Computer Software Applications Chapter 1

Front 1

medical necessity

Back 1

treatment that is in accordance with generally accepted medical practice

Front 2

Electronic medical record

Back 2

computerized record of one physicians encounters with a patient over time

Front 3

Health information technology

Back 3

using computers and electronic communications to manage medical information

Front 4

Electronic health record

Back 4

computerized lifelong health care record with data from all sources

Front 5

practice management programs (PM)

Back 5

program used to perform administrative and financial functions in a medical office

Front 6

ARRA

Back 6

American Recovery and reinvestment act of 2009. A $787 billion economic stimulus bill passed that allocates $19.2 billion to promote the use of HIT

Front 7

PAP ( pay for performance)

Back 7

provision of financial incentives to physicians who provide evidence - based treatments to their patients

Front 8

patient examination

Back 8

an examination of a person's body in order to determine his or her s tr ate of health

Front 9

certification

Back 9

a nationally recognized designation that acknowledges that an individual has mastered a standard body of knowledge and meets certain competencies

Front 10

revenue cycle management (RCM)

Back 10

management of the activities associated with a patient encounter to ensure that the provider receives full payment for services

Front 11

10 steps in medical documentation and billing cycle

Back 11

1) pre registering the patients.
2) establishing financial responsibility
3) checking in patients
4) reviewing coding compliance
5) reviewing billing compliance
6) checking out patients
7) preparing and transmitting claims
8) monitoring payer adjudication
9) generating patient statements
10) following up on patient payments and collections

Front 12

8 facts documented in medical record for an ambulatory patient

Back 12

1. patients name
2. encounter date and reason
3. appropriate history and physical examination
4. review of all test that were ordered
5. diagnosis
6. plan of care, notes on procedures or treatments that were given
7. instructions or recommendations that were given to patient
8. signature of the provider who saw the patient