Medical Insurance Ch 2

A file that contains the documentation of a patient's medical history, record of care, progress notes, correcpondence, and related billing/financial information.

The systematic, logical, and consistent recording of patient's health status-histgory, examinations, tests, re3sults of treatments, and ovservatins-in chronological order in a patient medical record.

State specified performance measures for the delivery of health care by medical professionals.

The office visit between a patient and a medical professional.

Procedure codes that cover physician's services performed to determine the optimum course for patient care; listed in the Evaluation and Management section of CPT.

S-Subjective (what patient names as problems)
O-Objective (what physician finds during exam)
A-Assessment (physician's diagnosis)
P-Plan (course of treatment)

The process by which a patient authorizes medical treatment after discussion about the nature, indications, benefits, and risks of a treatment a physician recommends.

A running collection of health information that provides immediate electronic access by authorized users.

Computerized records of one physician's encounters with a patient over time.

Federal agency within the Department of health and Human Services (HHS) that runs Medicare, medicaid, clinical laboratories (under the CLIA Pprogram), and other government health programs.

Federal act that set forth guidelines for standardizing the electronic data interchange of administrative and financial transactions, exposing fraud and abuse in government programs, and protecting the security and privacy of health information.

The system to system exchange of data in a standardized format.

Under HIPAA, the structured set of data transmitted between two parties to carry out financial or administrative activities related to health care; in a medical billing program, financial exchange that is recorded, such as a patient's copayment or deposit of funds into the provider's bank account.

1-HIPAA Privacy Rule
2-HIPAA Security Rule
3-HIPAA Electronic Transaction and Code Sets Standards

Under HIPAA, a health plan, clearinghouse, or provider that transmits any health information in electronic form in commection with a HIPAA transaction, does not specifically include worker's compensation programs, property and casualty programs, or disability insurance programs.