CMAA Patient Intake #2

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Electric Medical Record (EMR)
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Terms in this set (38)
Electric Medical Record (EMR)
An electronic record of health information that is created, added to, managed, and reviewed by authorized providers and staff within a single health care organization.
Advance Directive Form
Document that spells out what kind of treatment a patient wants in the event that he can't speak for himself. Also known as living will.
Protected Health Information (PHI)
Information about health status or health care that can be linked to a specific individual.
Electronic Health Record (EHR)
An electronic record of health-related information about a patient that conforms to nationally recognized interoperability standards that can be created, managed, and reviewed by authorized providers and staff from more than one health care organization.
Guarantor
Person or entity responsible for the remaining payment of services after insurance has paid.
Birthday Rule
The health plan of the parent whose birthday comes first in the calendar year is designated as the primary plan.
Healthcare Common Procedure Coding System (HCPCS)
A group of codes and descriptors used to represent health care procedures, supplies, products, and services.
Reimbursement
Payment from insurance companies.
Modifers
Added information or changed description of procedures and services, and are a part of valid CPT or HCPCS codes.
Health History Form
Form that asks patient to list any illnesses or surgeries they have had, family history, medication taken, chronic health issues, allergies, and other physicians they consulted.
Notice of Privacy PracticesDocument informing a patient of when and how their PHI can be used.ConsentA patient's permission.Patient Financial Responsibility FormForm that confirms that the patient is responsible for payments to the provider.Assignment of Benefits (AOB) FormForm that authorizes health insurance benefits to be sent directly to providers.Living WillDocument that spells out what kind of treatment a patient wants in the event that he can't speak for himself. Also known as advance directive.DNR FormForm that states that the patient does not want to be revived after experiencing a heart episode or other kind of life-threating event.Encounter FormA document used to collect data about elements of a patient visit that can become part of a patient record or be used for management purposes.Regular ReferralWhen a physician decides that a patient needs to see a specialist.Urgent ReferralWhen an urgent, but not life-threatening, situation occurs, requiring that the referral be taken care of quickly.Stat ReferralNeeded in an emergency situation, and can be approved immediately over the telephone after the utilization review has approved the faxed document.Active FilesSection of medical charts for patients currently receiving treatment.Inactive FilesSection of medical charts for patients the provider has not seen for 6 months or longer.Closed FilesSection of medical charts for patients who have died, moved away, or terminated their relationship with the physician.PurgingThe process of moving a file from active to inactive status.Provisional DiagonosisA temporary or working diagnosisDifferential DiagonosisThe process of weighing the probability that other diseases are the cause of the problem.List three way a medical office can accommodate patients who have vision lossPossible answers include having signage in Braille so the patient can find the office; having documents in Braille and large print; and having modifications built in the computer if the patient is asked to complete any forms electronically.Why is health insurance important?Health insurance is important because it serves as protections against protection against financial losses due to illness or injury. Insurance provides financial support for medical needs, hospitalization, medically necessary diagnostic tests and procedures, and many kinds of preventive services.True of False: If preauthorization is required but not done, the insurance carrier will not pay for the medical services provided.True. Before certain procedures can be performed or a patient hospitalization, many insurance companies required precertification, or preauthorization. If this is not done, insurance claims will be denied.Who is considered a guarantor?When the patient is the same as the insured, the patient is also referred to as the guarantor.What is the birthday rule?The birthday rule applies to dependent children whose parents have more than one insurance policy. Under the birthday rule, the health plan of the parent whose birthday comes first in the calendar year is designated as the primary plan.What are CPT codes used to described?Providers use CPT codes for hospital inpatient and outpatient service/ procedure.What is the HIPAA notice of privacy practice form?Under HIPAA, medical practices AREN'T allowed to release information unless patients first sign a notice of privacy practice form. This form explains what's in a patient's medical record, the patient's health information rights, and the medical practice's responsibilities to the patient.Name three forms that mat found in a patient's medical record?Examples of forms found in a patient's medical record include consent to release information, patient financial responsibilities form, and advance directives.When are regular referrals needed?A regular referral is when the provider decides that the patient needs to see a specialist.What is included in an accurate, up-to-date medical record?Medical records contain all information relevant to patient medical care and insurance.ICD-10-CMDisease and injury codes that contain up to seven alphanumeric characters.ICD-10-PCSProcedure codes that contain seven alphanumeric characters.