EMR (Cengage MINDTAP) Flashcards

accounts receivable

arise when a company provides goods or services on credit; money that is owed to your group broken out by financial class (e.g., Private Pay, Medicare, Blue Shield, Commercial, etc.) and also by age (e.g., current to 30 days old, 31 to 60 days old, etc.)

acknowledgment forms

a document that is signed by the patient confirming that the Privacy Notice for a provider entity (clinic, hospital, etc.) was received

Active alert

an alert that displays when the patient's medical record is launched. This type of alert contains important safety standards that indicate critical clinical information that you must attend to at any point of care (e.g., critical allergies and status requirements, such as interpreter or special exam table required).

adjustments

a sum of money that is written off a patient's account for any reason. An example would be the amount between the charges and allowed amount that is not collected due to contractual agreement.

aging

the classification of accounts by the time elapsed after the date of billing or the due date

aging report

a report that shows insurance claims that are unpaid or patient accounts that are in arrears. The usual aging time frames are current (0-30 days) and past due (31-60, 61-90, 91-120, and >120 days). Claims or patient accounts that are past due should be checked on starting at 30 days.

assessment

the diagnosis of a patient based on examination and testing. If a conclusive diagnosis cannot yet be reached, other terms can be used to categorize diagnoses until an exact conclusion can be arrived at. These include impression, provisional diagnosis, and differential diagnosis. Although the terms rule-in and rule-out are often used, the provider should change this to probable or possible if the diagnosis remains uncertain, or validate with a confirmed diagnosis for billing purposes.

Assignment

assigning direct payment by an insurance plan to the provider. With some plans, there may be requirements or agreements to be followed if assignment is accepted.

batch

assigns a name and establishes defaults to a group of financial transactions

beneficiary

an individual that is entitled to benefits of an insurance policy

benefits verification/eligibility

to confirm the coverage status, benefits details, preauthorization requirements, copayment, coinsurance, and deductibles as applicable to a provider entity

canceled

deleting an appointment without rescheduling it; this should be documented in the patient record

charges

fees for procedures performed or services rendered

chief complaint

the patient's reason for being seen for the visit, in his own words

Clinical documentation

documentation in the medical record detailing the patients' medical care and treatment

Co-payments

a fixed amount for a covered service, paid by the patient before the patient receives service from the provider. The co-payment is collected each time medical services are received.

coinsurance

the percentage of cost the insured is responsible for paying after deductibles have been met. For example, an insurance company may pay 80% and the insured may be responsible for 20% co-insurance.

Consultation

service provided when requested of another provider to either recommend care for a specific condition or problem, or to determine whether the consulting provider will accept responsibility for ongoing management of the patient's entire care for the specific condition or problem. Note: Medicare no longer accepts consultation codes, however, many non-Medicare plans do accept them for billing.

CPT

a medical code set maintained by the American Medical Association (AMA). Each CPT code identifies a medical, surgical, or diagnostic procedure or service performed.

Credentials

login information to access software, such as a username and password

Crossover claim

the transfer or forwarding of completed claim information from Medicare to Medicaid, Medi-Cal, or private insurance companies that provide supplemental insurance benefits to Medicare beneficiaries

Date of service

the date a medical service or procedure is actually provided or rendered

Day sheet

provides a summary of financial transactions; for example, charges, payments, and adjustments (also known as a journal)

deductibles

an out-of-pocket expense the patient must pay before the insurance company will pay on covered services

demographic information

basic information regarding the patient that includes address, phone number, date of birth, gender, marital status, employer, school, etc.

Dependent

dependent eligibility refers to who can be added onto an insurance plan where the policyholder is someone else. Dependents are typically spouses and children.

Deposit date

the date funds are expected to be deposited at a financial institution, such as a bank

Differential diagnosis

a diagnosis that distinguishes a particular disease or condition from others that have similar clinical signs and symptoms

Dunning message

a communication included on statements that alert the recipient of information regarding the amount due. Dunning messages assist in clarifying the balance due to encourage prompt payments.

