Medical Terminology Glossary

Medical Coding Terminology for all coders.  Click on the plus sign (+) to get the defination.

AAPC

American Academy of Professional Coders.

Accept Assignment

Provider has agreed to accept the insurance company allowed amount as full payment for the covered services.

Account

An identifying number for a patient given by the doctor to track medical visits.

Account Number

number the patient’s visit (account) is given by the hospital for documentation and billing purposes.

Accounts receivable

The total amount of money owed for professional services provided.

Acute Conditions

The medical conditions characterized by sudden onset, severe change, and/or short duration.

Additional Diagnosis

The secondary diagnosis code used, if available, to provide a more complete picture of the primary diagnosis.

Adjudication

The final determination of the issues involving settlement of an insurance claim, also known as a claim settlement.

Adjustment

Contractual Adjustment. The portion of your bill that the doctor or hospital has agreed not to charge you.

Admitting Diagnosis

The initial medical reason that was documented for the patient’s condition.

Advance Beneficiary Notice (ABN)

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.

Advance Directive

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.

Aging

One of the medical billing terms referring to the unpaid insurance claims or patient balances that are due past 30 days. Most medical billing software’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.

AHIMA

American Health Information Management Association.

Allowed Amount

The amount of the billed charge the insurance company deems is payable.

AMA

American Medical Association. The AMA is the largest association of doctors in the United States. They publish the Journal of American Medical Association which is one of the most widely circulated medical journals in the world. www.ama-assn.org

Ambulatory Care

Any medical care delivered on an outpatient basis.

Ambulatory Care Charge

these fees support the physician’s outpatient hospital practice and will be in addition to the physician’s charge. Charges represent services like outpatient nursing care, appointments, receptionists, medical records, housekeeping and facilities operations.

Ambulatory Surgery

Surgery done in the doctor’s office or at a surgical center, and not requiring an overnight stay.

Ancillary Providers

Services over and above physician services, including laboratory, radiology, home health and skilled nursing facilities.

Ancillary Services

Services rendered by the healthcare facility that are separate from the food and accommodation. Examples are tests, surgery, therapy, and so on.

APC (Ambulatory Payment Classification)

a Medicare payment system for grouping and classifying similar outpatient services and procedures so Medicare can pay all hospitals the same amount.

Appeal

 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.

Applied to Deductible

The amount the patient owes the healthcare provider; i.e. an amount not covered by the insurance company.

Approved Amount

The amount of the hospital’s charge that a payer will recognize in calculating benefits. (Under Medicare, also called “Medicare Allowable Charge”)

ARRA for Healthcare

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.

ASP

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.

Assignment

 a process under which Medicare pays its share of the allowed charge directly to the physician or supplier. Medicare will do this only if the physician accepts Medicare’s allowed charge as payment in full.

Assignment of Benefits

Insurance fees which are paid directly to the healthcare provider.

Authorization

Approval of care required before a service is provided. Pre-authorization may be necessary before hospital admission, or before care is given by non-HMO providers.

Authorization Number

a reference number stating that your treatment has been approved by insurance. Also called a certification number or prior-authorization number. See also preadmission approval/certification.

Balance Bill

The amount doctors charge patients after the patient’s insurance and health plans have paid.

Balance Billing

Billing a patient for charges not paid by their insurance plan because the charges are above the Usual and Customary Rate or because the insurer considered a procedure medically unnecessary.

Beneficiary

An individual covered by health insurance or other benefits.

Beneficiary liability

the amount beneficiaries must pay for covered services. These include co-payments, coinsurance, deductibles, and balance billing amounts.

Beneficiary/Patient Liability

the portion patients must pay out-of-pocket for medical services, including co-payments, co-insurance, and deductibles. This is in addition to the portion paid by insurance.

Benefit

The amount you are allowed in coverage from an insurance policy.

Benefit period

A benefit period begins the day you go to a hospital or skilled nursing facility. The benefit period ends when you haven’t received hospital or skilled nursing care for 60 days in a row.

Bilateral

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.

Billed Charges

the total charges that hospitals send to insurance companies/patients prior to any negotiated contracts or discounts being applied.

BillFlash

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.

Birthday Rule the Birthday Rule

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 mother’s birth date is June 10 and the father’s birth date is April 23, the father’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.

Blue Cross Blue Shield (BCBS)

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 association’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.

Bright Note Technology

A feature of Medisoft Clinical, Lytec MD and Practice Partner that allows you to enter information into a patient’s note and have it automatically populate the patient’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.

Capitation

A fixed payment paid per patient enrolled over a defined period of time, paid to a health plan or provider. This covers the costs associated with the patients health care services. This payment is not affected by the type or number of services provided.

