Term
| American Health Information Management Association (AHIMA)(1) |
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Definition
| A national professional organization for promoting the art and science of medical record management and improving the quality of comprehensive health information for the welfare of the public |
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Term
| American Medical Association (AMA)(1) |
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Definition
| A national professional society of physicians |
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Term
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Definition
| In a medical practice, the amount of actual cash generated and available for use by the medical practice within a given period of time |
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Term
| Claims Assistance Professional (CAP)(1) |
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Definition
| A practitioner who works for the consumer and helps patients organize, complete, file, and negotiate health insurance claims of all types to obtain maximum benefits, as well as tell patiants what checks to write to providers to eliminate overpayment |
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Term
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Definition
| Standards of conduct generally accepted as a moral guide for behavior by which an insurance billing or coding specialist may determine the appropriateness of his or her conduct in a relationship with patients, the physician, co-workers, the governement, and insurance companies |
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Term
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Definition
| Customs, rules of conduct, courtesy, and manners of the medical profession |
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Term
| Insurance Billing Specialist(1) |
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Definition
| A practitioner who carries out claims completion, coding, and billing responsibilities and may or may not perform managerial and supervisory functions; also know as an insurance claims processor, reimbursement specialist, medical billing representative, or senior billing representative |
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Term
| List service (listerv)(1) |
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Definition
| An online computer service run from a website where questions may be posted by subscribers |
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Term
| Medical Billing Representative(1) |
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Definition
| A practitioner who carries out claims completion, coding, and billing responsibilities and may or may not perform managerial and supervisory functions; also know as an insurance claims processor, reimbursement specialist, medical billing representative, or senior billing representative |
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Term
| Multiskilled Health Practitioner (MSHP)(1) |
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Definition
| An individual cross-trained to provide more than one function, often in more than one discipline. These combined functions can be found in a broad spectrum of health-related jobs, ranging in complexity including both clinical and administrative functions. The additional skills added the the original health care worker's job may be of a higher, lower, or parallel level. The terms multiskilled, multicompetent, and cross-trained can be used interchangeably |
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Term
| Reimbursement Specialist(1) |
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Definition
| A practitioner who carries out claims completion, coding, and billing responsibilities and may or may not perform managerial and supervisory functions; also know as an insurance claims processor, reimbursement specialist, medical billing representative, or senior billing representative |
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Term
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Definition
| "Let the master answer." Refers to a physicians's liability in certain cases for the wrongful acts of his or her assistant(s) or employee(s) |
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Term
| Senior Billing Representative(1) |
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Definition
| A practitioner who carries out claims completion, coding, and billing responsibilities and may or may not perform managerial and supervisory functions; also know as an insurance claims processor, reimbursement specialist, medical billing representative, or senior billing representative |
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Term
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Definition
| Incidents or practices, not usually considerec fradulent, that are inconsistent with accepted sound medical business or fiscal practices |
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Term
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Definition
| Under the HIPAA privacy rule, an individual's formal, written permission to use or disclose his or her personally identifiable health information for purposes other than reatment, payment, or health care operations |
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Term
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Definition
| A document signed by the patient that is needed for use and disclosure of protected health information that is not included in any existing consent form agreements |
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Term
| Breach of Confidential Communication(2) |
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Definition
| Breach means "breaking or violation of a law or agreement." In the context of the medical office it means the unauthorized release of information about the patient |
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Term
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Definition
| A person who, on behalf of the covered intity, performs or assits in the performance of a function or activity involving the use or disclosure or individually indentifiable health information includeding claims processing or administrations, data analysis, processing or administration, utilization review, quality assurance, bililng, benefit management, practice management, and repricing |
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Term
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Definition
| An independent organization that receives insurance claims from the physician's office, performs software edits, and redistributes the claims electromically to various insurance carriers |
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Term
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Definition
| Any set of codes with their descriptions used to encode data elements such as tables or terms, medical concepts, medical diagnostic codes, or medical procedure codes |
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Term
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Definition
| A process or meeting regulations, recommendations, and expectations of federal and state agencies that pay for health care servies and regulate the industry |
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Term
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Definition
| A management plan composed of policies and progedures to accomplish uniformity, consistency, and conformity in the medical record keeping that fufills official requirements |
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Term
| Confidential Communication(2) |
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Definition
| A privileged communication that may be disclosed only with the patient's permission |
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Term
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Definition
| The state of treating privately or secretly, and not disclosing to other individuals or for public knowledge, the patient's conversations or medical records |
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Term
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Definition
| Verbal or written agreement that gives approval to some action, situation, or statement |
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Term
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Definition
| A document that is not required before physicians use or disclose protected health information for treatment, payment,or routine health care operations of the patient. For other purposes, see Authorization form |
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Term
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Definition
| Transmits halth information in electronic form in connection with a transaction covered by HIPAA. The covered intity may be (1) a health care clearinghouse such as Blue Cross/Blue Shield, (2) a health care clearinghouse through with claims are submitted, or (3) a health care provider such as the primary care physician |
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Term
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Definition
| The release, transfer, proviion of access to, or divulging in any other manner of information outside the intity holding the information |
