Medical Coding Terminology for all coders.Â Click on the plus sign (+) to get the defination.
A notice the hospital or doctor gives you before you are treated explaining to you that Medicare will not pay for some treatment or services. The notice is given to you so that you may decide whether to have the treatment and how to pay for it.
a written document, such as a living will or durable power of attorney that says how the patient wants medical decisions to be made if they lose the ability to make decisions for themselves.
One of the medical billing terms referring to the unpaid insurance claims or patient balances that are due past 30 days. Most medical billing softwareâ€™s have the ability to generate a separate report for insurance aging and patient aging. These reports typically list balances by 30, 60, 90, and 120 day increments.
Services over and above physician services, including laboratory, radiology, home health and skilled nursing facilities.
Services rendered by the healthcare facility that are separate from the food and accommodation. Examples are tests, surgery, therapy, and so on.
Â When an insurance plan does not pay for treatment, an appeal (either by the provider or patient) is the process of objecting this decision. The insurer may require documentation when processing an appeal and typically has a formal policy or process established for submitting an appeal. Many times the process and associated forms can be found on the insurance providers web site.
The American Recovery and Reinvestment Act for Healthcare gives physicians incentives of up to$44,000 for Medicare or $64,000 for Medicaid for using EHR technology meaningfull. Physicians can qualify under either a Medicare or Medicaid provision. Payments are made over 5-6 years depending on which provision and when you qualify. Read more here.
Application Service Provider. This is a computer based services over a network for a particular application. Sometimes referred to as SaaS (Software as a Service). There application service providers that offer Medical Billing. The appeal of an ASP is it frees a business of the the need to purchase, maintain, and backup software and servers.
the amount beneficiaries must pay for covered services. These include co-payments, coinsurance, deductibles, and balance billing amounts.
A benefit period begins the day you go to a hospital or skilled nursing facility. The benefit period ends when you havenâ€™t received hospital or skilled nursing care for 60 days in a row.
For bilateral sites, the final character of the codes in the ICD-10-CM indicates laterality. An unspecified side code is also provided should the side not be identified in the medical record. If no bilateral code is provided and the condition is bilateral, assign separate codes for both the left and right side.
BillFlash is a service that handles all of your mailed bills. You upload your electronic statement to BillFlash online, and then BillFlash handles the printing, folding and mailing of your statement.
is approved by the National Association of Insurance Commissioners (NAIC). The Birthday Rule indicates that the plan of the parent whose date of birth (month and day) falls earlier in the calendar year is the primary plan for dependent children. For example, if the motherâ€™s birth date is June 10 and the fatherâ€™s birth date is April 23, the fatherâ€™s plan would be primary. If both parents have the same birth date, the health plan in effect for the longer period of time will be primary.
An organization of affiliated insurance companies (approximately 450), independent of the association (and each other), that offer insurance plans within local regions under one or both of the associationâ€™s brands (Blue Cross or Blue Shield). Many local BCBS associations are non profit BCBS sometimes acts as administrators of Medicare in many states or regions.
A feature of Medisoft Clinical, Lytec MD and Practice Partner that allows you to enter information into a patientâ€™s note and have it automatically populate the patientâ€™s chart, eliminating double entry. Bright Note Technology conforms to you preferred method of entry. You can enter information by keying it in manually or through voice dictation with Dragon Naturally Speaking software.
Â A contracted agreement between an insurance company and another company which provides special services to its members, such as prescription drugs or cancer treatment.
Â A case manager is a trained insurance professional, primarily in the areas of long-term medical care, life insurance and annuities, which presides over a patient or clientâ€™s account. Case managers are prevalent in the healthcare industry.
CCHIT stands for Certification Commission for Health Information Technology. CCHIT is an organization that provides standards for EMR software. An EMR is considered CCHIT certified if it is deemed to meet those standards by a board of CCHIT members.
A federal health data organization that helps maintain several code sets included in the HIPAA standards, including the ICD-9-CM codes. A division of the Department of Health and Human Services responsible for monitoring, researching and developing public health policies for the prevention of disease, injury and disability and the promotion of healthy behaviors. The National Center for Health Statistics is the part of the CDC that maintains health related statistics including the coordination with World Health Organization (WHO) on use of International Classification of Diseases (ICD) in North America.
The federal agency that runs the Medicare program. In addition, CMS works with the States to run the Medicaid program. CMS works to make sure that the beneficiaries in these programs are able to get high quality healthcare.
a description of the healthcare coverage included in an insurance companyâ€™s plan. The certificate of coverage is required by state laws and explains the healthcare coverage provided under the contract issued to the employer.
Civilian Health and Medical Program of the Uniformed Services. Recently renamed TRICARE. This is federal health insurance for active duty military, National Guard and Reserve, retirees, their families, and survivors.
Chart scanning is the act of physically scanning your paper charts and integrating or attaching them to the electronic charts in your EMR software. Microwize has partnered with Scan My Charts for your chart scanning needs. The inforation scanned into the EMR software is converted to searchable, editable text, for optimal convenience.
Child Health and Disability Prevention Program. A preventive program that delivers periodic health assessments and services to low income children and youth in California.
a federal program jointly funded by states and the federal government, which provides medical insurance coverage for children not covered by state Medicaid-funded programs.
Palmetto GBAâ€™s GPNet Claim Acceptance Response Report. This report is available for download immediately after claims submission. Report includes total claims submitted, accepted or rejected with error messages.