Carve-out Policy

 A contracted agreement between an insurance company and another company which provides special services to its members, such as prescription drugs or cancer treatment.

Case manager

 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 client’s account. Case managers are prevalent in the healthcare industry.

Category

The three-digit diagnosis code classifications that broadly define each condition (e.g., 250 for diabetes mellitus).

CCHIT

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.

CCS

California Children Services. A state program for children with certain diseases or health problems.

Centers for Disease Control and Prevention (CDC)

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.

Centers for Medicare & Medicaid Services (CMS)

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.

Certificate of Coverage (COC)

a description of the healthcare coverage included in an insurance company’s plan. The certificate of coverage is required by state laws and explains the healthcare coverage provided under the contract issued to the employer.

CHAMPUS

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.

Charity Care

Free medical care given to patients in financial difficulty who cannot afford to pay.

Chart Scanning

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.

CHDP

Child Health and Disability Prevention Program. A preventive program that delivers periodic health assessments and services to low income children and youth in California.

Children’s Health Insurance Program (CHIP)

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.

Chronic Conditions

Medical conditions characterized by long duration, frequent recurrence over a long period of time, and/or slow progression over time.

Claim

A medical bill sent to an insurance company.

Claim Control Number

A number assigned to a claim that is used to process the claim.

Claim Response Report

Palmetto GBA’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.

Claims Inquiry Form (CIF)

form used for tracking a claim or when requesting an adjustment.

Claims Review

The method by which a patient’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.

Clean Claim

An insurance claim that is completed on time with all the right information.

Clearinghouse

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.

Clinic

an area in a hospital or separate building that provides medical care to regularly scheduled or walk-in patients for non-emergency care.

Clinical Decision Support

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 patient’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.

CMS

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.

CMS 1450 UB-04

Uniform Bill formally known as UB-92 used for Institutional billing

CMS 1500

Medical claim form established by CMS to submit paper claims to Medicare and Medicaid. Most commercial insurance carriers also require paper claims be submitted on CMS 1500′s. The form is distinguished by it’s red ink.

CMS 1500 Form

Health Insurance Claim Form

Co payment

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.

Co Insurance

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%.

Co Pay

Amount paid by patient at each visit as defined by the insured plan.

Co-Insurance Days

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

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.

Co-Payment

This is the responsible party’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.

COB

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.

COBRA (Consolidated Omnibus Budget Reconciliation Act)

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.

COBRA Insurance

This is health insurance coverage available to an individual and their dependents after becoming unemployed  either voluntary or involuntary termination of employment for reasons other than gross misconduct. Because it does not typically receive company matching, It’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.

Coding

A system whereby a numerical code is applied to medical descriptions of diagnoses, procedures, pharmaceutical elements, and durable medical equipment.

Coding of Claims

a process through which diagnoses and procedures from the patient’s medical record are translated into numbers (codes) that computers can process for payment.

Coinsurance

A provision which limits the amount of the coverage paid by an insurance plan to a certain percentage, with the remaining costs paid by the member.

Collection Agency

a business that contracts with the hospital to collect money from patients for unpaid bills.

Collection Ratio

This is in reference to the providers accounts receivable. It’s the ratio of the payments received to the total amount of money owed on the providers accounts.

Combination Codes

A single code used to classify any of the following two diagnoses; a diagnosis with an associated secondary process (manifestation); or a diagnosis with an associated complication.

Computerized Physician Order Entry (CPOE)

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.

Consolidated Omnibus Budget Reconciliation Act (COBRA)

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.

Contractual Adjustment

The amount of charges a provider or hospital agrees to write off and not charge the patient per the contract terms with the insurance company.

Conventions of ICD-10

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 – Extra information to define or clarify code choice. 2) Includes Notes – 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) – This abbreviation is the equivalent of unspecified. 4) Excludes Notes – A type 1 Excludes note is a pure excludes note. It means “NOT CODED HERE!” 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 “Not included here.” 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) – This abbreviation in the Tabular List represents “other specified.” 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 “other specified” code.

Coordinated Coverage

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.

Coordination of Benefits

When a patient is covered by more than one insurance plan. One insurance carrier is designated as the primary carrier and the other as secondary.

Coordination of Benefits (COB)

the method for determining which insurance company is primarily responsible for payment when a patient is covered under more than one insurance plan. The insured’s total benefits do not exceed 100% of the medical expenses.

Coverage

This is the details of the insured person’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

Covered Days

days of the hospital stay that insurance company pays for in full or in part.

CPC

Certified Professional Coder for coders with at least two years of experience working in a physician-based setting.

