Action that improperly uses another person’s resources.

accept assignment (acceptance of assignment)

A participating physician’s agreement to accept the allowed charge as payment in full.

accountable care organization (ACO)

A network of doctors and hospitals that shares responsibility for managing the quality and cost of care provided to a group of patients.

accounting of disclosure

The documentation of the disclosure of a patient’s PHI in his or her medical record in cases when the individual did not authorize it and it was not a permitted disclosure.

accounts payable (AP)

The practice’s operating expenses, such as for overhead, salaries, supplies, and insurance.

accounts receivable (AR)

Monies owed to a medical practice by its patients and third-party payers.

Accredited Standards Committee X12, Insurance Subcommittee (ASC X12N)

The ANSI-accredited standards development organization that maintains the administrative and financial electronic transactions standards adopted under HIPAA.

Acknowledgment of Receipt of Notice of Privacy Practices

Form accompanying a covered entity’s Notice of Privacy Practices; covered entities must make a good-faith effort to have patients sign the acknowledgment.

Description of an illness or condition having severe symptoms and a short duration; can also refer to a sudden exacerbation of a chronic condition.

Updates to the ICD-9-CM diagnostic coding system.

Additional Documentation Request

Carrier request for information during a Medicare medical review.

additional documentation request (ADR)

A communication from a Medicare Program Review contractor that asks for more information regarding an appeal.

Procedure that is performed and reported only in addition to a primary procedure; indicated in CPT by a plus sign (+).

The process followed by health plans to examine claims and determine benefits.

A change, positive or negative, to correct a patient’s account balance for items such as returned check fees.

administrative code set

Under HIPAA, required codes for various data elements, such as taxonomy codes and place of service (POS) codes.

administrative services only (ASO)

Contract under which a third-party administrator or an insurer agrees to provide administrative services to an employer in exchange for a fixed fee per employee.

Admission of Liability

Carrier’s determination that an employer is responsible for an employee’s claim under workers’ compensation.

admitting diagnosis (ADX)

The patient’s condition determined by a physician at admission to an inpatient facility.

advance beneficiary notice of noncoverage (ABN)

Medicare form used to inform a patient that a service to be provided is not likely to be reimbursed by the program.

unintentional, harmful reaction to a proper dosage of a drug.

An opinion issued by CMS or OIG that becomes legal advice for the requesting party. A requesting party who acts according to the advice is immune from investigation on the matter; the advisory opinion provides guidance for others in similar matters.

Affordable Care Act (ACA)

Health system reform legislation that offers improved insurance coverage and other benefits.

Classification of AR by the length of time an account is due.

The maximum charge that a health plan pays for a specific service or procedure; also called allowable charge, maximum fee, and other terms.

A part of ICD-10-CM and of ICD-9-CM that lists disease and injuries alphabetically with corresponding diagnosis codes.

ambulatory patient classification (APC)

A Medicare payment classification for outpatient services.

ambulatory surgical center (ASC)

A clinic that provides outpatient surgery.

ambulatory surgical unit (ASU)

A hospital department that provides outpatient surgery. American Academy of Professional Coders (AAPC)

American Association of Medical Assistants

National association that fosters the profession of medical assisting.

American Association for Medical Transcription

National association fostering the profession of medical transcription.

American Health Information Management Association (AHIMA)

National association of health information management professionals that promotes valid, accessible, yet confidential health information and advocates quality healthcare.

American Medical Association (AMA)

Member organization for physicians that aims to promote the art and science of medicine, improve public health, and promote ethical, educational, and clinical standards for the medical profession.

American National Standards Institute (ANSI)

Organization that sets standards for electronic data interchange on a national level.

annual wellness visit (AWV)

A preventive service providing a health risk assessment and personal prevention plan.

A request sent to a payer for reconsideration of a claim adjudication.

One who appeals a claim decision.

assignment of benefits

Authorization by a policyholder that allows a health plan to pay benefits directly to a provider.

Reporting undocumented services that the coder assumes have been provided because of the nature of the case or condition.

at-home recovery care

Assistance with the activities of daily living provided for a patient in the home.

The clinician primarily responsible for the care of the patient from the beginning of a hospitalization.

Methodical review; in medical insurance, a formal examination of a physician’s accounting or patient medical records.

(1) Document signed by a patient to permit release of particular medical information under the stated specific conditions. (2) A health plan’s system of approving payment of benefits for services that satisfy the plan’s requirements for coverage; see prea

automobile insurance policy

A contract between an insurance company and an individual under which the individual pays a premium in exchange for coverage of specified car-related financial losses.

Software feature that enables automatic entry of payments on a remittance advice to credit an individual’s account.

An account deemed uncollectible.

The difference between a provider’s usual fee and a payer’s lower allowed charge from the insured.

Legal declaration that a person is unable to pay his or her debts.

The amount of money a health plan pays for services covered in an insurance policy.

The person or organization (often a clearinghouse or billing service) sending a HIPAA claim, as distinct from the pay-to provider who receives payment.

