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| 11356877924 | Abuse | Improper billing practices that result in financial benefit to the provider but are not fraudulent. | 0 | |
| 11356877925 | Add-on codes | CPT codes with a + symbol in front, used to specify procedures in addition to the primary procedure. An addition code cannot be used alone. | 1 | |
| 11356877926 | Adjustment | A positive or negative change to a patient's account balance. This is done to make changes, corrections, or discount write-offs. | 2 | |
| 11356877927 | Admitting Clerk | Clerk who enters patient's demographic information into a computer and obtains signed statement(s) from patients to protect hospitals' interests. Responsibilities of the admitting clerk may also include general filling of patient charts. | 3 | |
| 11356877928 | Admitting Physician | The doctor responsible for admitting a patient to a hospital or other inpatient health facility. | 4 | |
| 11356877929 | Advanced Beneficiary Notice (ABN) | A written notification that must be signed by the patient or guardian prior to the provider rendering a service to a Medicare beneficiary that could be potentially denied or deemed "not medically necessary." | 5 | |
| 11356877930 | Allowed Charges | Maximum amount an insurance payer considers reasonable for medical services. Participating providers agree by contract to accept the allowed charge for services they provide. The allowed charge is often paid in part by the insurance company and in part by the patient's co-insurance or co-payment. | 6 | |
| 11356877931 | Appeal | The process used by a provider to ask an insurance carrier to reconsider a denied claim. The provider bases an appeal on documentation that backs up the medical necessity of the medical treatment. | 7 | |
| 11356877932 | Assignment of Benefits | Request made by a patient to allow the insurance carrier to pay the healthcare professional directly rather than issuing monies to the patient. | 8 | |
| 11356877933 | Audit | A formal examination of patients' medical records and accounts. | 9 | |
| 11356877934 | Balance Billing | Billing patients for the dollar amount left over after the insurance carrier has paid. If the provider has a contract with the third-party payer, balance billing may be prohibited. | 10 | |
| 11356877935 | Benefit period | A period of time during which medical benefits are available to an insurance beneficiary. | 11 | |
| 11356877936 | Birthday Rule | Determines which insurance is primary when two policies are valid for a child. The plan of the parent whose birthday month comes first in the calendar year is usually primary. | 12 | |
| 11356877937 | Bundled Code | A group of related procedures covered by a single code. | 13 | |
| 11356877938 | Centers for Medicare and Medicaid Services (CMS) | The department of the federal government responsible for administering Medicare and Medicaid. Formerly the Health Care Financing Administration (HCFA). | 14 | |
| 11356877939 | Certifications | Training received in particular fields that acknowledges a medical office specialist's expertise. | 15 | |
| 11356877940 | Charges | Amounts a practice charges for medical services rendered. | 16 | |
| 11356877941 | Charge Description Master (CDM) | A database that contains a detailed narrative of each procedure, service, dollar amount and revenue code that is used in inpatient facilities. This information is transferred to the patient bill or UB-04 after the patient is discharged. | 17 | |
| 11356877942 | Chief Complaint (CC) | A concise statement describing the symptoms, problem, condition, diagnosis, or other factor that is the reason for the patient encounter. | 18 | |
| 11356877943 | Clean Claims | Claims that have no data errors when submitted to an insurance carrier. | 19 | |
| 11356877944 | Clearinghouse | A company that receives claim from multiple providers, evaluates them, and batches them for electronic submission to multiple insurance carriers. | 20 | |
| 11356877945 | CMS-1500 Claim Form | Standard claim form used by physicians and other healthcare professions to bill for services rendered. | 21 | |
| 11356877946 | Code Edits | Computer program function that screens for improperly or incorrectly reported procedure codes. | 22 | |
| 11356877947 | Code Linkage | The process of joining a diagnosis code and procedure code for the purpose of justifying medical necessity. | 23 | |
| 11356877948 | Coinsurance | Percentage of the allowed amount that is the patient's responsibility. | 24 | |
| 11356877949 | Commercial Health Insurance (CHI) | Any type of health insurance not paid for by a government agency. The policy can be based on fee for service or managed care. Also known as private health insurance. | 25 | |
| 11356877950 | Comorbidity | One or more disorders or diseases that presents in addition to the primary disease or disorders. | 26 | |
| 11356877951 | Compliance Officer | Individual responsible for reviewing office policies and procedures to ensure that all applicable HIPAA laws, rules, and regulations are being followed. | 27 | |
