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.
History and Physical (H&P)
A comprehensive note documenting a patient’s history and physical examination, typically for a new patient or admission.
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.

Platform

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.
Practice Management
The administrative side of running a clinic: patient intake, scheduling, provider availability, eligibility, and front-office workflows.
Telehealth
Care delivered over secure video or audio. Whadata’s telehealth runs in the browser with the camera optional, and Scribe transcribes the visit into the chart.
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 chart.

Coding standards

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

Revenue cycle

Revenue Cycle Management (RCM)
The financial process of capturing, submitting, and collecting payment for care, from charge capture through claims and patient billing.
National Correct Coding Initiative (NCCI)
CMS edits that prevent improper code combinations on claims. Whadata Claims scrubs against NCCI before you submit.
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.
Medically Unlikely Edits (MUE)
NCCI limits on the units of a service a provider would normally report for one patient on one day.
CMS-1500
The standard claim form for professional (non-institutional) provider claims. Whadata Claims generates the CMS-1500 and superbill.
Superbill
An itemized list of the services provided at a visit, used to generate a claim or for patient reimbursement.
Electronic Remittance Advice (ERA (835))
The electronic explanation of payment a payer returns (X12 835), used to auto-post payments to the ledger.
Charge capture
Recording the billable services from an encounter so they can be coded and submitted on a claim.
Denial management
Identifying, working, and preventing payer claim denials to recover revenue. Whadata Claims scores denial probability with ranked fixes.

Prescribing

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

Compliance

HIPAA
The US law that sets privacy and security standards for protected health information (PHI).
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.
HITECH
The US law that strengthened HIPAA enforcement and promoted secure adoption of electronic health records.