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  2. Medical billing - Wikipedia

    en.wikipedia.org/wiki/Medical_billing

    Achieving a high clean claims rate is a key metric for measuring the efficiency of the billing cycle. Creation of the claim is where medical billing most directly overlaps with medical coding because billers take the ICD/CPT codes used by the medical coders and creates the claim. Step 6: Monitoring payor Adjudication [4]

  3. SOAP note - Wikipedia

    en.wikipedia.org/wiki/SOAP_note

    [1] [2] Documenting patient encounters in the medical record is an integral part of practice workflow starting with appointment scheduling, patient check-in and exam, documentation of notes, check-out, rescheduling, and medical billing. [3] Additionally, it serves as a general cognitive framework for physicians to follow as they assess their ...

  4. Chief complaint - Wikipedia

    en.wikipedia.org/wiki/Chief_complaint

    It is sometimes also referred to as reason for encounter (RFE), presenting problem, problem on admission or reason for presenting. [ citation needed ] [ 1 ] The chief complaint is a concise statement describing the symptom , problem, condition , diagnosis , physician -recommended return, or other reason for a medical encounter. [ 2 ]

  5. Health Insurance Portability and Accountability Act - Wikipedia

    en.wikipedia.org/wiki/Health_Insurance...

    The EDI Health Care Claim Transaction Set (837) is used to submit health care claim billing information, encounter information, or both, except for retail pharmacy claims (see EDI Retail Pharmacy Claim Transaction). It can be sent from providers of health care services to payers, either directly or via intermediary billers and claims ...

  6. Revenue cycle management - Wikipedia

    en.wikipedia.org/wiki/Revenue_cycle_management

    Revenue cycle management (RCM) is the process used by healthcare systems in the United States and all over the world to track the revenue from patients, from their initial appointment or encounter with the healthcare system to their final payment of balance. It is a normal part of health administration. The revenue cycle can be defined as, "all ...

  7. Electronic health record - Wikipedia

    en.wikipedia.org/wiki/Electronic_health_record

    The electronic health record (EHR) is a more longitudinal collection of the electronic health information of individual patients or populations. The EMR, in contrast, is the patient record created by providers for specific encounters in hospitals and ambulatory environments and can serve as a data source for an EHR. [6] [7]

  8. Continuity of Care Document - Wikipedia

    en.wikipedia.org/wiki/Continuity_of_Care_Document

    The patient summary contains a core data set of the most relevant administrative, demographic, and clinical information facts about a patient's healthcare, covering one or more healthcare encounters. It provides a means for one healthcare practitioner, system, or setting to aggregate all of the pertinent data about a patient and forward it to ...

  9. Medical malpractice in the United States - Wikipedia

    en.wikipedia.org/wiki/Medical_malpractice_in_the...

    Thus, when a patient claims injury as the result of a medical professional's care, a malpractice case will most often be based upon one of three theories: [10] Failure to diagnose: a medical professional is alleged to have failed to diagnose an existing medical condition, or to have provided an incorrect diagnoses for the patient's medical ...