CPC-H

Certified Professional Coder for coders with at least two years of experience in a hospital setting.

CPC-P

Certified Professional Coder-Payer for experienced coders who demonstrate skills to adjudicate provider claims effectively.

CPT

current procedural technology

CPT Code

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.

CPT medical billing codes

A coding system used to describe what medical procedures a patient has been given.

CPT-4

A 5-digit code that applies to medical services delivered.

Credentialing

This is an application process for a provider to participate with an insurance carrier. Many carriers now request credentialing through CAQH. CAQH credentialing process is a universal system now accepted by insurance company networks.

Credit Balance

The balance thats shown in the “Balance” or “Amount Due” 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.

Crossover claim

Bill for services rendered to a patient receiving benefits simultaneously from Medicare and Medicaid.

Crosswalk/mapping

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.

Current Procedural Terminology (CPT )Codes

This is the procedural coding system that is currently used in America primarily to report physician professional services. Frequently called “CPT”, 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 “Level I” codes. Additional codes to describe use of healthcare facilities and services provided by healthcare professionals are known as “Level II” or “Healthcare Common Procedure Coding System” (HCPCS). Level II codes were developed are maintained by CMS.

Date of Bill

The date the bill for the treatment was prepared. This is separate from the Date of Service.

Date Of Service (DOS)

an agreed amount that a patient must pay before the insurance company will pay anything toward medical charges. Usually the amount must be met and paid by the patient each year.

Day Sheet

Summary of daily patient treatments, charges, and payments received.

Deductible

An insurance deductible is the amount that a policyholder is responsible for on a claim. Whether it is on an auto, homeowner’s or renter’s policy, the deductible must be paid before the insurer will cover any of the other expenses.

DEERS

Defense Enrollment Eligibility Reporting System

Demographics

Physical characteristics of a patient such as age, sex, address, etc. necessary for filing a claim.

Denial

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.

DHS

Department of Health Care Services for California www.dhcs.ca.gov

Diagnosis Code

a code used for billing that describes the patient’s illness. Diagnosis-Related Groups (DRGs) – 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.

Diagnosis-related group (DRG)

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.

Dirty Claim

claim submitted late or with missing information.

Disease Management

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

DME

Durable Medical Equipment. Medical supplies such as wheelchairs, oxygen, catheter, glucose monitors, crutches, walkers, etc.

DOB

Abbreviation for Date of Birth

DOS

Dates of Service. The date(s) when a patient was treated.

Downcoding

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 Naturally Speaking

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.

Due from Insurance

The amount of money owed by the patient’s insurance company.

Due from Patient

The amount of money owed by the patient.

Duplicate Coverage Inquiry (DCI)

Request by an insurance company or group medical plan by another insurance company or medical plan to determine if other coverage exists.

Durable Medical Equipment (DME) billing

Physical medical equipment such as crutches and wheelchairs which can be used over and over again.

Dx

Abbreviation for diagnosis code (ICD 9 or ICD 10 code).

E/M

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.

EDI

Electronic Data Interchange

eductible

the date(s) medical services were provided to the patient.

EEG

equipment or medical procedure that measures electricity in the brain.

EFT

Electronic Funds Transfer. A paperless computerized system enabling funds to be debited, credited, or transferred from the payer.

EIN

Employer Identification Number. Also known as Tax Identification Number (TIN)

EKG/ECG

equipment or medical procedure that measures how the heart works. Eligibility Verification – a way hospitals determine whether the patient has insurance coverage for the services they will provide.

Electronic Claim

Individual who converts insurance claims to standardized electronic format and transmits electronic insurance claims date to the insurance carrier or clearinghouse to help the physician receive payment.

Electronic Funds Transfer (EFT)

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.

Electronic Medical Records / Electronic Health Records (EMR/EHR)

The terms “electronic medical records (EMR)” and “electronic health records (EHR)” are used interchangeably to refer to computerized patient charts within software that allows for electronic patient charting, eprescribing, health maintenance and more.

Employee Retirement Income Security Act of 1974 (ERISA)

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.

EMR

Electronic Medical Records. Also referred to as EHR (Electronic Health Records). This is a medical record in digital format of a patients hospital or provider treatment.

EMR Stimulus

The EMR Stimulus gives qualifying providers up to $64,000 for using EMR technology meaniningfully. See also ARRA for Healthcare.

Enrollee

Individual covered by health insurance.

EOB

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

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.

EPSDT

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.

ERA

Electronic Remittance Advice. An ERA explains details about claim payment and includes information regarding claim statuses and denials.

ERISA

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.

Estimated Insurance

An estimation of the money paid by a patient’s insurance company.

Exclusion

Services or supplies not covered under a health plan.

