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  2. Current Procedural Terminology - Wikipedia

    en.wikipedia.org/wiki/Current_Procedural_Terminology

    The CPT code set describes medical, surgical, and diagnostic services and is designed to communicate uniform information about medical services and procedures among physicians, coders, patients, accreditation organizations, and payers for administrative, financial, and analytical purposes.

  3. Registered health information administrator - Wikipedia

    en.wikipedia.org/wiki/Registered_Health...

    Seeing that each patient's medical record is complete, kept confidential, and safeguarded from individuals not involved with the medical care of the patient are primary responsibilities. [ 4 ] A RHIA certification is a preferred qualification for positions including health information management director, clinical documentation improvement ...

  4. Healthcare Common Procedure Coding System - Wikipedia

    en.wikipedia.org/wiki/Healthcare_Common...

    Such coding is necessary for Medicare, Medicaid, and other health insurance programs to ensure that insurance claims are processed in an orderly and consistent manner. Initially, use of the codes was voluntary, but with the implementation of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) use of the HCPCS for ...

  5. Health information management - Wikipedia

    en.wikipedia.org/wiki/Health_information_management

    Health information management's standards history is dated back to the introduction of the American Health Information Management Association, founded in 1928 "when the American College of Surgeons established the Association of Record Librarians of North America (ARLNA) to 'elevate the standards of clinical records in hospitals and other medical institutions.'" [3]

  6. Clinical coder - Wikipedia

    en.wikipedia.org/wiki/Clinical_coder

    A clinical coder—also known as clinical coding officer, diagnostic coder, medical coder, or nosologist—is a health information professional whose main duties are to analyse clinical statements and assign standardized codes using a classification system.

  7. Diagnosis code - Wikipedia

    en.wikipedia.org/wiki/Diagnosis_code

    In particular the paper medical record standard 'AS 2828' created by Standards Australia focuses on a few key areas that are critical to maintaining a legible paper medical record. [ 7 ] The following criteria should be used as a guideline when creating a medical record specific to the aid of providing clear documentation for diagnostic coding.

  8. Medical classification - Wikipedia

    en.wikipedia.org/wiki/Medical_classification

    ICD has a hierarchical structure, and coding in this context, is the term applied when representations are assigned to the words they represent. [30] Coding diagnoses and procedures is the assignment of codes from a code set that follows the rules of the underlying classification or other coding guidelines.

  9. Clinical documentation improvement - Wikipedia

    en.wikipedia.org/wiki/Clinical_documentation...

    Clinical documentation improvement (CDI), also known as "clinical documentation integrity", is the best practices, processes, technology, people, and joint effort between providers and billers that advocates the completeness, precision, and validity of provider documentation inherent to transaction code sets (e.g. ICD-10-CM, ICD-10-PCS, CPT, HCPCS) sanctioned by the Health Insurance ...