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Medical billing Flashcards

Health insurance terminology

12853840789	Actuaries	Mathematicians who study trends & set the insurance premiums, deductibles, and co-pays	0
12853840790	Adjustment Codes	Payer codes that explain why a claim is paid differently from how it is billed	1
12853840791	Admitting Physician	A physician responsible for a patient's admission to a hospital	2
12853840792	ADFC	"Aid to families with dependent children"; requires meeting specific income level for services	3
12853840793	Aging Reports	Reports that specify the status of a claim and identify transactions requiring follow-up	4
12853840794	Allowable charges	Also known as maximum allowable charge; provider payment that is the lower amount of the providers fee and the maximum the insurance company pays for the service	5
12853840795	Ancillary medical provider	a limited-licensed professional who performs billable services	6
12853840796	ANSII format	A complex electronic claims format that is capable of attaching medical records to the claim	7
12853840797	APC	"Ambulatory patient classification"; Medicare payment system for facilities performing outpatient procedures	8
12853840798	Appeal	A formal request for penalty reversal or a changed decision on a claim	9
12853840799	ASC	"Ambulatory surgery center"; a freestanding facility that specializes in same-day surgery	10
12853840800	Assignment of benefits	An allocation of who receives the insurance payment	11
12853840801	Authorization number	The number is assigned by the insurance company when a decision is reached prior to the delivery of service. Therefore, service is medically necessary.	12
12853840802	Authorized provider	A hospital, institution, physician or other professional who meets the licensing and certification requirements of TRICARE and is practicing within the scope of that license	13
12853840803	Bad debt write off	A payment that is owed but not collectible	14
12853840804	Balanced billing	The process of billing a patient for the balance after the insurance payment has been posted	15
12853840805	beneficiary	The person entitled to insurance policy benefits	16
12853840806	Benefit period	A Medicare patient readmission within 60 days of discharge; considered part of a previous hospitalization for calculating the Medicare part A patient financial responsibility.	17
12853840807	Billing address	The mailing address for the patient or payer	18
12853840808	Birthday rule	A rule used when both parents have insurance policies that cover a dependent child; specifies as the primary payer the parent whose birthday is the first in the calendar year	19
12853840809	Capitation	Method of payment to a physician based on the amount of patients assigned by the medical plan not the actual costs.	20
12853840810	Carrier	The medical plan that administers or underwrites a health benefit program	21
12853840811	Carrier-direct	A billing method that allows a provider to submit claims directly to the insurance carrier	22
12853840812	Case number	Payer assigned number that has to appear on each page sent with an appeal	23
12853840813	Charge slip	Known as a superbill, encounter form, or routing form; documentation for financial, diagnostic, and treatment information	24
12853840814	CHIP	"Children's health insurance program"; also known as title 21; a program that allows states to create health insurance programs for low-income children	25
12853840815	Claim audits	A review for duplication of services or billing, and excessive services or billing	26
12853840816	Claim edits	A review for completeness and accuracy of the claim form	27
12853840817	Clean claim	A claim paid on the first submission by passing the payer claim edits and claim audits	28
12853840818	Coinsurance	Known as co-payment, the percentage the Patient must pay the provider	29
12853840819	Combination program	Combination of state, employer self-insured, and commercial workers compensation	30
12853840820	Compliance monitoring	Identifying responsibilities related to accuracy and verification of the services provided	31
12853840821	Concurrent payment audit	Auditing that's done at the time oayments are posted, to correctness of payments received.	32
12853840822	Confidentiality	An ethical and legal guideline that specifies that certain information is not to be shared with others	33
12853840823	COB	"Coordination of benefits"; a rule that determines how monies will be paid so that the total amount of the bill is not overlaid, for a patient with more than one insurance policy.	34
12853840824	Coverage	A statement of medical conditions that a policy may or may not pay by the insurance	35
12853840825	Day sheet	A chronological summary of transactions posted to patients ledgers on a given day	36
12853840826	Deductible	The amount a patient pays for services before the insurance plan pays	37
12853840827	Delinquent claim	Known also as pending claim; a claim for which payment is overdue	38
12853840828	Demographic	Information about a person	39
12853840829	Dependent	A person permitted serviced under an insured's health policy	40
12853840830	Direct pay	A billing method in which the patient pays for the services provided	41
