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ADJMT Adjustment found on the Ledger and Day Sheet. An adjustment is a change to a patient s account that is neither a charge for services nor a payment. Annual Exam Patient visit that occurs yearly and includes a complete physical examination. Assignment of Benefits Release a patient signs that gives the insurance carrier permission to pay the medical office directly instead of sending the payment to the patient. Audit Located in the Coding & Billing module, an audit can be run on submitted claims and can uncover improper use of diagnostic and procedure codes. Calendar The landing page upon entering the simulation used to review and manage appointments. Some fields throughout the simulation also utilize calendar pickers which indicates that a date must be chosen. Chief Complaint The reason a patient scheduled an appointment to see the physician. Although only one chief complaint can be assigned to an encounter, it could include several conditions such as sore throat, fever, and a headache. Only one Encounter type per day is allowed for a patient. Claim Located in the Coding & Billing Info Panel, the 5010 CMS Claim is submitted electronically to the insurance carrier and generated for a specific encounter. The Claim contains information the insurance carrier needs to process the charges associated with the patient visit and make a payment to the medical office. The claim can then be output to an auto-filled CMS 1500 printable form. 2 of 7
Clinical Care The second module in the simulation where all of the clinical charting for a patient occurs. Coding & Billing The third module in the simulation featuring all of the necessary forms and documentation for coding, billing, and ultimately completing a patient encounter. Comprehensive Visit First encounter type displayed in the Clinical Care Info Panel that includes Annual Exam, Follow-Up/Established Visit, New Patient Visit, Urgent Visit, and Wellness Exam. Correspondence Icon located in the task bar at the top of the screen that directs students to email and letter templates for patient and office communication. CPT Current Procedural Terminology used for procedural coding. Day Sheet Form located in the Coding & Billing module, used to record services and charges associated with patient care. Diagnostic/Lab Results Located in the Info Panel of the Clinical Care module, used to record the results of diagnostic procedures and laboratory tests. Encounter Patient visit. Students must select or create a new encounter before documenting in a patient record in order to tie documentation to a specific date and time. Encounter types include Comprehensive Visits, Office Visits, and Phone Consultations. 3 of 7
Established Patient A patient that has been seen in the medical office within the last three years. Fee Schedule A list of the amounts charged for services and supplies in a medical office. Find Patient Icon located in the task bar at the top of the screen which directs students to the Patient Search tool. Selecting a patient directs students to the Clinical Care module to begin documenting in the patient record. Follow-Up/Established Visit Patient visit for a patient following up on a previously diagnosed condition or a patient who has been seen in the medical office within the last three years but is not coming in for an annual exam, urgent visit, or wellness exam. Form Repository Icon located in the task bar at the top of the screen that contains all patient specific forms saved to the patient record. The repository also contains general Office Forms that are not saved to a patient record. Front Office The first module in the application featuring all of the administrative functionality performed in a medical office. Guarantor The individual legally responsible for the bill. A guarantor must be designated in the Patient Demographics section. The guarantor could be the patient or the patient s spouse or parent. See also: Insured. Grading Only visible to instructors, the Grading module displays the course Grade Book and allows instructors to view and comment on student work, as well as approve final grades and review competencies. 4 of 7
ICD-9/ICD-10 International Classification of Diseases 9th or 10th revision. Used for diagnostic coding. SimChart for the Medical Office utilizes both ICD-9 and ICD-10. Info Panel Located on the left side of the screen in all modules, the Info Panel is the user s primary source of navigation within the application. Options change depending on the selected module. Insured The policy holder for the health insurance policy. The insured could be the patient, a spouse, or a parent. See also: Guarantor. Ledger Located in the Coding & Billing module, the Ledger lists all of the transactions that have occurred for a guarantor, including transactions for all patients the guarantor is legally responsible for. All charges, payments and adjustments are recorded in the Ledger. Link Blue, underlined text that a user can click to navigate to another location or screen within SimChart for the Medical Office. Module Tabs displayed just below the SimChart for the Medical Office logo at the top of the screen that act as the main navigational method within the medical office. The three modules are Front Office, Clinical Care, and Coding & Billing. New Patient A patient who is seeing the physician for the first time or who has not been to the medical office within the last three years. New Patient Visit Patient visit for a patient who is seeing the physician for the first time or who has not been to the medical office within the last three years. 5 of 7
Office Visit Second encounter type displayed in the Clinical Care Info Panel for a generalized patient visit including Annual Exam, Follow-Up/Established Visit, New Patient Visit, Urgent Visit, and Wellness Exam. Patient Dashboard Located in the Clinical Care module, the Patient Dashboard provides a summary of the patient record, including a list of previous encounters. Patient Demographics Icon located in the task bar at the top of the screen used to add a new patient or edit an established patient s information. Any updates to patient information should be completed within patient demographics, not the Patient Information form. Updated patient information entered in Patient Demographics will update the Patient Information form upon saving. Phone Consultation Third encounter type displayed in the Clinical Care Info Panel, used to document a patient phone call. Unlike Comprehensive and Office visits, a patient can have more than one of these encounter types saved to their record in a business day. Progress Notes The section of the patient record where new information for each patient visit is recorded using the SOAPE format. Refer to information documented in the Progress Note from within the Coding & Billing module if there is a question during the billing process regarding services provided and/or the diagnosis. Record The Record dropdown menu displays the chart sections in a patient record. Menu options change based on the encounter type selected but most include allergies, chief complaint, health history, immunizations, medications, order entry, patient education, preventative services, problem list, progress notes, and vital signs. 6 of 7
Reporting A data tool located in the Coding & Billing module that allows the student to run usage reports surrounding procedural and diagnostic data from the Walden-Martin offices. The student can also run aging reports to see the history of an account by patient or by insurance. Signature on File Used in the Coding & Billing module, Signature on File indicates that the medical office has the patient s signature on file. This allows the release of information to an insurance carrier and usually includes the authorization for the assignment of benefits. SOAPE Format used in the Progress Note to record new information for the patient visit. The information is recorded in the appropriate category: S for subjective, O for objective, A for assessment, P for plan, and E for evaluation. Superbill Electronic form located in the Info Panel of the Coding & Billing module that acts as the first step in completing the billing process for a patient visit. All services, diagnoses, patient payments, and supplies provided must be recorded on the Superbill. TruCode Encoder A medical encoder tool embedded in SimChart for the Medical Office. The encoder includes a write-back feature that allows for more accuracy among coding. Urgent Visit Patient visit type for a patient with a serious condition who must see the physician on the same day they request an appointment. Wellness Exam Visit type for a patient who needs to see the doctor but is not sick. This visit type encompasses preventive services such as a colonoscopy, sigmoidoscopy, mammogram, or bone density study. 7 of 7