| 11356877952 | Consultation | Service provided by a physician whose opinions or advice regarding a patient's condition and/or treatment is requested by another physician. The consulting physician must communicate the findings, results, and recommendations in a written report to the requesting physician. | 28 | |
| 11356877953 | Coordination of Benefits (COB) | When a patient has more than one insurance policy, insurance carriers work together to coordinate the insurance benefit so that the maximum payment does not exceed 100% of the charge. | 29 | |
| 11356877954 | Copayment | A fixed dollar amount the patient pays at each office visit or hospital encounter, as specified in the patient's insurance policy. | 30 | |
| 11356877955 | Crossover | Reassignment of gaps in coverage that eliminates the need for a beneficiary to file a separate claim with his or her Medigap insurer. It usually requires the beneficiary to sign release-of-information and assignment-of-benefit forms with their providers. | 31 | |
| 11356877956 | Crosswalk | A reference aid that compares information in one system to information in another system. A crosswalk between ICD-9 and ICD-10 will allow a coder to look up an ICD-9 code and see what the corresponding code is in the new ICD-10 system. | 32 | |
| 11356877957 | Current Procedural Terminology (CPT) | A system of five-digit codes used to describe what procedures were performed. | 33 | |
| 11356877958 | Deductible | Amount a beneficiary is responsible for before the insurance company pays as stated in the insurance policy. | 34 | |
| 11356877959 | Dirty Claim | A claim that is incorrect or is missing information when submitted. | 35 | |
| 11356877960 | Documentation | A consistent, medical record format, often in chronological order, that records facts and observations regarding a patient's health status. | 36 | |
| 11356877961 | Downcode | Occurs when the procedure code billed is for a procedure that is less involved than the procedure actually documented in the chart. Carriers will downcode or deny payment when the documentation fails to justify the level of service billed. | 37 | |
| 11356877962 | Electronic Claims | The process of submitting medical claims electronically versus on paper claims. | 38 | |
| 11356877963 | E/M Codes | CPT codes 99201 to 99499. These codes are used to report encounters in which the physician evaluates the patient's problem or complaint, considers treatment options, and recommends a plan of treatment. The most common E/M visits are "office visits" and "hospital visits." Codes are categorized by place of service and subdivided based on the complexity of the problem and treatment options. 3 to 5 level of codes are available for reporting purposes. The number of levels in a category varies and is dependent on the types of services that might be provided. | 39 | |
| 11356877964 | Established Patient | One who has received professional services from a physician or another physician of the same specialty who belongs to the same group practice within the past 3 years. | 40 | |
| 11356877965 | Examination | An evaluation performed by a physician who is involved in a patient's care for the purpose of establishing a medical diagnosis and treatment. | 41 | |
| 11356877966 | Fraud | An intentional deception or misrepresentation that an individual knows, or should know, to be false, or does not believe to be true, and makes, knowing the deception could result in some unauthorized benefit to himself or some other person(s). | 42 | |
| 11356877967 | 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. | 43 | |
| 11356877968 | Guarantor | The person who is ultimately responsible for paying for the healthcare services rendered. | 44 | |
| 11356877969 | History of Present Illness (HPI) | A chronological description of the development of the patient's present illness from the first sign or symptom to the present. | 45 | |
| 11356877970 | ICD-9-CM | Abbreviation for International Classification of Diseases, Ninth Revision, Clinical Modification. A coding system used to code signs, symptoms, injuries, diseases, and conditions. | 46 | |
| 11356877971 | Inpatient | A patient who has been admitted to the hospital and is expected to stay 24 hours or more. | 47 | |
| 11356877972 | Insurance Verification Representative | Coordinates all financial aspects of patient visits and admissions, including insurance verification, precertification information, follow-up of third-party payment denials, and financial counseling. | 48 | |
| 11356877973 | Level I (HCPCS) | CPT coding levels published by the American Medical Association that are made up of five numeric digits. These codes are used to report services and procedures when billing insurance carriers. | 49 | |
| 11356877974 | Level II (HCPCS) | Alphanumeric CPT coding levels published by CMS that consists of one letter followed by four numbers. These codes are used to report certain medical services not included in the CPT manual, services by nonphysician providers and ambulances, and durable medical equipment and supplies when billing insurance carriers. | 50 | |
| 11356877975 | Lifetime Maximum | As stated in the insurance policy, the maximum amount of money a plan will pay toward health services over the lifetime of the insured. Once this amount has been met, no more benefits will be paid. | 51 | |
