Running head: DEFINITION OF TERMS 1

Definition of Terms
Patty Reagan
HCS/533
April 7, 2014
Catherine Doughty
DEFINITION OF TERMS 2


Definition of Terms
Health care has its own language. It has many abbreviations that are used every day from
diagnosing patients to billing third-party payers. Many systems are required to perform tasks
such as scheduling, billing, and receivables. The purpose and function of each system must be to
help the organization to run more efficiently. One must have an understanding of the terms and
their importance.
Ambulatory Medical Records
Ambulatory medical records (AMR) are outpatient medical records that are stored
electronically and contain a patients surgeries and other care that does not involve the
admittance to a hospital (Ambulatory Medical Record AMR, 2012-2013). These files are
accessed by doctors and other medical providers who need to know a patients non-admittance
history. AMRs can reduce space needed in the paper charts of the patients and more easily
accessible in the event of an emergency.
Computerized Medical Record
A computerized medical record (CMR) are a patients medical records that are stored in a
computerized system (Computerized Medical Record, 2012). Health professionals are able to
retrieve, display, and print the records. This type of system makes for faster retrieval and
reimbursement. Doctors notes are often illegible and this type of system reduces
misinterpretations.
Center for Medicare and Medicaid Services
Center of Medicare and Medicaid Services (CMS) is a federal organization that allows
for reimbursement of services provided to certain members of health care providers (). The
DEFINITION OF TERMS 3


organization must be certified in order to participate in the program. The federal government is
required to inspect participating facilities to ensure the set standards are being followed.
Claim Medical Services 1500
Claim medical services 1500 is the form used by non-institutional care providers such as
doctor offices, chiropractors, durable medical equipment, and home health care providers to bill
CMS patients (Wager, Lee, & Glaser, 2009). It is a form filled out by the provider when services
are rendered. The first section of the form contains information about the insured such as name,
Medicaid identification number, and diagnosis code. The second section contains information
about the provider such as name, address, National Provider Identifier and services and dates
provided. This form is mandatory when requesting reimbursement from governmental insurance
programs.
Current Procedural Terminology
The current procedural terminology (CPT) was established by the American Medical
Association (AMA) to provide standardization of and uniformed language of services and
procedures (Wager, et al., 2009). The CPT is updated yearly to help ensure that services are
coded correctly so payment may be received from insurance companies. The numerical codes
used represent specific medical, surgical, or services codes. The codes determine the amount of
reimbursement sent to the provider. The updates are issued by the AMA and provide manuals to
the providers.
Diagnosis Related Group
Diagnosis related group (DRG) is the system of classifications used by hospitals to group
into one of 500 groups for inpatient reimbursement from government and third-party insurers
(DRG Codes, 2000-2014). The groups are established by disease, severity of illness, and length
DEFINITION OF TERMS 4


of inpatient hospital stay. The DRGs also help to generate statistical information regarding the
number of patients treated and the severity of illnesses.
Electronic Patient Records
Electronic patient records (EPR) is the medical record of a patient (Electronic Patient
Records, n.d.). The medical record includes medical history, testing, surgeries, outpatient visits,
and inpatient hospital stays. EPRs is a complete medical record that can be accessed by medical
professionals. EPRs are easily transferred form one provider to another. EPRs are useful in
reducing duplicate testing, medical errors, and overall health care costs.
Health Level Seven
Health Level 7 (HL7) is an organization specializing in the development of standards for
the exchange of electronic health information (Rouse, 2010). It is structured as a way to manage
and exchange electronic health information in an effective and efficient manner. It is a system
that links the different systems together such as billing and medical records.
International Classification of Diseases, Ninth Revision
The International Classification of Diseases, 9
th
Revision (ICD-9) is a list of codes
established by the World Health Organization (WHO) to represent diseases and procedures
(Wager, et al., 2009). It is used in combination with the DRG to establish correct reimbursements
from payers. The use of the codes create an easier identifier of illnesses and procedures that a
patient has. The codes can also be used for statistical information within a population.
Uniform Bill 1992
The Uniform Bill is a standard of billing on one form and was created by the National
Uniform Billing Committee in 1975 (Wager, et al., 2009). There are been several versions of the
billing form with the latest being in 1992. Hospitals are required to use the UB-92, or latest
DEFINITION OF TERMS 5


version, to itemize the services, equipment, and medications that a patient may require as part of
therapies. The bill is sent electronically to the payer. It is required by government and third-party
payers when requesting payment.
Conclusion
All of the above systems have a purpose in the care of patients. They include
computerized charting, coding for billing purposes, standardization of terminology, and ways to
ensure payment from third-party insurers. They are designed to help health care be more
streamlined and easily accessible.















DEFINITION OF TERMS 6


Reference
Ambulatory Medical Record- AMR. (2012-2013). Retrieved from
http://ehrintelligence.com/glossary/ambulatory-medical-record-amr/
Computerized Medical Record. (2012). Retrieved from
http://dictionary.sensagent.com/computerized%20medical%20record/en-en/
DRG Codes. (2000-2014). Retrieved from https://www.findacode.com/drg/drg-diagnosis-
related-group-codes.html
Electronic Patient Records. (n.d.). Retrieved from
https://sites.google.com/site/emedicinetelemedicinelawinfo/electronic-patient-records-
epr-s-
Rouse, M. (2010). Health Level 7 International HL7. Retrieved from
http://searchhealthit.techtarget.com/definition/Health-Level-7-International-HL7