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Term
| E-Health Information Management (eHIM)(2) |
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Definition
| A term coined by the American Healther Information Management Association's eHealth Task Force to describe any and all transactions in which health care information is accessed, processed, stored, and transferred using electronic technologies |
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Term
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Definition
| The mode of electonic transmission (e.g., Internet, Extranet, laesed phone or dial-up phonelines, fax modems) |
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Term
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Definition
| A willful act by an employee of taking possession of an employer's money |
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Term
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Definition
| An intentional misrepresentation of the facts to deceive or mislead another |
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Term
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Definition
| A provider of medical or health services and any other person or organization wo furnishes bills or is paid for health care in the normal course of business |
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Term
| Individually Indentifiable Health Information (IIHI)(2) |
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Definition
| Any part of an individual's health information including demographic information (e.g., address, date of birth) collected from the individual that is created or received by a covered intity |
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Term
| Nonprivileged information(2) |
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Definition
| Information consisting of ordinary facts unrelated to the treatment of the patient. The patient's authorization is not required to disclose the data unless the record is in a specialty hospital or in a special service unit of a general hospital such as the psychiatric unit |
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Term
| Notice of Privacy Practices (NPP)(2) |
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Definition
| Under the HIPAA, a document given to the patient at the first visit or at enrollment explaining the individual's rights and the physician's leagal duties in regard to protected health information (PHI) |
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Term
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Definition
| Billing for services not performed |
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Term
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Definition
| The condition of being secluded from the presence or view of others |
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Term
| Privacy Officer, or Privacy Official (PO)(2) |
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Definition
| An individual designated to help the provider remain in compliance by setting policies and procedures in place, and by training and managing the staff regarding HIPAA and patient rights; usually the contact person for questions and complaints |
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Term
| Privileged Information(2) |
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Definition
| Data related to the treatment and progress of the patient that can be released only when written authorization of the patient of quardian is obtained |
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Term
| Protected Health Information (PHI) (2) |
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Definition
| Any data that idenify an individual and describes his or her health status, age, sex, ethnicity, or other demographic characteristics, whether or not that information is stored or transmitted electronically |
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Term
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Definition
| A person who protects the computer and networking systems within the practice and implements protocols such as password assignment, backup procedures, firewalls, virus protection, and contingency planning for emergencies |
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Term
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Definition
| Under the HIPAA, regulations realted to the security of ePHI that, along with regulations related to electronic transactions and code sets, privacy, and enforcement, compose the Administrative Simplification provisions |
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Term
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Definition
| A rule, condition, or requirement |
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Term
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Definition
| A complex technical issue not within the scope of the health care provider's role; refers to instances when a state law takes precedence over federal law |
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Term
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Definition
| The transmission of information between two parties to carry out financial or administrative activites related to health care |
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Term
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Definition
| The sharing, employment, application, utilization, examination, or analysis of individually identifiable health information (IIHI) within and organization |
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Term
| Accounts receivable management (3) |
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Definition
| The organization and administration of codeing and billing in a medical practice |
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Term
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Definition
| A person applying for insurance coverage |
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Term
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Definition
| A transfer, after an event insured against, or an individual's legal right to collect an amount payable under an insurance contract. When related to Medicare this is and agreement in shich a patient assigns the right to receive payment from the MEdicare administrative contractor to the physician. Under this agreement, the physician must agree to accept 80% of the allowed amound as payment in full once the deductible has been met. For TRICARE, providers who accept assignment agree to accept 75% or 80% of the TRICARE allowable charge as the full fee, collecting the deductible and 20% or 25% of the allowable charge from the patient. With other carriers, accepting the assignment means that, in return for payment of the claim, the provider accepts the terms of the contract between the patient and carrier. |
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Term
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Definition
| Comprehensive group insurance coverage through plans soponsored by professinal associations for their memebers. |
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Term
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Definition
| A renewal profision in an insurance agreement that grants the insurer the right to cancel the policy at any time and for any reason. |
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Term
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Definition
| A system of payment used by managed care plans in which physicians and hiospitals are paid a fixed per capity amount for each patient enrolled over a stated period of time, regardless of the type and number of services provided; reimbursement to the hospital on a per-member/per-month basis to cover costs for th members of the plan. Capitation can also mean a set amount to be paid per claim. |
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Term
| The Civilian Health and Medical Program of the Department of Veterans Affairs (CHAMPVA)(3) |
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Definition
| The Civilian Health an Medical Program for veterans with total, permanent, service-connected disabilites or surviving spouses and dependents of veterans who died of service-connected disabilites. |
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Term
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Definition
| A bill sent to an insurance carrier requsting payment for services rendered; also known as encounter report. |
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Term
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Definition
| (A) A cost-sharing requirement under a health insurance plicy providing that the insured will assume a percentage of the costs for covered services. (B) For Medicare, after application of the yearly cash deductible, the portion of the reasonable charges (20%) for which the beneficiary is responisble. (C) In the Medicaid Qualified Medicare Beneficiary program, the amount of the payment that is abov the rate that Medicare pays for medical services. The state assumes responisbility for payment of this amount. |
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Term
| Competitive Medical Plan (CMP)(3) |