The method by which a patientâ€™s health care service claims are reviewed before reimbursement is made. This is done to validate the appropriateness of services given and that the cost is not excessive.
A clearinghouse is a that handles your electronic claim submission to insurance carries. A good clearinghouse will scrub the claims prior to submission to check for errors and increase your claim acceptance rate.
Clinical decision support (CDS) is designed to help practitioners make decisions. It connects observations made my physicians with a knowledge database of healthcare to remind the provider about additional information related to a patientâ€™s symptoms. Of course, the provider still calls the shots. CDS is only a tool for physicians. CDS is a key component to meeting meaningful use requirements for the EMR Stimulus.
Centers for Medicare & Medicaid Services. Formally known as HCFA, CMS is responsible for oversight of HIPAA administrative simplification transaction and code sets, health identifiers, and security standards.
A type of cost sharing whereby the insured person pays a specified flat amount per unit of service or unit of time (e.g., $10 per visit, $25 per inpatient hospital day), with the insurer paying the balance.
Percentage or amount defined in the insurance plan for which the patient is responsible. Most plans have a ratio of 90/10 or 80/20, 70/30, etc. For example the insurance carrier pays 80% and the patient pays 20%.
Medicare coverage from day 61 to day 90 of continuous inpatient hospital stay. The patient is responsible for paying for a portion of those days. After the 90th day, the patient enters their lifetime reserve days.
Co-pay is the amount that a patient is responsible for at the time they visit a physician or hospital, or have a prescription filled. The patient is responsible for this up-front fee, while the insurance provider covers the remaining cost of a medical service or prescription.
This is the responsible partyâ€™s (usually the insured) portion of the claim that is left unpaid by details of the purchased insurance plan(s). Usually this is a set amount to be paid at each service visit before services are determined or billed.
Coordination of Benefits. The process to determine the obligation of payers when a patient is covered under 2 separate health care plans to avoid duplicate payments for a single service or procedure.
The COBRA Act allows for employees and their dependents to continue to receive insurance coverage after the loss of a job or reduction in hours. COBRA insurance is more expensive than group insurance, but is still usually less expensive than individual coverage.
This is health insurance coverage available to an individual and their dependents after becoming unemployedÂ either voluntary or involuntary termination of employment for reasons other than gross misconduct. Because it does not typically receive company matching, Itâ€™s typically more expensive than insurance the cost when employed but does benefit from the savings of being part of a group plan. Employers must extend COBRA coverage to employees dismissed for a. COBRA stands for Consolidated Omnibus Budget Reconciliation Act which was passed by Congress in 1986. COBRA coverage typically lasts up to 18 months after becoming unemployed and under certain conditions extend up to 36 months.
This is in reference to the providers accounts receivable. Itâ€™s the ratio of the payments received to the total amount of money owed on the providers accounts.
Computerized Physician Order Entry (CPOE) refers to the act of electronically prescribing medications, lab tests and radiology. By submitting this information electronically, the provider reduces the risk of errors due to misread handwriting, and also helps check for duplicate tests and prescriptions. CPOE is also a requirement of the meaningful use specifications for the EMR Stimulus.
a federal law that mandates employers with 20 or more eligible employees to provide continued health insurance under their group plan to terminated employees and their dependents. COBRA generally provides continued health insurance coverage for up to 18 or 36 months. COBRA beneficiaries may be required to pay 100 percent of the premium plus an administrative fee.
The general rules for use of the classification independent of guidelines. These conventions are incorporated within the Index and Tabular of the ICD-10-CM as instructional notes. Possible conventions to include with code are 1) Notes â€“ Extra information to define or clarify code choice. 2) Includes Notes â€“ This note appears immediately under a three character code title to further define, or give examples of, the content of the category. 3) Not otherwise specified (NOS) â€“ This abbreviation is the equivalent of unspecified. 4) Excludes Notes â€“ A type 1 Excludes note is a pure excludes note. It means â€œNOT CODED HERE!â€ An Excludes1 note indicates that the code excluded should never be used at the same time as the code above the Excludes1 note. An Excludes1 is used when two conditions cannot occur together, such as a congenital form versus an acquired form of the same condition. A type 2 excludes note represents â€œNot included here.â€ An excludes2 note indicates that the condition excluded is not part of the condition represented by the code, but a patient may have both conditions at the same time. When an Excludes2 note appears under a code, it is acceptable to use both the code and the excluded code together, when appropriate. 5) Not elsewhere classifiable (NEC) â€“ This abbreviation in the Tabular List represents â€œother specified.â€ When a specific code is not available for a condition the Tabular List includes an NEC entry under a code to identify the code as the â€œother specifiedâ€ code.
integrating benefits payable under more than one health insurance (for example, Medicare and retiree health benefits). Coordinated coverage is usually arranged so the insured benefits from all sources do not exceed 100 percent of allowable (discounted) medical charges. Coordinated coverage may require patients to pay some deductible or co-insurance.
the method for determining which insurance company is primarily responsible for payment when a patient is covered under more than one insurance plan. The insuredâ€™s total benefits do not exceed 100% of the medical expenses.
This is the details of the insured personâ€™s insurance plan. This detailed document states what is and is not covered and by how much by either dollar limit, percentage of value, number of visits or UCR coverage
Current Procedural Terminology. This is a 5 digit code assigned for reporting a procedure performed by the physician. The CPT has a corresponding ICD 9 diagnosis code. Established by the American Medical Association. This is one of the medical billing terms we use a lot.