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Glossary

Term	Definition
abuse	Action that improperly uses another person’s resources.
accept assignment (acceptance of assignment)	A participating physician’s agreement to accept the allowed charge as payment in full.
accountable care organization (ACO)	A network of doctors and hospitals that shares responsibility for managing the quality and cost of care provided to a group of patients.
accounting of disclosure	The documentation of the disclosure of a patient’s PHI in his or her medical record in cases when the individual did not authorize it and it was not a permitted disclosure.
accounts payable (AP)	The practice’s operating expenses, such as for overhead, salaries, supplies, and insurance.
accounts receivable (AR)	Monies owed to a medical practice by its patients and third-party payers.
Accredited Standards Committee X12, Insurance Subcommittee (ASC X12N)	The ANSI-accredited standards development organization that maintains the administrative and financial electronic transactions standards adopted under HIPAA.
Acknowledgment of Receipt of Notice of Privacy Practices	Form accompanying a covered entity’s Notice of Privacy Practices; covered entities must make a good-faith effort to have patients sign the acknowledgment.
acute	Description of an illness or condition having severe symptoms and a short duration; can also refer to a sudden exacerbation of a chronic condition.
addenda	Updates to the ICD-9-CM diagnostic coding system.
Additional Documentation Request	Carrier request for information during a Medicare medical review.
additional documentation request (ADR)	A communication from a Medicare Program Review contractor that asks for more information regarding an appeal.
add-on code	Procedure that is performed and reported only in addition to a primary procedure; indicated in CPT by a plus sign (+).
adjudication	The process followed by health plans to examine claims and determine benefits.
adjustment	A change, positive or negative, to correct a patient’s account balance for items such as returned check fees.
administrative code set	Under HIPAA, required codes for various data elements, such as taxonomy codes and place of service (POS) codes.
administrative services only (ASO)	Contract under which a third-party administrator or an insurer agrees to provide administrative services to an employer in exchange for a fixed fee per employee.
Admission of Liability	Carrier’s determination that an employer is responsible for an employee’s claim under workers’ compensation.
admitting diagnosis (ADX)	The patient’s condition determined by a physician at admission to an inpatient facility.
advance beneficiary notice of noncoverage (ABN)	Medicare form used to inform a patient that a service to be provided is not likely to be reimbursed by the program.
adverse effect	unintentional, harmful reaction to a proper dosage of a drug.
advisory opinion	An opinion issued by CMS or OIG that becomes legal advice for the requesting party. A requesting party who acts according to the advice is immune from investigation on the matter; the advisory opinion provides guidance for others in similar matters.
Affordable Care Act (ACA)	Health system reform legislation that offers improved insurance coverage and other benefits.
aging	Classification of AR by the length of time an account is due.
allowed charge	The maximum charge that a health plan pays for a specific service or procedure; also called allowable charge, maximum fee, and other terms.
Alphabetic Index	A part of ICD-10-CM and of ICD-9-CM that lists disease and injuries alphabetically with corresponding diagnosis codes.
ambulatory care	Outpatient care.
ambulatory patient classification (APC)	A Medicare payment classification for outpatient services.
ambulatory surgical center (ASC)	A clinic that provides outpatient surgery.
ambulatory surgical unit (ASU)	A hospital department that provides outpatient surgery. American Academy of Professional Coders (AAPC)
American Association of Medical Assistants	National association that fosters the profession of medical assisting.
American Association for Medical Transcription	National association fostering the profession of medical transcription.
American Health Information Management Association (AHIMA)	National association of health information management professionals that promotes valid, accessible, yet confidential health information and advocates quality healthcare.
American Medical Association (AMA)	Member organization for physicians that aims to promote the art and science of medicine, improve public health, and promote ethical, educational, and clinical standards for the medical profession.
American National Standards Institute (ANSI)	Organization that sets standards for electronic data interchange on a national level.
annual wellness visit (AWV)	A preventive service providing a health risk assessment and personal prevention plan.
appeal	A request sent to a payer for reconsideration of a claim adjudication.
appellant	One who appeals a claim decision.
assignment of benefits	Authorization by a policyholder that allows a health plan to pay benefits directly to a provider.
assumption coding	Reporting undocumented services that the coder assumes have been provided because of the nature of the case or condition.
at-home recovery care	Assistance with the activities of daily living provided for a patient in the home.
attending physician	The clinician primarily responsible for the care of the patient from the beginning of a hospitalization.
audit	Methodical review; in medical insurance, a formal examination of a physician’s accounting or patient medical records.
authorization	(1) Document signed by a patient to permit release of particular medical information under the stated specific conditions. (2) A health plan’s system of approving payment of benefits for services that satisfy the plan’s requirements for coverage; see prea
automobile insurance policy	A contract between an insurance company and an individual under which the individual pays a premium in exchange for coverage of specified car-related financial losses.
autoposting	Software feature that enables automatic entry of payments on a remittance advice to credit an individual’s account.
bad debt	An account deemed uncollectible.
balance billing	The difference between a provider’s usual fee and a payer’s lower allowed charge from the insured.
bankruptcy	Legal declaration that a person is unable to pay his or her debts.
benefit	The amount of money a health plan pays for services covered in an insurance policy.
billing provider	The person or organization (often a clearinghouse or billing service) sending a HIPAA claim, as distinct from the pay-to provider who receives payment.
billing service	Company that provides billing and claim processing services.
birthday rule	The guideline that determines which of two parents with medical coverage has the primary insurance for a child; the parent whose day of birth is earlier in the calendar year is considered primary.
BlueCard	A BlueCross BlueShield program that provides benefits for plan subscribers who are away from their local areas.
BlueCross	A primarily nonprofit corporation that offers prepaid medical benefits for hospital services and some outpatient, home care, and other institutional services.
BlueCross BlueShield Association (BCBS)	A national healthcare licensing association of more than forty payers.
BlueShield	A primarily nonprofit corporation that offers prepaid medical benefits for physician, dental, and vision services and other outpatient care.
breach	An impermissible use or disclosure under the Privacy Rule that compromises the security or privacy of PHI and also that could pose significant risk of financial, reputational, or other harm to the affected person.
breach notification	The document notifying an individual of a breach.
bundled payment	An experimental Medicare payment method by which an entire episode of care is paid for by a predetermined single payment.
bundling	Using a single procedure code that covers a group of related procedures.
business associate (BA)	A person or organization that performs a function or activity for a covered entity but is not part of its workforce.
capitation	Payment method in which a fixed prepayment covers the provider’s services to a plan member for a specified period of time.
capitation rate (cap rate)	The contractually set periodic prepayment to a provider for specified services to each enrolled plan member.
carrier	Health plan; also known as insurance company, payer, or third-party payer.
carrier block	Data entry area located in the upper right of the CMS-1500 that allows for a four-line address for the payer.
carve out	A part of a standard health plan that is changed under a negotiated employer sponsored plan; also refers to subcontracting of coverage by a health plan.
case mix index	A measure of the clinical severity or resource requirements of the patients in a particular hospital or treated by a particular clinician during a specific time period.
cash flow	The movement of monies into or out of a business.
catastrophic cap	The maximum annual amount a TRICARE beneficiary must pay for deductible and cost share.
categorically needy	A person who receives assistance from government programs such as Temporary Assistance for Needy Families (TANF).
category	A three-digit code used for classifying a disease or condition.
Category I codes	Procedure codes found in the main body of CPT (Evaluation and Management, Anesthesia, Surgery, Pathology and Laboratory, Radiology, and Medicine). Category II codes
Category III codes	Temporary codes for emerging technology, services, and procedures that are used instead of unlisted codes when available.
CCI column 1 and column 2 code pair edit	A Medicare code edit under which CPT codes in column 2 will not be paid if reported for the same patient on the same day of service by the same provider as the column 1 code.
CCI modifier indicator	A number that shows whether the use of a modifier can bypass a CCI edit.
CCI mutually exclusive code (MEC) edit	Under the CCI edits, both services represented by MEC codes that could not have reasonably been done during a single patient encounter, so they will not both be paid by Medicare; only the lower-paid code is reimbursed.
Centers for Medicare and Medicaid Services (CMS)	Federal agency within the Department of Health and Human Services (HHS) that runs Medicare, Medicaid, clinical laboratories (under the CLIA program), and other government health programs.
certificate	Term for a BlueCross BlueShield medical insurance policy.
Certificate of Medical Necessity (CMN)	A document used by the four DME MACs to assist them in gathering information before the supplier’s claim is paid.
certification	The recognition of a person demonstrating a superior level of skill on a national test by an official organization.
Certification Commission for Healthcare Information Technology(CCHIT)	Voluntary, private-sector organization that certifies EHR products.
certification number	Number returned electronically by a health plan approving a referral authorization request when preauthorization is required.
CHAMPUS	Now the TRICARE program; formerly the Civilian Health and Medical Program of the Uniformed Services (Army, Navy, Air Force, Marine Corps, Coast Guard, Public Health Service, and National Oceanic and Atmospheric Administration) that serves spouses and chil
CHAMPVA	The Civilian Health and Medical Program of the Department of Veterans Affairs (previously known as the Veterans Administration) that shares healthcare costs for families of veterans with 100 percent service connected disabilities and the surviving spouses
charge-based fee structure	Fees based on the amounts typically charged for similar services.
charge capture	Office procedures that ensure that billable services are recorded and reported for payment.
charge master	A hospital’s list of the codes and charges for its services.
chart number	A unique number that identifies a patient.
chief complaint (CC)	A patient’s description of the symptoms or other reasons for seeking medical care from a provider.
Children’s Health Insurance Program (CHIP)	Program offering health insurance coverage for uninsured children under Medicaid.
chronic	Description of an illness or condition with a long duration.
Civilian Health and Medical Program of the Department of Veterans Affairs	CHAMPVA
Civilian Health and Medical Program of the Uniformed Services	CHAMPUS