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Definition
| A state-licensed health plan similar to a heath maintenance orgaization (HMO) that delivers comprehensive, coordinated services to voluntarily enrolled memebers on a prepaid capitated basis. CMP status may be granted by the federal governement for the enrollment of Medicare beneficiaries into managed care plans, without having to quality as an HMO. |
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Term
| Conditionally renewable(3) |
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Definition
| An insurance policy renewal provison that grants the insurer a limited right ro refuse to renew a health insurance policy at the end of a premium payment period. |
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Term
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Definition
| A leagally enforceable agreement when relating to an insurance policy; for workers' compensation cases, and agreement involving two or more parties in which each is obligated to the other to fulfill promises made. (The contract exists between the physician and the insurance carrier.) |
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Term
| Coordination of benefits (COB)(3) |
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Definition
| Two insurance carriers working together and coordinating the payment of their benefits so that there is no dublication of benefits paid between the primary and secondary insurance carriers. In TRICARE, the coordination of the payment of TRICARE benefits with the payment of benefits made by the double coverage plan so that there is no duplication of benefits paid between the double coverage plan and TRICARE; likewise applied to disability programs. |
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Term
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Definition
| A register for recording daily business transactions (charges, payments, or adjustments); also known as daybook, daily log, or daily record sheet. |
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Term
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Definition
| A specific dollar amount that must be paid by the insured before a medical insurance plan or government progam begins covering health care costs. |
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Term
| Disability income insurance(3) |
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Definition
| A form of health insurance that provides periodic payments to replace income when the insured is unable to work as a result of illness, injury, or disease - not as a result of a work-related accident or condition |
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Term
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Definition
| An individualized computer acess and indintification system (e.g., a seriess of numbers, letters, electronic writing, voice, computer key, and fingerprint transmission [biometric]) accepted by both parties to show intent, approval of, or responisibility for somputer document consent. |
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Term
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Definition
| Qualifying factors that must be met before a patient recieves benfits (medical services) under a specified insurance plan, goverment program or maganged care plan. |
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Term
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Definition
| A person younger than 18 years of age who lives independently, is totally self-supporting, and possesses decision-making rights. |
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Term
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Definition
| An all-encompassing billing form personalized to the pracice of th ephysician, it ma be used when a patient submits an insurance billing; also called charge slip, communicator, multipurpose billing form, fee ticket, patient service slip, routing form, superbill, and transaction slip. |
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Term
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Definition
| Provisions written into the insurance contract dnying coverage or limiting the scope of coverage. |
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Term
| Exclusive Provider Organization (EPO)(3) |
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Definition
| A type or maganged health care plan that combines features of HMOs and PPOs. It is referred to as "exclusive" because it is offered to large inployers who agree not to contract with any other plan. EPOs ar regulated under state health insurance laws. |
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Term
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Definition
| A verbal or written agreement. |
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Term
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Definition
| To carry forward the balance of an individual financial accounting record. |
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Term
| Financial Accounting Record(3) |
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Definition
| An individual record indicating charges, payments, adjustments, and balances owed for services rendered; also known as a ledger. |
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Term
| Foundation for Medical Care (FMC)(3) |
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Definition
| An organization of physicians wponsored by a state or local medical association concerned with the development and deliver of medical services and the cost of health care. |
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Term
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Definition
| A clause in an insurance policy that means the insurance company must renew the policy as long as the premium payments are made. However, the premium my be increased with it is renewed. These policies may have age limits of 60, 65, or 70 years or may be renewable for life. |
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Term
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Definition
| An individual who promise to pay the medical bill by sighning a rom agreeing to pay or who accepts treatment, which sonstitutes and expressed promise. |
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Term
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Definition
| A contract between the policyholder or member and insurance carrier or government program to reimburse the policyholder or memeber for all or a portion of the cost of medical care rendered by health care professionals; generic term applying to lost income arising from illness or injury; also known as accident and health insurance or disability income insurance, |
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Term
| Health Maintenance Organization (HMO)(3) |
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Definition
| The oldest of all prepaid health plans. A comprehensive health care financing and delivery ortganization that provides a wide range of health care services with an emphasis on preventive medicine to enrollees with a geographic area through a panel or providers. Primary care physician "gatekeepers" are usually reimbursed via capitation. In genera, enrollees do not receive coverage fo rthe services from providers who are not in the the HMO network, except for emergency services. |
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Term
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Definition
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Term
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Definition
| A contract between physician and patient not manifessted by direct words but imopliedor deduced from the circumstance, general language, or conduct of the patient. |
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Term
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Definition
| Benefits paid to an insured while disabled; also known as reimbursement. |
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Term
| Indepentent or individual practice association (IPA)(3) |
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Definition
| A type of HMO in which a program administrator contracts with a number of physicians who agree to provide treatment to subscribers in their own offices. Physicians are not employees of the managed care orgaization (MCO) and ar not paid calaryies. They receive reimbursement on a capitation or fee-for-service basis; also referred to as a medical capitation plan. |
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Term
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Definition
| An individual or organization protected in case of a loss uner the terms of an inurance policy. |
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Term
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Definition
| A health insurance policy designed to offset heavy medical expenses resuliting from atastrophic or prolonged illness or injury. |
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Term
| Maternal and Child Health Program (MCHP)(3) |
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Definition
| A state service organization to assist children younger that 21 years of age who have conditions leading to health problems. |