12853840831	Dirty claim	A denied or rejected claim	42
12853840832	Downcoding	Also called under coding; selecting a code at a lower level than the services required	43
12853840833	Duplicate claim	Also called double billing; resubmission of identical claims without changes	44
12853840834	EDI	"Electronic data interchange"; a process used for sending electronic claims	45
12853840835	EOB	"Explanation of benefits"; a notification of decisions related to a claim	46
12853840836	EOMB	"Explanation of Medicare benefits"; a notification of decisions related to a Medicare claim	47
12853840837	Episode of care reimbursement	A single fee foe all services associated with the procedure or illness	48
12853840838	Exclusion	A condition not covered by an insurance policy	49
12853840839	fee-for-service	A billing method in which a price is charged for each individual service	50
12853840840	Financial hardship discount	A discount for which a patient have financial difficulties signs a waiver that is put in his or her financial file,and for which the physician accepts what the insurance pays and writes off the portion owed by the patient	51
12853840841	Facial intermediary (FI)	"Facial intermediary"; an insurance carrier that administers medical plans for a specific region	52
12853840842	Global period	A time frame when all care related to a procedure or service is considered part of the coding report the procedure and may not be billed separately	53
12853840843	Health insurance	A contractor that provides money to cover some or all of the cost of medically necessary services	54
12853840844	HIPAA	"Health insurance portability and accountability act of 1996"; a federal law that governs a variety of health insurance billing regulations	55
12853840845	HMO	"Health maintenance organization"; a managed care plan	56
12853840846	IME	"Independent medical examination"; a second opinion at is requested by a third-party payer such as workers compensation or disability insurance, and that is usually performed for confirmation of a level of impairment or injury	57
12853840847	Indemnity insurance plan	A fee for service plan; the purest form of commercial insurance, in which a patient directs his or her own care and pays a percentage of the cost	58
12853840848	IDS	"Integrated delivery system"; a managed care organization that integrates all aspects of patient care under one delivery system	59
12853840849	Indirect payer	A third party payer; an insurance company that pays for the fee for service instead of the patient	60
12853840850	IPA	"Independent practice association"; an HMO contract with physician who maintain his or her existing practice	61
12853840851	Kyle provision	A provision included in the 1997 BBA that allows providers who opted out of the Medicare program to enter into private contracts with Medicare recipients under special rules	62
12853840852	Lifetime reserve	60 extra days of hospital coverage that a Medicare coverage patient may use once if needed	63
12853840853	Limited charge	115% of the allowable charge billed for nonparticipating providers	64
12853840854	Limited fee charge	A fee set at a maximum of 15% above the nonPAR Medicare approved rates	65
12853840855	Line item posting	An accounting method in which every payment posted to the exact transaction for which payments are received.	66
12853840856	Locality code	A 3 digit number that represents a group of zip codes	67
12853840857	Maximum allowable fee	An established a physician may charge for a service	68
12853840858	MCO	"Managed care organization"; a prepaid managed health plan	69
12853840859	MDC	"Major diagnostic categories"; diagnostic code groups that are similar or related by treatment, diagnosis, or length of stay in a hospital setting	70
12853840860	Medi / Medi	Also known as 18/19 or care / caid; a combination of Medicare and Medicaid programs available to Medicare eligible patients whose income is below poverty level	71
12853840861	MFS	"Medicare fee schedule"; a list of Medicare approved fees for provider and physician services	72
12853840862	MMI	"Maximum medical improvement and impairment rating"; usually, a percentage of total body function measurement assiociated with long-term impairment	73
12853840863	MSN	"Medicare summary notice"; also known as Medicare remittance notice (MRD); an explanation of benefits remittance	74
12853840864	MTF	"Military treatment facility"; a healthcare facility for members of the armed forces	75
12853840865	National conversion factor	The figure multiplied by the relative value unit (RVU) into a payment amount	76
12853840866	NonPAR	"Nonparticipating provider"; a physician that does not agree to accept the Medicare approved rate for services provided to Medicare patients	77
12853840867	No-show	A patient who fails to call or arrive for a scheduled appointment	78
12853840868	NPI	"National provider identification"; identification number that is to replaced the UPIN and PIN systems for submitting claims to health insurance programs	79
12853840869	NSF Format	A simple form of sending electronic claim data; a form that can not submit supporting documentation with the claim	80
12853840870	OIG / HHS	"Office of inspector general, department of health and human services"	81
