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 |