What is the key to substantiating procedure and diagnostic code selections for proper reimbursement?

All information about Insurance Handbook For The Medical Office Chapter 4 Key Terms

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    Chapter 4, Medical Documentation and Electronic Health Record Terms in this set (145) health record A health record can be defined as written or graphic information documenting facts and events during the rendering of patient care. Either paper or electronic format. American Recovery and Reinvestment Act of 2009 (ARRA)


Insurance Handbook for the Medical Office: Chapter 4

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Insurance Handbook for the Medical Office, 14th Ed., …

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    109 Terms happyeducator Insurance Handbook for the Medical Office, 14th Ed., Chapter 4, Medical Documentation and the Electronic Health Record Acute Attending Physician Chief Complaint (CC) Acute refers to a medical condition that runs a short but rela… An attending physician is a medical staff member who is legall…


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Insurance Handbook For The Medical Office Chapter 4

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When a patient feels to return for needed treatment documentation should be made?

A Fordney Ch3.

Is a concise statement describing the symptom problem condition diagnosis physician recommended return or other factor that is the reason for the encounter?

CHIEF COMPLAINT (CC) The CC is a concise statement describing the symptom, problem, condition, diagnosis, physician recommended return, or other factor that is the reason for the encounter. DG: The medical record should clearly reflect the chief complaint.

Who renders a service to a patient?

The Rendering Provider is the person or company (laboratory or other facility) who rendered the care. In the case where a substitute provider (locum tenens) was used, enter that provider's information here. The Rendering Provider is the individual who provided the care.

What do administrative medical office responsibilities include?

They are responsible for front office duties, including tasks ranging from answering phones and greeting patients to managing health records and transcribing medical documents. Some of the work requires specialized skills, such as the usage of medical terminology or medical coding.

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