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Term
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Definition
| A federally aided, state-operated, and state-administered program that provides medical benefits for certain low-income persons in need of health and medical care. California's Medicaid program is know as Medi-Cal |
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Term
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Definition
| A nationwide health insurance program for persons 65 years of age and older and certain desabled or blind persons regardless of income, administered by HCFA. Local Social Secuity offices take applications and supply information about the program. |
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Term
| Medicare/Medicaid (Medi-Medi)(3) |
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Definition
| Refers to an individual who recieves medical or disability benefits from both Medicare and Medicaid programs; sometimes referred to as Medi-Medi case or a crossover. |
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Term
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Definition
| Person covered under an insurance program's contract, including (1) the subscriber or contrac holder who is the person named on the memebership identification card and (2) in the case of (a) two-person coverage, (b) one adult-one chile coverage, or (c) family coverage, the eligible family depenents enrolled under the subscriber's contract. |
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Term
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Definition
| An insurance policy clause that means the insurance company cannot increase premium rates and must renew the policy until the insured reaches the age stated in the contract. Some disability income policies have non-cancelable terms. |
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Term
| Nonparticipating Provider (nonpar)(3) |
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Definition
| A provider who does not have a signed agreement with Medicare and has an option about assignment. The physician may not accept assignment for all servies or has the option of accepting assignment for some services and collecting from the patient for other services perfomed at the same time and place. |
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Term
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Definition
| An insurance policy renewal provision in which the insureer has the right to refuse to renew the policy on a date and may add coverage limitations or increases premium rates |
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Term
| Participating provider (par)(3) |
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Definition
| One who accepts TRICARE assignment. Payment in this case goes directly to the provider. The patient must still pay the cost-share outpatient deductible and the cost of care not covered my TRICARE. See Assignment |
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Term
| Patient registration form(3) |
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Definition
| A questionnaire designed to collect demographic data and essential facts about medical insurance coverage for each patient seen for professional services; also called patient information form. |
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Term
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Definition
| An insurance plan issued to an individual (or his or her dependents); also known as individual contract. |
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Term
| Point-of-service (POS) plan(3) |
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Definition
| A Managed care plan in which memebers are given a choice as to how to receive services, whether through an HMO, PPO, or fee-for-service plan. The decision is made at the time the service is necessary (e.g., "at the point of service"); sometimes referred to as epen-ended HMO's, swing-out HMO's, self-referral options, or multiple option plans. |
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Term
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Definition
| To record or transfer financial entries, debit or credit, to an accout (e.g., daysheet, financial account record [ledger], bank deposit slip, check register, journal.) |
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Term
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Definition
| A requirement of some health insurance plans to obtain permission for a service or procedure before it is done and to see whether the insurance program agrees it is medically necessary. |
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Term
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Definition
| A procedure done to determine whether treatment (surgery, tests, or hospitalization) is covered under a patients's health insurance policy. |
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Term
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Definition
| A financial inquiry done before treatment to determine the maximum dollar amount the insurance company will pay for surgery, consultations, postoperative care, and so forth. |
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Term
| Preexisting conditions(3) |
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Definition
| Illness or injuries acquired by the patient before enrollment in an insurance plan. In some insurance plans, preexisting conditions are excluded from coverage temporarily or permanently or may disqualify membership in the plan. |
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Term
| Preferred Provider Organization (PPO)(3) |
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Definition
| A type of health benefit program in which the enrollees receive the highest level of benefits when they obtain services from a physician, hospital, or other health care provider designated by their program as a "preferrred provider." Enrollees may receive substantial, although reduced, benefits when they obtain care from a provider of their own choosing who is not designated as a "preferred provider" by their program. |
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Term
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Definition
| The cost of insurance coverage paid annually, semiannually, or monthly to keep the policy in force. In the Medicare program, monthyly fee that enrollees pay for Medicare Part B medical insurance. This fee is updated annually to reflect changes in program costs. |
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Term
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Definition
| An amount owed on a credit transaction; also know as oustanding or unpaid balance. |
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Term
| State Disability Insurance (SDI)(3) |
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Definition
| Insurance that covers off-the-job injury or sickness and is paid for a deductions from a person's paycheck. This program is administered by a state agency and is sometimes also known as State Disability Insurance (SDI) or temporary disability insurance (TDI). |
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Term
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Definition
| The contract holder covered by an insurance program or managed care plan, who either has a coverage through his or her place of employment or has purchased coverage directly from the plan or affiliate. This term is used primarily in Blue Cross and Blue Sheild plans. |
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Term
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Definition
| A three-option managed health care program offered to spouses and dependents of service personnel with uniform benefits and feels implemented nationwide by the federal government. |
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Term
| Unemployment compensation disability (3)(UCD) |
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Definition
| Insurance that covers off-the-job injury or sickness and is paid for a deductions from a person's paycheck. This program is administered by a state agency and is sometimes also known as State Disability Insurance (SDI) or temporary disability insurance (TDI). |
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Term
| Veterans Affairs (VA) out patient clinic(3) |
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Definition
| A facility where medical and dental services for service-related disabilites from a clinic. |
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Term
| Workers' compensation (WC) insurance(3) |
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Definition
| A contract that insures a person agains on-the-job injury or illness. They employer pays the premium for his or her employees. |
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Term
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Definition
| A medical condition that runs a short but relatively severe course. |
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Term
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Definition
| A medical staff memeber who is legally responsible for the care and treatment given to a patient. |
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Term
