Glossary

Plain-language definitions of the EHR, practice management, revenue cycle, and clinical coding terms behind the Whadata platform.

Documentation

SOAP note: A standard clinical note structured as Subjective, Objective, Assessment, and Plan. Whadata Scribe can draft the visit note in SOAP format. Scribe
History and Physical (H&P): A comprehensive note documenting a patient’s history and physical examination, typically for a new patient or admission. Scribe
AI medical scribe: Software that uses AI to transcribe the clinician-patient conversation and draft the clinical note in real time, reducing after-hours documentation. Scribe

Electronic Health Record (EHR): The digital record of a patient’s health information used across their care. Whadata is a complete clinical system of record, so no separate EHR is required. Compare Whadata to your EHR
Practice Management: The administrative side of running a clinic: patient intake, scheduling, provider availability, eligibility, and front-office workflows. Patients
Telehealth: Care delivered over secure video or audio. Whadata’s telehealth runs in the browser, either side can turn the camera off, and Scribe transcribes the visit into the chart. Telehealth
Cloud fax: Sending and receiving fax through software rather than a physical machine. Whadata’s Communications module OCR-matches inbound faxes to the right patient. Communications

ICD-10-CM (ICD-10): The diagnosis coding system used in the US to classify conditions for documentation and billing. Claims
Current Procedural Terminology (CPT): AMA-maintained codes describing medical procedures and services, used on claims. Claims
Healthcare Common Procedure Coding System (HCPCS): Codes for services, supplies, and drugs not covered by CPT, used especially by Medicare and Medicaid. Claims
SNOMED CT: A comprehensive clinical terminology for encoding conditions, procedures, and findings in a structured, interoperable way. Whadata Insights codes allergies and procedures to SNOMED CT. Insights
RxNorm: A standardized naming system for medications, used to code drugs consistently across systems. E-Prescriptions
LOINC: Logical Observation Identifiers Names and Codes, a standard for identifying lab tests and clinical observations. Insights
Hierarchical Condition Category (HCC): A risk-adjustment model that maps diagnoses to risk scores used in Medicare Advantage and value-based payment. Claims

Revenue Cycle Management (RCM): The financial process of capturing, submitting, and collecting payment for care, from charge capture through claims and patient billing. Claims
National Correct Coding Initiative (NCCI): CMS edits that prevent improper code combinations on claims. Whadata Claims scrubs against NCCI before you submit. Claims
Procedure-to-procedure edits (PTP): NCCI edits that flag pairs of codes that should not be billed together for the same patient on the same day. Claims
Medically Unlikely Edits (MUE): NCCI limits on the units of a service a provider would normally report for one patient on one day. Claims
CMS-1500: The standard claim form for professional (non-institutional) provider claims. Whadata Claims generates the CMS-1500 and superbill. Claims
Superbill: An itemized list of the services provided at a visit, used to generate a claim or for patient reimbursement. Claims
Electronic Remittance Advice (ERA (835)): The electronic explanation of payment a payer returns (X12 835), used to auto-post payments to the ledger. Billing
Charge capture: Recording the billable services from an encounter so they can be coded and submitted on a claim. Claims
Denial management: Identifying, working, and preventing payer claim denials to recover revenue. Whadata Claims scores denial probability with ranked fixes. Claims

Electronic Prescribing of Controlled Substances (EPCS): DEA-compliant electronic prescribing of controlled substances, requiring identity proofing and two-factor authentication. E-Prescriptions
Prescription Drug Monitoring Program (PDMP): A state database of controlled-substance prescriptions that clinicians check before prescribing. E-Prescriptions

HIPAA: The US law that sets privacy and security standards for protected health information (PHI). Health data privacy
Business Associate Agreement (BAA): A HIPAA-required contract between a covered entity and a vendor that handles PHI on its behalf. Whadata includes a BAA on every account. Health data privacy
HITECH: The US law that strengthened HIPAA enforcement and promoted secure adoption of electronic health records. Health data privacy