Common components of the clinical portion of the record include the identification sheet, problem list, dedication record, history and physical, progress notes, consultation, physician orders, imaging and x-ray reports, laboratory reports, consents, operative reports, pathology reports, and discharge summary (Wager, Lee, & Glasses, 2009). CAMS CAMS is the abbreviation for Center for Medicare and Medicaid Services. CAMS is charged with the oversight of the health care provided and reimbursement to Medicare and Medicaid recipients (Wager, Lee, & Glasses, 2009).
The center aggregates data from claim forms for analyzing national health care reimbursement, clinical, and population trends. The forms CAMS-1500 and PUB-04 collect the same data (Wager, Lee, & Glasses, 2009). CAMS-1500 CAMS-1500 is a form for billing that was developed by the National Uniform Claim Committee (UNC). This committee was created by the American Medical Association (AMA) for non-institutional care to submit claims. This form is the standard for physician billing and non-institutional provider claims The UNC has oversight for this form (Wager, Lee, & Glasses, 2009).
CAP CAP is the abbreviation for Current Procedural Technology and is published by the American Medical Association annually. This is a copyrighted book that was first developed and published in 1966 (Wager, Lee, & Glasses, 2009). In 1983, the federal government adopted CAP as the major component of the Healthcare Common Procedure Coding System (HASPS). It is the standard for physician’s offices, outpatient, and ambulatory care coding for reimbursement (Wager, Lee, & Glasses, 2009).
DRUG Drag’s or Diagnostic Related Groups is a prospective payment system in which reimbursement is dependent on the patient’s diagnosis and the accuracy of the ICED-9 codes. In this system, hospitals receive a pre-determined amount based n the patients DRUG, regardless of the total costs required to treat the patient (Wager, Lee, & Glasses, 2009). PER The PER is the Electronic Patient Record that encompasses patient information including administrative and clinical documents.
The PER tracks patient encounters and is a comprehensive collection of data (Wager, Lee, & Glasses, 2009). Aggregate data can be collected from Ewer’s for reporting purposes. These reports can be used for improving patient care and patient outcomes (Wager, Lee, & Glasses, 2009). HAL HAL is the abbreviation for Health Level Seven. HAL is the standardized language for exchange of clinical, financial, and administrative information between health care computer systems. Some examples of HAL are patient records, laboratory reporting, and billing.
Information sent through this standard is a collection of messages, each with a bit of information (“HUH Overview”, 2010). ICED-9 ICED-9 is a classification system that is derived from the International Classification of Diseases, Ninth revision. This book of codes was developed by the World Health Organization and is used in the United States to code diseases ND procedures. The ICED-9 is considered a federal document and can be used freely. It is updated annually and plays a major role in the reimbursement to hospitals.
Since 1983, the ICED-9 has been used for determining diagnostic- related groups to which a patient is assigned. The ICED-9 has no copyright (Wager, Lee, & Glasses, 2009). PUB-92 A BUBO is a medical claim form that was previously used for facility billing. It is no longer accepted and has been replaced by the JIB-04 (Redmond, n. D. ). The BUBO, also known as the SCHISMS is a billing form for institutional care, is considered he institutional standard billing form. It is required by the federal government and state government for institutional billing.
Each form must include a National Provider Number (NIP). The NIP number is a unique identifying number for each HAIFA covered health care provider (Wager, Lee, & Glasses, 2009). Conclusion Health care information systems are complex. They can communicate with each other through special languages to capture patient encounters from start to finish. Health care systems compile information for direct patient care as well as administrative functions including the required billing forms. These systems are capable of aggregating data for reporting purposes.
