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Ch 1 Key Terms

3-2-1 Code It!

Application Service Provider (ASP) 3rd-party entity that manages and distributes software-based services and solutions to customers across a wide area network (WAN) from a central data center.
Assessment (A) judgment, opinion, or evaluation made by the health care provider; considered part of the problem-oriented record (POR) SOAP note.
Assumption coding inappropriate assignment of codes based on assuming, from a review of clinical evidence in the patient's record, that the patient has certain diagnoses or received certain procedures without doctor approval
Automated case abstracting software software program that is used to collect and report inpatient and outpatient data for statistical analysis and reimbursement purposes
automated record type of record that is created using computer technology
Centers for Medicare & Medicaid Services (CMS) administrative agency in the federal Department of Health and Human Services
claims examiner basically a health insurance specialist
classification system basically a coding system
clearinghouse public or private entity that processes or facilitates the processing of health information and claims from a nonstandard to a standard format.
CMS-1450 same as UB-04
CMS-1500 standard claim submitted by physicians' offices to third-party payers
code numerical and alphanumerical characters
coder acquires a working knowledge of coding systems
coding assignment of codes to diagnoses, services, and procedures based on patient record documentation
computer-assisted coding (CAC) uses computer software to automatically generate medical codes by "reading" transcribed clinical documentation
concurrent coding review od recodes and/or use of encounter forms and chargemasters to assign codes during an inpatient stay or outpatient encounter
continuity of care documenting patient care services so that others who treat the patient have a source of information on which to base additional care and treatment.
Current Procedural Terminology (CPT) coding system used by health care professionals to assign CPT codes for reporting procedures and services on health insurance claims
database contains a minimum set of patient information collected on each patient, including chief complaint; present conditions and diagnoses; social data; part, personal, medical history
demographic data patient identification information that is collected according to facility policy
Diagnostic and Statistical Manual of Mental Disorders (DSM) manual published by the American Psychiatric Association that contains diagnostic assessment criteria used as tools to identify psychiatric disorders
diagnostic/management plan information about the patient's condition and the planned management of conditions; considered part of the problem-oriented record
discharge note documented in the progress note section of the problem-oriented record (POR) to summarize the patient's care, treatment, response to care, and condition on discharge
documentation includes dictated and transcribed, typed or handwritten, and computer-generated notes and reports recorded in the patient's records by a health care professional
document imaging same as optical disk imaging
downcoding routinely assigning lower-level CPT codes as a convenience instead of reviewing patient record documentation and the coding manual to determine the proper code to be reported
electronic health record (EHR) collection of patient info documented by a number of providers at one or more facilities regarding one patient
electronic medical record (EMR) created on a computer, using a keyboard, a mouse, an optical pen device, a voice recognition system, a scanner, or a touch screen
encoding process of standardizing data by assigning numeric values (codes or number) to text or other info
evidence-based coding clicking on codes that CAC software generates to review electronic health record documentation (evidence) used to generate the code;
HCPCS level II coding system managed by Centers for Medicare & Medicaid Services (CMS) that classifies medical equipment, injectable drugs, transportation services, and other services not classified in the CPT
HCPCS national codes same as HCPCS level II
health care clearinghouse same as clearinghouse
Healthcare Common Procedure Coding System (HCPCS) includes level I codes (CPT) and level II codes (HCPCS level II national codes)
health data collection performed by health care facilities to do administrative planning, to submit statistics to state and federal government agencies (and other organizations) and to report health claim data to third-party payers for reimbursement purposes
Health Insurance Portability and Accountability Act of 1996 (HIPAA) federal legislation that amended the Internal Revenue Code of 1986 to improve portability and continuity of health insurance coverage in the group and individual markets, combat waste/fraud/abuse in health insurance and healthcare delivery...
