chapter 7 Flashcards
Dictation
the process of recording spoken words that will later be transcribed into written form
Digital dictation
the process of dictating using a microphone a headset connected to a computer, a smart phone or a PDA
Voice recognition software
software that recognizes spoken words
template
performed files that serves as a starting point for a new document
SOAP
format used to enter progress notes: it stands for subject, objective, assessment and plans
Formulary
list of a plans selected drugs and their proper dosages
medical coding
the process of applying the HIPPA- mandated codes sets to assign codes to diagnosis and procedures
Primary diagnosis
the patients major illness or condition for an encounter
ICD-9CM
abbreviated titles of international classifications clinical modification, the source of the codes used for reporting diagnoses
ICD-9CM officel guidelines for coding and reporting
american hospital association publication that provides rules for selecting and sequencing diagnoses codes
ICD-10-CM
abbreviated title of international classification of diseases.
Current procedural terminology (CPT)
the standardized classification system for reporting medical procedures and services
HCPCS
procedure codes for medicare claims
Category I Codes
procedure codes found in the main body of CPT
category II codes
optional CPT codes that track performance
Category III codes
temporary codes for emerging technology services and procedures
Evaluation and management codes E/M
codes that cover physicians services performed to determine the optimum course for patient care
Key components
factors documents for various levels of evaluation and management services
Computer assisted coding
assigning preliminary diagnosis and procedure codes using computers software
upcoding
assigning a higher level code than is supported by document
Electronic encounter form EEF
an electronic version of the form that is listed procedures and charges for a patients visits