Explanation of Benefits (EOB)

 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.

Family and Medical Leave Act (FMLA)

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.

Federal Register

The “Federal Register” 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.

Fee for Service

A method of payment for medical services rendered

Fee Schedule

A listing of the maximum fee which a health plan will pay for services based on CPT billing codes.

Financial Responsibility

The portion of the charges that are the responsibility of the patient or insured.

Fiscal Intermediary (FI)

A Medicare representative who processes Medicare claims.

Formulary

A list of prescription drug costs which an insurance company will provide reimbursement for.

Fraud

When a provider receives payment or a patient obtains services by deliberate, dishonest, or misleading means.

GEMs

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.

GPH

Group Health Plan. A means for one or more employer who provide health benefits or medical care for their employees (or former employees).

GPNet

The EDI gateway to Palmetto GBA

Group Name

The name of the group or plan which the patient is insured by.

Group Number

Number assigned by insurance company to identify the group under which a patient is insured.

Group provider number

A number assigned to a group of physicians submitting insurance claims together usually as a practice.

Guarantor

someone who either accepts or is legally responsible to pay for a given patient’s hospital bill. The guarantor may or may not be the patient.

HCFA

Health Care Financing Administration. Now know as CMS (see above in Medical Billing Terms).

HCFA/CMS 1500

 a billing form used by doctors to file insurance claims for medical services.

HCPCS

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 – American Medical Associations Current Procedural Terminology (CPT) codes. 2) Level II – 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 – Local codes used by state Medicaid organizations, Medicare contractors, and private insurers for specific areas or programs.

HCPCS codes

(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.

Health Care Provider

a person or entity that provides medical services (e.g. a physician, hospital or laboratory). Health Insurance – 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.

Health Care Reform Act

Health care legislation championed by President Obama in 2010 to provide improved individual health care insurance or national health care insurance for Americans. Also referred to as the Health Care Reform Bill or the Obama Health Care Plan.

Health Insurance Portability & Accountability Act (HIPAA)

 A law passed in 1996 which is also sometimes called the “Kassebaum-Kennedy” law. This law expands healthcare coverage for patients who have lost or changed jobs, or have pre-existing conditions. HIPAA does not replace the states’ roles as primary regulators of insurance. The HIPAA legislation has the following broad goals, to provide 1) a way to uniquely identify providers, employers and health plans, 2) a uniform level of protection of health information, known as the “Security Rule,” 3) a uniform level of protection of the privacy of health data associated with patients, known as the “Privacy Rule” and 4) a simpler healthcare electronic transaction process by describing standards by which all healthcare administrative entities would use, which is known as the “Transactions and Code Sets Rule”.

Health Maintenance

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.

Health Maintenance Organization

An insurance plan that pays for preventative and other medical services provided by a specific group of participating providers.

Healthcare Insurance

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 beneficiary’s family members. May include coverage for disability or accidental death or dismemberment.

Heathcare Provider

Typically a physician, hospital, nursing facility, or laboratory that provides medical care services. Not to be confused with insurance providers or the organization that provides insurance coverage.

HIC

Health Insurance Claim. This is a number assigned by the the Social Security Administration to a person to identify them as a Medicare beneficiary. This unique number is used when processing Medicare claims.

HIPAA 4010

The original healthcare transactions version of HIPAA (officially known as Version 004010 of the ASC X12 transaction implementation guides) named as part of HIPAA’s Electronic Transaction Standards regulation. Version 4010 was required to be used by HIPAA covered healthcare entities by Oct. 16, 2003.

HIPAA 5010

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.

HIT

Health Information Technology.

HITECH

The Health Information Technology for Economic and Clinical Health Act (HITECH) Act is the name given to the American Recovery and Reinvestment Act (ARRA) for healthcare providers. See also EMR Stimulus and ARRA for Healthcare.

HL7

Health Level Seven. A data exchange protocol and interface for medical records and billing software that allows different systems to interoperate.

Home Health Agency

an agency that offers medical care to patients in their homes. Hospice – a group that provides inpatient, outpatient, and home health care for terminally ill patients.

Home health agency (HHA)

a facility or program licensed, certified, or otherwise authorized according to state and federal laws to provide health care services in the home.

Hospice

Inpatient, outpatient, or home healthcare for terminally ill patients.

Hospital Inpatient Prospective Payment System (IPPS)

Medicare’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).

ICD

International Classification of Disease Coding

ICD 10 Code

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

ICD 9 Code

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.

ICD Codes

International Classification of Disease. Used to assign codes to patient diagnosis.

ICD-10

The mortality and morbidity classification coding system implemented by WHO in 1993 to replace ICD-9.

