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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. The health data produced are an integral part of health information ...
Medical billing is a payment practice within the United States healthcare system. The process involves the systematic submission and processing of healthcare claims for reimbursement. Once the services are provided, the healthcare provider creates a detailed record of the patient's visit, including the diagnoses, procedures performed, and any ...
Resource-based relative value scale. Resource-based relative value scale ( RBRVS) is a schema used to determine how much money medical providers should be paid. It is partially used by Medicare in the United States and by nearly all health maintenance organizations (HMOs). RBRVS assigns procedures performed by a physician or other medical ...
The AAPC, previously known by the full title of the American Academy of Professional Coders, [ 4] is a professional association for people working in specific areas of administration within healthcare businesses in the United States. [ 5] AAPC is one of a number of providers who offer services such as certification and training to medical ...
Health information management ( HIM) is information management applied to health and health care. It is the practice of analyzing and protecting digital and traditional medical information vital to providing quality patient care. With the widespread computerization of health records, traditional (paper-based) records are being replaced with ...
The Current Procedural Terminology ( CPT) code set is a procedural code set developed by the American Medical Association (AMA). It is maintained by the CPT Editorial Panel. [ 1] The CPT code set describes medical, surgical, and diagnostic services and is designed to communicate uniform information about medical services and procedures among ...
Registered health information administrator ( RHIA ), previously known as registered record administrator, is a professional certification administered by the American Health Information Management Association (AHIMA) in the United States. Passing the exam results in certification for health information management .
Reproducible: A coder would need to make sure that the record is reproducible in that copies can be made to aid in effective coding. [8] Clinical coder experience. The experience of the health professional coding a medical record is an essential variable that must be accounted for when analysing the accuracy of coding.
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