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Computer Class Vocab
Computers In The Medical Office
| Term | Definition |
|---|---|
| Health Information Technology (HIT) | Technology that is used to record, store, and manage patient healthcare information. |
| Practice Management Programs (PMPs) | Software programs that automate many of the administrative and financial tasks in a medical practice. |
| Electronic Health Record (EHR) | A computerized lifelong healthcare record for an individual that incorporates data from all providers who treat the individual. |
| Documentation | A record of healthcare encounters between the provider and the patient. |
| Electronic Medical Records (EMRs) | The computerized records of one physician's encounters with a patient over time. |
| Personal Health Records (PHRs) | Private, secure electronic files that are created, maintained, and owned by the patient. |
| Electronic Prescribing | The use of computers and handheld devices to transmit prescriptions in digital format. |
| Medical Documentation and Billing Cycle | A 10 step process that results in timely payment for medical services. |
| Steps in The Medical Documentation and Billing Cycle | Before the encounter: Step 1-Preregister Patients During the encounter: Step 2-Establish financial responsibility Step 3-Check in patients Step 4-Review coding compliance Step 5-Review billing compliance Step 6-Check out patients |
| Cont. Steps in the Medical Documentation and Billing Cycle | After the encounter: Step 7-Prepare and transmit claims Step 8-Monitor payer adjudication Step 9-Generate patient statements Step 10- Follow up payments and collections |
| Patient Information Form | A form that includes a patient's personal, employment, and insurance data needed to complete an insurance claim. |
| Diagnosis | Physician's opinion of the nature of the patient's illness or injury. |
| Procedure | Medical treatment provided by a physician or other healthcare provider. |
| Coding | The process of translating a description of a diagnosis or procedure into a standardized code. |
| Diagnosis Code | A standardized value that represents a patient's illness, signs, and symptoms. |
| ICD-9-CM | Abbreviated title of International Classification of Diseases, Ninth Revision, Clinical Modification, the source of the codes used for reporting diagnosis until October 1, 2014. |
| ICD-10-CM | Abbreviated title of International Classification of Diseases, Tenth Revision, Clinical Modification, which will be used beginning on October 1, 2014. |
| Procedure Code | A code that identifies a medical service. |
| Current Procedural Terminology (CPT) | The standardized classification system for reporting medical procedures and services. |
| HCPCS | Codes used for supplies, equipment, and services not included in the CPT codes. |
| Encounter Form | A list of the procedures and diagnosis for a patient's visit. |
| Clearinghouse | A company that receives claims from a provider, prepares them for processing, and transmits them to the payers in the required format. |
| Adjudication | Series of steps that determine whether a claim should be paid. |
| Remittance Advice (RA) | A document that lists the amount that has been paid on each claim as well as the reasons for nonpayment or partial payment. |
| Explanation of Benefits (EOB) | Paper Document from a payer that shows how the amount of a benefit was determined. |
| Revenue Cycle Management (RCM) | Managing the activities associated with a patient encounter to ensure that the provider receives full payment for services. |
| Health Insurance Portability and Accountability Act of 1996 (HIPAA) | Federal Act that set forth guidelines for standardizing the electronic data interchange of administrative and financial transactions, exposing fraud and abuse in govt. programs, and protecting the security and privacy of health information. |
| Electronic Data Interchange (EDI) | The exchange of routine business transactions from one computer to another using publicly available communications protocols. |
| National Provider Identifier (NPI) | A standard identifier for healthcare providers consisting of ten numbers. |
| HIPAA Privacy Rule | Regulations for protecting individually identifiable information about a patient's health and payment for healthcare that is created or received by a healthcare provider. |
| Protected Health Information (PHI) | Information about a patient's health or payment for healthcare that can be used to identify the person. |
| HIPAA Security Rule | Regulations outlining the minimum administrative,technical, and physical safeguards required to prevent unauthorized access to protected healthcare inofrmation. |
| Audit Trail | A report that traces who has accessed electronic information, when information was accessed, and whether any information was changed. |
| Health Information Technology for Economic and Clinical Health (HITECH) Act | Part of the American Recovery and Reinvestment Act of 2009 that provides financial incentives to physicians and hospitals to adopt EHRs and strengthens HIPAA privacy and security regulations. |
| Meaningful Use | The utilization of certified EHR technology to improve quality, efficiency, and patient safety in the healthcare system. |
| Regional Extension Centers (RECs) | Centers that offer information, guidance, training, and support services to providers transitioning to an EHR system. |
| Health Information Exchange (HIE) | A network that enables the sharing of health-related information among provider organizations according to nationally recognized standards. |
| National Health Information Network (NHIN) | A common platform for health information exchange across the country. |
| Affordable Care Act (ACA) | Federal legislation passed in 2010 that includes a number of provisions designated to increase access to healthcare, improve the quality of healthcare, and explore new models of delivering and paying for healthcare. |
| Accountable Care Organization (ACO) | A network of doctors and hospitals that shares responsibility for managing the quality and cost of care provided to a group of patients. |
| Patient-Centered Medical Home (PCMH) | A model of primary care that provides comprehensive and timely care to patients, while emphasizing teamwork and patient involvement. |
Created by:
nharvey64
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