ICD-10-CM

 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.

ICD-10-PCS

The updated procedural coding system defined by CMS that will replace Volume 3 of ICD-9-CM for hospital inpatient services.

ICD-9

A 3 to 5-digit number code describing a diagnosis or medical procedure.

ICD-9 Codes

(International Classification of Diseases). A 3 to 5 digit number given to diagnoses, services and treatments to classify them.

ICD-9-CM

The “clinical modification” to the ICD-9 code set that is currently used in America to report medical diagnoses. The “Clinical Modification” 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).

ICD-9-CM

International Classification of Diseases. The official system of assigning codes to diagnoses and procedures associated with hospital utilization in the United States.

ICD-9-PCS

 The procedural coding system currently used in America primarily for hospital inpatient services. It is contained in Volume 3 of ICD-9-CM.

In Network (or Participating)

 An insurance plan in which a provider signs a contract to participate in. The provider agrees to accept a discounted rate for procedures.

In-Network Provider

Physicians and other service providers who are contracted with a managed care plan.

Incremental Nursing Charge

Charges for hospital nursing services in addition to basic room and board.

Indemnity

Also referred to as fee for service. This is a type of commercial insurance were the patient can use any provider or hospital

Index (to diseases)

 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.

Inpatient

A patient who is admitted to a hospital and receives medical services from a physician during at least a 24-hour period.

Insurance balance billing

A bill that shows the patient what is the remaining due after an insurance payment has been made.

Insurance cap

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.

Intensive 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.

International Classification of Diseases (ICD)

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, “Clinical Modification,” is maintained by the NCHS within the CDC to more precisely define ICD use in the U.S.

International Classification of Diseases, 9th Edition (Clinical Modification) (ICD-9-CM)

a coding system used to describe the patient’s diagnosis and the procedures performed to treat them.

Inventory Tracking

Inventory tracking is a feature of Lytec and PeakPractice that allows you to manage your supply and track as well as order inventory.

IPA

Independent Practice Association. An organization of physicians who are contracted with an HMO plan

IVR

Interactive Voice Response. Palmetto GBA 24 hour telephone line, obtain Medicare Part B information, such as claim status, last 3 checks issues, and eligibility.

Jurisdiction 1

California, Hawaii, Nevada, Guam, American Samoa, Northern Mariana Islands

Kiosk

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.

KLAS

An organization that rates EMR software.

LAN

Local Area Network. A LAN connects all the computers in your office so that you can share files, resources and internet connection.

Lifetime Reserve Days

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 patient’s life.

Long Term Care

Medical care received in a nursing home.

Lytec

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

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.

MAC

Medicare Administrative Contractor

Major Diagnostic Categories (MDCs)

A broad classification of diagnoses that covers most of the diagnoses doctors provide to patients.

Managed Care Plan

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.

Manifestation Codes

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 “use additional code” note at the etiology code, and a “code first” note at the manifestation code. These instructional notes indicate the proper sequencing order of the codes, etiology followed by manifestation.

Maximum Out of Pocket

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.

MCARE Non-Covered drug

see self-administered drug.

Meaningful Use

Meaningful Use refers to the quality standards that must be met in order to qualify for the HITECH EMR stimulus incentive.

Medi-Cal

Medi-Cal is California’s Medicaid program. Provides health services for categorically eligible and low-income persons. www.medi-cal.ca.gov.

Medicaid

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.

Medical Assistant

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 and Insurance Coding

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.

Medical billing company

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).

Medical billing or physician billing

the process that converts documentation of a physician visit (“encounter”) into a “claim”, filing it with a “payer” or “payor” (insurance company or carrier), posting payments, following-up on any”denial”, billing the patient for any remaining balance, and managing the practices “accounts receivable”. For more information on medical billing (click here). Note: billing for hospital (in-patient) services may also be referred to as “medical billing” though the skills and technology required differ signficantly between hospital billing and physician billing.

Medical billing services

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).

Medical billing software

the software used by medical billers. Billers can bill for one group as part of the group’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 “front office” functions associated with office-based physician groups. For more information on medical billing software (click here).

Medical Billing Specialist

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.

Medical Coder

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.

Medical coding, coding services

the process of assigning the correct “codes”, usually CPT (“procedure codes”) and ICD (“diagnosis codes”), 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 “medical record”). A common saying, “If it isn’t documented, it didn’t happen.”

Medical Necessity

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.

Medical Record Number

A unique number assigned by the provider or health care facility to identify the patient medical record.

Medical Savings Account

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.

Medical Transcription

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.

Medically Necessary

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.

Medicare

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

Medicare + Choice

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.

