chapter 1 key terms
Quiz yourself by thinking what should be in
each of the black spaces below before clicking
on it to display the answer.
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| 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
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| Assessment (A) | judgment, opinion, or evaluation made by the health care provider
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| assumption coding | assignment of codes based on assuming (prohibited)
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| automated case abstracting software | inpatient and outpatient data for statistical analysis and reimbursement purposes
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| automated record | uses computer technology
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| centers for Medicare &Medicaid services (CMS) | administrative agency in the federal department of health and human services
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| claims examiner | specialist review health related claims to determine whether the cost are reasonable and medically necessary based on the patients diagnosis
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| classification system | organizes a medical nomenclature according to similar conditions, diseases, procedures, and services also contains codes for each
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| clearinghouse | public/private entity that processes or facilitates the processing of health info, and claims from nonstandard to standard format.
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| CMS-1450 | a claim for submission to third party payers send by the facility's billing department
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| CMS-1500 | standard claim submitted by physicians offices to third party payers.
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| code | numeric and alphanumeric characters that are reported to health plans for health care reimbursement
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| coder | knowledge in coding systems, coding conventions, and guidelines and third party requirements
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| coding | assignment of codes to diagnose, services, and procedures based on patient record documentation
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| coding system | organizes medical nomenclature according to similar conditions, diseases, procedures, and services; codes for each
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| computer-assisted coding (CAC) | software to automatically generate medical codes by "reading" transcribed clinical documents by health care practitioners
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| concurrent coding | review of records and/or use of encounter forms and chargemaster to assign codes during inpatient stay or outpatient center
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| continuity of care | documenting patients care services so that others who treat the patient have a source of information for additional care/treatment
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| current procedural terminology (CPT) | classifies procedures and services to assign cpt codes to reporting o health insurance claims
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| database | contains patient information collected on each patient
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| demographic data | patient identification information includes info such as patient's name, dater of birth, mother's maiden name
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| diagnostic and statistical manual of mental disorders (DSM) | standard classification of mental disorders
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| diagnostic/management plan | plans to learn more about the patients condition and the management of the condition
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| discharge note | summarize the patient's care, treatment, response to care, and condition of discharge
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| documentation | handwritten, keyboarding, dictated, computer generated notes recorded in the patients records by health care professional
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| document imaging | same as optimal disk imagining
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| downcoding | routinely assigning lower level cpt codes as a convenience
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| electronic health record (EHR) | collection of patient information documented by different number of facilities regarding on patient
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| electronic medical record (EMR) | created on a computer using EMR software
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| encoding | process of standardizing data by assigning codes or numbers to text or other information
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| evidence-based coding | clicking on codes that CAC software generates to review electronic health record documentation
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| HCPCS level II | classifies medical equipment, injectable drugs, transportation services, and other not in CPT
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| HCPCS national codes | same as HCPCS level II
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| health care clearinghouse | same as clearinghouse
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| healthcare common procedure coding system (HCPCS) | includes level II national codes, called HCPCS level II or HCPCS national codes
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| health care provider | physician or another health professional who performs procedures or provides services to patients
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| health data collection | performed by health care facilities and providers for administrative planning, submitting data to state and federal government agencies
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| health insurance portability and accountability act of 1996 (HIPPA) | federal legislation that amended the internal revenue code of 1986
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| health insurance specialist | review health related claims to determine if the costs are reasonable and medically necessary
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| health plan | insurance company that establishes a contract to reimburse health care facilities and patients for procedures/services
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| hospitalist | physician who provides care for hospital inpatients
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| hybrid record | consists of both paper based and computer generated documents
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| indexed | identified according to unique identification number
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| initial plan | contains the strategy for managing patient care and any actions taken to investigate patients condition, to treat and educate patient
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| integrated record | reports are arranged in strict chronological date or in reverse order allows to observe how patient is progressing
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| ICD-9-CM | classify diagnoses and procedures
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| ICD-10-CM/PCS | classify all diagnoses
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| ICD-10-PCS | classify inpatient procedures and services
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| ICD-O-3 | classification of neoplasms, record malignancy and survival rates
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| international classification of functioning, disability and health (ICF) | classifies health and health related domains that describe body functions, structures, activities, and participation
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| internship | on the job experience before graduation
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| internship supervisor | person to whom the student reports at the site
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| jamming | routinely assigning unspecific icd-10 disease code instead of appropriate codes
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| jukebox | stores large numbers of optical disks resulting in huge storage capabilities
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| listserv | same as online discussion board
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| logical observation identifiers names and codes (LOINC) | electronic database used to identify medical laboratory observations/for purpose of clinical care and managment
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| manual record | paper based record
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| medical assistant | performs administrative and clinical tasks
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| medical coding process | review of patient record documentation to identify diagnoses, procedure, services to assign codes
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| medical management software | medical billing software that automates the daily workflow and procedures of physicians office or clinic
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| medical necessity | patients diagnosis must also justify diagnostic and therapeutic procedures or services provided
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| medical nomenclature | vocabulary of clinical and medical terms used by health providers to document patient care
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| medical record | business record for patient encounters documents health care services provided to a patient
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| national drug codes (NDC) | published by variety of vendors and the coding system is in the public domain
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| objective (O) | observations about the patient, physical findings, lab or x-ray results
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| online discussion board | internet based or email discussion forum that covers variety of topics and issues
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| optical disk imaging | patients records are converted to electronic image and saved on storage media
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| overcoding | reporting signs and symptoms as codes in addition to the established diagnosis code
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| patient education plan | plans to educate the patient about conditions for which the patient is being treated
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| patient record | same as medical record
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| physician query process | contacting the responsible physician to request clarification about documentation and the codes to be assigned
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| plan (P) | diagnostic, therapeutic, and education plans to resolve the problems
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| problem list | contains a numbered list of the patient's problem's, filed at beginning of record
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| problem-oriented record (POR) | systematic method of documentation: database, problem list, initial plan, progress note
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| progress note | documents for each problem assigned to the patient using the SOAP structure
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| provider | same as health care provider
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| resident physician | individual who participates in approved GME program
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| RxNorm | provides normalized names for clinical drugs
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| scanner | used to capture paper record images onto the storage media
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| sectionalized record | same as source oriented record
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| SNOMED CT | comprehensive coverage of diseases, clinical findings, therapies, procedures, and outcomes
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| source-oriented record (SOR) | organized according to documentation source or data, each are located in a labeled section
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| specialty coders | coders who have advanced training in medical specialties, compliance and reimbursement areas
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| subjective (S) | patient statement about how she or he feels, including symptomatic information
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| teaching hospital | approved graduate medical education residency program
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| teaching physician | physician who supervises residents during patient care
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| therapeutic plan | specific medications, goals, procedures, therapies, and treatments used to treat the patient
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| third-party administration | entity that processes health care claims and performs related business function's for health plan
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| third-party payer | same as health plan
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| transfer note | documented when a patient is being transferred to another facility
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| UB-04 | standard claim form submitted by health care institutions to payers for inpatient and outpatient services
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| unbundling | reporting multiple codes to increase reimbursement when a single combination code should be reported
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| unified medical language system (UMLS) | set of files and software that allows many health an biomedical vocab to enable interoperability among computer systems
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| upcoding | reporting codes not supported by patient documentation for increased reimbursment
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