health insurance specialist employed by 3rd-party payers to review health-related claims to determine whether the costs are reasonable and medically necessary based on the patient's diagnosis
health plan contract established by a n insurance company to reimburse healthcare facilities and patients for procedures and services provided
hospitalist physician who provides care for hospital inpatients
hybrid record combined paper-based and computer-generated documents
indexed identified according to a unique identification number
initial plan documentation of the strategy for managing patient care and actions taken to investigate the patient's condition and to treat/educate the patient
integrated record arranged in strict chronological date order (or in reverse date order), which allows for observation of how the patient is progressing according to test results and how the patient responds to treatment based on test results
International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) adopted in 1979 to classify diagnoses (VOL 1&2) and procedures (VOL3)
International Classification of Diseases, Tenth Revision, Clinical Modification/Procedure Coding System (ICD-10-CM/PCS) shortened name the Centers for Medicare and Medicaid Services uses to identify the classification systems
International Classification of Diseases, Tenth Revision, Procedure Coding System (ICD-10-PCS) developed by the National Center for Health Statistics (NCHS) to classify inpatient procedures and services
International Classification of Diseases for Oncology, Third Edition (ICD-O-3) implemented in 2001 to classify a tumor according to primary site (topography) and morphology (histology, behavior, and aggression of tumor)
International Classification of Functioning, Disability and Health (ICF) classifies health and health-related domains that describe body functions and structures, activities, and participation
internship student placement in a health care facility to provide on-the-job experience prior to graduation
internship supervisor person to whom a student reports at an internship site
jamming routinely assigning an unspecified ICD-10-CM disease code instead of reviewing the coding manual to select the appropriate code number
juxebox equipment that store large numbers of optical disks, resulting in huge storage capabilities
listserv see online discussion board
Logical Observation Identifiers Name and Codes (LOINC) electronic database and universal standard used to identify medical laboratory observation and for the purpose of clinical care and management
manual record paper-based record that includes handwritten progress notes and physician orders, graphic charts, and so on
Medical assistant health care professional employed by a provider to perform administrative and clinical tasks
medical coding process requires the review of patient record documentation to identify diagnoses, procedures, and services for the purpose of assigning ICD-10-CM/PCS, HCPCS level II, and/or CPT codes
medical management software combination practice management and medical billing software that automates the daily workflow and procedures of a physician's office or clinic
medical necessity determination that a service or procedure rendered is reasonable and necessary for the diagnosis or treatment of an illness or injury
medical record same as a patient record
medical nomenclature vocabulary of clinical and medical terms used by health care providers to document patient care
National Drug Codes (NDC) contains prescription drugs and few selected over-the-counter (OTC) products, which pharmacies use to report transactions and some health care professional use for reporting on claims
Objective (O) observations about the patient, such as physical findings or lab or x-ray results; considered part of the problem-oriented record (POR) SOAP note
online discussion board internet-based or e-mail discussion forum that covers a variety of topics and issues
optical disk imaging alternative to traditional microfilm or remote storage systems because patient records are converted to an electronic image and saved on storage media
overcoding reporting codes for signs and symptoms associated, in addition to an established diagnosis code
patient education plan program to educate the patient about conditions for which the patient is being treated
patient record business record for an inpatient or outpatient encounter that documents health care services provided to a patient
physician query process contacting the responsible physician to request clarification about documentation and codes to be assigned
Plan (P) diagnostic, therapeutic, and education plans to resolve the problems
problem list serves as a table of contents for the patient record because it is files at the beginning of the record and contains a numbered list of the patient's problem
problem-oriented record (POR) systematic method of documentation that consists of four components; database, problem list, initial plan, and progress notes
progress notes narrative notes documented by the provider to demonstrate continuity of care and the patient's response to treatment
provider physician or other health care professional who performs procedures or provides services to patients
resident physician individual who participates in an approved graduate medical education (GME) program
RxNorm provides normalized names for clinical drugs and links its names to man of the drug vocabularies commonly used in pharmacy management and drug interaction software, including those of First Databank, Micromedex, MediSpan, etc.
scanner equipment that captures paper record images onto the storage media
sectionalized record see source-oriented record
SNOMED CT includes comprehensive coverage of diseases, clinical findings, therapies, procedures, and outcomes
source-oriented record (SOR) reports organized according to documentation source, each of which is located in a labeled section of the record
specialty coders individuals who have obtained advanced training in medical specialties and who are skilled in that medical specialty's compliance and reimbursement areas
Subjective (S) patient's statement about how he or she feels, including symptomatic information; considered part of the problem-oriented record (POR) SOAP note
teaching hospital hospital engaged in an approved graduate medical education (GME) residency program in medicine, osteopathy, dentistry, and podiatry
teaching physician physician who supervises residents during patient care
therapeutic plan specific medication, goals, procedures, therapies, and treatments used to treat the patient; considered part of the problem oriented record
third-party administrator (TPA) entity that processes health care claims and performs related business functions for a health plan
third-party payer see health plan
transfer note documentation when a patient is transferred to another facility; summarize reason for admission
UB-04 standard claim submitted by health care institutions to payers for inpatient and outpatient services
unbundling reporting multiple codes to increase reimbursement when a single combination code should be reported
Unified Medical Language System (UMLS) set of files and software that allows many health and biomedical vocabularies and standards to enable interoperability among computer systems
upcoding reporting codes that are not supported by documentation in the patient record for the purpose of increasing reimbursement
coding system organizes a medical nomenclature according to similar conditions, diseases, procedures, and services; it contains codes for each.
Created by: Cristinacholi
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