documents after billing an insurance carrier to determine documentation deficiences and errors? Retrospective review
Created by: dsljulian
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