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Electronic Health Records Final Exam2022/2023

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Clinical coders Medical coders, or coders and are responsible for assigning accurate codes based on health record documentation and coding guidelines SNOMED-CT Standardized vocabulary of clin... ical terminology used by healthcare providers for clinical documentation and reporting, and it is considered the most comprehensive healthcare terminology in the world MEDCIN Is a naming system primarily used in physicians' offices, was developed by MediComp Systems, Inc. and is derived from the U.S. Centers for Medicare & Medicaid Services (CMS) guidelines for evaluation and management coding/charges Classification system Used in healthcare, is a standardized coding method that organizes diagnoses and procedures into related groups to facilitate reimbursement, reporting, and clinical research International Classification of Diseases (ICD) and Current Procedural Terminology (CPT) Two most widely used classification systems. Hospitals, medical offices, long-term care facilities, ambulatory care centers, and many other healthcare institutions use ICD and CPT. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) Classifies psychiatric disorders Healthcare Common Procedure Coding System (HCPCS) Codes ancillary services and procedures Current Dental Terminology (CDT) Codes dental procedures Reimbursement Enabling healthcare facilities and providers to bill for services and treatment rendered Research Helping researchers with studies and clinical trials Decision making Supporting healthcare systems with operational and strategic planning [Show More]

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