claim adjustment group code (CAGC)	Code used by a payer on an RA to indicate the general type of reason code for an adjustment.
claim adjustment reason code (CARC)	Code used by a payer on an RA to explain why a payment does not match the amount billed.
claimant	Person or entity exercising the right to receive benefits.
claim attachment	Documentation that a provider sends to a payer in support of a healthcare claim.
claim control number	Unique number assigned to a healthcare claim by the sender. claim filing indicator code
claim frequency code (claim submission reason code)	Administrative code that identifies the claim as original, replacement, or void/cancel action.
claim scrubber	Software that checks claims to permit error correction for clean claims.
claim status category codes	Codes used by payers on a HIPAA 277 to report the status group for a claim, such as received or pending.
claim status codes	Codes used by payers on a HIPAA 277 to provide a detailed answer to a claim status inquiry.
claim turnaround time	The time period in which a health plan is obligated to process a claim.
clean claim	A claim that is accepted by a health plan for adjudication.
clearinghouse	A company (billing service, repricing company, or network) that converts nonstandard transactions into standard transactions and transmits the data to health plans; also handles the reverse process, changing standard transactions from health plans into no
Clinical Laboratory Improvement Amendments (CLIA)	Federal law establishing standards for laboratory testing performed in hospital-based facilities, physicians’ office laboratories, and other locations; administered by CMS.
CMS	Centers for Medicare and Medicaid Services.
CMS-1450	Paper claim for hospital services; also known as the UB-92.
CMS-1500	Paper claim for physician services.
CMS-1500 (02/12)	Current paper claim approved by the NUCC.
CMS HCPCS Workgroup	Federal government committee that maintains the Level II HCPCS code set.
code	In ICD-10-CM, three-, four-, five-, six-, or seven-digit characters used to represent a disease, injury, or symptom.
code edits	Computerized screening system used to identify improperly or incorrectly reported codes.
code linkage	The connection between a service and a patient’s condition or illness; establishes the medical necessity of the procedure.
code set	Alphabetic and/or numeric representations for data. Medical code sets are systems of medical terms that are required for HIPAA transactions. Administrative (nonmedical) code sets, such as taxonomy codes and ZIP codes, are also used in HIPAA transactions.
coding	The process of assigning numerical codes to diagnoses and procedures/services.
coexisting condition	Additional illness that either has an effect on the patient’s primary illness or is also treated during the encounter.
coinsurance	The portion of charges that an insured person must pay for healthcare services after payment of the deductible amount; usually stated as a percentage.
collection agency	Outside firm hired by a practice or facility to collect overdue accounts from patients.
collection ratio	The average number of days it takes a practice to convert its accounts receivable into cash.
collections	The process of following up on overdue accounts.
collections specialist	Administrative staff member with training in proper collections techniques.
combination code	A single code that classifies both the etiology and the manifestation(s) of an illness or injury.
Common Working File (CWF)	Medicare’s master patient/procedural database.
comorbidity	Admitted patient’s coexisting condition that affects the length of the hospital stay or the course of treatment.
compliance	Actions that satisfy official guidelines and requirements.
compliance plan	A medical practice’s written plan for the following: the appointment of a compliance officer and committee; a code of conduct for physicians’ business arrangements and employees’ compliance; training plans; properly prepared and updated coding tools such
complication	Condition an admitted patient develops after surgery or treatment that affects the length of hospital stay or the course of further treatment.
computer-assisted coding (CAC)	A software program that assists providers and medical coders in assigning codes based on the documentation of a visit.
concierge medicine	A primary care arrangement with a patient under which the provider agrees to accept a retainer in exchange for enhanced care and access to the patient.
concurrent care	Medical situation in which a patient receives extensive, independent care from two or more attending physicians on the same date of service.
condition code	Two-digit numeric or alphanumeric code used to report a special condition or unique circumstance about a claim; reported in Item Number 10d on the CMS-1500 claim form.
conditions of participation (Medicare) (COP)	Regulations concerning provider participation in the Medicare program.
Consolidated Omnibus Budget Reconciliation Act (COBRA)	Federal law requiring employers with more than twenty employees to allow employees who have been terminated for reasons other than gross misconduct to pay for coverage under the employer’s group health plan for eighteen months after termination.
consultation	Service performed by a physician to advise a requesting physician about a patient’s condition and care; the consultant does not assume responsibility for the patient’s care and must send a written report back to the requestor.
consumer-driven health plan (CDHP)	Type of medical insurance that combines a high deductible health plan with a medical savings plan that covers some out-of-pocket expenses.
contract	An enforceable voluntary agreement in which specific promises are made by one party in exchange for some consideration by the other party.
convention	Agreement to use typographic techniques or standard practices that provide visual guidelines for understanding printed material.
conversion factor	Dollar amount used to multiply a relative value unit to arrive at a charge.
coordination of benefits (COB)	A clause in an insurance policy that explains how the policy will pay if more than one insurance policy applies to the claim.
copayment	An amount that a health plan requires a beneficiary to pay at the time of service for each healthcare encounter.
corporate integrity agreement	A compliance action under which a provider’s Medicare billing is monitored by the Office of the Inspector General.
Correct Coding Initiative (CCI)	Computerized Medicare system that controls improper coding which would lead to inappropriate payment for Medicare claims.
Correct Coding Initiative edits	Pairs of CPT or HCPCS Level II codes that are not separately payable by Medicare except under certain circumstances; the edits apply to services by the same provider for the same beneficiary on the same date of service.
cost-share	Coinsurance for a TRICARE or CHAMPVA beneficiary.
cost sharing	The insured’s deductible and coinsurance.
counseling	Physician’s discussion with a patient and/or family about diagnostic results, prognosis, treatment options, and/or instructions.
Coverage Issues Manual (CIM)	Information about Medicare-qualified clinical trials, treatments, therapeutic interventions, diagnostic testing, durable medical equipment, therapies, and services referenced in the HCPCS code manual.
covered entity (CE)	Under HIPAA, a health plan, clearinghouse, or provider who transmits any health information in electronic form in connection with a HIPAA transaction; does not specifically include workers’ compensation programs, property and casualty programs, or disabil
covered services	Medical procedures and treatments that are included as benefits under an insured’s health plan.
CPT	Current Procedural Terminology, a publication of the American Medical Association.
credentialing	Periodic verification that a provider or facility meets the professional standards of a certifying organization; physician credentialing involves screening and evaluating qualifications and other credentials, including licensure, required education, relev
creditable coverage	History of health insurance coverage for calculation of COBRA benefits.
credit bureaus	Organizations that supply information about consumers’ credit history and relative standing.
credit card on file (CCOF)	Policy of collecting and retaining patients’ credit card information.
credit reporting	Analyzing a person’s credit standing during the collections process.
crossover claim	Claim for a Medicare or Medicaid beneficiary; Medicare is the primary payer and automatically transmits claim information to Medicaid as the secondary payer.
cross-reference	Directions in printed material that tell a reader where to look for additional information.
crosswalk	A comparison or map of the codes for the same or similar classifications under two coding systems; it serves as a guide for selecting the closest match.
Current Procedural Terminology (CPT)	Publication of the American Medical Association containing the HIPAA-mandated standardized classification system for reporting medical procedures and services performed by physicians.
Cybersecurity	The process of protecting information confidentiality, integrity, and availability by preventing, detecting, and responding to attacks on digital data.
cycle billing	Type of billing in which patients with current balances are divided into groups to equalize statement printing and mailing throughout a month, rather than mailing all statements once a month.
database	An organized collection of related data items having a specific structure.
data element	The smallest unit of information in a HIPAA transaction.
data format	An arrangement of electronic data for transmission.
date of service	The date of a patient encounter for medical services.
day sheet	In a medical office, a report that summarizes the business day’s charges and payments, drawn from all the patient ledgers for the day.
deductible	An amount that an insured person must pay, usually on an annual basis, for healthcare services before a health plan’s payment begins.
default code	ICD-10-CM code listed next to the main term in the Alphabetic Index that is most often associated with a particular disease or condition.
Defense Enrollment Eligibility Reporting System (DEERS)	The worldwide database of TRICARE and CHAMPVA beneficiaries.
de-identified health information	Medical data from which individual identifiers have been removed; also known as a redacted or blinded record.
dependent	A person other than the insured, such as a spouse or child, who is covered under a health plan.
designated record set (DRS)	A covered entity’s records that contain protected health information (PHI); for providers, the designated record set is the medical/financial patient record.
destination payer	In HIPAA claims, the health plan receiving the claim.
determination	A payer’s decision about the benefits due for a claim.
development	Payer process of gathering information in order to adjudicate a claim. diagnosis
diagnosis code	The number assigned to a diagnosis in the International Classification of Diseases.
diagnosis-related group (DRGs)	A system of analyzing conditions and treatments for similar groups of patients used to establish Medicare fees for hospital inpatient services. diagnostic statement A physician’s description of the main reason for a patient’s encounter; may also describ
diagnostic statement	A physician’s description of the main reason for a patient’s encounter; may also describe related conditions or symptoms.
direct primary care (DPC)	An arrangement between a provider and a patient that removes an insurance plan; it is usually paired with either a high-deductible health plan or an HRA/FSA.
direct provider	Clinician who treats the patient face-to-face, in contrast to an indirect provider such as a laboratory.
disability compensation program	A plan that reimburses the insured for lost income when the insured cannot work because of an illness or injury, whether or not it is work related.
disallowed charge	An item on a remittance advice that identifies the difference between the allowable charge and the amount the physician charged for a service.
disclosure	The release, transfer, provision of, access to, or divulging in any other manner of information outside the entity that holds it.
discounted fee-for-service	A negotiated payment schedule for healthcare services based on a reduced percentage of a provider’s usual charges.
