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Billing and Coding
General Abbreviations
| Term | Definition |
|---|---|
| ABN | ADVANCED BENEFICIARY NOTICE |
| AMA | AMERICAN MEDICAL ASSOCIATION |
| AOB | ASSIGNMENTS OF BENEFITS |
| CDC | CENTER FOR DISEASE CONTROL |
| CPT-4 | CURRENT PROCEDURAL TEMINOLOGY 4TH VERSION |
| DNR | DO NOT RESUSCITATE |
| EHR | ELECTRONIC HEALTH RECORD |
| EMR | ELECTRONIC MEDICAL RECORD |
| EOB | EXPLANATION OF BENEFITS |
| HCPCS | HEALTHCARE COMMON PROCEDURE CODING SYSTEM |
| HHS | HEALTH AND HUMAN SERVICES |
| HIPAA | HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT |
| HMO | HEALTH MAINTENANCE ORGANIZATION |
| ICD-10 CM | INTERNATIONAL CLASSIFICATION OF DISEASE 10 REVISION CLINICAL MODICATION |
| IIHI | INDIVIDUALLY IDENTIFIABLE HEALTH INFORMATION |
| NPP | NOTICE OF PRIVACY PRACTICES |
| OCR | OFFICE OF CIVIL RIGHTS |
| OIG | OFFICE OF INSPECTOR GENERAL |
| P&P | POLICIES AND PROCEDURES |
| PHI | PROTECTED HEALTH INFORMATION |
| PO | PRIVACY OFFICER |
| POMR | PROBLEM-ORIENTED MEDICAL RECORD |
| PPO | PREFERRED PROVIDER ORGANIZATION |
| RA | REMITTANCE ADVICE |
| RBRVS | RESOURCE BASED RELATIVE VALUE SCALE |
| SO | SECURITY OFFICER |
| SOAP | SUBJECTIVE, OBJECTIVE, ASSESSMENT PLAN |
| TPO | TREATMENT PAYMENT AND HEALTHCARE OPERATIONS |
| ABSTRACTING | THE EXTRACTION OF SPECIFIC DATA FROM A MEDICAL RECORD, OFTEN FOR USE IN AN EXTERNAL DATABASE, SUCH AS A CANCER REGISTRY. |
| ABUSE | PRACTICES THAT DIRECTLY OR INDIRECTLY RESULT IN UNNECESSARY COSTS TO THE MEDICARE PROGRAM. |
| ACCOUNT NUMBER | NUMBER THAT IDENTIFIES SPECIFIC EPISODE OF CARE, DATE OF SERVICE OR PATIENT. |
| ACCOUNTS RECEIVABLE DEPARTMENT | DEPARTMENT THAT KEEPS TRACK OF WHAT THIRD-PARTY PAYERS THE PROVIDER IS WAITING TO HEAR FROM AND WHAT PATIENTS ARE DUE TO MAKE PAYMENTS. |
| ADVANCED BENEFICIARY NOTICE OF NON-COVERAGE | FORM PROVIDED IF A PROVIDER BELIEVES THAT A SERVICE MAY BE DECLINED BECAUSE MEDICARE MIGHT CONSIDER UNNECESSARY. |
| AGING REPORT | MEASURES THE OUTSTANDING BALANCES IN EACH ACCOUNT |
| AHIMA | AMERICAN HEALTH INFORMATION MANAGEMENT ASSOCIATION. |
| ALLOWABLE CHARGE | THE AMOUNT AN INSURER WILL ACCEPT AS FULL PAYMENT MINUS APPLICABLE COST SHARING |
| APC GROUPER | HELPS CODERS DETERMINE THE APPROPRIATE AMBULATORY PAYMENT CLASSIFICATION (APC) FOR AN OUTPATIENT ENCOUNTER |
| AUDITING | REVIEW OF CLAIMS FOR ACCURACY AND COMPLETENESS |
| AUTHORIZATION | PERMISSION GRANTED BY THE PATIENT OR THE PATIENT'S REPRESENTATIVE TO RELEASE INFORMATION FOR REASONS OTHER THAN TPO. |
| BALANCE BILLING | BILLING PATIENTS FOR CHARGES IN EXCESS OF THE MEDICARE FEE SCHEDULE |
| BATCH | A GROUP OF SUBMITTED CLAIMS |
| BUSINESS ASSOCIATE (BA) | INDIVIDUALS, GROUPS OR ORGANIZATIONS WHO ARE NOT MEMBERS OF A COVERED ENTITY'S WORKFORCE THAT PERFORM FUNCTIONS OR ACTIVITIES ON BEHALF OF OR FOR A COVERED ENTITY. |
