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EVOLVE.ELSEVIER EHR
Chapter 6 Vocab
| Term | Definition |
|---|---|
| Abstracting | Collecting data from a health record. Used for determining CPT, HCPCS, or ICD -CM codes and for release of information |
| Abuse | Unintentional deception in which a provider inappropriately bills for services that are not medically necessary, do not meet current standards for care or are medically sound |
| Coding Variance | Medical coding mistakes caused by computer error or by various kinds of human error, from simple carelessness to incorrect application of coding guidelines and procedures |
| Compliance Plan | A written set of office policies and procedurees intended to ensure compliance with laws regulating billing, coding, and third-party reimbursement |
| Current Procedural Terminology (CPT) | A comprehensive set of medical codes that describe procedures, treatments, and services for financieal reimbursement and analytical purposes |
| Electronic Data Interchange (EDI) | The standardized format used to transfer data from one computer system to another |
| Eligibility | Entitled to recieve benefits from a health plan |
| Encounter Form | A form generated to reflect the services and charges for a patient visit. It includes patient information and account balance. This may also be referred to as a superbill |
| Explanation of Benefits (EOB) | A document sent by the insurance company to the provider and the patient eplaining the allowed charge amount , the amount reimbursed for services, and the patient's financial responsibilities |
| Fraud | Presenting claims for services that an idivial or entity knows or should know to be false, resulting in a benefit to the presenting pa |
| Guarantor | The person who is legally responsible for a patient's account; the guarantor is usually the patient, but the guarantor for a minor or a person of decreased mental capacity may be a parent, trustee, or legal guardian |
| HIPAA 5010 | The standard electronic claim format used by a non institutional privider or supplier to submit a claim electronically to Medicare and most other insurance carriers for covered services |
| ICD-10-CM | International Classification of Diseases, 10th Revision, with Clinical Modification. A coding system used to describe inpatient and outpatient diagnoses |
| Medical Coding | The process of assigning standard nu meric or alphanumeric codes to diagnoses, procedures, and treatments for research, disease tracking, and reimbursement purposes |
| Medical Identity Theft | The unauthorized use of someone else's personal information to obtain medical services or to submit fraudulent medical insurance claims for reimbursement |
| pay for performance (P4P) | An outcome-based payment model that offers providers financial incentives for meeting specific standards and electronically documenting compliance with them; punitive measures may be app[lied to providers who fail to comply |
| Third Party Payer | An organization, other than the patient, that pays for the incurred medicalexpenses. This could be a federal program or a commercial insurance company (for example, Medicare, Medicaid, BCBS, and Humana) |
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