documentation	The systematic, logical, and consistent recording of a patient’s health status —history, examinations, tests, results of treatments, and observations—in chronological order in a patient medical record.
documentation template	Physician practice form used to prompt the physician to document a complete review of systems (ROS) when done and the medical necessity for the planned treatment.
domiciliary care	Care provided in the home; or providing care and living space, such as a home for disabled veterans.
downcoding	A payer’s review and reduction of a procedure code (often an E/M code) to a lower level than reported by the provider.
dual-eligible	A Medicare-Medicaid beneficiary.
durable medical equipment (DME)	Medicare term for reusable physical supplies such as wheelchairs and hospital beds that are ordered by the provider for use in the home; reported with HCPCS Level II codes.
Durable Medical Equipment Medicare Administrative Contractor (DMEMAC)	The four CMS contractors who process Medicare claims for DMEPOS.
durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS)	Category of HCPCS services.
Early and Periodic Screening, Diagnosis, and Treatment (EPSDT)	Medicaid’s prevention, early detection, and treatment program for eligible children under the age of twenty-one.
E code	Alphanumeric ICD-9-CM code for an external cause of injury or poisoning.
edits	Computerized screening system used to identify improperly or incorrectly reported codes.
elective surgery	Nonemergency surgical procedure that can be scheduled in advance.
electronic claim	A healthcare claim that is transmitted electronically; also known as an electronic media claim (EMC).
electronic data interchange (EDI)	The system-to-system exchange of data in a standardized format.
electronic eligibility verification	Required payer response to the HIPAA standard transaction.
electronic funds transfer (EFT)	Electronic routing of funds between banks.
electronic health record (EHR)	A computerized lifelong healthcare record for an individual that incorporates data from all sources that provide treatment for the individual. electronic media
electronic remittance	Payment made through electronic funds transfer.
emancipated minor	A person who has reached the legal age to live as an adult under state law.
embezzlement	Theft of funds by an employee or contractor.
emergency	A situation in which a delay in the treatment of the patient would lead to a significant increase in the threat to life or a body part.
Employee Retirement Income Security Act (ERISA) of 1974	A federal law that provides incentives and protection against litigation for companies that set up employee health and pension plans.
encounter	An office visit between a patient and a medical professional.
encounter form	A list of the diagnoses, procedures, and charges for a patient’s visit; also called the superbill.
encryption	A method of scrambling transmitted data so they cannot be deciphered without the use of a confidential process or key.
episode-of-care (EOC) option	A flat payment by a health plan to a provider for a defined set of services, such as care provided for a normal pregnancy, or for services for a certain period of time, such as a hospital stay.
eponym	A name or phrase that is formed from or based on a person’s name; usually describes a condition or procedure associated with that person.
Equal Credit Opportunity Act (ECOA)	Law that prohibits credit discrimination on the basis of race, color, religion, national origin, sex, marital status, age, or because a person receives public assistance.
essential health benefits (EHB)	Required benefits that must be offered by metal plans as well as some other insurance plans.
established patient (EP)	Patient who has received professional services from a provider (or another provider with the same specialty in the same practice) within the past three years.
ethics	Standards of conduct based on moral principles.
etiology	The cause or origin of a disease.
etiquette	Standards of professional behavior.
evaluation and management (E/M)	Provider’s evaluation of a patient’s condition and decision on a course of treatment to manage it.
evaluation and management (E/M) codes	Procedure codes that cover physicians’ services performed to determine the optimum course for patient care; listed in the Evaluation and Management section of CPT.
excluded parties	Individuals or companies that, because of reasons bearing on professional competence, professional performance, or financial integrity, are not permitted by OIG to participate in any federal healthcare programs.
excluded service	A service specified in a medical insurance contract as not covered. excludes 1
excludes 2	A type of exclusion note that is used when a condition is “not included here,” but a patient could have both conditions at the same time.
exclusion notes	Tabular List entries limiting applicability of particular codes to specified conditions.
explanation of benefits (EOB)	Document sent by a payer to a patient that shows how the amount of a benefit was determined.
(EOMB)	Explanation of Medicare benefits
external audit	Audit conducted by an organization outside of the practice, such as a federal agency.
external cause code	Diagnosis code that reports the cause of injuries from various environmental events.
Fair and Accurate Credit Transaction Act (FACTA)	Law designed to modify the Fair Credit Reporting Act to protect the accuracy and privacy of credit reports.
Fair Credit Reporting Act (FCRA)	Law requiring consumer reporting agencies to have reasonable and fair procedures to protect both consumers and business users of the reports.
Fair Debt Collection Practices Act (FDCPA) of 1977	Laws regulating collection practices.
family deductible	Fixed, periodic amount that must be met by the combination of payments for covered services to each individual of an insured/dependent group before benefits from a payer begin.
Federal Claims Act	A federal law that prohibits intentional misrepresentation related to healthcare claims.
Federal Employees’ Compensation Act (FECA)	A federal law that provides workers’ compensation insurance for civilian employees of the federal government.
Federal Employees Health Benefits (FEHB) program	The health insurance program that covers employees and retirees and their families of the federal government.
Federal Employees Retirement System (FERS)	Disability program for employees of the federal government.
Federal Insurance Contribution Act (FICA)	The federal law that authorizes payroll deductions for the Social Security Disability Program.
Federal Medicaid Assistance Percentage (FMAP)	Basis for federal government Medicaid allocations to individual states.
fee-for-service	A payment method based on provider charges.
fee schedule	List of charges for services performed.
final report	A document filed by the physician in a state workers’ compensation case when the patient is discharged.
financial policy	A practice’s rules governing payment for medical services from patients.
first-listed code	Code for diagnosis that is the patient’s main condition; in cases involving an underlying condition and a manifestation, the underlying condition is the first-listed code.
first report of injury	A document filed in state workers’ compensation cases that contains the employer’s name and address, employee’s supervisor, date and time of accident, geographic location of injury, and patient’s description of what happened.
fiscal intermediary	Government contractor that processes claims for government programs; for Medicare, the fiscal intermediary (FI) processes Part A claims.
5010A1 version	Under HIPAA, the newest format for EDI transactions to accommodate ICD-10-CM codes and additional data.
Flexible Blue	The BlueCross BlueShield consumer-driven health plan.
flexible savings (spending) account (FSA)	Type of consumer-driven health funding plan option that has employer and employee contributions; funds left over revert to the employer.
formulary	A list of a health plan’s selected drugs and their proper dosages; often a plan pays only for the drugs it lists.
fragmented billing	Incorrect billing practice in which procedures covered under a single bundled code are unbundled and separately reported.
fraud	Intentional deceptive act to obtain a benefit.
gatekeeper	also known as a primary care physician(PCP).
GEMs	An acronym that stands for general equivalence mappings, which are prepared by the federal government to aid coders in selecting codes for ICD-10-CM.
gender rule	Coordination of benefits rule for a child insured under both parents’ plans under which the father’s insurance is primary.
geographic practice cost index (GPCI)	Medicare factor used to adjust providers’ fees to reflect the cost of providing services in a particular geographic area relative to national averages.
global period	The number of days surrounding a surgical procedure during which all services relating to the procedure—preoperative, during the surgery, and postoperative—are considered part of the surgical package and are not additionally reimbursed.
grievance	Complaint by a medical practice against a payer filed with the state insurance commission by a practice.
grouper	Software used to calculate the DRG to be paid based on the codes assigned for the patient’s stay.
group health plan (GHP)	Under HIPAA, a plan (including a self-insured plan) of an employer or employee organization to provide healthcare to the employees, former employees, or their families. Plans that are self-administered and have fewer than fifty participants are not group
guarantor	A person who is financially responsible for the bill from the practice.
guarantor billing	Billing system that groups patient bills under the insurance policyholder; the guarantor receives statements for all patients covered under the policy. guardian
HCFA	Health Care Financing Administration
Health and Human Services (HHS)	The U.S. Department of Health and Human Services whose agencies have authority to create and enforce HIPAA regulations.
healthcare claim	An electronic transaction or a paper document filed with a health plan to receive benefits.
Healthcare Provider Taxonomy Code (HPTC)	Administrative code set used to report a physician’s specialty.
Healthcare Common Procedure Coding System (HCPCS)	Procedure codes for Medicare claims, made up of CPT codes (Level I) and national codes (Level II).
Health Care Fraud and Abuse Control Program	Government program to uncover
misuse of funds in federal healthcare programs; run by the Office of the Inspector General. Health Employer Data and Information Set (HEDIS)	Set of standard performance measures on the quality of a healthcare plan collected and disseminated by the National Committee for Quality Assurance (NCQA).
health information exchange (HIE)	Enables the sharing of health-related information among provider organizations
health information management (HIM)	Hospital department that organizes and maintains patient medical records; also profession devoted to managing, analyzing, and utilizing data vital for patient care, making the data accessible to healthcare providers.
health information technology (HIT)	Computer hardware and software information systems that record, store, and manage patient information.
Health Information Technology for Economic and Clinical Health (HITECH) Act	Law promoting the adoption and use of health information technology.
health insurance exchange (HIX)	Government-regulated marketplace offering insurance plans to individuals.
Health Insurance Portability and Accountability Act (HIPAA) of 1996	Federal act that set forth guidelines for standardizing the electronic data interchange of administrative and financial transactions, exposing fraud and abuse in government programs, and protecting the security and privacy of health information.
health maintenance organization (HMO)	A managed healthcare system in which providers agree to offer healthcare to the organization’s members for fixed periodic payments from the plan; usually members must receive medical services only from the plan’s providers. health plan
Health Professional Shortage Area (HPSA)	Medicare-defined geographic area offering participation bonuses to physicians.
health reimbursement account (HRA)	Type of consumer-driven health plan funding option under which an employer sets aside an annual amount an employee can use to pay for certain types of healthcare costs.
health savings account (HSA)	Type of consumer-driven health plan funding option under which employers, employees, both employers and employees, or individuals set aside funds that can be used to pay for certain types of healthcare costs.