| 11356877976 | Limiting Charge | The maximum amount a non-participating physician can charge a Medicare patient on a non-assigned claim. | 52 | |
| 11356877977 | Local Coverage Determination (LCD) | A decision by a Medicare fiscal intermediary or carrier on whether to cover a particular service on an intermediary-wide or carrier-wide basis in accordance with Section 1862 (a) (1) (A) of the Social Security Act (i.e., a determination as to whether the service is reasonable and necessary). | 53 | |
| 11356877978 | Main Term | The term used when searching for a specific diagnosis code. Is usually the chief complaint (CC). | 54 | |
| 11356877979 | Medical Biller | Individual who submits and tracks all insurance claims and ensures that insurance companies correctly reimburse the healthcare provider. | 55 | |
| 11356877980 | Medical Coder | Individual who assigns numerical codes to diagnoses and procedures using no the ICD-9(10)-CM and CPT manuals. | 56 | |
| 11356877981 | Medical Decision Making (MDM) | The process of establishing a diagnosis and selecting a management option as measured by the number of diagnoses or treatment options, the amount and complexity of data (medical records, test result, or other information) to be reviewed, and the risk of complications, morbidity, or mortality. | 57 | |
| 11356877982 | Medicare Part A | The U.S. government's health insurance program for the elderly, individuals with disabilities, and individuals with qualifying end-stage renal disease. This portion covers hospital fees. | 58 | |
| 11356877983 | Medicare Part B | Medical insurance that helps pay for physicians' services, outpatient hospital care, durable medical equipment, and some medical services that are not covered by Medicare Part A. | 59 | |
| 11356877984 | Medicare Part C | Offers expanded benefits for a fee through private health insurance programs such as health maintenance organizations and preferred provider organizations that have contracts with Medicare. Also called Medicare Advantage. | 60 | |
| 11356877985 | Medicare Part D | Medicare prescription drug coverage program. | 61 | |
| 11356877986 | Medicare Remittance Notice (MRN) | Notice sent to providers by Medicare contractors on assigned claims; details how a claim was processed. | 62 | |
| 11356877987 | Medicare Secondary Payer (MSP) | Any situation in which a payer is required by federal law to pay before Medicare pays. In several instances another payer could be primary to Medicare | 63 | |
| 11356877988 | Medicare Summary Notice (MSN) | An easy-to-read document that clearly lists the health insurance claim information. The MSN lists the details of the services rendered by a provider and show amounts paid and beneficiaries' responsibilities. | 64 | |
| 11356877989 | Medigap | A privately offered, Medicare-supplemental health insurance policy designed to provide additional coverage for services that Medicare does not pay for and noncovered services. | 65 | |
| 11356877990 | Modifiers | Two-digit numbers placed after the five-digit CPT code to indicate that the description of the service or procedure has been altered. | 66 | |
| 11356877991 | National Provider Identifier (NPI) | A unique 10-digit number for HIPAA-covered healthcare providers to be used in the administrative and financial transactions adopted under HIPAA. | 67 | |
| 11356877992 | Network | An organization of members contracted with a managed care organization. | 68 | |
| 11356877993 | New Patient | A person who does not receive any professional services within the past 3 years from the physician or another physician of the same specialty who belongs to the same group practice. | 69 | |
| 11356877994 | Nonparticipating Provider (Non-Par) | A provider who does not have a contract with a designated insurance carrier and is not obligated to offer discounted rates. | 70 | |
| 11356877995 | Occupational Safety and Health Administration (OSHA) | A federal agency that oversees the federal laws requiring employers to provide employees with a workplace free from hazardous conditions. | 71 | |
| 11356877996 | Office of Inspector General (OIG) | The largest inspector general's office in the federal government, it is dedicated to combating fraud, waste, and abuse, and to improving the efficiency of HHS programs. The majority of OIGS resources goes toward overseeing Medicare and Medicaid programs. | 72 | |
| 11356877997 | Out-of-Pocket Expenses | Amount of healthcare expenses for which a policyholder or patient is responsible. The amount is determined by the payer and is listed in the insured's policy. The payer reimburses services at 100% once the out-of-pocket expenses are met in a calendar year. | 73 | |
| 11356877998 | Participating Provider (PAR) | A provider who signs a contract with an insurance carrier to see patients at a discounted rate. PARs are usually listed in a provider book given to beneficiaries at enrollment. | 74 | |
| 11356877999 | Past, Family, and Social History (PFSH) | A review of the past medical experiences of the patient and the patient's family as well as an age-appropriate review of past and current social activities such as marital status, employment, sexual history, and use of drugs, alcohol, and tobacco. | 75 | |
