It is maintained by the cpt editorial panel Factors that contribute to a medical records quality are physician documentation, handwriting legibility, compilation of forms, duplication and inaccurate patient data. [1] the cpt code set describes medical, surgical, and diagnostic services and is designed to communicate uniform information about medical services and procedures among physicians, coders, patients, accreditation organizations, and payers for administrative, financial, and analytical purposes.
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The acronym hcpcs originally stood for hcfa common procedure coding system, a medical billing process used by the centers for medicare and medicaid services (cms)
Prior to 2001, cms was known as the health care financing administration (hcfa)
Hcpcs was established in 1978 to provide a standardized coding system for describing the specific items and services provided in the delivery of health. 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 structure of the codes will depend on the classification For example some use a numerical system, others alphanumeric.
Snomed ct is considered to be the most comprehensive, multilingual clinical healthcare terminology in the world [1][2] the primary purpose of snomed ct is to encode the meanings that are. The assigned proxy that is extracting information from the medical record is dependent on the quality of the medical record
