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MED 112
FINALS Terms (Chapter 1-4)
| Question | Answer |
|---|---|
| cash flow | The movement of monies into or out of a business. |
| accounts receivable (AR) | Monies owed to a medical practice by its patients and third-party payers. |
| accounts payable (AP) | The practice’s operating expenses, such as for overhead, salaries, supplies, and insurance. |
| revenue cycle | All administrative and clinical functions that help capture and collect patients’ payments for medical. |
| health information technology (HIT) | Computer hardware and software information systems that record, store, and manage patient information. |
| 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. |
| electronic health record (EHR) | A computerized lifelong healthcare record for an individual that incorporates data from all sources that provide treatment for the individual. |
| PM/EHR | A software program that combines both a PMP and an EHR into a single product. |
| medical insurance | A written policy stating the terms of an agreement between a policy-holder and a health plan. |
| policyholder | Person who buys an insurance plan. |
| health plan | Under HIPAA, an individual or group plan that either provides or pays for the cost of medical care; includes group health plans, health insurance issuers, health maintenance organizations, Medicare Part A or B, Medicaid, TRICARE, and other government and |
| benefit | The amount of money a health plan pays for services covered in an insurance policy. |
| 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. |
| schedule of benefits | List of the medical expenses that a health plan covers. |
| 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 |
| 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 |
| covered services | Medical procedures and treatments that are included as benefits under an insured’s health plan. |
| preventive medical services | Care that is provided to keep patients healthy or to prevent illness, such as routine checkups and screening tests. |
| noncovered/excluded services | Medical procedures that are not included in a plan’s benefits. |
| indemnity plan | Type of medical insurance that reimburses a policyholder for medical services under the terms of its schedule of benefits. |
| healthcare claim | An electronic transaction or a paper document filed with a health plan to receive benefits. |
| premium | Money the insured pays to a health plan for a healthcare policy. |
| deductible | An amount that an insured person must pay, usually on an annual basis, for healthcare services before a health plan’s payment begins. |
| 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. |
| out-of-pocket | Description of the expenses the insured must pay before benefits begin. |
| fee-for-service | A payment method based on provider charges. |
| 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. |
| participation | Contractual agreement by a provider to provide medical services to a payer’s policyholders. |
| 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. |
| capitation | Payment method in which a fixed prepayment covers the provider’s services to a plan member for a specified period of time. |
| per member per month (PMPM) | Periodic capitated prospective payment to a provider who covers only services listed on the schedule of benefits. |
| network | A group of healthcare providers, including physicians and hospitals, who sign a contract with a health plan to provide services to plan members. |
| 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. |
| prior authorization (PA) | Advance approval for procedures/services. |
| copayment | An amount that a health plan requires a beneficiary to pay at the time of service for each healthcare encounter. |
| 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. |
| referral | Transfer of patient care from one physician to another. |
| 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. |
| 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. |
| 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. |
| medical insurance specialist | Medical office administrative staff member who handles billing, checks insurance, and processes payments. |
| medical coder | Medical office staff member with specialized training who handles the diagnostic and procedural coding of medical records. |
| diagnosis code | The number assigned to a diagnosis in the International Classification of Diseases. |
| procedure code | Code that identifies medical treatment or diagnostic services. |
| patient ledger | Record of all charges, payments, and adjustments made on a particular patient’s account. |
| compliance | Actions that satisfy official guidelines and requirements. |
| adjudication | The process followed by health plans to examine claims and determine benefits. |
| 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. |
| ethics | Standards of conduct based on moral principles. |
| 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. |
| malpractice | Failure to use an acceptable level of professional skill when giving medical services that results in injury or harm to a patient. |
| 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. |
| medical standards of care | State-specified performance measures for the delivery of healthcare by medical professionals. |
| encounter | An office visit between a patient and a medical professional. |
| 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. |
| 21st Century Cures Act | A federal law that requires providers to make certain specific categories of clinical notes digitally accessible to patients. |
| 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. |