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Definition
| A patient's statement describing symptoms, problems, or conditions as the reson for seaking health care services from a physician. |
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Term
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Definition
| A medical condition persisting over a long period of time. |
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Term
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Definition
| An ongoing condition that exists along with the condition from which the patient is receiving treatment; in regard, to DRGs, a preexisting condition that, because of its presence with a certain principal diagnosis, will caruse and increase in length of stay by at least 1 day in approximately 75% of cases. Also known as substantial comorbidity. |
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Term
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Definition
| A term used to describe a level of history or physical examiniation. |
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Term
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Definition
| The provision of similar services (e.g., hospital visits) to the same patient by more than one physician on the same day. Usually a serperate physical disorder is present. |
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Term
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Definition
| Services rendered by a physican whos opinion or advice is requested by another physican or angency in the evaluation or treatment of a patient's illness or suspected problem. |
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Term
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Definition
| A provider whose opinion or advice about evaluation or management of a specific problem is requested by another physician. |
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Term
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Definition
| When a physician sees a patient who has received treatment for a condition and is referred by the previous doctor for treatment of the same condition. |
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Term
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Definition
| A discussion between the physican and a patient, family, or both concerning the diagnosis, recommended studies or tests, prognosis, resks, and benefits or treatment, treatment options, patient and family education, and so on. |
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Term
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Definition
| In reference to coding professional services, this phrase relates to the intensive care provided in a varity of acute life-threatening conditions requiring constant bedside attention by a physician. |
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Term
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Definition
| A term used to describe a level of history or physical examination. |
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Term
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Definition
| A chronologic detailed recording of pertinient facts and observations about a patient's health as seen in chart notes and medical reports; entries in the medical record such as prescription refills, telephone calls, and other pertinent data. For computer software, a user's guide to a program or piece of equipment. |
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Term
| electronic health recordd (EHR)(4) |
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Definition
| A patient record that is created using a computer with software. A template is brought up and by answering a series of questions data are entered. |
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Term
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Definition
| Health care services provided to prevent serious impairment of bodily functions or serious dysfunction to any body organ or part. Advanced life support may be necessary. Not all are provided in an emergency department of a hospital can be termed "emergency care." |
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Term
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Definition
| The name of a disease, anatomic structure, operation, or procedure, usually derived from the name of a place where it first occurred or a person who discovered or first described it. |
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Term
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Definition
| An individual who has recieved professional services within the past 3 years from the physician or another physician of the same specialty who belongs to the same group practice. |
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Term
| expanded problem focused (EPF)(4) |
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Definition
| A phrase used to describe a level of history or physical examiniation. |
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Term
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Definition
| A review done after claims have been submitted (retrospective review) of medical and financial records by an insurance company or Medicare representative to investigate suspected fraud or abusive billing practices. |
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Term
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Definition
| An electronic process for transmitting graphic and written documents over telephone lines; also referred to as fax. |
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Term
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Definition
| A review of medical events in the patient's family including diseases that may be hereditary or place the patient at risk. |
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Term
| health record/medical record(4) |
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Definition
| Written or graphic information documenting facts and events during the rendering of patient care. Also known as medical record. |
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Term
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Definition
| A phrase used to describe a type of medical decision making when a patient is seen for an E/M service. |
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Term
| history of present illness (HPI)(4) |
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Definition
| A chronologic description of the development of the patient's present illness from the first sign or symptom or from the previous encounter to the present. |
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Term
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Definition
| The process of going over financial documents before and after billing to insuance arriers to determine documentation deficiencies or errors. |
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Term
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Definition
| Phrase used to describe a type of medical decision making when a patient is seen for an E/M service |
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Term
| medical decision making (MDM)(4) |
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Definition
| Health care management process deone after performing a history and physical examination on a patient that results in a plan of treatment. It is based on establishing one or more diagnoses and/or selecting a management or treatment option, amount of data or complexity of data reviewed, and complications and/or morbidity or mortality. |
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Term
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Definition
| The performance of services and procedures that are consistent with the diagnosis in accordance with standards of good medical practice, performed at the proper level, and provieded in the most appropriate setting. Medical necessity must be established (via diagnostic or other information presented on the individual claim under consideration) before the carrier may make a payment. |
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Term
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Definition
| A permanent, legal document (letter or report format) that formally states the consequences of the patient's examination or treatment. |
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Term
| moderate complexity (MC)(4) |
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Definition
| A phrase used to describe a type of medical decision making when a patient is seen for an E/M sevice. |
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Term
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Definition
| An individual who has not received any professional servies from the physician or another physican of the same specialty who belongs to the same group practice within the past 3 years. |
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Term
| non-physician practitioner (NPP)(4) |
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Definition
