Rhonda B. Kiker
January 30, 2012
Health care information systems are a collection of data and information unique to health care. This information includes starting with an information structure that collects both administrative and clinical patient data, compiles the information, makes information available for up-to-date patient care all the way through the reimbursement process. These systems also aggregate data for reporting to measure outcomes. A description of different types of patient information and the key elements associated with the capture of health care data will be discussed. AMR
AMR is the abbreviation for the Administrative Medical Record. This deals with the non- patient care portion of records and keeps business flowing. This portion of the patient record …show more content…
This book of codes was developed by the World Health Organization and is used in the United States to code diseases and procedures. The ICD-9 is considered a federal document and can be used freely. It is updated annually and plays a major role in the reimbursement to hospitals. Since 1983, the ICD-9 has been used for determining diagnostic- related groups to which a patient is assigned. The ICD-9 has no copyright (Wager, Lee, & Glaser, 2009).
A UB92 is a medical claim form that was previously used for facility billing. It is no longer accepted and has been replaced by the UB-04 (Redmond, n.d.).
The UB-04, also known as the CMS1450 is a billing form for institutional care, is considered the institutional standard billing form. It is required by the federal government and state government for institutional billing. Each form must include a National Provider Number (NPI). The NPI number is a unique identifying number for each HIPAA covered health care provider (Wager, Lee, & Glaser, 2009).