12853840871	Outliers	Claims that are outside the normal statistical patterns for the region	82
12853840872	Out of plan	Services performed where there is no contact agreement with the medical plan of the patient	83
12853840873	Out of picket expenses	Money the patient must pay for services	84
12853840874	PAR	"Participating provider"; a physician who has signed a contract with a medical plan and has agreed to accept the fee schedule for services provided to patients	85
12853840875	Patient account ledger	A permanent financial record of transactions for a patient	86
12853840876	Patient account number	An internal identification number assigned by a practice for each patients financial record	87
12853840877	Patient discount	A discount given to self-pay patients; can not be lower than the Medicare fee schedule	88
12853840878	Patient eligibility	Contacting and verifying coverage of a patient to verify that the policy information is accurate and that coverage is active	89
12853840879	Patient supplied information	The billing information for the top half of the insurance claim form	90
12853840880	Penalized claim	A claim that does not pass the claim edits or audits; results in a reduction in payment	91
12853840881	Pigeonholing	Using a short list of diagnosis codes for all patients, even when the codes don't match the actual diagnosis or condition	92
12853840882	PIN	"Physician / provider identification number"; a unique number given by the insurance company that identifies the provider	93
12853840883	Place of service codes	Codes that identify where the service is provided	94
12853840884	Policyholder	Also known as the subscriber or beneficiary; the purchaser of the health insurance policy	95
12853840885	POS	"Point of service"; allows HMO patients limited coverage for out of plan providers	96
12853840886	PPO	"Preferred provider organization"; a managed care medical plan	97
12853840887	Preauthorization	Obtaining prior approval before a service is provided	98
12853840888	Pre existing condition	Any condition for which a person has received prior treatment	99
12853840889	Premium	A free paid at regular intervals by the policyholder	100
12853840890	Primary payer	The legally first billable insurance when more than one insurance policy is available	101
12853840891	Professional courtesy	A decision by a physician to see a patient at no charge	102
12853840892	Provider- supplied information	The billing information for the bottom half of the insurance claim form	103
12853840893	PSO	"Provider sponsored organization"; a Medicare managed care plan	104
12853840894	Qui tam	Provisions under the False Claims Act that allow anyone to report violations without repercussions	105
12853840895	QMB	"Qualified Medicare beneficiary program"; a program that pays premiums, deductibles, and co-payments for Medicare low-income patients	106
12853840896	RBRVS	"Resource based relative value system"; a basis for the physician fee schedule that applies work, overhead, and geographic adjustment in determining established fees	107
12853840897	Re-bill	Also known as repeat claim; resubmission of a corrected claim	108
12853840898	Right of subrogation	The substitution of one person for another in claiming a lawful right or debt	109
12853840899	Scope of practice	The legal limits of licensure; the type of services that can be provided with given credentials	110
12853840900	Secondary payer	The legally second billable insurance after the primary payer has sent payment, when more than one insurance policy is available.	111
12853840901	Special report	A report that explains any unusual, variable, or infrequently performed procedures or services; should be sent with the claim for processing	112
12853840902	Superbill	Also known as the charge slip, routing form, or encounter form; a documentation source for diagnostic, financial, and treatment information	113
12853840903	TPA	3rd party administrator; also known as a clearinghouse; a processing center for insurance claims	114
12853840904	Title 19	A social security act amendment establishing Medicaid	115
12853840905	Title 21	A social security act amendment establishing children's health insurance program (CHIP)	116
12853840906	Turn around time	The time from claim to submission to payment	117
12853840907	UCR	"Usual, customary, and reasonable fee"; the fee the provider usually charges for the service	118
12853840908	Unbundling	Billing separately for procedures that are usually grouped or bundled together in a comprehensive code or codes; considered a fraudulent and/or illegal act	119
12853840909	Unprocessable claim	A claim that can not be processed due to missing information	120
12853840910	Upcoding	Choosing a higher level code than what is documented for the service provided; can be considered a fraudulent practice	121
12853840911	UPIN	Unique provider identification number; specific number given to a provider by Medicare to identify the provider	122
12853840912	Waiver	Also known as a rider; an addendum to an insurance policy that excludes certain conditions from coverage	123
12853840913	Write off	The difference between the full fee and the allowed fee in a payer contract	124

