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Definitions of Terms

The document defines several medical terms and acronyms used in medical records and billing including AMR, CMR, CMS, CPT, DRG, EPR, HL7, ICD-9, and UB-92. These terms relate to ambulatory medical records, computerized medical records, Centers for Medicare and Medicaid, Current Procedural Terminology codes, diagnosis related groups, electronic patient records, health data standards, disease classification, and hospital billing forms.

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248 views

Definitions of Terms

The document defines several medical terms and acronyms used in medical records and billing including AMR, CMR, CMS, CPT, DRG, EPR, HL7, ICD-9, and UB-92. These terms relate to ambulatory medical records, computerized medical records, Centers for Medicare and Medicaid, Current Procedural Terminology codes, diagnosis related groups, electronic patient records, health data standards, disease classification, and hospital billing forms.

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sexyma1126
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Definitions of Terms Amber Kinard HCS/533 January 14, 2013 Sheryl-Anne Murray

AMR- Ambulatory Medical Records are medical records in which physicians use. If the physician is using the same information system as the hospital, they can be linked together to show visits in the ambulatory setting. The medical records are kept at the office that provides the care (Wager, Lee, & Glaser, 2009). The AMR system includes billing, coding, and the transcription of doctors notes. AMRs are important because they can ensure compliance, increase the time which doctors spend with their patients, and reduce the space in the offices for paper charts. CMR- Computerized Medical Records are health information about patients stored within the system. Recently, the use of computerized medical records has become a requirement for the government and CMS in order to obtain reimbursements for services rendered (Wager, Lee, & Glaser, 2009). CMRs are important and increases reimbursement time processes, increases retrieval times of patient records, makes physician handwriting more legible, and assists with organization of patient information. The CMR includes information that was previously obtained by scanning the patient chart into the computer system. CMS- Centers for Medicare and Medicaid focuses on physicians, nursing homes, longterm care, home care and hospitals. They ensure compliance of government policies and procedures of these facilities. CMS aggregates data from CMS1500 (Insurance claims forms) for analyzing national health care reimbursements as well as clinical and population trends (Wager, Lee, & Glaser, 2009). CMS-1500 is an insurance claim form adopted by the federal government. It was created by the American Medical Association (AMA) and maintained by the National Uniform Claim Committee. This form is used for noninstitutional provider claims, such as physician services (Wager, Lee, & Glaser, 2009). CMS-1500 data must be reported for aggregating and analyzing the States health information. CPT- Current Procedural Terminology is copyrighted by the AMA. It was first developed and published in 1966 to describe medical and surgical devices. It was then adopted in 1983 as a major component of the Health Care Common Procedure Coding System (Wager, Lee, & Glaser, 2009). It is used for coding for reimbursements in physician offices, outpatient, and ambulatory care. Without CPT, reimbursements would not be possible in these organizations. DRG-Diagnosis Related Groups are how appropriate inpatient reimbursements for Medicare, Medicaid, and other health care insurances are determined (Wager, Lee, & Glaser, 2009). These groups have to be documented accurately to ensure that reimbursements are accurately given to the biller.

EPR- Electronic Patient Record provides immediate access by the physician to the patients medical records. Regardless of where the information is stored physicians and health care providers who are allowed access will be able to view patient information. The use of EPRs will allow more room in the physician offices because paper charts will not need to be stored. HL7-Health Level Seven is a process of exchanging health care information between medical applications. Information sent using HL7 is sent as one or more messages which obtain health care information such as patient records, laboratory records, and billing information (Interface Ware, 2010). This system can make transmittal of information more organized and easier to retrieve. ICD-9- the ICD-9 are classifications that comes from the International Classification of Diseases, Ninth Division, which was developed by the World Health Organization (WHO) to obtain disease data (Wager, Lee, & Glaser, 2009). It is used in the United States to code disease information as well as procedure information. Currently updated ICD-9s are published every year. Because there are updated versions published every year, it makes it easier to keep up with current codes and prevent using older codes that are no longer used. UB-92- The UB-92 claim form is used by hospitals and facilities for billing to Medicare and third party payers for reimbursements for services. UB92 claim forms were updated and are now referred to as the UB04 form (Free Dictionary, 2013). This form can help to ensure that all the appropriate reimbursements are rendered to organizations for their services.

References

Free Dictionary (2013). UB92. Retrieved January 13. 2013 from www.medical-dictionary.com Interface Ware (2010). HL7 Overview. Retrieved January 13, 2013 from www.interfaceware.com Wager, K.A., Lee, F.W., & Glaser, J.P. (2009). Health care information systems: A practical approach for health care management (2nd ed.). San Francisco, CA: Jossey-Bass.

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