The balance thats shown in the â€œBalanceâ€ or â€œAmount Dueâ€ column of your account statement with a minus sign after the amount (for example $50 ). It may also be shown in parenthesis; ($50). The provider may owe the patient a refund.
A new test is determined to be similar to an existing test, multiple existing test codes, or a portion of an existing test code. The new test code is then assigned to the related existing local fee schedule amounts and resulting national limitation amount. In some instances, a test may only equate to a portion of a test, and, in those instances, payment at an appropriate percentage of the payment for the existing test is assigned.
This is the procedural coding system that is currently used in America primarily to report physician professional services. Frequently called â€œCPTâ€, the Current Procedural Terminology, is a code set, developed in 1966 and maintained by the American Medical Association (AMA), used to describe what healthcare professional services were provided or utilized by healthcare professionals. CPT codes are also known as â€œLevel Iâ€ codes. Additional codes to describe use of healthcare facilities and services provided by healthcare professionals are known as â€œLevel IIâ€ or â€œHealthcare Common Procedure Coding Systemâ€ (HCPCS). Level II codes were developed are maintained by CMS.
a decision by insurance company not to pay for part or all of a medical bill based on a lack of medical necessity or pre-admission approval/certification, terminated coverage, or other reasons. Denied amounts may be charged to the patient. See also appeal.
a code used for billing that describes the patientâ€™s illness. Diagnosis-Related Groups (DRGs) â€“ a payment system of classifying patients on the basis of diagnosis. The DRG system categorizes payments into groups based on the principal diagnosis, type of surgical procedure, complications, and other indicators.
a system of classifying patients on the basis of diagnosis for purposes of payment to hospitals. The DRG system classifies payments into groups based on the principal diagnosis, type of surgical procedure, presence or absence of complications, and other relevant indicators.
Disease Management refers to a healthcare system in which patients with a specific condition that requires self-care efforts can communicate with nurses or providers to ensure better care. The 6 components of Disease Management are: 1) Population identification process 2) Evidence-based practice guidelines 3) Collaborative practice models to include physician and support-service providers 4) Patient self-management education (may include primary prevention, behavior modification programs, and compliance/surveillance) 5) Process and outcomes measurement, evaluation, and management 6) Routine reporting/feedback loop (may include communication with patient, physician, health plan and ancillary providers, and practice profiling
A way of reducing the payment an insurer makes by using a computer program to convert billing codes to the closest code in use, usually one payment level lower than the item originally billed.
Dragon software transcribes voice dictation into text in our EMR software. Dragon also allows you to navigate your EMR software with your voice and works great with Bright Note Technology. Learn more about Dragon Naturally Speaking.
Evaluation and Management section of the CPT codes. These are the CPT codes 99201 thru 99499 most used by physicians to access (or evaluate) a patients treatment needs.
equipment or medical procedure that measures how the heart works. Eligibility Verification â€“ a way hospitals determine whether the patient has insurance coverage for the services they will provide.
An electronic paperless means of transferring money. This allows funds to be transferred, credited, or debited to a bank account and eliminates the need for paper checks.
The terms â€œelectronic medical records (EMR)â€ and â€œelectronic health records (EHR)â€ are used interchangeably to refer to computerized patient charts within software that allows for electronic patient charting, eprescribing, health maintenance and more.
this law regulates self-insured plans and makes them exempt from many state regulations that regulate other insurance plans. ERISA mandates financial standards and other requirements for group insurance plans.
Explanation of Benefits. Details regarding how your insurance company processed medical insurance claims, explains what portion of a claim was vpaid to the health care provider and what portion of the payment.
ePrescribing means prescribing electronically. ePrescribing is a key component of meaningful use requirements for the EMR stimulus.ePrescribing is also referred to as eRx and electronic prescriptions.
Early and Periodic Screening, Diagnosis, and Treatment. A Medi-Cal program for individuals under the age of 21 who have full-scope Medi-Cal eligibility. This program allows for periodic screening to determine health care needs.
Employee Retirement Income Security Act of 1974. This law established the reporting, disclosure of grievances, and appeals requirements and financial standards for group life and health. Selfinsured plans are regulated by this law.
Â The information an insurance company sends a patient after the patient has received medical treatment. It details the amount charged, how much of that the insurance company is approved to pay, the amount already paid, and what the patient owes.
The FMLA provides up to 12 weeks of unpaid leave per year for employees with medical issues, for those who are caring for family members, or for births and adoptions. All public agencies, elementary and middle schools, and businesses with more than 50 employees are subject to the FMLA guidelines.
The â€œFederal Registerâ€ is the official daily publication for rules, proposed rules and notices of federal agencies and organizations, as well as Executive Orders and other Presidential documents.
This reference mapping attempts to include all valid relationships between the codes in the ICD-9-CM diagnosis classification and the ICD-10-CM diagnosis classification.
Health Care Financing Administration Common Procedure Coding System. Three level system of codes. CPT is Level I. A standardized medical coding system used to describe specific items or services provided when delivering health services. May also be referred to as a procedure code in the medical billing glossary. 1) Level I â€“ American Medical Associations Current Procedural Terminology (CPT) codes. 2) Level II â€“ The alphanumeric codes which include mostly non-physician items or services such as medical supplies, ambulatory services, prosthesis, etc. These are items and services not covered by CPT (Level I) procedures. 3) Level III â€“ Local codes used by state Medicaid organizations, Medicare contractors, and private insurers for specific areas or programs.