| CARC'S | CLAIM ADJUSTMENT REASON CODES |
| CLEAN CLAIM | CLAIM THAT IS ACCURATE AND COMPLETE. ALL INFORMATION IS FILLED OUT AND CLAIM IS FILED IN A TIMELY MANNER. |
| CLEARINGHOUSE | AGENCY THAT CONVERTS CLAIMS INTO A STANDARDIZED ELECTRONIC FORMAT, LOOKS FOR ERRORS AND FORMATS THEM ACCORDING TO HIPAA AND INSURANCE STANDARDS |
| CMS | CENTERS FOR MEDICARE AND MEDICAID SERVICES |
| COINSURANCE | THE PRE-ESTABLISHED PERCENTAGE OF EXPENSES PAID BY THE INSURANCE COMPANY AFTER THE DEDUCTIBLE HAS BEEN MET. |
| COMPUTER-ASSISTED CODING (CAC) | SOFTWARE THAT SCANS THE ENTIRE PATIENT'S ELECTRONIC RECORD AND CODES THE ENCOUNTER BASED ON THE DOCUMENTATION IN THE RECORD. |
| CONDITIONAL PAYMENT | MEDICARE PAYMENT THAT IS RECOVERED AFTER PRIMARY INSURANCE PAYS. |
| CONSENT | A PATIENT'S PERMISSION EVIDENCED BY SIGNATURE |
| COORDINATION OF BENEFITS | DETERMINES WHICH INSURANCE PLAN IS PRIMARY AND WHICH IS SECONDARY |
| COPAYMENT | A FIXED DOLLAR AMOUNT THAT MUST BE PAID EACH TIME A PATIENT VISITS A PROVIDER |
| COST SHARING | THE BALANCE THE POLICYHOLDER MUST PAY TO THE PROVIDER |
| CROSS OVER CLAIM | CLAIM SUBMITTED BY PEOPLE COVERED BY A PRIMARY AND SECONDARY PLAN |
| DEDUCTIBLE | THE AMOUNT OF MONEY A PATIENT MUST PAY OUT OF POCKET BEFORE THE INSURANCE COMPANY WILL START TO PAY FOR COVERED BENEFITS |
| DE-IDENTIFIED INFORMATION | INFORMATION THAT DOES NOT IDENTIFY AN INDIVIDUAL BECAUSE UNIQUE AND PERSONAL CHARACTERISTICS HAVE BEEN REMOVED |
| DEMOGRAPHIC INFORMATION | DATE OF BIRTH, SEX, MARITAL STATUS, ADDRESS, PHONE NUMBER, RELATIONSHIP TO SUBSCRIBER, AND CIRCUMSTANCES OF CONDITIONS. |
| DIRTY CLAIM | CLAIM THAT IS INACCURATE, INCOMPLETE, OR CONTAINS OTHER ERRORS. |
| ELECTRONIC DATA EXCHANGE (EDI) | THE TRANSFER OF ELECTRONIC INFORMATION IN A STANDARD FORMAT. |
| ENCODER | SOFTWARE THAT SUGGESTS CODES BASED ON DOCUMENTATION |
| ENCOUNTER | A DIRECT, PROFESSIONAL MEETING BETWEEN A PATIENT AND A HEALTH CARE PROFESSIONAL WHO IS LICENSED TO PROVIDE MEDICAL SERVICES. |
| ENCOUNTER FORM | FORM THAT INCLUDES INFORMATION ABOUT PAST HISTORY, CURRENT HISTORY, INPATIENT AND INSURANCE INFORMATION. |
| EXPLANATION OF BENEFITS (EOB) | DESCRIBES THE SERVICES RENDERED, PAYMENT COVERED AND BENEFIT LIMITS AND DENIALS. |
| FAIR DEBT COLLECTION PRACTICES ACT (FDCPA) | THIS LAW STATES THAT DEBT COLLECTORS CANNOT USE UNFAIR OR ABUSIVE PRACTICES TO COLLECT PAYMENTS. |
| FALSE CLAIMS ACT | THE FALSE CLAIMS ACT PROTECTS THE GOVERNMENT FROM BEING OVERCHARGED FOR SERVICES PROVIDED OR SOLD, OR SUBSTANDARD GOODS OR SERVICES |
| FORMULARY | A LIST OF PRESCRIPTION DRUGS COVERED BY AN INSURANCE PLAN |
| FRAUD | MAKING FALSE STATEMENTS OR REPRESENTATIVES OF MATERIAL FACTS TO OBTAIN SOME BENEFIT OR PAYMENT FOR WHICH NO ENTITLEMENT EXISTS. |
