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chapter 1 key terms

TermDefinition
application service provider (ASP) 3rd party entity that manages and distributes software-based services and solutions to customers across a wide are network from a central data center
Assessment (A) judgment, opinion, or evaluation made by the health care provider
assumption coding assignment of codes based on assuming (prohibited)
automated case abstracting software inpatient and outpatient data for statistical analysis and reimbursement purposes
automated record uses computer technology
centers for Medicare &Medicaid services (CMS) administrative agency in the federal department of health and human services
claims examiner specialist review health related claims to determine whether the cost are reasonable and medically necessary based on the patients diagnosis
classification system organizes a medical nomenclature according to similar conditions, diseases, procedures, and services also contains codes for each
clearinghouse public/private entity that processes or facilitates the processing of health info, and claims from nonstandard to standard format.
CMS-1450 a claim for submission to third party payers send by the facility's billing department
CMS-1500 standard claim submitted by physicians offices to third party payers.
code numeric and alphanumeric characters that are reported to health plans for health care reimbursement
coder knowledge in coding systems, coding conventions, and guidelines and third party requirements
coding assignment of codes to diagnose, services, and procedures based on patient record documentation
coding system organizes medical nomenclature according to similar conditions, diseases, procedures, and services; codes for each
computer-assisted coding (CAC) software to automatically generate medical codes by "reading" transcribed clinical documents by health care practitioners
concurrent coding review of records and/or use of encounter forms and chargemaster to assign codes during inpatient stay or outpatient center
continuity of care documenting patients care services so that others who treat the patient have a source of information for additional care/treatment
current procedural terminology (CPT) classifies procedures and services to assign cpt codes to reporting o health insurance claims
database contains patient information collected on each patient
demographic data patient identification information includes info such as patient's name, dater of birth, mother's maiden name
diagnostic and statistical manual of mental disorders (DSM) standard classification of mental disorders
diagnostic/management plan plans to learn more about the patients condition and the management of the condition
discharge note summarize the patient's care, treatment, response to care, and condition of discharge
documentation handwritten, keyboarding, dictated, computer generated notes recorded in the patients records by health care professional
document imaging same as optimal disk imagining
downcoding routinely assigning lower level cpt codes as a convenience
electronic health record (EHR) collection of patient information documented by different number of facilities regarding on patient
electronic medical record (EMR) created on a computer using EMR software
encoding process of standardizing data by assigning codes or numbers to text or other information
evidence-based coding clicking on codes that CAC software generates to review electronic health record documentation
HCPCS level II classifies medical equipment, injectable drugs, transportation services, and other not in CPT
HCPCS national codes same as HCPCS level II
health care clearinghouse same as clearinghouse
healthcare common procedure coding system (HCPCS) includes level II national codes, called HCPCS level II or HCPCS national codes
health care provider physician or another health professional who performs procedures or provides services to patients
health data collection performed by health care facilities and providers for administrative planning, submitting data to state and federal government agencies
health insurance portability and accountability act of 1996 (HIPPA) federal legislation that amended the internal revenue code of 1986
health insurance specialist review health related claims to determine if the costs are reasonable and medically necessary
health plan insurance company that establishes a contract to reimburse health care facilities and patients for procedures/services
hospitalist physician who provides care for hospital inpatients
hybrid record consists of both paper based and computer generated documents
indexed identified according to unique identification number
initial plan contains the strategy for managing patient care and any actions taken to investigate patients condition, to treat and educate patient
integrated record reports are arranged in strict chronological date or in reverse order allows to observe how patient is progressing
ICD-9-CM classify diagnoses and procedures
ICD-10-CM/PCS classify all diagnoses
ICD-10-PCS classify inpatient procedures and services
ICD-O-3 classification of neoplasms, record malignancy and survival rates
international classification of functioning, disability and health (ICF) classifies health and health related domains that describe body functions, structures, activities, and participation
internship on the job experience before graduation
internship supervisor person to whom the student reports at the site
jamming routinely assigning unspecific icd-10 disease code instead of appropriate codes
jukebox stores large numbers of optical disks resulting in huge storage capabilities
listserv same as online discussion board
logical observation identifiers names and codes (LOINC) electronic database used to identify medical laboratory observations/for purpose of clinical care and managment
manual record paper based record
medical assistant performs administrative and clinical tasks
medical coding process review of patient record documentation to identify diagnoses, procedure, services to assign codes
medical management software medical billing software that automates the daily workflow and procedures of physicians office or clinic
medical necessity patients diagnosis must also justify diagnostic and therapeutic procedures or services provided
medical nomenclature vocabulary of clinical and medical terms used by health providers to document patient care
medical record business record for patient encounters documents health care services provided to a patient
national drug codes (NDC) published by variety of vendors and the coding system is in the public domain
objective (O) observations about the patient, physical findings, lab or x-ray results
online discussion board internet based or email discussion forum that covers variety of topics and issues
optical disk imaging patients records are converted to electronic image and saved on storage media
overcoding reporting signs and symptoms as codes in addition to the established diagnosis code
patient education plan plans to educate the patient about conditions for which the patient is being treated
patient record same as medical record
physician query process contacting the responsible physician to request clarification about documentation and the codes to be assigned
plan (P) diagnostic, therapeutic, and education plans to resolve the problems
problem list contains a numbered list of the patient's problem's, filed at beginning of record
problem-oriented record (POR) systematic method of documentation: database, problem list, initial plan, progress note
progress note documents for each problem assigned to the patient using the SOAP structure
provider same as health care provider
resident physician individual who participates in approved GME program
RxNorm provides normalized names for clinical drugs
scanner used to capture paper record images onto the storage media
sectionalized record same as source oriented record
SNOMED CT comprehensive coverage of diseases, clinical findings, therapies, procedures, and outcomes
source-oriented record (SOR) organized according to documentation source or data, each are located in a labeled section
specialty coders coders who have advanced training in medical specialties, compliance and reimbursement areas
subjective (S) patient statement about how she or he feels, including symptomatic information
teaching hospital approved graduate medical education residency program
teaching physician physician who supervises residents during patient care
therapeutic plan specific medications, goals, procedures, therapies, and treatments used to treat the patient
third-party administration entity that processes health care claims and performs related business function's for health plan
third-party payer same as health plan
transfer note documented when a patient is being transferred to another facility
UB-04 standard claim form 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 an biomedical vocab to enable interoperability among computer systems
upcoding reporting codes not supported by patient documentation for increased reimbursment
Created by: jenthebunbun