high-deductible health plan (HDHP)	Type of health plan combining high-deductible insurance, usually a PPO with a relatively low premium, and a funding option to pay for patients’ out-of-pocket expenses up to the deductible.
HIPAA claim	Generic term for the HIPAA X12N 837 professional healthcare claim transaction.
HIPAA Claim Status—Inquiry/Response	The HIPAA X12N 276/277 transaction in which a provider asks a health plan for information on a claim’s status and receives an answer from the plan.
HIPAA Coordination of Benefits	The HIPAA ASCX12N 837 transaction that is sent to a secondary or tertiary payer on a claim with the primary payer’s remittance advice.
HIPAA Electronic Health Care Transactions and Code Sets (TCS)	The HIPAA rule governing the electronic exchange of health information.
HIPAA Eligibility for a Health Plan	The HIPAA X12N 270/217 transaction in which a provider asks a health plan for information on a patient’s eligibility for benefits and receives an answer from the plan.
HIPAA Health Care Payment and Remittance Advice	The HIPAA X12N 835 transaction used by a health plan to describe a payment in response to a healthcare claim.
HIPAA National Identifier	HIPAA-mandated identification systems for employers, healthcare providers, health plans, and patients; the NPI, National Provider System, and employer system are in place; health plan and patient systems are yet to be created.
HIPAA Privacy Rule	Law that regulates the use and disclosure of patients’ protected health information (PHI).
HIPAA Referral Certification and Authorization	The HIPAA X12N 278 transaction in which a provider asks a health plan for approval of a service and the health plan responds, providing a certification number for an approved request.
HIPAA Security Rule	Law that requires covered entities to establish administrative, physical, and technical safeguards to protect the confidentiality, integrity, and availability of health information.
HIPAA transaction	General term for electronic transactions, such as claim status inquiries, healthcare claim transmittal, and coordination of benefits regulated under the HIPAA Health Care Transactions and Code Sets standards.
HIPAA X12 276/277 Health Care Claim Status Inquiry/Response (HIPAA 276/277)	The standard electronic transaction to obtain information on the status of a claim.
HIPAA X12 835 Health Care Payment and Remittance Advice (HIPAA 835)	The electronic transaction for payment explanation.
HIPAA X12 837 Health Care Claim: Institutional (837I)	The format for claims for institutional services.
HIPAA X12 837 Health Care Claim: Professional (837P)	The form used to send a claim for physician services to both primary and secondary payers.
Health Information Technology for Economic and Clinical Health (HITECH)Act	Law that guides the use of federal stimulus money to promote the adoption and meaningful use of health information technology, mainly using electronic health records. home health agency (HHA)
home healthcare	Care given to patients in their homes, such as skilled nursing care.
home plan	BlueCross BlueShield plan in the community where the subscriber has contracted for coverage.
hospice	Public or private organization that provides services for people who are terminally ill and their families.
hospice care	Care for terminally ill people provided by a public or private organization.
hospital-acquired condition (HAC)	A condition that a hospital causes or allows to develop during an inpatient stay.
hospital-issued notice of noncoverage (HINN)	A form used to describe benefit guidelines for inpatient hospital services.
host plan	Participating provider’s local BlueCross BlueShield plan.
ICD code	System of diagnosis codes based on the International Classification of Diseases.
ICD-10-CM	Abbreviated title of International Classification of Diseases, Tenth Revision, Clinical Modification, the HIPAA-mandated diagnosis code set as of October 1, 2015.
ICD-10-CM	Official Guidelines for Coding and Reporting The general rules, inpatient (hospital), and outpatient coding guidance from the four cooperating parties (CMS advisers and participants from the AHA, AHIMA, and NCHS).
ICD-10-PCS	Mandated code set for inpatient procedural reporting for hospitals and payers as of October 1, 2015.
incident-to services	Term for services of allied health professionals, such as nurses, technicians, and therapists, provided under the physician’s direct supervision that may be billed under Medicare.
inclusion notes	Notes that are headed by the word includes and refine the content of the category appearing above them.
indemnify	A health plan’s agreement to reimburse a policyholder for covered losses. indemnity
indemnity plan	Type of medical insurance that reimburses a policyholder for medical services under the terms of its schedule of benefits.
independent medical examination (IME)	Examination by a physician conducted at the request of a state workers’ compensation office or an insurance carrier to confirm that an individual is permanently disabled.
independent (or individual) practice association (IPA)	Type of health maintenance organization in which physicians are self-employed and provide services to both HMO members and nonmembers.
Index to External Causes	An index of all the external causes of diseases and injuries that are listed in the related chapter of the Tabular List.
indirect provider	Clinician who does not interact face-to-face with the patient, such as a laboratory.
individual deductible	Fixed amount that must be met periodically by each individual of an insured/dependent group before benefits from a payer begin.
individual health plan (IHP)	Medical insurance plan purchased by an individual, rather than through a group affiliation.
individual relationship code	Administrative code that specifies the patient’s relationship to the subscriber (insured).
information technology (IT)	The development, management, and support of computer based hardware and software systems.
informed consent	The process by which a patient authorizes medical treatment after discussion about the nature, indications, benefits, and risks of a treatment a physician recommends.
initial preventive physical examination (IPPE)	Medicare benefit of a preventive visit for new beneficiaries.
inpatient	A person admitted to a medical facility for services that require a stay over two midnights.
inpatient-only list	Describes procedures that can be billed only from the facility inpatient setting.
Inpatient Prospective Payment System (IPPS)	Medicare payment system for hospital services; based on diagnosis-related groups (DRGs).
insurance aging report	A report grouping unpaid claims transmitted to payers by the length of time that they remain due, such as 30, 60, 90, or 120 days.
insurance commission	State’s regulatory agency for the insurance industry that serves as liaison between patient and payer and between provider and payer.
insured or subscriber	The policyholder of a health plan or medical insurance policy; also known as guarantor.
internal audit	Self-audit conducted by a staff member or consultant as a routine check of compliance with reporting regulations.
International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM)	Publication containing the previously HIPAA-mandated standardized classification system for diseases and injuries developed by the World Health Organization and modified for use in the United States.
Internet-Only Manuals	The Medicare online manuals that offer day-to-day operating instructions, policies, and procedures based on statutes and regulations, guidelines, models, and directives.
job reference aid	List of a medical practice’s frequently reported procedures and diagnoses.
The Joint Commission (TJC)	Organization that reviews accreditation of hospitals and other organizations/programs.
key component	Factor required to be documented for various levels of evaluation and management services.
late effect (ICD-9-CM)	Condition that appears after the acute phase of the disease or accident has concluded.
late enrollee	Category of enrollment in a commercial health plan that may have different eligibility requirements.
laterality	Use of ICD-10-CM classification system to capture the side of the body that is documented; the fourth, fifth, or sixth characters of a code specify the affected side(s).
LCD	Local coverage determination.
Level II	HCPCS national codes.
Level II modifiers	HCPCS national code set modifiers.
liable	Legally responsible.
liens	Written, legal claims on property to secure the payment of a debt.
limiting charge	In Medicare, the highest fee (115 percent of the Medicare Fee Schedule) that nonparticipating physicians may charge for a particular service.
line item control number	On a HIPAA claim, the unique number assigned by the sender to each service line item reported.
local coverage determinations (LCDs)	Decisions by MACs about the coding and medical necessity of a specific Medicare service.
Local Medical Review Policy(LMRP)	an administrative and educational tool to assist providers, physicians and suppliers in submitting correct claims for payment
main number	The five-digit procedure code listed in the CPT.
main term	A word that identifies a disease or condition in the Alphabetic Index.
major diagnostic categories (MDCs)	Twenty-five categories in which MS-DRGs are grouped; each MDC is subdivided into medical and surgical MS-DRGs.
malpractice	Failure to use an acceptable level of professional skill when giving medical services that results in injury or harm to a patient.
managed care	System that combines the financing and the delivery of appropriate, cost effective healthcare services to its members.
managed care organization (MCO)	Organization offering some type of managed healthcare plan.
manifestation	A disease’s typical signs, symptoms, or secondary processes.
master patient index (MPI)	Hospital’s main patient database.
M code	Classification number that identifies the morphology of neoplasms.
meaningful use	The utilization of certified EHR technology to improve quality, efficiency, and patient safety in the healthcare system.
means test	Process of fairly determining a patient’s ability to pay.
Medicaid	A federal and state assistance program that pays for healthcare services for people who cannot afford them.
Medicaid Integrity Program (MIP)	Program created by the Deficit Reduction Act of 2005 to prevent and reduce fraud, waste, and abuse in Medicaid.
MediCal	California’s Medicaid program.
medical coder	Medical office staff member with specialized training who handles the diagnostic and procedural coding of medical records.
medical decision making (MDM)	In determining the correct level of E/M office visit codes, the problems, data, and risks the physician evaluates are counted as one of two main factors.
medical documentation and revenue cycle	A series of steps that explain how using EHRs is integrated with practice management programs as the 10-step billing process is formed.
medical error	Failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim.
medical home model	Care plans that emphasize primary care with coordinated care involving communications among the patient’s physicians.
medical insurance	A written policy stating the terms of an agreement between a policyholder and a health plan.
medical insurance specialist	Medical office administrative staff member who handles billing, checks insurance, and processes payments.
medically indigent	Medically needy.
medically needy	Medicaid classification for people with high medical expenses and low financial resources, although not sufficiently low to receive cash assistance.
medically unlikely edits (MUEs)	CMS unit of service edits that check for clerical or software-based coding or billing errors, such as anatomically related mistakes.
medical necessity	Payment criterion of payers that requires medical treatments to be clinically appropriate and provided in accordance with generally accepted standards of medical practice. To be medically necessary, the reported procedure or service must match the diagnos
medical necessity denial	Refusal by a health plan to pay for a reported procedure that does not meet its medical necessity criteria.
medical record	A file that contains the documentation of a patient’s medical history, record of care, progress notes, correspondence, and related billing/financial information. Medical Review (MR) Program
Medical Savings Account (MSA)	The Medicare health savings account program.
