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Ch.1 key terms
3-2-1 code it !
| Question | Answer |
|---|---|
| Application service provider (ASP) | third-party entity that manages and distributes software-based services and solutions to costumers 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/services even though the provider did not or specify. |
| 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 & Medicare Services (CMS) | administrative agency in the federal Department of Health & Human Services. |
| Claims examiner | ( health insurance specialist) employed by third-party payers to review health related claims to determine whether the cost are reasonable and medically necessary based on the patient's diagnosis. |
| Classification system | (or coding system) organizes a medical nomenclature according to similar conditions, diseases, procedure, and services, and it contains codes for each. |
| Clearinghouse | public or private entity that processes or facilitates the processing of health information and claims from a nonstandard to standard format |
| CMS-1450 | see( UB-04) standard claim submitted by the health care institution to payers for inpatient and outpatient services. |
| CMS-1500 | Standard claim submitted by physicians' offices to third-party payers. |
| Code | numerical and alphanumerical characters that are reported to health plans for health care reimbursement and to external agencies(Ex. state department of health) for data collection, in addition to being reported internally for education and research. |
| Coder | acquires a working knowledge of coding systems, coding principles are rules , government regulations, and third-payer requirements to ensure that all diagnoses , services, and procedures documented in patients records are coded accurately . |
| Coding | assignment of codes to diagnoses, services, and procedures based on patient record . |
| Coding system | organizes a medical nomenclature according to similar conditions, diseases, procedures, and services, and it contains codes for each (e.g. ICD-10-CM arranges these elements into appropriate chapters and sections). |
| Computer- assisted coding (CAC) | uses software to automatically generate medical codes by "reading" transcribed clinical documentation provided by health care practitioners. |
| Concurrent coding | review of records and/or use of encounter forms and chargemasters to assign codes during an inpatient stay or an outpatient encounter; typically performed for outpatient encounters because encounters forms and chargemasters are completed in "real time". |
| 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 physician and outpatient health care setting to assign on CPT codes for reporting procedures and services on health insurance claims; |
| Database | contains a minimum data set of patient information collected on each patient, including chief complains; present conditions and diagnosis; social data; past, personal, medical, and social history; review of systems; physical examination; etc... |
| Demographic data | patient identification information that is collected according to facility policy (e.g. patient's name, date of birth, mother's maiden name, and social security number). |
| 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 planned management of conditions; considered part of the problem-oriented record (POR). |
| 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 | (or optical disk imaging) provides an alternative to traditional microfilm or remote (off-site) storage systems because patient records are converted to an electronic image and saved on storage media (e.g., optical disk). |
| Downcoding | routinely assigning lower-level CPT codes as a convenience instead of reviewing patients record documentation and the coding manual to determine the proper code to be reported |
| Electronic health record ( EHR) | collection of information documented by a number of providers at one or more facilities regarding one patient. |
| Electronic medical record (EMR) | created on a computer, using keyboard, a mouse, an optical pen device, a voice recognition system, a scanner, or a touchscreen; records are created using vendor software, which also assists in provider decision making regarding patients care and treatment |
| Encoding | process of standardizing data by assigning numeric values (codes or numbers) to text or other information. |
| Evidence-based coding | on codes that CAC software generates to review electronic heath 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 | (HCPCS II) coding system managed by the centers for Medicare & Medicaid services (CMS) that classifies medical equipment, injectable drugs, transportation services, and other services not classified in the CPT. |
| Health care clearinghouse | public or private entity that processes or facilitates the processing of health information and claims from a nonstandard to standard format. (Clearinghouse). |
| Healthcare Common Procedure Coding System (HCPCS) | includes level I codes (CPT) and level II codes (HCPCS level II national codes). |
| Health care provider | (Provider)physician or other health care professional who performs procedures or provides services to patients. |
| health data collection | performed by health care facilities to do administrative planning, to submit statistics to state and federal government agencies (and other organization),and report to health claim third-party payers for reimbursement purposes. |
| Health Insurance portability and Accountability Act of 1996 (HIPPA) | federal legislation that emended the Internal Revenue Code of 1986 to improve portability and continuity of health insurance coverage in the group and individuals markets, combat waste/fraud/abuse in the health insurance and health care delivery. |
| Health insurance specialist | employed by third-party payer to review health-related claims to determine whether the cost are reasonable and medically necessary based on the patient's diagnosis. |
| Health plan | contract established by an insurance company to reimburse health care 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 strategy for managing patient care and actions taken to investigate the patient's condition and to treat/educate patient. |
