AMR– Automated Medical Record – Paper based record with some computer generated documents A- Automated
Definition - AMR or Automated Medical Record is defined as a collection of electronic health information about a patient. It is electronic access of a person’s information by authorized users. In simplest terms, instead of having all of a person's medical record written down or kept in filing cabinets, the information is stored on a computer. The most important aspect of AMR is that a nurse does not have to go through filing cabinets, It is as simple as imputing a name into the computer, access the record, and print a copy for the physician. CMR-CMR – Computerized Medical Record – AMR with all documents electronic C-Computerized
Computerized medical records are the digital version to patient medical records kept in paper files and folders in health care offices (Wisegeek, 2003). Paper medical records are scanned and put into electronic medical records. It is the same exact version as the paper chart. The most important aspect of a CMR (Computer Medical Record) is saving money and time for the facility. The facility can expand with using storage space for retaining medical records. It is safe and reliable. A person does not have to stand and look for the paper chart. It is as easy as using your computer mouse and clicking on the information in the computer. CMS- CENTERS FOR MEDICARE & MEDICAID SERVICES
M-Medicare & Medicaid
The Center for Medicare and Medicaid Services provides Medicare, Medicaid, and related quality assurance programs. The most important aspect of the CMS is the center provides regulations for Medicare and Medicaid to the people of the United States and makes sure that the states are in compliance. It makes certain that its beneficiaries are aware of the services for which they are eligible, what services are accessible, and that the services are provided in an effective and safe way (healthfinders.gov, 2011). CMS is also responsible for overseeing of HIPAA administrative functions, health identifiers, and security standards. CMS-1500-
M-Medicare & Medicaid
According to Department of Health & Human Services (2011), “CMS-1500 is the standard paper claim form used by health care professionals and suppliers to bill Medicare carriers and Medical Equipment Medicare Administrative Contractors” (para.1). It is the only form accepted by Medicare. All health care professionals or organizations are responsible to file the claim if payment is to be release. Patients cannot be charged to have this claim filed by the facility. Any claim must be done within one year of services. The most important aspect of the CMS-1500 form is that hospitals or health care professionals cannot claim whatever they wanted to. There are certain codes and regulations they must follow.
The American Medical Association (AMA) sets a medical code for physician and other services. ICD-9
International Classification of Diseases-
The International Classification of Diseases, ninth revision, is developed by the World Health Organization to classify diseases. It is used in the United States to code diseases and procedure information (Wagner, Lee, & Glaser, 2009). The most important aspect of the ICD-9 is that it has become the major part in reimbursements for hospitals. All the codes are the same. It does not matter where it is used or how it is used, the codes are the same and it makes it easy to use.
Health Level 7
HL7 is the acronym for Health Level 7. According to Health Level 7 ( 2011), “HL7 provides standards for interoperability that improve care delivery, optimize workflow, reduce ambiguity and enhance knowledge transfer among all of our stakeholders, including healthcare providers, government agencies, the vendor community, fellow SDOs and patients” (para. 1). The most important aspect of HL7 is that is the standard healthcare communication. It is a non- profit organization that is interested in developing health care standards internationally. UB-92
Universal/Uniform Billing, form 92.
UB-92 or Universal/Uniform Billing, form 92 is the form used by hospitals and health care centers when submitting bills to Medicare and third-party payers for reimbursement for health services provided to patients. The most important aspect of this form is that it is exactly what it says it is, universal. It is the same form for billing everywhere you go. All medical organizations use it to bill for reimbursement without having to guess or add to it. It is electronic and health care professionals are able to pull it up online and fill it out.