Medicare Approved

Medical services which Medicare pays for.

Medicare Assignment

Doctors and hospitals who have accepted Medicare patients and agreed not to charge them more than Medicare has approved.

Medicare Coinsurance Days

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 “Lifetime Reserve Days.”

Medicare Donut Hole

The gap or difference between the initial limits of insurance and the catastrophic Medicare Part D coverage limits for prescription drugs.

Medicare Medical Savings Account

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.

Medicare Number

 number given to every Medicare patient for tracking and billing purposes. This number can be found on the Medicare card.

Medicare Paid

The amount of a patient’s bill paid by Medicare.

Medicare Part A

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 Part B

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 Part B

Medicare coverage helps pay for physician services, medical supplies, and other outpatient services not paid for by Medicare Part A.

Medicare Part D

Medicare coverage that helps pay for the costs of prescription drugs.

Medicare secondary payer (MSP)

the term used by Medicare when Medicare is not responsible for paying first. (The private insurance industry generally talks about “coordination of benefits” when assigning responsibility for first and second payment.)

Medicare Summary Notice (MSN)

also called an Explanation of Medicare Benefits (EOMB). See explanation of benefits.

Medicare supplement policy (Medsupp)

an insurer will pay a policyholder’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.

Medigap

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.

Medigap insurance

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.

Medigap plan

purchased by Medicare enrollees to cover co-payments, deductibles, and health care goods or services not paid for by Medicare. Also known as a Medicare supplement policy.

Medigap policy

a privately purchased insurance policy that supplements Medicare coverage.

Medisoft

Medisoft is America’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

Medisoft Clinical combines Medisoft’s medical billing, scheduling and electronic claim submission with electronic medical records.

Modifier

Modifier to a CPT treatment code that provide additional information to insurance payers for procedures or services that have been altered or “modified” in some way. Modifiers are important to explain additional procedures and obtain reimbursement for them.

Morbidity

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.

Mortality

Term refers to the death rate reflected by the population in a given region, age range, or other relevant statistical grouping

MSP

Medicare Secondary Payer

N/C

Non-Covered Charge. Procedure is not covered by health plan.

N/C Non Covered Charge.

 A procedure not covered by the patients health insurance plan.

National Center for Health Statistics (NCHS)

A federal organization within the CDC that collects, analyzes, and distributes healthcare statistics. The NCHS helps maintain the ICD-CM codes.

National Drug Code (NDC) system

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.

NEC Not Elsewhere Classifiable.

Medical billing terminology used in ICD when information needed to code the term in a more specific category is not available.

Network

a group of doctors, hospitals, and other health care providers that have a contract with an insurance plan to provide services to its patients.

Network Provider

Health care provider who is contracted with an insurance provider to provide care at a negotiated cost.

Non-Covered Charges

charges for medical services denied or excluded by insurance. The patient may be billed for these charges. Also called “non covered amount.”

Non-Participating Provider (non-par)

a doctor, hospital, or other health care entity that is not part of an insurance plan’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.

Nonparticipation

 When a healthcare provider chooses not to accept Medicare approved payment amounts as payment in full.

NOS

Not Otherwise Specified. Used in ICD for unspecified diagnosis.

NPI

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.

NPI Number

National Provider Identifier. A unique 10 digit identification number required by HIPAA and assigned through theNational Plan and Provider Enumeration System (NPPES).

Observation

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.

OCR

Optical Character Recognition. The process by which scanned patients charts can be converted to searchable, editable text when converting paper charts to electronic.

OIG Office of Inspector General

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.

Original Medicare Plan

The traditional pay per visit arrangement that covers Part A and Part B services.

Out of Network (or NonParticipating)

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.

Out of Network Provider

 A doctor or other healthcare provider who is not part of an insurance plan’s doctor or hospital network. Same as non

Out Of Pocket Maximum

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.

Out-of-Network (OON) Services

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.

Out-of-Network Provider

Physicians who are not contracted with a managed care plan.

Out-of-Pocket (OOP)

Payment for medical services due from the patient, including copayments, co-insurance, and deductible.

Out-of-pocket costs/expenses (OOPs)

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.)

Outpatient

Medical treatment lasting less than 24 hours, normally in a doctor’s office or day facility. Examples include x-rays, simple surgeries, and blood tests.

Outpatient (OP)

a patient who does not need to stay overnight in a hospital. Outpatient services include lab tests, X-rays, and some surgeries.

Over-the-counter (OTC) drug

 a drug product that does not require a prescription under federal or state law.

Paid to Provider

The amount a health insurance company pays a healthcare provider.

Palmetto GBA

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.