| Health care provider who meets state licensing requirements to provide specific medical services. Medicare allows payment for services furnished by non-physician practitioners including, by not limited to, advance registered nurse practitioners (ARNPs), certified registered nurse practitioners, clinical registered nurse practitioners, clinical nurse specialists (CNSs), licensed clinical social workers (LCSWs), physician speech therapists, and audiologists. Also referred to as midlevel practitioner, midlevel provider (MLP), or physican extender (PE). |
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Term
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Definition
| The physician ordering non-physician servies for a patient (e.g., diagnostic laboratory tests, pharmaceutical services, or durable medical equipment) when an insurance claim is submitted by a nonphysican supplier of services. The odering physician also may by the treating or performing physician. |
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Term
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Definition
| A patient's past experiences with illnesses, operations, injuries, and treatments. |
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Term
| physical examination (PE or PX)(4) |
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Definition
| Objective inspection or testing of organ systems or body areas of a patien by a physician. |
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Term
| primary care physician (PCP)(4) |
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Definition
| A physician (e.g., family practitioner, general practitioner, pediatrician, obstetrician/gynegologist, or genteral internist) who oversees the care of patients in a managed health care plan (HMO or PPO) and refers patients to see specialists (e.g., cardiologists, oncologists, or surgeons) for services ad needed. Also knows as a gatekeeper. |
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Term
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Definition
| A phrase used to describe a type of medical decision making when a patient is seen for an E/M service. |
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Term
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Definition
| The process of going over financial documents before billing is submitted to the insurance company to determine documentation deficiencies and errors. |
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Term
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Definition
| The process of going over financial documents after billing and insurance carrier to determine documentation deficiencies and errors. |
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Term
| review of systems (ROS)(4) |
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Definition
| An inventory of body systems obtained through a series of questions used to identify signs or symptoms that the patient might be experiencing or has experienced. |
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Term
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Definition
| An age-appropriate review or a patient's past and current activites (e.g., smoking, diet intake, alcohol use). |
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Term
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Definition
| Phrase sued to describe a trype of medical decision making when a patient is seen for an E/M service. |
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Term
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Definition
| "Under penalty." A writ that commands a witness to appear at a trial or other proceeding and give testimony. |
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Term
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Definition
| "In his possession." A subpoena that requires the appearanc eof a witness with his or her records. Sometimes the judge permits the mailing of records and it is not nexessary for the physician to appear in court. |
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Term
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Definition
| A physician who is responsible for trainign and supervising medical students, interns, or residents and who takes them to the bedisdes of patients in a teaching hospital to review course and treatment. |
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Term
| treating or performing physician(4) |
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Definition
| A provider who renders a service to a patient. |
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Term
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Definition
| An unfavorable, detrimental, or pathologic reaction to a drug that occurs when appropriate doses are given to humans for prophylaxis (prevention of disease), diagnosis, and therapy. |
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Term
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Definition
| An abnormal growth that does not have the properties of invasion and metastasis and is usually surrounded by a fibrous capsule; also called a neoplasm. |
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Term
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Definition
| A patient's statement describing symptoms, problems, or conditions as the reason for seekign health care services from a physician. |
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Term
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Definition
| A code from one section of the procedural code book combined with a code from another section that is used to completely describe a procedure performed; in diagnostic coding, a single five-digit code used to identify etiology and secondary process (manifestation) or complication of a disease. |
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Term
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Definition
| A disase or condition arising during the couse of, or as a result of, another disease modifying medical care requirements; for DRGs, a condition that arises during the hospital stay that prolongs the length of stay by at least 1 day in approximately 75% of cases. Also known as substantial complication. |
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Term
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Definition
| Rules or principles for determining a diagnostic code when using diagnostic code books such as each space, typefaces, indetations, punctuation marks, instructional notes, abbreviations, cross-reference notes, and specific usuage of the words and, with, and due to. These rules assist in the selction of correct codes for the diagnoses encountered. |
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Term
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Definition
| A classification of ICD-9-CM coding used to describe enviromental events, circumstances, and conditions as the external cause of injury, poisoning, and other adverse effects. E codes are also used in coding adverse reactions to medications. |
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Term
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Definition
| The name of a disease, anatomic structure, operation, or procedure, usually derived from the name of a place where it first occurred or a person who discovered or first described it. |
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Term
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Definition
| The cause of disease; the study of the cause of a disease. |
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Term
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Definition
| A description applied to a malignant growth confined to the site of origin without invasion of neighboring tissues. |
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Term
| Internationsl Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM)(5) |
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Definition
| A diagnostic code book that uses a syspem for classifying diseases and operations to assist collection of uniform and comparable health information. A code system used to replace this IDE-10, which is being modified for use in the United States. |
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Term
| International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM)(5) |
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Definition
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Term
| International Classification of Diseases, Tenth Revision, Procedural Coding System (ICD-10-PCS)(5) |
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Definition
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Term
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Definition
| A dignostic coding term that relates to an adverse effect rather than a poisoning when drugs such as digitalis, steroid agents, and so on are involved. |
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Term
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Definition
| A diagnostic code in ICD-9-CM, Volume 1, Tabular list, that may never be sequenced as the principal diagnosis. |
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Term
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Definition
| An inactive residual effect or condition produced after the acute pahse of an illness or injury has ended. |
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Term
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Definition