(HCFA Common Procedural Coding System)-A coding system used to describe outpatient services provided to the patient. HCPCS codes include CPT codes and other codes.
a person or entity that provides medical services (e.g. a physician, hospital or laboratory). Health Insurance â€“ coverage that provides for the payment of medical services as a result of sickness or injury. It includes insurance for losses from accident, medical expense, disability, or accidental death and dismemberment.
A system of tests that help with disease prevention. For example, health maintenance can include sending reminders for follow up appointments. Health Maintenance is a requirements of meaningful use for the EMR stimulus.
Insurance coverage to cover the cost of medical care necessary as a result of illness or injury. May be an individual policy or family policy which covers the beneficiaryâ€™s family members. May include coverage for disability or accidental death or dismemberment.
The original healthcare transactions version of HIPAA (officially known as Version 004010 of the ASC X12 transaction implementation guides) named as part of HIPAAâ€™s Electronic Transaction Standards regulation. Version 4010 was required to be used by HIPAA covered healthcare entities by Oct. 16, 2003.
Required by Jan. 1, 2012 to be the new version of the HIPAA healthcare transactions. Officially known as Version 005010 of the ASC X12 transaction Technical Report Type 3. This new version was required as a result of Department of Health and Human Services (HHS) final rules published on Jan. 6, 2009.
Medicareâ€™s way of paying acute care hospitals for inpatient care. Prospective per-case payment rates are determined at a level to cover operating costs for treating a typical inpatient in a given Diagnosis-Related Groups (DRG).
10th revision of the International Classification of Diseases. Uses 3 to 7 digit. Includes additional digits to allow more available codes. The U.S. Department of Health and Human Services has set an implementation deadline of October, 2013 for ICD 10
Also know as ICD 9 CM. International Classification of Diseases classification system used to assign codes to patient diagnosis. This is a 3 to 5 digit number.
Â The updated version of the clinical modification coding set defined by the National Center for Health Statistics that will replace ICD-9-CM on Oct. 1, 2013.
(International Classification of Diseases). A 3 to 5 digit number given to diagnoses, services and treatments to classify them.
The â€œclinical modificationâ€ to the ICD-9 code set that is currently used in America to report medical diagnoses. The â€œClinical Modificationâ€ refers to the base WHO defined ICD-9 code set that has been defined for use in United State by the National Center for Health Statistics (NCHS) division of the Centers for Disease Control (CDC).
International Classification of Diseases. The official system of assigning codes to diagnoses and procedures associated with hospital utilization in the United States.
Physicians and other service providers who are contracted with a managed care plan.
Â The ICD-10-CM is divided into the Alphabetic Index, an alphabetical list of terms and their corresponding code, and the Tabular List, a chronological list of codes divided into chapters based on body system or condition. The Alphabetic Index consists of the following parts the Index of Diseases and Injury, the Index of External Causes of Injury, the Table of Neoplasms and the Table of Drugs and Chemicals.
A patient who is admitted to a hospital and receives medical services from a physician during at least a 24-hour period.
A bill that shows the patient what is the remaining due after an insurance payment has been made.
An insurance cap is the total lifetime dollar amount that a provider will pay on a particular policy. Many insurance companies have a lifetime cap of $1 million, which can be easily attained in cases of prolonged medical treatment and care.
Hospital care unit providing care for patients who need more than the typical general medical or surgical area of the hospital can provide. May be extremely ill or seriously injured and require closer observation and/or frequent medical attention.
A medical code set maintained by the World Health Organization (WHO). The primary purpose of this code set is to classify both causes of death or mortality and diseases or morbidity. A U.S. extension, known as ICD-CM, â€œClinical Modification,â€ is maintained by the NCHS within the CDC to more precisely define ICD use in the U.S.
a coding system used to describe the patientâ€™s diagnosis and the procedures performed to treat them.
Inventory tracking is a feature of Lytec and PeakPractice that allows you to manage your supply and track as well as order inventory.
Independent Practice Association. An organization of physicians who are contracted with an HMO plan
Interactive Voice Response. Palmetto GBA 24 hour telephone line, obtain Medicare Part B information, such as claim status, last 3 checks issues, and eligibility.
A kiosk is a computer workstation in which a patient can input information at a medical practice. This is usually located in the waiting room of a medical practice.
under Medicare provision, a patient has a lifetime reserve of 60 days of inpatient services they can receive after they receive more than 90 days of inpatient services in a benefit period. The patient must pay a daily co-insurance for each lifetime reserve day used. Additionally, lifetime reserve days can only be used once during a patientâ€™s life.
Lytec is a state-of-the-art medical billing software, made by McKesson, that handles patient appointment scheduling, electronic claim submission and medical billing. Lytec comes complete with key medical billing features and easy appointment scheduling, as well as inventory tracking and revenue management.
Lytec MD is a fully integrated EMR and medical billing software, made by McKesson, that combines the billing and scheduling features of Lytec with electronic medical records.
A broad classification of diagnoses that covers most of the diagnoses doctors provide to patients.
Insurance plan requiring patient to see doctors and hospitals that are contracted with the managed care insurance company. Medical emergencies or urgent care are exceptions when out of the managed care plan service area.
Certain conditions have both an underlying etiology and multiple body system manifestations due to the underlying etiology. For such conditions, the ICD-10-CM has a coding convention that requires the underlying condition be sequenced first followed by the manifestation. Wherever such a combination exists, there is a â€œuse additional codeâ€ note at the etiology code, and a â€œcode firstâ€ note at the manifestation code. These instructional notes indicate the proper sequencing order of the codes, etiology followed by manifestation.