| PCP | PRIMARY CARE PHYSICIAN |
| GATEKEEPER | PRIMARY CARE PHYSICIAN |
| HEALTH MAINTENANCE ORGANIZATION (HMO) | PLAN THAT ALLOWS PATIENTS TO ONLY GO TO PHYSICIANS, OTHER HEALTH CARE PROFESSIONALS, OR HOSPITALS ON A LIST OF APPROVED PROVIDERS EXCEPT FOR EMERGENCY. |
| HEALTH RECORD NUMBER | NUMBER THE PROVIDER USES TO IDENTIFY AN INDIVIDUAL PATIENT'S RECORD |
| IMPLIED CONSENT | A PATIENT PRESENTS FOR TREATMENT, SUCH AS EXTENDING AN ARM TO ALLOW A VENI-PUNCTURE TO BE PERFORMED |
| INFORMED CONSENT | PROVIDERS EXPLAIN MEDICAL OR DIAGNOSTIC PROCEDURES, SURGICAL INTERVENTION, AND THE BENEFITS AND RISKS INVOLVED, GIVING PATIENTS AN OPPORTUNITY TO ASK QUESTIONS BEFORE MEDICAL INTERVENTION IS PROVIDED. |
| MEDICAID | A GOVERMENT BASED HEALTH INSURANCE OPTION THAT PAYS FOR MEDICAL ASSISTANCE FOR INDIVIDUALS WHO HAVE LOW INCOMES AND LIMITED FINANCIAL RESOURCES. FUNDED AT THE STATE AND NATIONAL LEVEL. ADMINISTERED AT THE STATE LEVEL. |
| MEDICARE ADMINISTRATIVE CONTRACTOR (MAC) | PROCESS MEDICARE PARTS A & B CLAIMS FROM HOSPITALS, PHYSICIANS, AND OTHER PROVIDERS. |
| MEDICARE PART A | HOSPITALIZATION COVERAGE FOR ELIGIBLE INDIVIDUALS |
| MEDICARE PART B | ALL PROFESSIONAL SERVICES |
| MEDICARE PART C | COMBINATION PART A & B |
| MEDICARE PART D | PRESCRIPTION COVERAGE |
| MEDICARE SUMMARY NOTICE | DOCUMENT THAT OUTLINES THE AMOUNT BILLED BY THE PROVIDER AND WHAT THE PATIENT MUST PAY THE PROVIDER |
| MEDICARE | FEDERALLY FUNDED HEALTH INSURANCE PROVIDED TO PEOPLE AGE 65 OR OLDER, PEOPLE YOUNGER THAN 65 WHO HAVE CERTAIN DISABILITIES, AND PEOPLE OF ALL AGES WITH END-STAGE KIDNEY DISEASE. FUNDED AND ADMINISTERED AT THE NATIONAL LEVEL. |
| MEDIGAP | A PRIVATE HEALTH INSURANCE THAT PAYS FOR MOST OF THE CHARGES NOT COVERED BY A & B. |
| MODIFIER | ADDITIONAL INFORMATION ABOUT TYPES OF SERVICES, AND PART OF A VALID CPT OR HCPCS CODES. |
| MORBIDITY | THE NUMBER OF CASES OF DISEASE IN A SPECIFIC CONDITION |
| MORTALITY | THE INCIDENCE OF DEATH IN A SPECIFIC POPULATION |
| MS-DRG GROUPER | SOFTWARE THAT HELPS CODERS ASSIGN THE APPROPRIATE MEDICARE SEVERITY DIAGNOSIS - RELATED GROUP BASED ON THE LEVEL OF SERVICES PROVIDED, SEVERITY OF THE ILLNESS OR INJURY, AND OTHER FACTORS. |
| NATIONAL PROVIDER IDENTIFIER - NPI | UNIQUE 10-DIGIT CODE FOR PROVIDERS REQUIRED BY HIPAA |
| NPI | NATIONAL PROVIDER IDENTIFIER |
| NOTICE OF EXCLUSIONS FROM MEDICARE BENEFITS | NOTIFICATION BY THE PHYSICIAN TO A PATIENT THAT A SERVICE WILL NOT BE PAID |
| NOTICE OF PRIVACY PRACTICES | HIPAA PRIVACY RULES GIVES INDIVIDUALS A RIGHT TO BE INFORMED OF THE PRIVACY PRACTICES OF THEIR HEALTH PLANS AND OF MOST OF THEIR HEALTH CARE PROVIDERS, AND TO BE INFORMED OF THEIR INDIVIDUAL RIGHTS WITH RESPECT TO THEIR PROTECTED HEALTH INFORMATION. PHI |
