Medical cases that support clinical situations related to some evaluation and management services and shown in an appendix of the Current Procedural Terminology code book. These illustrations may be used as a tool in coding professional services for billing.

Computer system that maintains a database of actual patient information on active medical care and treatment. CIS may be used for supporting medical decisions. In expanded form, a CIS becomes an electronic health record system. Also called clinical system.

Workplace where diagnostic tests and procedures are performed on specimens that are directly related to the care of patients such as blood, infectious materials, saliva, and tissues.

Federal act established in 1988 that regulates laboratory certification and accreditation standards, quality control, proficiency testing, personnel standards, program administration, and safety measures for all freestanding laboratories including physician office laboratories (POLs). CLIA mandates that all laboratories have a CLIA certificate to receive payment from federal programs. Adopted by Medicare and Medicaid programs.

Person who, under the direction of a physician, performs various routine back office tasks in a hospital, clinic, or other health facility. These duties may consist of assisting with the physical examinations, taking x-rays, performing electrocardiograms, taking vital signs, weighing patients, obtaining urine specimens, and other medical-related activities. Also see administrative medical assistant.

Memo or concise written communication about contact with a patient that includes the date seen; description of signs and symptoms, treatment, and drugs administered; the patient’s reaction; and any changes in physical or emotional condition.

Cases that cannot adequately be assigned to an appropriate DRG owing to unique combinations of diagnoses and surgeries, very rare conditions, or other unique clinical reasons. Such cases are grouped together into clinical outlier DRGs and are therefore considered outliers. Also see outlier.

Study of disease by the use of laboratory tests and methods of body tissue and fluids.

Description of an activity or practice that may result in favorable outcomes for patients with a specific disease. A clinical pathway uses defined resources to keep costs down. It may be based on research, literature, or common practice. Also called critical pathway, practice guideline, or treatment protocol.

This is a method or instrument to estimate or monitor the extent to which the actions of a health care practitioner or provider conform to practice guidelines, medical review criteria, or standards of quality.