The maximum amount the insured is responsible for paying for eligible health plan expenses. When this maximum limit is reached, the insurance typically then pays 100% of eligible expenses.
Medi-Cal is Californiaâ€™s Medicaid program. Provides health services for categorically eligible and low-income persons. www.medi-cal.ca.gov.
a state/federal benefit program for the poor who are aged, blind, disabled, or members of families with dependent children. Each state sets its own eligibility standards. Only 40 percent of individuals with income below the poverty level currently are covered.
A health care worker who performs administrative and clinical duties in support of a licensed health care provider such as a physician, physicians assistant, nurse, nurse practitioner, etc.
Medical Billing is the process of submitting a claim to the insurance company or government after a patient has received treatment from a health care provider. There are different specialties of the Medical Billing profession that cover different parts of the billing process, each of the specialties playing an important role in the manner that the health care providers receive payment.
a company that performs the medical billing process for one or more physician groups. Many billing companies concentrate on selected physician specialties. For more information about medical billing companies (click here).
the process that converts documentation of a physician visit (â€œencounterâ€) into a â€œclaimâ€, filing it with a â€œpayerâ€ or â€œpayorâ€ (insurance company or carrier), posting payments, following-up on anyâ€denialâ€, billing the patient for any remaining balance, and managing the practices â€œaccounts receivableâ€. For more information on medical billing (click here). Note: billing for hospital (in-patient) services may also be referred to as â€œmedical billingâ€ though the skills and technology required differ signficantly between hospital billing and physician billing.
the array of functions performed by a medical billing company, including charge entry, electronic claims filing, payment posting, denial management, A/R management and patient billing. For more information about medical billing services (click here).
the software used by medical billers. Billers can bill for one group as part of the groupâ€™s staff or for many groups as part of a medical billing company. In addition to supporting all of the medical billing functions, the software usually supports scheduling, check-in and other â€œfront officeâ€ functions associated with office-based physician groups. For more information on medical billing software (click here).
Processes insurance claims for payment of services performed by a physician or other health care provider. Ensures patient medical billing codes, diagnosis, and insurance information are entered correctly and submitted to insurance payer. Enters insurance payment information and processes patient statements and payments. Performs tasks vital to the financial operation of a practice. Knowledgeable in medical billing terminology.
Analyzes patient charts and assigns the appropriate code. These codes are derived from ICD 9 codes (soon to be ICD 10) and corresponding CPT treatment codes and any related CPT modifiers.
the process of assigning the correct â€œcodesâ€, usually CPT (â€œprocedure codesâ€) and ICD (â€œdiagnosis codesâ€), to a specific encounter. In many cases, the coding is performed by the physician when they sign off on a case (i.e. sign off on the documentation). In other cases, a coder performs the task. It is recommended that coders be certified by the American Academy of Professional Coders. In either case, the coding is based on, and must correspond with, the physicians documentation (the â€œmedical recordâ€). A common saying, â€œIf it isnâ€™t documented, it didnâ€™t happen.â€
Services or supplies that are proper and needed for the diagnosis or treatment of a medical condition; are provided for the diagnosis, direct care, and treatment of a medical condition; meet the standards of good medical practice in the local area; and are not mainly for the convenience of the patient or doctor.
A unique number assigned by the provider or health care facility to identify the patient medical record.
Tax exempt account for paying medical expenses administered by a third party to reimburse a patient for eligible health care expenses. Typically provided by employer where the employee contributes regularly to the account before taxes and submits claims or receipts for reimbursement. Sometimes also referred to in medical billing terminology as a Medical Spending Account.
The conversion of voice recorded or hand written medical information dictated by health care professionals (such as physicians) into text format records. These records can be either electronic or paper.
refers to services or supplies that are required to properly treat a specific medical condition. Services or supplies that are not considered medically necessary by insurance may be denied.
A health insurance program for people age 65 and older, some people with disabilities under age 65, and people with end-stage renal disease (ESRD). www.medicare.gov
gives Medicare patients the option of enrolling in a variety of private plans including health maintenance organizations (HMOs), preferred provider organizations (PPOs), provider-sponsored organizations (PSOs), private fee-for-service (PFFS) plans, and medical savings accounts (MSAs) with high deductible insurance plans. Under M+C plans, patients receive medical services without additional out-of-pocket costs.
Medical billing terminology for inpatient hospital coverage from day 61 to day 90 of a continuous hospitalization. The patient is responsible for paying for part of the costs during those days. After the 90th day, the patient enters â€œLifetime Reserve Days.â€
A Medicare health plan option made up of two parts. One part is a Medicare MSA Health Policy with a high deductible. The other part is a special savings account, called a Medicare MSA.
Â number given to every Medicare patient for tracking and billing purposes. This number can be found on the Medicare card.
Medical hospital insurance (HI) under Part A of title XVIII of the Social Security Act, which covers patients for inpatient hospital, home health, hospice, and limited skilled nursing facility services. Beneficiaries are responsible for deductibles and co-payments.
Medicare supplement medical insurance (SMI) under Part B of Title XVII of the Social Security Act, which covers Medicare beneficiaries for physician services, medical supplies, and other outpatient treatment. Beneficiaries are responsible for monthly premiums, co-payments, deductibles, and billing balances.