| 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. |
| 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 Information Technology for Economic and Clinical Health (HITECH) Act | Law promoting the adoption and use of health information technology. |
| meaningful use | The utilization of certified EHR technology to improve quality, efficiency, and patient safety in the healthcare system. |
| Affordable Care Act (ACA) | Health system reform legislation that offers improved insurance coverage and other benefits. |
| electronic data interchange (EDI) | The system-to-system exchange of data in a standardized format. |
| interoperability | Ability of different computer systems and devices to share data. |
| 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 |
| 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 |
| 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 |
| business associate (BA) | A person or organization that performs a function or activity for a covered entity but is not part of its workforce. |
| HIPAA Privacy Rule | Law that regulates the use and disclosure of patients’ protected health information (PHI). |
| protected health information (PHI) | Individually identifiable health information that is transmitted or maintained by electronic media. |
| 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. |
| minimum necessary standard | Principle that individually identifiable health information should be disclosed only to the extent needed to support the purpose of the disclosure. |
| 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. |
| Notice of Privacy Practices (NPP) | A HIPAA-mandated description of a covered entity’s principles and procedures related to the protection of patients’ health information. |
| 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. |
| de-identified health information | Medical data from which individual identifiers have been removed; also known as a redacted or blinded record. |
| 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. |
| password | Confidential authentication information composed of a string of characters. |
| cybersecurity | The process of protecting information confidentiality, integrity, and availability by preventing, detecting, and responding to attacks on digital data. |
| deepfake | Type of synthetic data intended to imitate real people or entities for criminal purposes. |
| Artificial Intelligence (AI) | Machine-based system that can make predictions, recommendations, or decisions |
| 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. |
| HIPAA Electronic Health Care Transactions and Code Sets (TCS) | The HIPAA rule governing the electronic exchange of health information. |
| operating rules | Rules that improve interoperability between the data systems of different entities, such as health plans and providers, and so increase their usefulness. |
| 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. |
| 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. |
| National Provider Identifier (NPI) | Under HIPAA, unique ten-digit identifier assigned to each provider by the National Provider System. |
| Omnibus Rule | Set of regulations enhancing patients’ privacy protections and rights to information and the government’s ability to enforce HIPAA. |
| Office for Civil Rights (OCR) | Government agency that enforces the HIPAA Privacy Act. |
| Office of the Inspector General (OIG) | Government agency that investigates and prosecutes fraud against government healthcare programs such as Medicare. |
| False Claims Act | A federal law that prohibits intentional misrepresentation related to healthcare claims. |
| relator | Person who makes an accusation of fraud or abuse in a qui tam case. |
| audit | Methodical review; in medical insurance, a formal examination of a physician’s accounting or patient medical records. |
| Stark Law | A federal law that governs physician self-referrals in financial relationships with other healthcare service providers. |
| fraud | Intentional deceptive act to obtain a benefit. |
| abuse | Action that improperly uses another person’s resources. |
| 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 |
| 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. |
| 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. |
| referring physician | The physician who refers the patient to another physician for treatment. |
| 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. |
| nonparticipating provider (nonPAR) | A provider who chooses not to join a particular government or other health plan. |
| 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. |
| insured or subscriber | The policyholder of a health plan or medical insurance policy; also known as guarantor. |
| guarantor | A person who is financially responsible for the bill from the practice. |
| assignment of benefits | Authorization by a policyholder that allows a health plan to pay benefits directly to a provider. |
| 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. |
| direct provider | Clinician who treats the patient face-to-face, in contrast to an indirect provider such as a laboratory. |
| indirect provider | Clinician who does not interact face-to-face with the patient, such as a laboratory. |
| chart number | A unique number that identifies a patient. |
| 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. |
| electronic eligibility verification | Required payer response to the HIPAA standard transaction. |
| trace number | A number assigned to a HIPAA 270 electronic transaction sent to a health plan to inquire about patient eligibility for benefits. |