| 11356878000 | Payer of Last Resort | Under the Medicaid program, if an insured person has any insurance in addition to Medicaid, then those insurance carriers will be approached first for payment and Medicaid will be approached last. | 76 | |
| 11356878001 | Payment | Money received in a physician's practice. Includes insurance payments attached to an Explanation of Benefits or patient payments by check, money order, or cash. | 77 | |
| 11356878002 | Physical Status Modifier | A two-character code beginning with "P", required after a CPT code for anesthesia to indicate the patient's health status at the time anesthesia is administered. Established by the American Society of Anesthesiologists. | 78 | |
| 11356878003 | Point-of -Service (POS) | A type of managed healthcare plan that allows the member to choose between an HMO, PPO, or indemnity plan at the time of service. | 79 | |
| 11356878004 | Preauthorization | Authorizations from an insurance company that allow a patient to receive treatment using their benefits. Some insurance companies require this prior to admission for a hospital stay or outpatient surgery. | 80 | |
| 11356878005 | Premiums | Dollar amounts a person pays for an insurance policy. Often deducted from an employee's paycheck. | 81 | |
| 11356878006 | Primary Care Physician (PCP) | A provider who coordinated a patient's care. | 82 | |
| 11356878007 | Professional Component | The part of the relative value associated with a procedure that represents a physician's skill, time, and expertise used in performing the procedure. | 83 | |
| 11356878008 | Recovery Audit Contractor (RAC) | Audits the processed claims by MAC and recovers improper paid claims. | 84 | |
| 11356878009 | Referral | The transfer of total care or a specific portion of care of a patient from one physician to another. | 85 | |
| 11356878010 | Registration | The process of collecting a patient's personal information, including insurance information, and entering it into the hospital's computer system. Includes scheduling the hospital stay, completing preadmission testing, receiving and following all of the appropriate preadmission instructions, completing all consent forms, and verifying insurance benefits. | 86 | |
| 11356878011 | Release of Information Form | Specifies which information from a patient's medical chart may be released and to whom it may be released. | 87 | |
| 11356878012 | Review of Systems (ROS) | An inventory of body systems obtained through a series of questions asked by the physician, who seeks to identify signs or symptoms that the patient may be experiencing. | 88 | |
| 11356878013 | Schedule of Benefits (SOB) | A list of medical services covered under an insurance policy and the amount paid for each treatment. | 89 | |
| 11356878014 | Superbills | Document that contains ICD-9(10) and CPT codes for the diagnoses and services that the office routinely uses. Also referred to as an encounter form, charge slip, or routing ship. | 90 | |
| 11356878015 | Surgical Package | The services before and after a surgical procedure that are considered to be part of the CPT code billed and should not be part of the CPT code billed and should not be billed separately. The CPT manual defines the "CPT surgical package," but payers may vary this to suit their needs. Also called a global package. | 91 | |
| 11356878016 | Symbols | Used in the CPT book to show changes and alert the reader to new codes, deletions, or alternations to a code. The symbol is located before the code number for 1 year, after which it becomes part of the next annual printing. | 92 | |
| 11356878017 | Technical Component | Part of the relative value associated with a procedure that reflects the technologist, equipment, and processing including pre-injection and post-injection services. | 93 | |
| 11356878018 | TRICARE | The civilian health and medical program of the uniformed services for qualified family members of military personnel. | 94 | |
| 11356878019 | TRICARE Extra | A PPO type of managed care plan that allows TRICARE beneficiaries who do not have priority at a military treatment facility to receive services primarily from a civilian provider at a reduced fee. | 95 | |
| 11356878020 | TRICARE Prime | A voluntary HMO-style plan for TRICARE beneficiaries that offers preventive care and routine physical examinations. Each individual on this plan is assigned a primary care manager. | 96 | |
| 11356878021 | TRICARE Standard | A fee-for-service health plan for families of active-duty personnel and retirees that goes into effect when treated by a civilian provider. Most enrollees pay an annual deductible. | 97 | |
| 11356878022 | UB-04 Claim Form | Standard health insurance claim form used by institutional providers, such as hospitals, skilled nursing facility, and rehabilitation centers, to file insurance claims with Medicare Part A and other health insurance companies. The UB-04 replaced the UB-92 and was mandatory beginning in 2007. | 98 | |
| 11356878023 | Upcode | Occurs when the procedure code stated is for a procedure that is more involved than the one actually documented in the chart. | 99 |