medical standards of care	State-specified performance measures for the delivery of healthcare by medical professionals.
medical terminology	The terms used to describe diagnoses and procedures; based on anatomy.
Medicare	The federal health insurance program for people sixty-five or older and some people with disabilities.
Medicare Access and CHIP Reauthorization Act of 2015(MACRA)	Legislation that redesigned the Medicare Part B reimbursement incentive and mandated the transition to the MBI.
Medicare administrative contractor (MAC)	New entities assigned by CMS to replace the Part A fiscal intermediaries and the Part B carriers; also known as A/B MACs, they handle claims and related functions for both Parts A and B within specified multistate jurisdictions. DME MACs handle claims for
Medicare Advantage (MA)	Medicare plans other than the Original Medicare Plan.
Medicare beneficiary	A person covered by Medicare.
Medicare Beneficiary Identifier (MBI)	Medicare beneficiary’s identification number.
Medicare card	Insurance identification card issued to Medicare beneficiaries.
Medicare carrier	A private organization under contract with CMS to administer Medicare Part B claims in an assigned region.
Medicare Carriers Manual (MCM)	Guidelines established by Medicare about coverage for HCPCS Level II services; references to the MCM appear in the HCPCS code book. Medicare Integrity Program (MIP)
Medicare Learning Network (MLN) Matters	An online collection of articles that explain all Medicare topics.
Medicare Modernization Act (MMA)	Short name for the Medicare Prescription Drug, Improvement, and Modernization Act of 2003, which included a prescription drug benefit.
Medicare Outpatient Adjudication (MOA) remark codes	Remittance advice codes that explain Medicare payment decisions.
Medicare Part A (Hospital Insurance [HI])	The part of the Medicare program that pays for hospitalization, care in a skilled nursing facility, home healthcare, and hospice care. Medicare Part B (Supplementary Medical Insurance [SMI])
Medicare Part C	Managed care health plans offered to Medicare beneficiaries under the Medicare Advantage program.
Medicare Part D	Prescription drug reimbursement plans offered to Medicare beneficiaries.
Medicare-participating agreement	Describes agreement signed by physicians and other providers of medical services with Medicare to accept assignment on all Medicare claims.
Medicare Physician Fee Schedule (MPFS)	The RBRVS-based allowed fees that are the basis for Medicare reimbursement.
Medicare Redetermination Notice (MRN)	Communication of the resolution of a first appeal for Medicare fee-for-service claims; a written decision notification letter is due within sixty days of the appeal.
Medicare Secondary Payer (MSP)	Federal law requiring private payers who provide general health insurance to Medicare beneficiaries to be the primary payers for beneficiaries’ claims.
Medicare-Severity DRGs (MS-DRGs)	Medicare Inpatient Prospective Payment System revision that takes into account whether certain conditions were present on admission. Medicare Summary Notice (MSN)
Medigap	Insurance plan offered by a private insurance carrier to supplement Medicare Original Plan coverage.
Medi-Medi beneficiary	Person who is eligible for both Medicare and Medicaid benefits.
metal plans	New health plans created by the ACA named after different types of metals according to the services they cover.
Military Treatment Facility (MTF)	Government facility providing medical services for members and dependents of the uniformed services.
minimum necessary standard	Principle that individually identifiable health information should be disclosed only to the extent needed to support the purpose of the disclosure.
modifier	A number that is appended to a code to report particular facts. CPT modifiers report special circumstances involved with a procedure or service. HCPCS modifiers are often used to designate a body part, such as left side or right side.
monthly enrollment list	Document of eligible members of a capitated plan registered with a particular PCP for a monthly period.
moribund	Being in a state of approaching death.
MS-DRGs (Medicare-Severity DRGs)	Type of DRG designed to better reflect the different severity of illness among patients who have the same basic diagnosis.
multiple modifiers	Two or more modifiers used to augment a procedure code.
narrow network	Payer network of physicians and hospitals with limited choices for patients.
National Committee for Quality Assurance (NCQA)	Organization that collects and disseminates the HEDIS information rating the quality of health maintenance organizations. national coverage determination (NCD)
National Patient ID (Individual Identifier)	Unique individual identification system to be created under HIPAA National Identifiers.
National Payer ID (Health Plan ID)	Unique health plan identification system to be created under HIPAA National Identifiers.
National Plan and Provider Enumerator System (NPPES)	A system set up by HHS that processes applications for NPIs, assigns them, and then stores the data and identifying numbers for both health plans and providers.
National Provider Identifier (NPI)	Under HIPAA, unique ten-digit identifier assigned to each provider by the National Provider System.
National Uniform Claim Committee (NUCC)	Organization responsible for the content of healthcare claims.
NEC (not elsewhere classifiable)	An abbreviation indicating the code to use when a disease or condition cannot be placed in any other category.
negligence	In the medical profession, failure to perform duties properly according to the state-required standard of care.
Neoplasm Table	A summary table of code numbers for neoplasms by anatomical site and divided by the description of the neoplasm.
network	A group of healthcare providers, including physicians and hospitals, who sign a contract with a health plan to provide services to plan members.
network model HMO	A type of health maintenance organization in which physicians remain self-employed and provide services to both HMO members and nonmembers.
never event	Preventable medical error resulting in serious consequences for the patient; Medicare policy is never to pay the healthcare provider for these conditions.
new patient (NP)	A patient who has not received professional services from a provider (or another provider with the same specialty in the same practice) within the past three years.
No Surprises Act	A law that protects patients from unanticipated medical bills from out-of-network providers that they did not choose.
noncovered services	Medical procedures that are not included in a plan’s benefits.
nonessential modifier	Supplementary terms that are not essential to the selection of the correct code, and which are shown in parentheses on the same line as a main term or subterm.
nonparticipating provider (nonPAR)	A provider who chooses not to join a particular government or other health plan.
nonsufficient fund (NSF) check	A check that is not honored by the bank because the account lacks funds to cover it; also called a “bounced,” “returned,” or “bad” check.
nontraumatic injury	A condition caused by the work environment over a period longer than one work day or shift; also known as occupational disease or illness.
NOS (not otherwise specified)	An abbreviation indicating the code to use when no information is available for assigning the disease or condition to a more specific code; unspecified.
Notice of Contest	Carrier’s notification of determination to deny liability for an employee’s workers’ compensation claim.
Notice of Exclusions from Medicare Benefits (NEMB)	Former form for notifying Medicare beneficiaries that a service is not covered by the program; now included in the ABN. Notice of Privacy Practices (NPP)
observation services	Medical service furnished in a hospital to evaluate an outpatient’s condition or determine the need for admission as an inpatient; billed as outpatient services.
occupational disease or illness	Condition caused by the work environment over a period longer than one workday or shift; also known as nontraumatic injuries.
Occupational Safety and Health Administration (OSHA)	Federal agency that regulates workers’ health and safety risks in the workplace.
Office for Civil Rights (OCR)	Government agency that enforces the HIPAA Privacy Act.
Office of E-Health Standards and Services (OESS)	A part of CMS, which helps to develop and coordinate the implementation of a comprehensive e-health strategy for CMS.
Office of the Inspector General (OIG)	Government agency that investigates and prosecutes fraud against government healthcare programs such as Medicare.
Office of Workers’ Compensation Programs (OWCP)	The office of the U.S. Department of Labor that administers the Federal Employees’ Compensation Act which covers work-related injuries or illnesses suffered by civilian employees of federal agencies.
OIG Compliance Program Guidance for Individual and Small Group Physician Practices	OIG publication that explains the recommended features of compliance plans for small providers.
OIG Fraud Alert	Notice issued by OIG to advise providers about potentially fraudulent or noncompliant actions regarding billing and reporting practices.
OIG Work Plan	OIG’s annual list of planned projects under the Medicare Fraud and Abuse Initiative.
Omnibus Rule	Set of regulations enhancing patients’ privacy protections and rights to information and the government’s ability to enforce HIPAA
open enrollment period	Span of time during which a policyholder selects from an employer’s offered benefits; often used to describe the fourth quarter of the year for employees in employer-sponsored health plans or the designated period for enrollment in a Medicare or Medigap p
operating rules	Rules that improve interoperability between the data systems of different entities, such as health plans and providers, and so increase their usefulness.
operations (healthcare)	Activities such as conducting quality assessment and improvement, developing protocol, and reviewing the competence or qualifications of healthcare professionals and actions to implement compliance with regulations.
Original Medicare Plan	The Medicare fee-for-service plan.
other ID number	Additional provider identification number supplied on a healthcare claim.
out-of-network	Description of a provider who does not have a participation agreement with a plan. Using out-of-network providers is more expensive for the plan’s enrollees.
out-of-pocket	Description of the expenses the insured must pay before benefits begin.
outpatient	A patient who receives healthcare in a hospital setting without admission; the length of stay is generally less than twenty-three hours.
Outpatient Prospective Payment System (OPPS)	The payment system for Medicare Part B services that facilities provide on an outpatient basis.
outside laboratory	Purchased laboratory services.
overpayment	An improper or excessive payment resulting from billing errors to a provider as a result of billing or claims processing errors for which a refund is owed by the provider.
panel	In CPT, a single code grouping laboratory tests that are frequently done together.
parity	Equal in value; refers to comparable coverage for medical/surgical benefits with other benefits such as mental health.
partial payment	An amount a medical practice may ask the patient to pay at the time of service that represents a percentage of the total estimated amount due for the current services received.
participating provider (PAR)	A provider who agrees to provide medical services to a payer’s policyholders according to the terms of the plan’s contract.
participation	Contractual agreement by a provider to provide medical services to a payer’s policyholders.
password	Confidential authentication information composed of a string of characters.
patient aging report	A report grouping unpaid patients’ bills by the length of time that they remain due, such as 30, 60, 90, or 120 days.
patient information form	Form that includes a patient’s personal, employment, and insurance company data needed to complete a healthcare claim; also known as a registration form.
patient ledger	Record of all charges, payments, and adjustments made on a particular patient’s account.
patient ledger card	Card used to record charges, payments, and adjustments for a patient’s account.
patient refunds	Monies that are owed to patients.
patient statement	A report that shows the services provided to a patient, total payments made, total charges, adjustments, and balance due.