EIN/FEIN

an acronym for Federal Employer Identification Number, also known as EIN (Employer Identification Number). A FEIN is a nine-digit unique number assigned by the Internal Revenue Service (IRS) to identify a business operating in the United States.

electronic funds transfer (EFT)

also known as direct deposit; transfers payments from the insurance company directly into the provider's bank account. By enrolling in ERA and EFT, insurance payments are received more quickly and it is simpler to post and reconcile patient accounts.

electronic health record

a platform that can be accessed, managed, and consulted across more than one health care organization; refers to the shared information from all clinicians involved in a patient's care

electronic medical record

used to record patient health information in a digital format that allows the provider(s) to track a patient's health over time, improving the quality of care

Electronic Remittance Advice (ERA)

an electronic report provided in a computer-readable format sent by insurance companies to health care service providers, which explains the payment of medical claims; an electronic version of an Explanation of Benefits (EOB)

encounter

an interaction with a patient on a specific date and time. Encounter types include visits, phone calls, referrals, results of a test, and more.

encounter form

also known as superbill, a charge ticket, or visit/fee slip; contains all of the information insurance companies require in order to consider a claim for payment

established patient

an individual who has received professional services from a physician within the past three years, or from another physician of the same specialty who belongs to the same group practice

Explanation code

the explanation codes column contains Remittance Advice Remark Codes (RARCs), which provide the explanation for an adjustment or payment, or a lack of payment due to a specific reason

Family History (FH)

displays part of a patient's medical history in which questions are asked in an attempt to find out whether the patient has hereditary tendencies toward particular diseases. Family history is to be present in all patients' charts, including children.

Flow Board

a screen in MOSS 3.0 that tracks and displays the patient workflow during appointments. Information available for viewing includes arrivals, patient wait times, and examination rooms assigned to patients ready to be seen

Formulary

a list of drugs covered by an insurance plan. The list typically includes generic and brand name forms of a drug, further grouped into tiers.

Global

a term used to mean "all" or "applicable to everything". In terms of a global dunning message, the message appears on all statements generated to be sent to patients.

group number

a health insurer assigns a number to a group of insured persons on an insurance plan. This can identify an employer group, or a population of patients in a particular area, or members of an association that purchases a health plan for a group of members.

Growth chart

a tool used to compare an infant or child's height, weight, and head size to other children of the same age. A provider plots the growth of a child yielding data based on a percentile, which is used to determine if the growth is within the expected "normal".

guarantor

the person responsible for paying medical expenses; often included on the registration form

guardian

a person or entity that is legally responsible for another person's care, management, or their estate because they have been deemed disabled or incapacitated and cannot manage their own affairs. The term guardianship refers to care of a minor. A person can also appoint their own adult guardian by using a document called the Advance Directive.

health maintenance organizations (HMOs)

a medical insurance model that utilizes a Primary Care Physician (PCP) from a network of local providers who will refer patients to in-network specialists or hospitals when needed. All patient care is coordinated through the PCP, also known as a "gatekeeper".

HIPAA

abbreviation for Health Insurance Portability and Accountability Act of 1996; United States legislation that assures patient privacy and security provisions for medical information

History of Present Illness (HPI)

describes the symptoms or clinical problem from the onset to present time

ICD

a medical code set developed by the World Health Organization (WHO). Each ICD-10 code identifies and classifies diagnoses and symptoms.

ID/policy number

a unique number assigned to the policyholder, identifying the policy or account, and primarily used for billing purposes

immunization records

sometimes referred to as vaccination record; provides a history of all vaccines that a patient has received; can be required for certain jobs, overseas travel, or school registration

insured

an individual that is entitled to benefits of an insurance policy

journal

provides a summary of financial transactions; for example, charges, payments, and adjustments (also known as a day sheet)

Matched claim

an ERA transaction that matches the charges on a patient account and is ready for posting

matrix

to block an appointment schedule to reflect the clinic hours and provider schedules to include outside office appointments, vacations, meetings, hospital rounds, and other responsibilities that affect the times they are unavailable, especially to see patients. The times left open on the matrix are usually for in-office appointments, such as to see patients.