| An abnormal growththat has the properties of invasion and metastasis (e.g., transfer of diseases from one organ to another). The word carcinoma (CA) refers to a cancerous or malignant tumor. |
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Term
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Definition
| Process in which tumor cells spread and transfer from one organ to another site. |
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Term
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Definition
| A spontaneous new growth of tissue forming and abnormal mass that is known as a tumor. It may be benign or malignant. |
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Term
| not elsewhere classifiable (NEC)(5) |
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Definition
| This term is used in the ICD-9-CM diagnostic coding system when the code lacks the information necessary to code the term in a more specific category. |
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Term
| not otherwise specified (NOS)(5) |
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Definition
| Unspecified. Used in ICD-9-CM numeric code system for coding diagnoses. |
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Term
| physicians's fee profile(5) |
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Definition
| A compilation of each physician's charges and the payments made to him or her over a given period of time for each specifice professional service rendered to a patient. |
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Term
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Definition
| A condition resulting from and overdose of drugs or chemical substances or from the wrong drug or agent given or taken in error. |
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Term
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Definition
| Initial identification of the condition or cheif complaint for which the patient is treated for outpatient medical care. |
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Term
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Definition
| A condition established after study that is cheifly responsible for the admission of the patient to the hospital. |
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Term
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Definition
| A reason subsequent to the primary diagnosis for an offic eor hospital encounter that may contribute to the condition or define the need for a higher level of care but is not the underlying cause. There may be more that one secondary diagnosis. |
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Term
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Definition
| A symbol used with a diagnositic code in ICD-9-CM, Volume 2, Alphabetic Index, indicating the code may be sequenced as the principal diagnosis. |
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Term
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Definition
| Another name for a symptom complex (a set of complex signs, symptoms, or other manifestations resulting from a common cause or appearing in combination, presenting a distinct clinical picture or a disease or inherited abnormality). |
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Term
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Definition
| A subclassification of ICD-9-CM coding used to identify health care encounters that occur for reasons other than illness or injury and to identify patients whose injury or illness is influenced by special circumstances or problems. |
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Term
| alternative billing codes (ABCs)(6) |
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Definition
| A code system for integrative health care products and services consisting of five-character alphabetic symbols with appended two-character practitioner modifiers that represent the practitioner type. |
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Term
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Definition
| When coding surgical procedures, this term refers to both sides of the body. |
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Term
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Definition
| To group more than one component (service or procedure) into one CPT code. |
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Term
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Definition
| A single procedural code that describes or covers two or more CPT component codes that are bundled together as one unit. |
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Term
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Definition
| The dollars and cents amoun that is established for one unit as applied to a procedure or service rendered. This unit is then used to convert various procedures into fee-schedule payment amounts by multiplying the relative value unit by the conversion factor. |
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Term
| Current Procedual Terminology (CPT)(6) |
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Definition
| A reference procedual code book useing a five-diget numerical system to identify and code procedures established by the American Medical Association. |
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Term
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Definition
| The amount that a physician usually charges most of his or her patients. |
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Term
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Definition
| This occurs when the coding system used by the physician's office on a claim does not match the coding system used by the insurance company receiving the claim. The insurance company computer system converts the code submitted to the closest code in use, which is usually down one level from teh submitted code, generating decreased payment. |
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Term
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Definition
| A list of charges or established allowances for specific medical services and procedures. See also Relative value studies (RVS) |
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Term
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Definition
| A Medicare plicy relating to surgical procedures in which preoperative and postoperative visits (24 hours before [major} and day of [minor]), usual, intraoperative servies, and complications not requiring additional trips to the operating room are included in one fee. |
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Term
| Healthcare Common Procedue Coding System (HCPCS)(6) |
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Definition
| The CMS's Common Procedure Coding System. A three-tier national uniform coding system developed by the Centers for Medicare and Medicaid Services (CMS), formerly HCFA, used for reporting physician or supplier servies and procedures under the Medicare program. Level I codes are national CPT codes. Level II codes are HCPCS national codes used to report items not covered un CPT. Level III codes are HCPCS regional or local codes used to identify new procedures or items for which there is no national code. Pronounced "high-picks." |
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Term
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Definition
| In CPT coding, a two-digit add-on number placed after the usual procedure code number to indicate a procedure or service had been altered by specific circumstances. The two-digit modifier may be serpated by a hypen. In HCPCS level II coding, one-digit or two-digit add-on alpha characters, placed after the usual procedure code number (Example G.1). |
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Term
| procedure code numbers(6) |
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Definition
| Five-digit numeric codes that describe each sevice the physician renders to a patient. |
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Term
| professional component (PC)(6) |
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Definition
| That portion of a test or procedure (containing both a professional and technical componet) which the physician performs (e.g., interpreting and electrocardiogram [ECG], reading an x-ray, making an obervation and determination using a microscope). |
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Term
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Definition
| A charge is considered reasonable if it is deemed acceptable after peer review even though it does not meet the customary or prevailing criteria. This includes unusual circumstances or complications requiring additional time, skill, or experience in connection with particular service or procedure. In Medicare, the amount on which payment is based for participating physicians. |
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Term
| relative value studies (RVS)(6) |
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Definition
| A list of procedure codes for professional servies and procedures that are assigned unit values that indicate the relative value of one procedure over another. |
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Term
| relative value unit (RVU)(6) |
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Definition