payer	Health plan or program.
payer of last resort	Regulation that Medicaid pays last on a claim when a patient has other insurance coverage.
pay-for-performance (P4P)	Health plan financial incentives program to encourage providers to follow recommended care management protocols.
payment plan	Patient’s agreement to pay medical bills over time according to an established schedule.
pay-to provider	The person or organization that is to receive payment for services reported on a HIPAA claim; may be the same as or different from the billing provider.
PECOS	Provider Enrollment Chain and Ownership System.
pending	Claim status during adjudication when the payer is waiting for information from the submitter.
permanent disability	Condition that prevents a person in a disability compensation program from doing any job.
permanent national codes	HCPCS Level II codes.
per member per month (PMPM)	Periodic capitated prospective payment to a provider who covers only services listed on the schedule of benefits.
personal injury protection (PIP)	Insurance coverage for medical expenses and other expenses related to a motor vehicle accident.
pharmacy	Facility or location where drugs and other medically related items and services are sold, dispensed, or otherwise provided directly to patients.
pharmacy benefit manager	Company that operates an employer’s pharmacy benefits program, buying drugs, setting up the formulary, and pricing the prescriptions for the insured.
physical status modifier	Code used in the Anesthesia Section of CPT with procedure codes to indicate the patient’s health status.
physician of record	Provider under a workers’ compensation claim who first treats the patient and assesses the level of disability.
placeholder character (x)	Designated as “x” in some codes when a fifth-, sixth-, or seventh digit character is required but the digit space to the left of that character is empty.
place of service (POS) code	HIPAA administrative code that indicates where medical services were provided.
plan summary grid	Quick-reference table for frequently billed health plans.
PM/EHR	A software program that combines both a PMP and an EHR into a single product.
policyholder	Person who buys an insurance plan.
portal	Website that serves as an entry point to other websites
practice management program (PMP)	Business software designed to organize and store a medical practice’s financial information; often includes scheduling, billing, and electronic medical records features.
preauthorization	Prior authorization from a payer for services to be provided; if preauthorization is not received, the charge is usually not covered.
precertification	Generally, preauthorization for hospital admission or outpatient procedure; see preauthorization.
preferred provider organization (PPO)	Managed care organization structured as a network of healthcare providers who agree to perform services for plan members at discounted fees; usually, plan members can receive services from non-network providers for a higher charge.
premium	Money the insured pays to a health plan for a healthcare policy.
prepayment plan	Payment arrangement made before medical services are provided. present on admission (POA)
preventive medical services	Care that is provided to keep patients healthy or to prevent illness, such as routine checkups and screening tests.
Pricing, Data Analysis, and Coding (PDAC) contractor	Contractor under CMS who is responsible for providing assistance in determining which HCPCS code describes DMEPOS items for Medicare billing purpose.
Primary Care Manager (PCM)	Provider who coordinates and manages the care of TRICARE beneficiaries.
primary care physician (PCP)	A physician in a health maintenance organization who directs all aspects of a patient’s care, including routine services, referrals to specialists within the system, and supervision of hospital admissions; also known as a gatekeeper.
primary diagnosis	The first-listed diagnosis.
primary insurance (payer)	Health plan that pays benefits first when a patient is covered by more than one plan.
primary procedure	The most resource-intensive (highest paid) CPT procedure done during a patient’s encounter.
Prime Service Area	Geographic area designated to ensure medical readiness for active-duty members.
principal diagnosis (PDX)	In inpatient coding, the condition that after study is established as chiefly responsible for a patient’s admission to a hospital.
principal procedure	The main service performed for the condition listed as the principal diagnosis for a hospital inpatient.
prior authorization number	Identifying code assigned by a government program or health insurance plan when preauthorization is required; also called the certification number. private disability insurance
privileging	The process of determining a healthcare professional’s skills and competence to perform specific procedures as a participant in, or an affiliate of, a healthcare facility or system. Once a facility privileges a practitioner, the practitioner may perform t
procedure code	Code that identifies medical treatment or diagnostic services.
professional component (PC)	The part of the relative value associated with a procedure code that represents a physician’s skill, time, and expertise used in performing it; contrast with the technical component.
professional courtesy	Providing free medical services to other physicians.
professionalism	For a medical insurance specialist, the quality of always acting for the good of the public and the medical practice being served. This includes acting with honor and integrity, being motivated to do one’s best, and maintaining a professional image. progn
prompt-pay laws	Regulations that obligate payers to pay clean claims within a certain time period.
prospective audit	Internal audit of particular claims conducted before they are transmitted to payers.
prospective payment	Payment for healthcare determined before the services are provided. Prospective Payment System (PPS)
protected health information (PHI)	Individually identifiable health information that is transmitted or maintained by electronic media.
provider	Person or entity that supplies medical or health services and bills for, or is paid for, the services in the normal course of business. A provider may be a professional member of the healthcare team, such as a physician, or a facility, such as a hospital
Provider Enrollment Chain and Ownership System (PECOS)	CMS national database of participating providers.
provider-sponsored organization (PSO)	Capitated Medicare managed care plan in which the physicians and hospitals that provide treatment also own and operate the plan.
provider withhold	Amount withheld from a provider’s payment by an MCO under contractual terms; may be paid if stated financial requirements are met.
qualifier	Two-digit code for a type of provider identification number other than the National Provider Identifier (NPI).
Quality Payment Program (QPP)	Two-track value-based reimbursement system designed to incentivize high quality of care over service volume.
Qui tam	in healthcare refers to a legal provision within the False Claims Act (FCA) that allows individuals, known as whistleblowers, to file lawsuits on behalf of the government against healthcare providers or entities suspected of fraudulent billing practices t
RA	Payer document detailing the results of claim adjudication and payment.
real-time	Information technology term for computer systems that update information the same time they receive it; the sender and receiver “converse” by inquiring and responding to data while remaining connected.
real-time adjudication (RCA)	Electronic health insurance claim processed at patient check-out; allows practice to know what the patient will owe for the visit.
reasonable fee	The lower of either the fee the physician bills or the usual fee, unless special circumstances apply.
reassociation trace number (TRN)	Identifier that is passed from the payer to the payer’s bank, then to the practice’s bank, and finally to the practice.
reconciliation	Comparison of two numbers to determine whether they differ.
Recovery Audit Contractor (RAC)	A type of contractor hired by CMS to validate claims that have been paid to providers and to collect a payback of any incorrect payments that are identified.
recovery auditor program	A Medicare post payment claim review program. redetermination
reference pricing	Method to control costs for expensive procedures with varying prices.
referral	Transfer of patient care from one physician to another.
referral number	Authorization number given by a referring physician to the referred physician.
referral waiver	Document a patient is asked to sign guaranteeing payment when a required referral authorization is pending.
referring physician	The physician who refers the patient to another physician for treatment.
registration	Process of gathering personal and insurance information about a patient during admission to a hospital.
Regulation F	A rule that clarifies debt collection practices created by the FDCPA.
relative value scale (RVS)	System of assigning unit values to medical services based on an analysis of the skill and time required of the physician to perform them.
relative value unit (RVU)	A factor assigned to a medical service based on the relative skill and time required to perform it.
relator	Person who makes an accusation of fraud or abuse in a qui tam case.
remittance	The statement of the results of the health plan’s adjudication of a claim.
remittance advice (RA)	Health plan document describing a payment resulting from a claim adjudication; the copy sent to the insured is called an explanation of benefits (EOB).
remittance advice remark code (RARC)	Code that explains payers’ payment decisions.
rendering provider	Term used to identify the physician or other medical professional who provides the procedure reported on a healthcare claim if other than the pay-to provider. reprice
repricer	Vendor that sets up fee schedules and discounts, and processes out-of-network claims for payers.
required data element	Information that must be supplied on an electronic claim.
resequenced	CPT procedure codes that have been reassigned to another sequence, or CPT range of codes.
resource-based fee structure	Setting fees based on the relative skill and time required to provide similar services.
resource-based relative value scale (RBRVS)	Federally mandated relative value scale for establishing Medicare charges.
responsible party	Person or entity other than the insured or the patient who will pay a patient’s charges.
restricted status	A category of Medicaid beneficiary.
retention schedule	A practice policy that governs which information from patients’ medical records is to be stored, for how long it is to be retained, and the storage medium to be used.
retroactive payment	Payer’s payment for healthcare after the services are provided.
retrospective audit	An internal audit conducted after claims are processed by payers and after RAs have been received for comparison with submitted charges.
revenue cycle	All administrative and clinical functions that help capture and collect patients’ payments for medical.
revenue cycle management (RCM)	All actions taken to make sure that sufficient monies flow into the practice from patients and insurance companies paying for medical services to pay the practice’s bills.
rider	Document that modifies an insurance contract.
roster billing	Under Medicare, simplified billing for pneumococcal, influenza virus, and hepatitis B vaccines.
schedule of benefits	List of the medical expenses that a health plan covers.
screening services	Tests or procedures performed for a patient who does not have symptoms, abnormal findings, or any past history of the disease; used to detect an undiagnosed disease so that medical treatment can begin.
SDOH	Social determinants of health comprise a category of Z codes assigned to capture a patient’s social determinants of health as documented in the medical record.
secondary condition	Additional diagnosis that occurs at the same time as a primary diagnosis and that affects its treatment.
secondary insurance (payer)	The health plan that pays benefits after the primary plan pays when a patient is covered by more than one plan.
secondary provider identifier	On HIPAA claims, identifiers that may be required by various plans in addition to the NPI, such as a plan identification number.
section guidelines	Usage notes provided at the beginnings of CPT sections.