Meaningful Use

refers to a set of specified objectives that medical providers must meet in order to prove that they are using their EHR as an effective tool in their practice. Those effective tools are further defined as: (1) Using certified electronic health record technology to improve quality, safety, efficiency, and reduce health disparities; (2) Engaging patients and family; (3) Improving care coordination, and population and public health; (4) Maintaining privacy and security of patient health information. Meaningful use Stage 1 includes both a core set and a menu set of objectives that are specific to eligible professionals or eligible hospitals and CAHs.

Medicaid

a federal/state program for the medical care of low-income patients on public assistance

medical claim

a bill submitted to an insurance carrier for reimbursement of medical services or procedures rendered to a patient by a provider

Medicare

a federal government program that provides health insurance to those 65 or older, under 65 and receiving Social Security Disability Insurance (SSDI), or under 65 with End-Stage Renal Disease (ESRD) or amyotrophic lateral sclerosis (ALS)

Medicare Advantage Plan

also known as Part C or MA; a type of medical plan that replaces Original Medicare and provides all Part A and Part B benefits. Often, additional benefits not available with Original Medicare are covered, such as certain services, prescription drugs, and the Silver Sneakers and Silver and Fit programs. Medicare Advantage plans include HMOs, PPOs, fee-for-service plans, Medicare medical savings account plans, and special needs plans. The patient may return to Original Medicare coverage at any time.

Medicare as secondary payer (MSP)

a term used to refer to another entity, such as an insurance plan that pays first before Medicare pays. Providers of Part B benefits must obtain and follow proper claim rules to obtain MSP information. This includes group health coverage through employment or non-group health coverage resulting from an injury or illness. When billing MSP, an Explanation of Benefits (EOB) with all appropriate MSP information must be submitted to the designated carrier. If submitting an electronic claim, the necessary fields, loops, and segments needed to process an MSP claim must also be included (the EMR assists in gathering this data for claims submission).

Medigap

a coverage that helps pay for the deductible and co-insurance and other "gaps" in coverage in the Medicare plan

messages

electronic communication method between patient, provider, clinic staff, and other health care related providers/services in an electronic health record

Modifier

a two-character code added to a CPT® or HCPCS code that provides further information about the procedure

MSP code

codes that are used to explain why Medicare is the secondary payor for a patient's claim

new patient

an individual who has not received services from the provider, or from an associate provider of the same specialty who belongs to the same group practice, within the past three years

Non-Formulary

drugs that are not on the formulary for a plan and will either cost more, be non-covered, or require special authorization in order to be covered, as available under the insurance plan

Non-Matched claim

an ERA transaction that does not match due to an issue that needs further follow-up, edits, or completion in order for the payer to reimburse for the service. Unmatched services need to be followed up and resolved before posting of payments and adjustments can be applied.

NOS

number of service, or the number of units of service provided to the patient

NSF

non-sufficient funds is an acronym used to describe a check that is returned non-paid by a bank due to the account not having funds to cover the payment. Also known as a returned check.

objective

the second section of SOAP notes; this portion consists of items observed or measured by the clinician. Examples include vital signs, height, weight, neurological assessments, laboratory results, and range of motion testing.

Office hours

the time when the ongoing responsibilities of office management are completed

Passive alert

an alert that displays clinical information and is primarily for information and follow-up only. An example of a passive alert is a patient vaccination overdue status.