Paper Claims Processing

The process of posting payments, processing data, billing service providers, and building reports.

Participating Provider

a doctor, hospital, or other health care entity that is part of an insurance plan’s network. They agree to accept insurance payment for covered medical services as payment in full, less any patient liability.

Patient Navigator

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.

Patient Responsibility

The amount a patient is responsible for paying that is not covered by the insurance plan.

Patient Type

a way to classify patients based on the type of services they receive from the hospital, such as outpatient, inpatient, and Emergency, etc.

PCP

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

PCP Primary Care Physician

Usually the physician who provides initial care and coordinates additional care if necessary.

PeakPractice

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 Diem

per day. Typically refers to charge or payment methods based on a set rate per day of medical care.

Physician Participation

 a way in which a physician agrees to accept an insurance company’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 patient’s co-insurance, deductibles, and non-covered services.

PM or PMS

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).

Point-of-Service Plan (POS)

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 – a number that the insurance company assigns the patient to identify the contract for coverage.

Portal

A portal is a feature in some EMR’s that allows the provider to electronically give patients access to health information and patient education via the internet.

POS (Used on Claims)

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.

PPO

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.

PQRI

Physician Quality Reporting Initiative.

Practice management services

another term for medical billing services, though it sometimes may include other back office functions such as practice payroll, accounts payable, etc.

Practice Management Software

software used for the daily operations of a providers office. Typically used for appointment scheduling and billing.

Practice Partner

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.

Pre Certification

Sometimes required by the patients insurance company to determine medical necessity for the services proposed or rendered. This doesn’t guarantee the benefits will be paid.

Pre existing Condition (PEC)

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).

Pre-certification

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.

Preadmission certification (PAC)

a review of the need for inpatient hospital care, performed before the actual admission.

Preauthorization

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.

Preauthorization

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.

Predetermination

Maximum payment insurance will pay towards surgery, consultation, or other medical care determined before treatment.

Preexisting condition (PEC)

any medical condition that has been diagnosed or treated within a specified period immediately preceding the covered person’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.

Preexisting condition exclusion

 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.

Preferred provider organization (PPO)

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.

Premium

(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

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.

Prepayment

money paid before receiving medical services.

Prevailing charge

determines a physician’s payment for a service under the Medicare payment system.

Primary Care Network (PCN)

 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.

Primary Care Physician

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.

Primary Insurance

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.

Primary Insurance Company

The insurance company responsible for paying your claim first. If you have another insurance company, it is referred to as the Secondary Insurance Company.

Principle Diagnosis

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.

Privacy Rule

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.

Private Fee for Service Plan

A private insurance plan that accepts Medicare beneficiaries.

Procedure Code

CPT or HCPC code used to describe the service rendered.

Procedure Code (CPT)

 A code given to medical and surgical procedures and treatments.

Procedure/CPT code

a coding system used to describe medical services and surgical procedures provided to the patient.

Provider

A physician, hospital, laboratory, pharmacy or other organization that provides health care, goods or services.

PTAN (Provider Transaction Access Number)

Provider Transaction Access Number. Also known as your legacy Medicare number.

RA (Remittance Advice)

 Remittance Advice. Supplied by the payer to outline payment for submitted claims. Also contains explanations for claim denials. Also referred to as EOB.

Reasonable and customary (R and C)

a term used to refer to the commonly charged or prevailing fees for health services within a geographic area.

Referral

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.

Referral Authorization

Approval for a member to see a physician or access services outside of the participating medical group.

Referral Physician

A physician who sees a patient after another doctor has sent them for specialty care or services.

Referring Physician

A physician who sends a patient to another doctor for specialty care or services.

Release of Information

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.

Remittance Advice (R/A)

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).

Responsible Party

The person(s) responsible for paying a patient’s office or hospital bill, usually referred to as the guarantor

Revenue Code

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.

Revenue cycle management

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).

Revenue Manager

Part of a practice management system that allows you to electronically send, edit and error-check claims, as well as post ERA.

ROI

Return on Investment. Check out or EMR ROI!

RVU

 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.

Scrubbing

Process of checking an insurance claim for errors in the health insurance claim software prior to submitting to the payer.

Secondary Insurance

Extra insurance that may pay some charges not paid by your primary insurance company.  Whether payment is made depends on your insurance benefits, your coverage and your benefit coordination .

Secondary Insurance Claim

claim for insurance coverage paid after the primary insurance makes payment. Secondary insurance is typically used to cover gaps in insurance coverage.

Secondary Procedure

 When a second CPT procedure is performed during the same physician visit as the primary procedure.

Security Standard

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.

Self Pay

Payment made at the time of service by the patient.

