Medical Records and Billing Glossary
CCR - Continuity Care Record
In an electronic medical records system, the minimum clinical and demographic data that a physician needs to make informed medical decisions.
CHR - Computerized Health Record
Term synonymous with Electronic Medical Record (EMR).
COB - Coordination of Benefits
Used by medical insurers to eliminate duplicate coverage when a patient is covered by multiple insurance benefit plans.
CPOE - Computerized Physician Order Entry
Software in medical records and billing systems for ordering tests, treatments or medications from another computer on a network. Orders are transferred to a lab, pharmacy, or other medical unit.
CPR - Computerized Patient Record
Term synonymous with Electronic Medical Record (EMR).
CPT - Current Procedural Terminology
A 5-digit code used in medical billing and records systems that defines the medical procedures and medical services provided.
DICOM - Digital Image Communication in Medicine
Industry standard for transferring medical images between medical records & billing systems and between electronic devices.
DRG - Diagnosis Related Group
Codes used by Medicare for classification of in-patient medical services.
EHR - Electronic Health Record
Term synonymous with Electronic Medical Record (EMR).
EMR - Electronic Medical Record
A computer-based medical record for a patient that provides secure, real-time data access, sharing and evaluation for medical care.
EPR - Electronic Patient Record
Term synonymous with Electronic Medical Record (EMR).
HCFA 1500
A medical billing form used by doctors to file insurance claims for medical services.
HCPCS - HCFA Common Procedural Coding System
A medical coding system used to describe what treatment or services were provided by a physician. The HCPCS Level II Coding books contain codes and descriptions for durable medical goods, injections, supplies and services not listed by CPT Coding books.
HL7 - Health Level Seven
A data exchange protocol and interface for medical records and billing software that allows different systems to interoperate.
HIPAA - Health Insurance Portability and Accountability Act
A body of national standards for electronic medical records and transactions for healthcare providers, health plans, and employers. It also addresses the security and privacy of electronic health records.
HIS - Hospital Information System
A computer-based system used to meet the clinical and support information needs of a hospital.
ICD-9 - International Classification of Diseases, 9th Edition
A numerical code used in medical billing describing a diagnosis or medical procedure to treat a disease, syndrom or disorder.
UB-92
A form used in medical billing by hospitals to file insurance claims for medical services.
Medical billing & medical records software providers
|