Medicare coverage helps pay for physician services, medical supplies, and other outpatient services not paid for by Medicare Part A.
the term used by Medicare when Medicare is not responsible for paying first. (The private insurance industry generally talks about â€œcoordination of benefitsâ€ when assigning responsibility for first and second payment.)
an insurer will pay a policyholderâ€™s Medicare co-insurance, deductible, and co-payments for Medicare Part A and Part B and may provide additional supplement benefits according to the supplement policy selected. Also called Medigap or Medicare wrap.
Insurance provided by carriers to supplement the monies reimbursed by Medicare for medical services. Medigap is meant to fill this gap in reimbursement, so that the Medicare beneficiary is not at risk for the difference.
privately purchased individual or group health insurance policies designed to supplement Medicare coverage. Benefits may include payment of Medicare deductibles, co-insurance, and bill balances as well as payment for services not covered by Medicare.
a privately purchased insurance policy that supplements Medicare coverage.
Medisoft is Americaâ€™s most popular medical billing software that handles all of your billing, appointment scheduling and electronic claim submission. Medisoft, made by McKesson comes complete with medical billing, scheduling and revenue management.
Medisoft Clinical combines Medisoftâ€™s medical billing, scheduling and electronic claim submission with electronic medical records.
Modifier to a CPT treatment code that provide additional information to insurance payers for procedures or services that have been altered or â€œmodifiedâ€ in some way. Modifiers are important to explain additional procedures and obtain reimbursement for them.
Term refers to the disease rate or number of cases of a particular disease in a given age range, gender, occupation, or other relevant population based grouping.
Term refers to the death rate reflected by the population in a given region, age range, or other relevant statistical grouping
A federal organization within the CDC that collects, analyzes, and distributes healthcare statistics. The NCHS helps maintain the ICD-CM codes.
a system designed to provide drugs in the United States with a specific 11-digit number that describes the product. Originally created under Medicare to help identify drugs for reimbursement, the usefulness of the system has now become more widespread.
a group of doctors, hospitals, and other health care providers that have a contract with an insurance plan to provide services to its patients.
Health care provider who is contracted with an insurance provider to provide care at a negotiated cost.
charges for medical services denied or excluded by insurance. The patient may be billed for these charges. Also called â€œnon covered amount.â€
a doctor, hospital, or other health care entity that is not part of an insurance planâ€™s network. For medical services rendered by non-participating provider, the patient may be responsible for payment in full or higher costs. Also known as out-of-network provider.
National Provider Identification Number. It is a 10-digit intelligence free number. Intelligence free means that the numbers do not carry information about health care providers, such as the state in which they practice or their provider type or specialization.
National Provider Identifier. A unique 10 digit identification number required by HIPAA and assigned through theNational Plan and Provider Enumeration System (NPPES).
type of medical service used by doctors and hospitals to determine whether the patient needs inpatient care, outpatient care or whether they can recover at home. Observation is usually charged by the hour and may include an overnight hospital stay.
Part of department of Health and Human Services. Establish compliance requirements to combat healthcare fraud and abuse. Has guidelines for billing services and individual and small group physician practices.
The traditional pay per visit arrangement that covers Part A and Part B services.
A provider that does not have a contract with the insurance carrier. Patients usually responsible for a greater portion of the charges or may have to pay all the charges for using an out of network provider.
Â A doctor or other healthcare provider who is not part of an insurance planâ€™s doctor or hospital network. Same as non
The maximum amount the patient has to pay under their insurance policy. Anything above this limit is the insurers obligation. These Out of pocket maximums can apply to all coverage or to a specific benefit category such as prescriptions.
Medical services received from a non-participating provider. Coverage generally requires payment of a higher deductible, co-payment, and/or coinsurance than for medical services from a participating provider.
Payment for medical services due from the patient, including copayments, co-insurance, and deductible.
the portion of payments for covered health services required to be paid by the patient, including co-payments, co-insurance, and deductible. (See beneficiary liability, co-insurance, deductible, and co-payment.)
Medical treatment lasting less than 24 hours, normally in a doctorâ€™s office or day facility. Examples include x-rays, simple surgeries, and blood tests.
a patient who does not need to stay overnight in a hospital. Outpatient services include lab tests, X-rays, and some surgeries.
The amount a health insurance company pays a healthcare provider.
An administrator of Medicare health insurance for the Centers for Medicare & Medicaid Services (CMS) in the US and its territories. A wholly owned subsidiary of BlueCross BlueShield of South Carolina based in Columbia, South Carolina.
The process of posting payments, processing data, billing service providers, and building reports.
a doctor, hospital, or other health care entity that is part of an insurance planâ€™s network. They agree to accept insurance payment for covered medical services as payment in full, less any patient liability.
Patient Navigator is an organization that assists families with medical treatment options and with the explanation of insurance coverage and acts as a liaison with medical personnel.
a way to classify patients based on the type of services they receive from the hospital, such as outpatient, inpatient, and Emergency, etc.
Primary Care Physician. The doctor you see first for most health problems and may talk with other doctors and health care providers about your care and refer you to them
PeakPractice is a fully integrated EMR/medical billing and scheduling software created by Eclipsys.PeakPractice comes complete with medical billing, appointment scheduling, supply chain (advanced inventory management, and patient portal/kiosk.
per day. Typically refers to charge or payment methods based on a set rate per day of medical care.
Â a way in which a physician agrees to accept an insurance companyâ€™s payment level as payment in full. The bill is sent directly to the insurance company with payment made directly to the physician. This does not include patientâ€™s co-insurance, deductibles, and non-covered services.