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Medical Billing and Reimbursement Flashcards

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14793468201	Medical Billing Process	Collect as much patient information as possible regarding insurance coverage and payment expectations of the patient when the patient makes the appointment. Make a copy of the patient's insurance card and a government-issued photo ID at the time of the appointment. Remember to update the copies of insurance cards once a year. Once the patient's copayment responsibility is determined, collect the copayment before any medical services are provided. Verify the patient's coverage and eligibility prior to the appointment. Contact the provider services department or check online to confirm if the patient's contract with the insurance company is valid for the date of service. Contact the health insurance company's representative to request for precertification, if needed. In some instances, precertification is required in order for any payment to be authorized prior to medical services being provided. Code the diagnosis or procedure appropriately after medical services are provided. This coding information is provided to the insurer. Complete and submit the insurance claim form. Most insurance companies have an electronic claim form that is submitted online. Ensure accuracy during the billing process by reviewing the claims submission report.	0
14793468202	Patient's Financial Responsibilities to Third Party	Copayment Deductible Out of Pocket Costs Coinsurance	1
14793468203	CMS-1500 Form	Universal claim form used by most insurance providers to authorize payment for services. The MA can fill out the paper form or the electronic claim form depending upon the insurance company's policies. The information to be filled in an electronic claim form is identical to the information filled in the paper form and is divided into three sections.	2
14793468204	CMS-1500 Section I	This section indicates the type of insurance, insurance address, and insurance number.	3
14793468205	CMS-1500 Section II	This section includes patient and insured information. This is to specify which person is covered by the plan and how they are related to the insured.	4
14793468206	CMS-1500 Section III	This section includes physician or supplier information. This information is about the service provider, services provided, and the medical conditions being treated.	5
14793468207	When should the copayment be collected?	Before medical services are provided	6
14793468208	How is patient eligibility confirmed?	Contacting the provider services department to confirm that the patient's contract with the insurance company is valid for the date of service	7
14793468209	Direct Billing	the submission of electronic claims directly to the insurer. In the initial insurance claim, only basic patient information is provided to the insurance company, including patient name, date of birth, and insurance ID number. Diagnostic and procedural information is also sent. Transmitter IDs do not need to be included, as they are identifiers that are already part of the billing system.	8
14793468210	Carrier direct Billing	When physician's office or other medical office sends a claim directly to the medical insurance carrier. Major insurance companies-like Medicare, Medicaid, Aetna, and Cigna-provide billing software to the provider or office at no cost. It is simple and supplies required information, but is limited in that information can only be supplied to specific carriers, such as Medicare or Medicaid. This type of billing cannot be used for multiple third-party payers.	9
14793468211	Sending an Electronic Claim Form	When an electronic claim is sent, the MA should monitor processing and look for communication from the insurer. The insurer may request additional information, and the MA should address these requests as soon as possible. Delays in fulfilling requests may mean delays in payment. Further information may include progress notes or notes made by the provider about treatment provided. If this information is delayed, reimbursement to the provider may be suspended or withheld. The MA should always work to complete the electronic forms with a very high level of attention to detail and accuracy. Forms that are submitted with errors will delay payment or even lead to denial of benefits. Electronic submission should be reviewed for accuracy, and denials should be checked closely.	10
14793468212	Clearinghouse Services	Services provided by clearinghouses include: Auditing claims for accuracy. This helps in identifying errors and ensuring completeness, which in turn expedites payment and reduces the instances of denied claims. Generating statistical reports on the total number of claims, as well as the number of errors in a submission. Forwarding claims to other clearinghouses that may have contracts. This means that if the claim is submitted once, it does not need to be resubmitted to a different insurer. This can be helpful if the patient has more than one insurance carrier. Keeping medical offices informed of new insurance carriers added to the database. Providing reports on the number of claims submitted to third-party payers as well as the number of errors and their specifics. For example, a provider may want to see how many claims have been submitted to Blue Cross.	11

