HIPAA/Medical Records
Coding
Insurance
Abbreviations
Medical Terminology
100

A physician dictates notes and patient care and notes are then transcribed.

Narrative style

100

Is coding without being specific enough

truncated coding

100

Is a government funded insurance for low-income families/person

Medicaid

100

RADT

registration, admission, discharge, transfer

100

is a fracture characterized by crushed bones

Comminuted

200

These are "covered entities" under HIPAA

Health Plans

Healthcare clearinghouse

Healthcare providers

200

coding that reports what is NOT documented

Assumption coding

200

Is a government funded insurance for over 65 and end-stage renal disease

Medicare

200

SOAP

Subjective, objective, assessment, and plan

200

Is a common fracture in a child; partially broken bone or partially bent

Greenstick fracture

300

This is the utilization of certified EHR technology to improve quality, efficiency and patient safety in healthcare documentation

Meaningful Use

300

Are codes that designate procedures that were done on patient

CPT codes

300
Is the meaning of the abbreviation COB
Coordination of Benefts
300

Is a clinical vocabulary to encompass all terms in medicine

SNOMED-CT
300

Is a muscle movement that "increases" the angle of a joint

Extension

400

Allows providers to share information through organized networks

Health Information Exchange (HIE)

400

Are codes that are disease-related 

ICD-10-DM

400

Is the form used to submit hospital claims

UB-04 form

400

Terms and codes used for electronic exchange of lab results

LOINC

400

These are joints that have free movement

diathroses

500

Consists of patient records from ALL healthcare providers, not just primary care physician

Electronic Health Record

500

Are codes that designated external causes of morbidity (disease)

V-codes

500

Is what patient pays out of pocket at doctor's visit

Co-pay

500

is a unique patient identifier like a record # or DOB

UPI

500

Is the combining form for "clot"

Thromb/o-