Practice Management System. Software that handles office needs such as medical billing and appointment scheduling. Practice Management can com standalone or it can be bundled with electronic medical records (EMR).
a health insurance plan that allows the patient to choose to receive a medical service from a participating or non-participating provider, with different benefit levels with the use of participating providers. Policy Number â€“ a number that the insurance company assigns the patient to identify the contract for coverage.
A portal is a feature in some EMRâ€™s that allows the provider to electronically give patients access to health information and patient education via the internet.
Place of Service. Medical billing terminology used on medical insurance claims such as the CMS 1500 block 24B. A two digit code which defines where the procedure was performed. For example 11 is for the doctors office, 12 is for home, 21 is for inpatient hospital, etc.
Preferred Provider Organization. A plan that contracts with independent providers at a discount for services. The physicians in a PPO are paid on a fee-for-service schedule that is discounted, usually about 10% to 20% below normal fees. A patient can use a physician outside of the PPO providers, but he or she will have to bear a bigger portion of the fee.
Practice Partner is a fully integrated EMR/practice management system that allows large practice and hospitals to use an EMR efficiently Read more about Practice Partner.
A medical condition that has been diagnosed or treated within a certain specified period of time just before the patients effective date of coverage. A Pre-existing condition may not be covered for a determined amount of time as defined in the insurance terms of coverage (typically 6 to 12 months).
An insurance plan may require pre-certification for some services (most commonly required for hospital services) for plan consideration prior to services being rendered. Members should always contact their health plan administrators to obtain information regarding the pre-certification requirements of their health plan.
Requirement of insurance plan for primary care doctor to notify the patient insurance carrier of certain medical procedures (such as outpatient surgery) for those procedures to be considered a covered expense.
An insurance plan may require preauthorization for some services for plan consideration prior to services being rendered. Members should always contact their health plan administrators to obtain information regarding the preauthorization requirements of their health plan.
any medical condition that has been diagnosed or treated within a specified period immediately preceding the covered personâ€™s effective date of coverage. Preexisting conditions may not be covered for some specified amount of time as defined in the certificate of coverage (usually 6 to 12 months). Individuals can be required to satisfy a preexisting waiting period only once, so long as they maintain continuous group health plan coverage with one or more carriers.
Â a practice of some health insurers to deny coverage to individuals for a certain period for health conditions that already exist when coverage is initiated.
a program that establishes contracts with providers of medical care. Providers under such contracts are referred to as preferred providers. Usually, the benefit contract provides significantly better benefits and lower member costs for services received from preferred providers, thus encouraging covered persons to use these providers.
(1) amount paid periodically to purchase health insurance benefits or (2) the amount paid or payable in advance, often in monthly installments, for an insurance policy.
Premium pre-certification occurs when a person requesting insurance coverage fills out additional paperwork to determine whether they meet the requirements for policy coverage. This occurs primarily in mental health insurance cases.
Â group of primary care physicians who have agreed to share the risk of providing medical care to their patients who are covered by a given health plan.
A physician, usually a general, family practitioner or internist, who delivers general health care, and is most often the first doctor a patient sees. This physician treats the patient directly, refers them to a specialist (or secondary care physician) or admits them to the hospital.
the insurance plan responsible for paying the bill first. If a patient is covered by another insurance, it is referred to as the secondary insurance. See also coordination of benefits.
The insurance company responsible for paying your claim first. If you have another insurance company, it is referred to as the Secondary Insurance Company.
First-listed/primary diagnosis code. The code sequenced first on a medical record defines the primary reason for the encounter as determined at the end of the encounter.
The HIPAA privacy standard establishes requirements for disclosing what the HIPAA privacy law calls Protected Health Information (PHI). PHI is any information on a patient about the status of their health, treatment, or payments.
A physician, hospital, laboratory, pharmacy or other organization that provides health care, goods or services.
Â Remittance Advice. Supplied by the payer to outline payment for submitted claims. Also contains explanations for claim denials. Also referred to as EOB.
a term used to refer to the commonly charged or prevailing fees for health services within a geographic area.
approval needed for medical care beyond that offered by a primary care physician or hospital. For example, HMO plans typically require referrals from a primary care physician to see specialists.
Approval for a member to see a physician or access services outside of the participating medical group.
A form signed by the responsible party or patient allowing healthcare providers to give insurance company medical information, so that the claim can be covered.
A document supplied by the insurance payer with information on claims submitted for payment. Contains explanations for rejected or denied claims. Also referred to as an EOB (Explanation of Benefits).
The person(s) responsible for paying a patientâ€™s office or hospital bill, usually referred to as the guarantor
Medical billing terminology for a 3 digit number used on hospital bills to tell the insurer where the patient was when they received treatment, or what type of item a patient received.
another term for medical billing, usually used when a medical billing company is performing the billing function. Initially used to refer to hospital billing, but the term has come in to common usage for physician billing as well. For more information on revenue cycle management (click here) or revenue management (click here).
Part of a practice management system that allows you to electronically send, edit and error-check claims, as well as post ERA.
Â Relative Value Amount. This is the average amount Medicare will pay a provider or hospital for a procedure (CPT 4). This amount varies depending on geographic location.
Process of checking an insurance claim for errors in the health insurance claim software prior to submitting to the payer.
Extra insurance that may pay some charges not paid by your primary insurance company.Â Whether payment is made depends on your insurance benefits, your coverage and your benefit coordination .
claim for insurance coverage paid after the primary insurance makes payment. Secondary insurance is typically used to cover gaps in insurance coverage.