| integrated record | arranged in strict chronological date order (or in inverse 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 diagnosis (volumes 1and 2) and procedures (volume 3) |
| International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) | developed by the Centers of Medicare & Medicaid Services (CMS) to classify all diseases and injuries. |
| International Classification of Diseases, Tenth Revision, Clinical Modification/procedure coding system (ICD-10-CM/PCS) | shortened name for the Centers for Medicare and Medicaid Services (CMS) to classification systems. |
| International Classification of Disease, Tenth Revision, Procedure Coding System (ICD-10-PCS) | developed by the National Center for health Statics (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 on tumor). |
| International Classification of Functioning, Disability and Health (ICF) | classifies health and health-related domains that describes body functions and structures, activities, and participation; complements ICD-10, looking beyond mortality and disease. |
| 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 proper code number. |
| jukebox | equipment that stores large numbers of optical disks, resulting in huge storage capabilities. |
| listserv | (online discussion board) internet-based or e-mail discussion forum that covers a variety of topics and issues. |
| Logical Observation Identifiers Names and Codes ( LOINC) | electronic database and universal standard used to identify medical laboratory observations and for the purpose of clinical care and management. |
| manual record | paper-based record that includes hand-written progress notes and physician orders, graphic charts , and so on. |
| medical assistant | health care professional employed by a provider to performed administrative and clinical tasks. |
| medial 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 of 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 nomenclature | vocabulary of clinical and medical terms (e.g., arthritis , gastritis, and pneumonia) used by health care provider to document patients. |
| medical record | (patient record)business record for an inpatient or outpatient encounter that documents health care services provided to a patient; stores patient demographics data and documentation that supports diagnoses and justifies treatment. |
| National Drug Codes (NDC) | contains prescription drugs and a few selected over-the-counter (OTC) products, Which pharmacies use to report transactions and some health care professionals use for reporting claims. |
| Objective (O) | observation about the patients, such as physical findings or lab or X-rays results; considered part of the problem-orientated 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 remotes storage systems because patients records are converted to an electronic image saved on storage media. |
| overcoding | reporting codes for sighs 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 ; considered part of the problem-oriented record (POR). |
| patient record | business record for an inpatient or outpatient encounters that documents health care services provided to a patient; stores paints demographics data and documentation that supports diagnoses and justifies treatment; and contains results of treatment. |
| physician query process | contacting the responsible physician to request clarification about documentation and codes to be assigned; the process is activated when the coder notices a problem with the documentation quality. |
| plan (P) | diagnostic, therapeutic, and education plans to resolve the problems; considered part of the problem-oriented record (POR) SOAP note. |
| problem list | serves as a table of content for the patient record because it is filed at the beginning of the record and contains a numbered list of the patient's problems which helps to index documentation throughout the record; considered part of problem-orientated. |
| problem-oriented record (POR) | systematic method of documentation that consist 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 patient's responses to treatment; |
| provider | physician and 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 many of the drug vocabularies commonly used in pharmacy management and drug interaction software, including those of first Databank, Micromedex ,MediSpa, Gold Standard Drug database.. |
| scanner | equipment that captures paper record images onto the storage media. |
| sectionalized record | (source-oriented record (SOR) reports organized according to documentation source, each of which is located in a labeled section of the record. |
| SNOMED CT | The current revision, was created in 2002; it 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 (e.g. anesthesia, obstetrics) 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-orientated record (POR) SOAP note. |
| teaching hospital | hospital engage in an approved graduate medical education (GME) residency program in medicine, osteophaty, dentistry, or podiatry. |
| teaching physician | physician (other than another resident physician) who supervises residents during patient care. |
| therapeutic plan | specific medications, goals, procedures, therapies, and treatments used to treat the patients ; considered part of the problem -oriented (POR) SOAP note. |
| Third-party administrator (TPA) | entity that processes health care claims and performs related business functions for a health plan; the TPA might contract with a health care clearinghouse to standardize data for claim processing. |
| third-party payer | (Health plan) contract established by an insurance company to reimburse health care facilities and patients for procedures and services provided. |
| transfer note | documentation when a patient is transferred to another facility; summarizes the reason for admission , current diagnoses and medical information, reason for transfer. |
| UB-04 | standard claim submitted by the 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 incising reimbursement. |
Created by:
mariaparra
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