Section 125 cafeteria plan	Employers’ health plans that are structured under income tax laws to permit funding of premiums with pretax payroll deductions.
self-funded (self-insured) employer	A company that creates its own insurance plan for its employees, rather than using a carrier; the plan assumes payment risk, contracts with physicians, and pays for claims from its fund.
self-funded (self-insured) health plan	An organization that assumes the risks of paying for health insurance directly and sets up a fund from which to pay.
self-pay patient	A patient who does not have insurance coverage.
separate procedure	Descriptor used in the Surgery Section of CPT for a procedure that is usually part of a surgical package but may also be performed separately or for a different purpose, in which case it may be billed.
sequelae	Conditions that remain after a patient’s acute illness or injury has ended. sequencing
service line information	On a HIPAA claim, information about the services being reported.
seventh-character extension	A requirement contained in the note at the start of the code it covers; a seventh character must always be in position 7 of the alphanumeric code.
silent PPO	Managed care organization that purchases a list of a PPO’s participating providers and pays those providers’ claims for its enrollees according to the contract’s fee schedule even though the providers do not have contracts with the silent PPO. A provider
situational data element	Information that must be supplied on a claim when certain other data elements are provided.
skilled nursing facility (SNF)	Healthcare facility in which licensed nurses provide nursing and/or rehabilitation services under a physician’s direction.
skip trace	The process of locating a patient who has not paid on an outstanding balance.
small group health plan	Under HIPAA, generally a health plan sponsored by an employer with fewer than fifty employees.
SNODENT	Systemized nomenclature of dentistry.
SNOMED	Systemized nomenclature of medicine.
SOAP (subjective/objective/assessment/plan)	Documentation format in which encounter information is grouped into four sections containing the patient’s subjective descriptions of signs and symptoms; the physician’s notes on the objective information regarding the condition and examination/test resul
Social Security Disability Insurance (SSDI)	The federal disability compensation program for salaried and hourly wage earners, self-employed people who pay a special tax, and widows, widowers, and minor children with disabilities whose deceased spouse/parent would qualify for Social Security benefit
special report	Note explaining the reasons for a new, variable, or unlisted procedure or service; describes the patient’s condition and justifies the procedure’s medical necessity.
spenddown	State-based Medicaid program requiring beneficiaries to pay part of their monthly medical expenses.
sponsor	The uniformed service member in a family qualified for TRICARE or CHAMPVA.
staff model HMO	A type of HMO in which member providers are employees of the organization and provide services for HMO-member patients only.
standards of care (medical)	State-specified performance measures for the delivery of healthcare by medical professionals.
Stark Law	A federal law that governs physician self-referrals in financial relationships with other healthcare service providers.
statistical analysis durable medical equipment regional carrier (SADMERC)	CMS contractors who provide assistance in determining which HCPCS codes describe DMEPOS items for Medicare billing purposes.
stop-loss provision	Protection against the risk of large losses or severely adverse claims experience; may be included in a participating provider’s contract with a plan or bought by a self-funded plan.
subcapitation	Arrangement under which a capitated provider prepays an ancillary provider for specified medical services for plan members.
subcategory	A four- or five-character code number.
subclassification (ICD-9-CM)	A five-digit code number.
subrogation	Action by payer to recoup expenses for a claim it paid when another party should have been responsible for paying at least a portion of that claim.
subterm	Word or phrase that describes a main term in the Alphabetic Index.
Summary Plan Description (SPD)	Legally required document for self-funded plans that states beneficiaries’ benefits and legal rights.
superbill	also known as an encounter form.
supplemental insurance	Health plan, such as Medigap, that provides benefits for services that are not normally covered by a primary plan.
supplemental report	Report filed by the physician in state workers’ compensation cases when a patient’s medical condition or disability changes; also known as progress report. Supplemental Security Income (SSI)
suspended	Claim status during adjudication when the payer is developing the claim.
Table of Drugs and Chemicals	An index in table format of drugs and chemicals that are listed in the Tabular List.
Tabular List	The part of ICD 10-CM that lists diagnosis codes in chapters alphanumerically.
technical component (TC)	The part of the relative value associated with a procedure code that reflects the technician’s work and the equipment and supplies used in performing it; in contrast to the professional component.
telehealth/E-visit	A category of E/M codes covering non-face-to-face office visits such as those via telephone or secure platforms like electronic health records or secure email.
Telephone Consumer Protection Act of 1991	Federal law that regulates consumer collections to ensure fair and ethical treatment of debtors; governs calling hours and methods. Temporary Assistance for Needy Families (TANF)
temporary disability	Condition that keeps a person with a private disability compensation program from working at the usual job for a short time, but from which the worker is expected to recover completely and return to work.
temporary national codes	HCPCS Level II codes available for use but not part of the standard code set.
tertiary insurance	The third payer on a claim.
third-party claims administrator (TPA)	Company that provides administrative services for health plans but is not a contractual party.
third-party payer	Private or government organization that insures or pays for healthcare on the behalf of beneficiaries; the insured person is the first party, the provider the second party, and the payer the third party.
three-day payment window	Rules requiring Medicare to bundle all outpatient services provided by a hospital to a patient within three days before admission into the DRG payment for that patient.
tiered network	Plan feature that pays more to providers that the plan rates as providing the highest-quality, most cost-effective medical services.
Time	In determining the correct level of E/M codes for office visits, the measurement of total time spent on day of encounter is one of two main components.
trace number	A number assigned to a HIPAA 270 electronic transaction sent to a health plan to inquire about patient eligibility for benefits.
transaction	Under HIPAA, structured set of electronic data transmitted between two parties to carry out financial or administrative activities related to healthcare; in a medical billing program, electronic financial exchange that is recorded, such as a patient’s cop
traumatic injury	Injury caused by a specific event or series of events within a single workday or shift.
treatment, payment, and healthcare operation (TPO)	Under HIPAA, patients’ protected health information may be shared without authorization for the purposes of treatment, payment, and operations.
TRICARE	Government health program that serves dependents of active-duty service members, military retirees and their families, some former spouses, and survivors of deceased military members; formerly called CHAMPUS.
TRICARE For Life	Program for beneficiaries who are both Medicare and TRICARE eligible.
TRICARE Prime	The basic managed care health plan offered by TRICARE.
TRICARE Select	The fee-for-service military health plan.
truncated coding	Diagnoses that are not coded at the highest level of specificity available.
Truth in Lending Act	Federal law requiring disclosure of finance charges and late fees for payment plans.
21st Century Cures Act	A federal law that requires providers to make certain specific categories of clinical notes digitally accessible to patients.
UB-04	Currently mandated paper claim for hospital billing.
UB-92	Former paper hospital claim; also known as the CMS-1450.
unbundling	The incorrect billing practice of breaking a panel or package of services/procedures into component parts and reporting them separately.
uncollectible accounts	Monies that cannot be collected from the practice’s payers or patients and must be written off.
Uniform Hospital Discharge Data Set (UHDDS)	Classification system for inpatient health data.
United States Preventive Services Task Force (USPSTF)	An independent panel of nonfederal experts in prevention and evidence-based medicine that conducts scientific evidence review of a broad range of clinical preventive healthcare services (such as screening, counseling, and preventive medications) and devel
unlisted procedure	A service that is not listed in CPT; it is reported with an unlisted procedure code and requires a special report when used.
unspecified	Incompletely described condition that must be coded with an unspecified ICD code
upcoding	Use of a procedure code that provides a higher payment than the code for the service actually provided.
urgently needed care	In Medicare, a beneficiary’s unexpected illness or injury requiring immediate treatment; Medicare plans pay for this service even if it is provided outside the plan’s service area.
usual, customary, and reasonable (UCR)	Setting fees by comparing the usual fee the provider charges for the service, the customary fee charged by most providers in the community, and the fee that is reasonable considering the circumstances.
usual fee	Fee for a service or procedure that is charged by a provider for most patients under typical circumstances.
utilization	Pattern of usage for a medical service or procedure.
utilization review	Payer’s process to determine the appropriateness of hospital-based healthcare services delivered to a member of a plan.
utilization review organization (URO)	Organization hired by a payer to evaluate the medical necessity of procedures before they are provided to a member of a plan.
V code	Alphanumeric code in ICD-9-CM that identifies factors that influence health status and encounters that are not due to illness or injury.
verification report	Report created by a medical billing program to permit double-checking of basic claim content before transmission.
vocational rehabilitation	Retraining program covered by workers’ compensation to prepare a patient for reentry into the workforce.
waiting period	The amount of time that must pass before an employee or dependent may enroll in a health plan.
waived tests	Particular low-risk laboratory tests that Medicare permits physicians to perform in their offices.
walkout receipt	Medical billing program report given to a patient that lists the diagnoses, services provided, fees, and payments received and due after an encounter.
“Welcome to Medicare” preventive visit	This initial review of Medicare Part B provides a baseline examination of a beneficiary’s medical and social history.
Welfare Reform Act	Law that established the Temporary Assistance for Needy Families program in place of the Aid to Families with Dependent Children program and that tightened Medicaid eligibility requirements.
workers’ compensation insurance	State or federal plan that covers medical care and other benefits for employees who suffer accidental injury or become ill as a result of employment.
write off	(noun: write-off) To deduct an amount from a patient’s account because of a contractual agreement to accept a payer’s allowed charge or for other reasons.
X modifiers	New HCPCS modifiers that define specific subsets of modifier 59.
Z code	Abbreviation for code from the twenty-first chapter of the ICD-10-CM that identify factors that influence health status and encounters that are not due to illness or injury.
Zone Program Integrity Contractor (ZPIC)	An antifraud agency that conducts both prepayment and post payment audits based on the rules for medical necessity that are set by LCDs.
firewall	A software system designed to block unauthorized entry to a computer’s data.
claim	request for payment

Created by: VA_MedCod3r

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