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Insurance Handbook For The Medical Office Fordney Chapter 4

1212 words - 5 pages

INSURANCE BILLING FOR THE MEDICAL OFFICE CH 4 SHIRLEY QUAN

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Acute | A medical condition that runs a short but relatively severe course. |
Attending physician | A medical staff member who is legally responsible for the care and treatment given to a patient. |
Chief complaint (CC) | A patient's statement describing symptoms, problems, or conditions as the reason for seeking health care services from a physician. |
Chronic | A medical condition persisting over a long period of time. |
Comorbidity | An ongoing condition that exists along with the condition for which the patient is receiving treatment. |
Comprehensive | A term used to describe a level of history or ...view middle of the document...

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Documentation | A chronologic detailed recording of pertinent facts and observations about a patient's health as seen in chart notes and medical reports. |
Electronic health record (EHR) | A patient record that is created using a computer with software. A template is brought up and by answering a series of questions data are entered. |
Emergency care | Health care services provided to prevent serious impairment of bodily functions or serious dysfunction to any body organ or part. Advanced life support may be necessary. |
Eponym | The name of a disease, anatomic structure, operation, or procedure, usually derived from the name of a place where it first occurred or a person who discovered or first described it. |
Established patient | An individual who has received professional services within the past 3 years from the physician or another physician of the same specialty who belongs to the same group practice. |
Expanded problem focused (EPF) | A phrase used to describe a level of history or physical examination. |
External audit | A review done after claims have been submitted (retrospective review) of medical and financial records by an insurance company or Medicare representative to investigate suspected fraud or abusive billing practices. |
Facsimile | An electronic process for transmitting graphic and written documents over telephone lines; also referred to as fax. |
Family history (FH) | A review of medical events in the patient's family including diseases that may be hereditary or place the patient at risk. |
Health record | Written or graphic information documenting facts and events during the rendering of patient care. Also known as medical record. |
High complexity (HC) | A phrase used to describe a type of medical decision making when a patient is seen for an E/M service. |
History of present illness (HPI) | A chronologic description of the development of the patient's present illness from the first sign or symptom or from the previous encounter to the present. |
Internal review | The process of going over financial documents before and after billing to insurance carriers to determine documentation deficiencies or errors. |
Low complexity (LC) | Phrase used to describe a type of medical decision making when a patient is seen for an E/M service. |
Medical decision making (MDM) | Health care management process done after performing a history and physical examination on a patient that results in a plan of treatment. |
Medical necessity | The performance of services and procedures that are consistent with the diagnosis in accordance with standards of good medical practice, performed at the proper level, and provided in the most appropriate setting. |
Medical report | A permanent, legal document (letter or report format) that formally states the consequences of the patient's examination or treatment. |
Moderate complexity (MC) | A phrase used to describe a type of medical decision making when a patient...

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