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