Past Medical History (PMH)

an account of past diseases, injuries, treatments, and medical data relevant to a patient's current health status

patient collections

the act of collecting patient balances

patient education

application within an electronic health record that provides access to a comprehensive list of patient education material that is provided to educate or instruct a patient based on the patient's condition and treatment options

patient portal

a secure online website that provides patients with 24 hour access to their medical information; details on office visits, procedures, or medications; communication with staff and providers; methods to request or schedule appointments online; or other types of patient interaction with the clinic through an internet connection

patient registration

the collection of patient data in order to start a patient record

Payee

a name to reference the insured on the policy, or the party entitled to payment, such as the provider or facility

payer

an entity other than the patient that reimburses expenses for health care services. These include insurance companies, or other third party payers, such as No-fault insurance, Workers Comp, or other responsibility party.

physician assistant (PA)

specialized professional health care providers who work primarily in the clinical back office. While these individuals work closely with the staff of the front office, and may even share responsibilities from both areas, their main focus is centered on direct patient care.

plan

outlines how the patient will be treated. This may include progress since last visit, and types of treatments to be given, to include medication, therapies, and surgeries. It may also list recommended changes to lifestyle, as well as short and long term goals for the patient in addition to goals the provider would like to accomplish with the treatment, such as pain reduction, increase strength, improve range of motion, lower blood glucose levels, etc.

point of service plans

a type of managed care health insurance plan that combines features of the health maintenance organization (HMO) and the preferred provider organization (PPO). With this type of plan you pay less if you use health care providers and hospitals that belong to the plan's network, and a referral will be required from your primary care provider in order to see a specialist.

point-of-service plan (POS)

insurance coverage that offers an in-network and an out-of-network option to receive services. When using the plan in-network, it is usually an HMO model with a PCP and referrals needed for specialists. When used out-of-network, there is a higher out of pocket cost to the patient; however, a PCP and referrals are not required.

policyholder

the principal holder or owner of an insurance policy. The policyholder may also be known as an insured, subscriber, or beneficiary of the policy, as are the qualifying dependents or other individuals that receive benefits on the policyholder's plan.

Post payment

to allocate funds to the balance due of an account

Posting date

the date funds are allocated to the balance due of an account

Power of attorney (POA)

a document that appoints an entity to manage the specified affairs of another person if they become unable to do so. Different categories and levels of control are granted to the principal entity on the document. The term POA is also used to refer to the entity that is given this control, also called the attorney-in-fact. An example: The patient's eldest son is the POA for her financials.

practice management

software used for administrative and billing tasks, such as scheduling appointments, generating reports, and billing insurance providers and patients

preferred provider organizations (PPOs)

a PPO plan offers a network of in- or out-of-network doctors, specialists or hospitals without a referral. Out-of-pocket medical costs are lower when receiving services from an in-network provider.

primary insurance

the first insurance company that is billed for patient services

privacy notice

policies set forth to abide by the Privacy Rule, which protects individually identifiable health information, called "protected health information (PHI)". The notice discloses the privacy practices of an entity (such as a clinic) and the patient's rights with respect to their PHI in clear language.

provider participation

health care providers that have entered into an agreement, or contract, with an insurance carrier. The insurance carrier directs patients to the provider and, in exchange, the provider accepts a lower fee for services.

provider's impression

the initial impression of a provider upon examining the patient, or reviewing diagnostic tests

provisional diagnosis

a diagnosis based on information obtained at the moment. After further testing or information, an exact diagnosis can be made.

reference sheet

shows all patients scheduled for an office visit for a specified time period

referral

required by most health insurance companies to ensure that patients are seeing the correct providers. For most (but not all) HMO plans, a referral from the patient's primary care physician is required before the patient can see any other health care professional (except in an emergency). If the patient's health insurance plan requires a referral and one is not obtained first, the insurance won't cover the cost to see the specialist.

referring providers

a provider that transfers a patient to a new physician, for partial or complete care, for a specific medical problem. A referring provider may also be the ordering provider for certain procedures.

registration

also called a patient information data sheet; filled out by the person, or guardian of the person, to be treated by the physician