Self Referral

When a patient sees a specialist without a primary physician referral.

Self-Insured Plan

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.

Sequelae

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.

Signs/Symptoms

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.

Skilled Nursing Facility

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.

Skilled nursing facility (SNF)

 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.

SOF

Stands for ‘Signature on File’.

Software As A Service (SAAS)

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.

Source of Admission

the way a patient was admitted to the hospital. For example, physician referral, transfer from another hospital, emergency room visit, etc.

Specialist

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.

State Children’s Health Insurance Program (SCHIP)

a federal program funded by states and the federal government, which offers health insurance coverage for children not covered by state Medicaid-funded programs.

Stimulus

In regards to healthcare, the stimulus is the government act that gives medical professionals incentives to improve their information technology.

Subacute care

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.

Subscriber

For group policies, subscriber is the term used to describe the employee. For individual policies, subscriber is the term to describe the policyholder.

Superbill

One of the medical billing terms for the form the provider uses to document the treatment and diagnosis for a patient visit. Typically includes several commonly used ICD-9 diagnosis and CPT procedural codes. One of the most frequently used medical billing terms.

Supplemental Insurance

An additional insurance company that handles claims for deductibles and coinsurance reimbursement. Many private insurance companies sell Supplemental Insurance for Medicare.

Supplemental Insurance Company

A secondary policy which covers claims for bills paid after the primary policy has paid.

Supplemental Insurance Policy

An additional insurance company that handles claims for deductibles and coinsurance reimbursement. Many private insurance companies sell Medicare Supplemental Insurance.

Swing Bed

Refers to a bed for a patient who receives skilled nursing care in a non-skilled nursing facility.

Tablet PC

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.

Tabular List

 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.

Taxonomy Code

Specialty standard codes used to indicate a providers specialty sometimes required to process a claim.

Tele Comm Support

Internet software or hardware support with the staff of Tele Comm Computer Systems, Inc.

Term Date

The date the insurance contract expired or the date a subscriber or dependent ceases to be eligible for coverage.

Tertiary Insurance Claim

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.

Thin Client

A think client environment is one in which software is installed on one network computer and can be accessed from other computers or workstations.

Third Party Administrator (TPA)

 An independent corporate entity or person (third party) who administers group benefits, claims and administration for a self-insured company or group.

TIN Tax Identification Number

Also known as Employer Identification Number (EIN)

TOP

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.

TOS

Type of Service. A description of the category of the service preformed.

Treating Physician

A physician who provides care to the patient while in the hospital, and usually works at the hospital or comes in as a specialist.

TRICARE

This is federal health insurance for active duty military, National Guard and Reserve, retirees, their families, and survivors. Formerly know as CHAMPUS.

TTY

Teletypewriter for the hearing impaired

UB-92

A form developed by the National Uniform Billing Committee for hospital inpatient billing and payment transactions.

UB04

Claim form for hospitals, clinics, or any provider billing for facility fees similar to CMS 1500. Replaces the UB92 form.

UCR

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.

Unbundling

Submitting several CPT treatment codes when only one code is necessary.

Uniform Hospital Discharge Data Set (UHDDS)

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 – The detailed, tabular list of diagnosis codes in the ICD-9-CM manual. 2) Volume II – The alphabetical index to diseases in the ICD-9-CM diagnosis coding manual. 3) Volume III – The ICD-9/ICD-10 list of procedure codes, used in inpatient settings.

Untimely Submission

A medical claim must be submitted within the time frame given by the insurance company or the claim will be denied.

Upcoding

 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.

UPIN

Unique Physician Identification Number. 6 digit physician identification number created by CMS. Discontinued in 2007 and replaced by NPI number.

Urgently Need Care

Unexpected illness or injury that needs immediate medical attention, but is not life threatening.

Usual, Customary, or Reasonable (UCR)

the amount insurance companies believe to be the common or prevailing charges for medical services provided in a region or community.

Utilization Limit

The limits that Medicare sets on how many times certain services can be provided within a year. The patients claim can be denied if the services exceed this limit.

Utilization Review (UR)

A review of a patient’s situation to determine whether is it more cost-effective for them to receive inpatient or outpatient treatment.

V Codes

ICD9 CM coding classification to identify health care encounters for reasons other than illness or injury.

WAN

Wide Area Network.

Workers Comp

Insurance claim that results from a work related injury or illness.

World Health Organization (WHO)

An organization that maintains the International Classification of Diseases (ICD) medical code set.

Writeoff

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 “not covered” in some glossary of billing terms.

XPrint Terminal

Emulator that enables printing from the Legacy Medical Billing system

XTerm Terminal

Emulator to connect the Legacy Medical Billing system

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