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chapter medical billing and reimbursement Flashcards

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10680168617	Black 1	Type of insurance coverage	0
10680168618	The insured's name is found in block	Block4	1
10680168619	Patients name	Block 2	2
10680168620	The insured address in block 7 refer to	Policyholders address	3
10680168621	The physicians office place of service code	11	4
10680168622	Physicians signature	31	5
10680168623	The assignment is benefits	Block 13	6
10680168624	Procedures performed	24d	7
10680168625	The onset of illness	Block 14	8
10680168626	The billing provider NPI #	33A	9
10680168627	A secondary insurance is	11d	10
10680168628	When completing CMS1500 form, which contains indie about the patient and insured	Section 2	11
10680168629	Which is a fixed amount per visit and is typically paid at the time of medical services	Copayment	12
10680168630	Block 14	Date of current illness injury or pregnancy	13
10680168631	Block17	Name of referring provider and NPI #	14
10680168632	Block21	Diagnosis or nature of illness or injury	15
10680168633	Block18	Hospitalization dates related to current services	16
10680168634	Block23	Prior authorization number	17

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MA: Medical Billing, Coding, & Insurance Key Terms Flashcards

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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

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13246901143	American Association of Medical Assistants (AAMA):	Enables medical assisting professionals to enhance and demonstrate the knowledge, skills, and professionalism required by employers and patients; as well as protect medical assistants' right to practice.	0
13246909150	Centers for Medicare and Medicaid Services (CMS)	Formerly known as the Health Care Financing Administration (HCFA); an administrative agency within the federal Department of Health and Human Services (DHHS).	1
13246918898	Coding	Process of reporting diagnosis, procedures, and services as numeric and alphanumeric characters (called codes) on the insurance claim	2
13246928107	Current Procedural Terminology (CPT)	Published by the American Medical Association; includes five-digit numeric codes and descriptors for procedures and services performed by providers.	3
13246936923	Department of Health and Human Services (DHHS)	The United States government's principal agency for "protecting the health of all Americans and providing essential human services, especially for those who are least able to help themselves	4
13246943248	Embezzle	The illegal transfer of money or property as a fraudulent action; to steal money from an employer.	5
13246950961	Ethics	Principal of right or good conduct; rules that govern the conduct of members of a profession	6
13246959948	Explanation of benefits (EOB)	Report that details the results of processing a claim.	7
13246968818	HCPCS level II codes	: National codes published by CMS, which include five-digit alphanumeric codes for procedures, services, and supplies not classified in CPT.	8
13246976915	Health insurance claim	documentation of submitted to an insurance plan requesting reimbursement for health care services provided.	9
13246986941	Hold harmless cause	Policy that the patient is not responsible for paying what the insurance plan denies.	10
13246995576	International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM)	Coding system to be implemented October 1, 2015, and used to report diseases, injuries, and other reasons for inpatient and outpatient encounters	11
13247008202	International Classification of Diseases, 10th Revision, Procedural Coding System (ICD-10-PCS):	Coding system to be implemented on October 1, 2015 and used to report procedures and services on impatient claims.	12
13247015761	Medical Malpractice Insurance	A type of liability insurance that covers physicians and other health care professionals for liability claims arising from patient treatment.	13
13247023393	Medical necessity	involves linking every procedure or service code reported on an insurance claim to a condition code that justifies the need to perform that procedure or service.	14
13247029791	National Codes	Commonly referred to as HCPCS level II codes; include five-digit alphanumeric codes for procedures, services, and supplies that are not classified in CPT.	15
13247036272	Preauthorization	Health plan review that grants prior approval health care services	16
13247042285	Professionalism	Conduct or qualities that characterize a professional person	17
13247051887	Remittance advice (remit)	Electronic or paper-based report of payment sent by the payer to the provider; includes patient name, patient health insurance claim (HIC) number, facility provider number/name, dates of service (from date/thru date), type of bill (TOB), charges, payment information, and reason and/or remark codes	18
13247056561	Respondeat Superior	Latin for "let the master answer"; legal doctrine holding that the employer is liable for the actions and omissions of employees performed and committed within the scope of their employment	19
13247063068	Scope of Practice	Health care services, determined by the state, that an NP and PA can perform.	20

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