Hcs/533 - Definition of Terms Essay

829 Words Jun 5th, 2012 4 Pages
Definition of Terms
Technology today has revolutionized the health care realm, as technology evolves so does the environment promoting quality care for that in need. This presentation will explain multiple abbreviations needed to translate and describe AMR, CMR, CMS, along with CMS – 1500, and CPT. Also, explore the meaning of DRG, EPR, HL7, ICD – 9 codes, and UB – 92.
Medication administration record is a system put in place to document the administration of medications order verbally or written by the patient’s physician to prove and organize that a medication was given properly to a patient. Other information documented is allergies and is the responsibility of the registered nurse (RN) or Licensed practical nurse (LPN) (Wager,
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The most important aspect of this form is that it provides quick turnaround for payment and pays for most anything a patient may need ("Form CMS 1500At A Glance," 2012).
Current Procedural Terminology (CPT) is published by the AMA and updated yearly. This terminology was devised to have a standard language of defining medical and surgical procedures for billing purposes. Insurances use this information to evaluate and decide on the proper amount of reimbursement (Wager et al., 2009).
Diagnosis related group (DRG) is a category a patient is assigned in correlation with the ICD – 9 codes. This information is the basic determining inpatient reimbursement for Medicare, Medicaid, and many other insurance carriers. Each code has a payment grid assigned to it based on location and cost of living factors. If the DRG code is wrong it can be considered fraud or the professional may not get paid properly.
Electronic Patient Record (EPR) is where essential patient information during each visit or admission is stored. Historical events pertinent to each patient are also stored within each individual record. This system has also enabled professional care givers to quickly, securely, and effectively transfer patient information to other professionals on transfer, consult, or for advice (Wager et al., 2009).

HL7 Health Level 7 (HL7) is used for the exchange or medical

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