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chapter 1 key terms
| Term | Definition |
|---|---|
| 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
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