Â When a second CPT procedure is performed during the same physician visit as the primary procedure.
Provides guidance for developing and implementing policies and procedures to guard and mitigate compromises to security. The HIPAA security standard is kind of a subset or compliment to the HIPAA privacy standard. Where the HIPAA policy privacy requirements apply to all patient Protected Health Information (PHI), HIPAA policy security laws apply more specifically to electronic PHI.
an insurance plan where financial responsibility for medical expenses is assumed by the group (usually an employer) rather than an insurance company. Self-insured plans are often managed by Third Party Administrators (TPA). Also known as self-funded plan.
A late effect is the residual effect (condition produced) after the acute phase of an illness or injury has terminated. There is no time limit on when a late effect code can be used. The residual may be apparent early, such as in cerebral infarction, or it may occur months or years later, such as that due to a previous injury.
Codes that describe symptoms and signs, as opposed to diagnoses, are acceptable for reporting purposes when a related definitive diagnosis has not been established (confirmed) by the provider.
Typically an institution for convalescence or a nursing home. The skilled nursing facility provides a high level of specialized care for long-term or acute illness. It is an alternative to extended hospital stays or difficult home care.
Â a facility, either freestanding or part of a hospital, that accepts patients seeking rehabilitation or medical care that is less intensive than that received in a hospital.
One of the medical billing terms for a software application that is hosted on a server and accessible over the Internet. SAAS relieves the user of software maintenance and support and the need to install and run an application on an individual local PC or server. Many medical billing applications are available as SAAS.
the way a patient was admitted to the hospital. For example, physician referral, transfer from another hospital, emergency room visit, etc.
Physician who specializes in a specific area of medicine, such as urology, cardiology, orthopedics, oncology, etc. Some heathcare plans require beneficiaries to obtain a referral from their primary care doctor before making an appointment to see a Specialist.
a federal program funded by states and the federal government, which offers health insurance coverage for children not covered by state Medicaid-funded programs.
In regards to healthcare, the stimulus is the government act that gives medical professionals incentives to improve their information technology.
usually described as a comprehensive inpatient program for those who have experienced a serious illness, injury, or disease but do not require intensive hospital services. The range of services considered subacute can include infusion therapy; respiratory care; cardiac services; wound care; rehabilitation services; postoperative recovery programs for knee and hip replacements; and cancer, stroke, and AIDS care.
For group policies, subscriber is the term used to describe the employee. For individual policies, subscriber is the term to describe the policyholder.
An additional insurance company that handles claims for deductibles and coinsurance reimbursement. Many private insurance companies sell Supplemental Insurance for Medicare.
An additional insurance company that handles claims for deductibles and coinsurance reimbursement. Many private insurance companies sell Medicare Supplemental Insurance.
Refers to a bed for a patient who receives skilled nursing care in a non-skilled nursing facility.
A Tablet PC is a hand-held computer that allows you to have use your computer and relevant software at point-of-care with your patients.
Â It is essential to use both the Alphabetic Index and Tabular List when locating and assigning a code. The Alphabetic Index does not always provide the full code. Selection of the full code, including laterality and any applicable 7th character can only be done in the Tabular List. A dash (-) at the end of an Alphabetic Index entry indicates that additional characters are required. Even if a dash is not included at the Alphabetic Index entry, it is necessary to refer to the Tabular List to verify that no 7th character is required.
Specialty standard codes used to indicate a providers specialty sometimes required to process a claim.
The date the insurance contract expired or the date a subscriber or dependent ceases to be eligible for coverage.
Claim for insurance coverage paid in addition to primary and secondary insurance. Tertiary insurance covers gaps in coverage the primary and secondary insurance may not cover.
A think client environment is one in which software is installed on one network computer and can be accessed from other computers or workstations.
Â An independent corporate entity or person (third party) who administers group benefits, claims and administration for a self-insured company or group.
Triple Option Plan. An insurance plan which offers the enrolled a choice of a more traditional plan, an HMO, or a PPO. This is also commonly referred to as a cafeteria plan.
This is federal health insurance for active duty military, National Guard and Reserve, retirees, their families, and survivors. Formerly know as CHAMPUS.
A form developed by the National Uniform Billing Committee for hospital inpatient billing and payment transactions.
Claim form for hospitals, clinics, or any provider billing for facility fees similar to CMS 1500. Replaces the UB92 form.
Usual Customary and Reasonable or UCR is a table kept by the insurance company that details (by ICD-9 code) the maximum dollar amount the insurance company will consider for billed services. This schedule of fees is the commonly charged or prevailing fees for health services within a geographic area.
The UHDDS definitions are used by hospitals to report inpatient data elements in a standardized manner. These data elements and their definitions can be found in the July 31, 1985, Federal Register (Vol. 50, No, 147), pp. 31038-40. 1) Volume I â€“ The detailed, tabular list of diagnosis codes in the ICD-9-CM manual. 2) Volume II â€“ The alphabetical index to diseases in the ICD-9-CM diagnosis coding manual. 3) Volume III â€“ The ICD-9/ICD-10 list of procedure codes, used in inpatient settings.
A medical claim must be submitted within the time frame given by the insurance company or the claim will be denied.
Â An illegal practice of assigning an ICD-9 diagnosis code that does not agree with the patient records for the purpose of increasing the reimbursement from the insurance payor.
Typically reference to the difference between what the physician charges and what the insurance plan contractually allows and the patient is not responsible for. May also be referred to as â€œnot coveredâ€ in some glossary of billing terms.