| A monetary value assigned to each service on the basis of the amount of physican work, proactice expenses, and cost of professional liability insurance. These three RVUs are then adjusted according to geographic area and used in a formula to determine Medicare fees. |
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Term
| resource-based relative value scale (RBRVS)(6) |
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Definition
| A system that ransk physicians services by units and provides a formula to determine a Medicare fee schedule. |
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Term
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Definition
| Surgical procedure code numbers include the operation; local infiltration, digital block, or topical enesthesia; and normal, uncomplicated postoperative care. This is referred to as a package, and one fee covers the whole package. |
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Term
| technical component (TC)(6) |
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Definition
| Portion of a test of procedure (containing both technical and a professional component) that pertains to the use of the equipment and the operator who performs it (e.g, ECG machine and techinician, radiography machine and technician, microscope and techinician. |
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Term
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Definition
| The practice of using numerous CPT codes to identify procedures normally covered by a single code; also known as itemizing, fragmented billing, exploding, or a la carte medicine; billing under Medicare Part B for nonphysician services to hospital inpatients furnisshed to the hospital by an outside supplier or another provider. Under the new law, unbundling is prohibited and all nonphysician servics provided in an inpatient setting will be paid as hospital services. |
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Term
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Definition
| Deliberate manipulation of CPT codes for increased payment. |
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Term
| usual, customary, and reasonable (UCR)(6) |
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Definition
| A method used by insurance companies to establish their fee schedules in which three fees are considered in calculating payment: (1) the usual fee is the fee typically submitted by the physician, (2) the customary fee falls within the range of usual fees charged by providers of similar training in a geographic area, and (3)the reasonable fee meets the aforementioned criteria or is considered justifiable because of special circumstances. UCR used the conversion factor metod of establishing maximums; the method of reimbursement used under Medicaid by which state Medicaid programs set reimbursement rates using the Medicare method or a fee schedule, whichever is lower. |
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Term
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Definition
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Term
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Definition
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Term
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Definition
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Term
| durable medical equipment (DME) number(7) |
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Definition
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Term
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Definition
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Term
| employer identification number (EIN)(7) |
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Definition
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Term
| facility provider number(7) |
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Definition
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Term
| group National Provider Identifier (group NPI)(7) |
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Definition
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Term
| Health Insurance Claim Form (CMS-1500 [08-05])(7) |
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Definition
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Term
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Definition
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Term
| intelligent character recognition (ICR)(7) |
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Definition
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Term
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Definition
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Term
| National Provider Identifier (NPI)(7) |
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Definition
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Term
| optical character recognition (OCR)(7) |
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Definition
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Term
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Definition
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Term
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Definition
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Term
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Definition
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Term
| physically clean claim(7) |
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Definition
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Term
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Definition
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Term
| Social Security Number (SSN)(7) |
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Definition
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Term
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Definition
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Term
| Accredited Standards Committee X12 (ASC X12) (8) |
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Definition
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Term
| application service provider (ASP)(8) |
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Definition
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Term
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Definition
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Term
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Definition
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Term
| business associate agreement(8) |
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Definition
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Term
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Definition
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Term
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Definition
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Term
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Definition
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Term
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Definition
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Term
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Definition
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Term
| digital subscriber line (DSL)(8) |
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Definition
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Term
| direct data entry (DDE)(8) |
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Definition
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Term
| eletronic data interchange (EDI)(8) |
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Definition
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Term
| electronic funds transfer (EFT)(8) |
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Definition
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Term
| electronic remittance advice (ERA)(8) |
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Definition
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Term
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Definition
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Term
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Definition
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Term
| HIPAA Transaction and Code Set (TCS) Rule(8) |
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Definition
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Term
| National Standard Format (NSF)(8) |
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Definition
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Term
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Definition
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Term
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Definition
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Term
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Definition
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Term
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Definition
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Term
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Definition
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Term
| trading partner agreement(8) |
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Definition
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