Definition of Terms
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The goal of promoting quality health care progresses as technology continues to expand within the health care industry. This paper will discuss the abbreviations and definitions of AMR, CMR, CMS, along with CMS-1500, and CPT. Included also will be DRG, EPR, HL7, ICD-9, and UB-92. AMR
The Automated Medical Record is the first level of a computerized patient record. According to the University of Phoenix eBook, “the organization is still heavily dependent upon paper records” (Wager, Lee, & Glaser 2005). The organization works with automated systems, but a hard copy is printed and added to the patient’s profile. CMR
Computerized Medical Record is the second level of a computerized patient record. It is an electronic information system that keeps records of patients’ health. The electronic record is created, gathered, managed, and consulted by authorized clinicians and staff within an organization (Wager et al 2009, Chapter 1). CMS
The Centers for Medicare and Medicaid Services is a clinical indicator that focuses on improving clinical outcomes. The CMS aims at physicians, nursing home, hospice care (long-term and home), and hospitals. The information obtained is compared to other hospitals and target locations, medical conditions, outcomes, and payment information. CMS-1500
The CMS-1500 is a standardized form developed by the National Uniform Claim Committee (NUCC) used for claims such as physician services. The same data is collected for the CMS-1500 and UB-04 regardless of an organization’s location or patient’s insurance provider. CPT
An updated Current Procedural Terminology is published each year by the American Medical Association (AMA). The first publication of CPT was in 1966 and later adopted by the government in 1983. CPT began as a uniform language for describing medical and surgical services, but later became the standard for office, outpatient, and ambulatory coding for reimbursement purposes.
The diagnosis related groups determine the appropriate inpatient reimbursements for Medicaid and Medicare. Payments are dependent on the patient’s diagnosis and correct ICD-9 codes. Once private insurance plans saw the effectiveness of the DRGs for Medicaid and Medicare, they also adopted the payment system. EPR
The electronic patient record is the fourth level of computerized records. The EPR is managed by a single organization, meaning various departments can update records that are seen and shared throughout the organization. HL7
Health Level 7 is the standard exchange of information between medical applications. Information transmitted using HL7 is sent in messages such as patient records, laboratory records and billing information. Most systems require a translator because they do not speak the language of HL7. ICD-9
The World Health Organization developed the International Classification of Diseases, Ninth Revision, to capture disease data. This system is a government document that is published each year but is updated by multiple companies to easier to read documents. Earlier versions of the system were used to compare illness and death statistics between nations. “Since 1983, it has been used for determining the diagnosis related group into which a patient is assigned” (Wager, Lee, Glaser, & Burns, 2009). UB-92
The National Uniform Billing Committee was formed to bring the national provider and payer organizations together to use a one specific billing form and data set to process health care claims. The first bill was the UB-82, followed by UB-92, now using UB-04. The biggest change from UB-92 to UB-04 is the adding of the National Provider Identifier (NPI), which is 10 digit number given to each health provider. As new technology is introduced to the health care industry organizations will continue to work with patients to ensure a smooth transition and earn their trust with private information.
(2013). HL7 overview. Retrieved from www.interfaceware.com
Wager, K. A., Lee, F. W., & Glaser, J.P. (2005). Health care information systems: A practical approach for health care management (1st ed.). San Francisco, CA: Jossey-Bass Wager, K. A., Lee, F. W., & Glaser, J., P., (2009). Healthcare information systems: A practical approach for health care management, (2nd Ed.) (Ch. 1), San Francisco, CA; Josey-Bass, retrieved from University of Phoenix eBook Collection https://newclassroom3.phoenix.edu