| prior authorization number | Identifying code assigned by a government program or health insurance plan when preauthorization is required; also called the certification number. |
| certification number | Number returned electronically by a health plan approving a referral authorization request when preauthorization is required. |
| referral number | Authorization number given by a referring physician to the referred physician. |
| 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. |
| referral waiver | Document a patient is asked to sign guaranteeing payment when a required referral authorization is pending. |
| primary insurance (payer) | Health plan that pays benefits first when a patient is covered by more than one plan. |
| secondary insurance (payer) | The health plan that pays benefits after the primary plan pays when a patient is covered by more than one plan. |
| supplemental insurance | Health plan, such as Medigap, that provides benefits for services that are not normally covered by a primary plan. |
| 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. |
| 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. |
| gender rule | Coordination of benefits rule for a child insured under both parents’ plans under which the father’s insurance is primary. |
| 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. |
| encounter form | A list of the diagnoses, procedures, and charges for a patient’s visit; also called the superbill. |
| charge capture | Office procedures that ensure that billable services are recorded and reported for payment. |
| accept assignment (acceptance of assignment) | A participating physician’s agreement to accept the allowed charge as payment in full. |
| self-pay patient | A patient who does not have insurance coverage. |
| 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. |
| financial policy | A practice’s rules governing payment for medical services from patients. |
| real-time adjudication (RTA) | Electronic health insurance claim processed at patient check-out; allows practice to know what the patient will owe for the visit. |
| 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. In ICD-10-CM, three-, four-, five-, six-, or seven-digit characters used to represent a dise |
| ICD-10-CM code | (also called an ICD code) three- to seven-digit characters alphanumeric representation of a disease or condition |
| Alphabetic Index | A part of ICD-10-CM and of ICD-9-CM that lists disease and injuries alphabetically with corresponding diagnosis codes. |
| Tabular List | The part of ICD 10-CM that lists diagnosis codes, descriptions, and notes in chapters alphanumerically. |
| Neoplasm Table | A summary table of code numbers for neoplasms by anatomical site and divided by the description of the neoplasm. |
| Table of Drugs and Chemicals | An index in table format of drugs and chemicals to identify poisoning status and external causes of adverse effects. |
| Index to External Causes | An index of the external cause-of-injury codes used to classify injury incidents by mechanism and intent. |
| diagnostic statement | A provider’s description of the main reason for a patient’s encounter; may also describe related conditions or symptoms. |
| convention | Agreement to use typographic techniques or standard practices that provide visual guidelines for understanding printed material. |
| main term | A word that identifies a disease or condition in the Alphabetic Index. |
| 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. |
| subterm | Word or phrase that describes a main term in the Alphabetic Index. |
| etiology | The cause or origin of a disease. |
| 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. |
| 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. |
| NEC (not elsewhere classifiable) | An abbreviation indicating the code to use when a disease or condition cannot be placed in any other category. |
| 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. |
| manifestation | A disease’s typical signs, symptoms, or secondary processes. |
| 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. |
| combination code | A single code that classifies both the etiology and the manifestation(s) of an illness or injury. |
| 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. |
| 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. |
| category | A three-digit code used for classifying a disease or condition. |
| subcategory | A four- or five-character code number. |
| inclusion notes | Notes that are headed by the word includes and refine the content of the category appearing above them. |
| exclusion notes | Tabular List entries limiting applicability of particular codes to specified conditions. |
| excludes 1 | A type of exclusion note that is used when two conditions could not exist together. |
| 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. |
| primary diagnosis | The first-listed diagnosis. |
| coexisting condition | Additional illness that either has an effect on the patient’s primary illness or is also treated during the encounter. |
| 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. |
| chronic | Description of an illness or condition with a long duration. |
| sequelae | Conditions that remain after a patient’s acute illness or injury has ended. |
| external cause code | Diagnosis code that reports the cause of injuries from various environmental events. |
| 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. |
| SDOH | Social determinants of health are non-medical factors that influence a person's health and wellbeing, identified by Z codes in ICD-10-CM. |
| chief complaint (CC) | A patient’s description of the symptoms or other reasons for seeking medical care from a provider. |
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