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Term

Definition

Authorization

Formal approval from an insurer for a service or medication

Beneficiary

Person covered under a health insurance plan

Co-payment

Fixed fee paid by a patient at the time of service

Deductible

Amount paid out-of-pocket before insurance coverage begins

EOB (Explanation of Benefits)

Statement detailing what the insurer paid, denied, or adjusted

ICD-10

Diagnostic coding system for medical conditions

CPT Code

Procedure codes used for billing medical services

HCPCS

Medicare billing codes for supplies and services

HIPAA

Law protecting patient data privacy and security

EMR

Electronic record of a patient’s health data within a single practice

EHR

Shared electronic health record across multiple providers

Clearinghouse

Entity that transmits medical claims between providers and payers

CMS-1500

Standard claim form for outpatient services

UB-04

Claim form used for inpatient hospital billing

Referral

Sending a patient to another provider for specialized care

Audit

Inspection or review of records and procedures

Matrix

Format used to establish a time schedule for appointments

Encounter Form

Document listing procedures performed and their billing codes

SOAP

Charting method: Subjective, Objective, Assessment, Plan

Dictation

Verbal recording of clinical notes for transcription

Subjective

Information provided by the patient, not measurable

Objective

Observable and measurable clinical findings

Progress Note

Record of ongoing treatment and patient progress

Privacy Officer

Person responsible for managing protected health information

Promoting Interoperability

CMS program for improving health data exchange and access

Indexing

Cross-referencing system for organizing office files

Continuity of Care

Uninterrupted delivery of healthcare services

Encoder

Software for searching medical billing codes

Chronologic

Arranged in order of time or occurrence

CHEDDAR

Charting method: Chief Complaint, History, Examination, Details, Drugs, Assessment, Return visit

HL7 Protocols

Standards for exchanging health information between applications

Chief Complaint (C/C)

Main reason for the patient’s visit

Transcription

Conversion of dictated notes into written format

Utilization

The act of using resources effectively

Flex Time

Flexible scheduling of work hours

Tickler File

Chronologic file used for follow-up reminders

HPIP

Charting method: History, Physical, Impression, Plan