| OFFICE OF THE INSPECTOR GENERAL | THE OFFICE OF THE INSPECTOR GENERAL PROTECTS MEDICARE AND OTHER HHS PROGRAMS FROM FRAUD AND ABUSE BY CONDUCTING AUDITS, INVESTIGATIONS AND INSPECTIONS |
| PPO | ARE MORE FLEXIBLE THAN AN HMO AND HAVE BROADER RANGE OF REQUIREMENTS FOR SERVICES |
| PREAUTHORIZATION | APPROVAL FROM THE INSURANCE COMPANY FOR AN INPATIENT HOSPITAL STAY OR SURGERY |
| PRECERTIFICATION | A REVIEW THAT LOOKS AT WHETHER THE PROCEDURE COULD BE PERFORMED SAFELY BUT LESS EXPENSIVELY IN A OUTPATIENT SETTING |
| PREDETERMINATION | A WRITTEN REQUEST FOR A VERIFICATION OF BENEFITS |
| PROTECTED HEALTH INFORMATION (PHI) | IS ANY INFORMATION ABOUT HEALTH STATUS, PROVISION OF HEALTH CARE, OR PAYMENT FOR HEALTH CARE THAT CAN BE LINKED TO A SPECIFIC INDIVIDUAL. |
| RARC'S | REMITTANCE ADVICE REASON CODES |
| REFERRAL | WRITTEN RECOMMENDATION TO A SPECIALIST |
| REIMBURSEMENT | PAYMENT FOR SERVICES RENDERED FROMA THIRD PARTY PAYER |
| REMITTANCE ADVICE (RA) | THE REPORT SENT FROM THIRD PARTY PAYER TO THE PROVIDER THAT REFLECTS ANY CHANGES MADE TO THE ORIGINAL BILLING |
| STARK LAW | THE STARK LAW IS A LIMITATION ON CERTAIN PHYSICIAN REFERRALS. IT PROHIBITS PHYSICIAN REFERRALS OF DESIGNATED HEALTH SERVICES FOR MEDICARE AND MEDICAID PATIENTS IF THE PHYSICIAN (OR AN IMMEDIATE FAMILY MEMBER) HAS A FINANCIAL RELATIONSHIP WITH THAT ENTITY |
| SUBSCRIBER NUMBER | UNIQUE CODE USED TO IDENTIFY A SUBSCRIBERS POLICY. |
| SUBSCRIBER | PURCHASER OF THE INSURANCE OR THE MEMBER OF A GROUP FOR WHICH AN EMPLOYER OR ASSOCIATION AS PURCHASED INSURANCE |
| THIRD PARTY PAYER | ORGANIZATION OTHER THAN A PATIENT WHO PAYS FOR SERVICES, SUCH AS INSURANCE COMPANIES, MEDICARE AND MEDICAID |
| TIER 1 | PROVIDERS AND FACILITIES IN A PPO NETWORK |
| TIER 2 | PROVIDERS AND FACILITIES WITHIN A BROADER CONTRACTED NETWORK OF THE INSURANCE COMPANY |
| TIER 3 | PROVIDERS AND FACILITIES OUT OF NETWORK |
| TIER 4 | PROVIDERS AND FACILITIES NOT ON THE FORMULARY |
| TIMELY FILING | WITHIN ONE CALENDAR YEAR OF A CLAIMS DATE OF SERVICE |
| TPO | TREATMENT, PAYMENT, AND OR HEALTHCARE OPERATIONS |
| UNBUNDLING | USING MULTIPLE CODES THAT DESCRIBE DIFFERENT COMPONENTS OF A TREATMENT INSTEAD OF USING A SINGLE CODE THAT DESCRIBES ALL STEPS OF THE PROCEDURE |
| UPCODING | ASSIGNING A DIAGNOSIS OR PROCEDURE CODE AT A HIGHER LEVEL THAN THE DOCUMENTATION SUPPORTS, SUCH AS |
| VICARIOUS LIABILITY | REFERS TO A SITUATION WHERE SOMEONE IS HELD RESPONSIBLE FOR THE ACTIONS OR OMISSIONS OF ANOTHER PERSON. |
| WRITE-OFF | THE DIFFERENCE BETWEEN THE PROVIDER'S ACTUAL CHARGE AND THE ALLOWABLE CHARGE |
| NCHS | NATIONAL CENTER FOR HEALTH STATISTICS |
| WHO | WORLD HEALTH ORGANIZATION |
| MPI | Master Patient Index |
| PPSs | Prospective Payment Systems |
Created by:
ainnes
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