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Billing & Coding - Glossary

Abbreviation for antibiotics
Ambulatory Surgical Center:
Any public or private establishment with an organized medical staff of physicians; with permanent facilities that are equipped and operated for the purpose of performing surgical procedures; and which does not provide services for patients to stay overnight.
A physician who specializes in providing anesthetics (local or general) to patients undergoing surgery or other procedures.
Assignment of Benefits
The payment of medical benefits directly to a provider of care rather than to a member. Generally requires either a contract between the health plan and the provider, or a written release from the subscriber to the provider allowing the provider to bill the health plan.
Attending physician
the physician who is in charge of your care while your are hospitalized. Though medical students, residents and other doctors may treat you, the Attending Physician is your physician of record while you are hospitalized.
a set amount of money received or paid out to a health provider. It is based on membership rather than on the medical services delivered and usually is expressed in units of per member per month.
(doctor of chiropractic) a licensed health professional (not a physician) who has extensive training and treats diseases caused by malfunction of the nerve system using manipulation and other treatments most commonly of the spine and pelvis.
(Clinical Laboratory Improvement Act) - "CLIA" is the common term for the laws governing laboratory tests and the facilities in which they are conducted. The laws are very strict and CLIA certification is usually required for a lab to be reimbursed. The CLIA number assigned to a lab will need to be included for billing of certain lab tests and is entered in the setup for tops Bill.
Certified Nursing Assistant.
Consolidated Omnibus Reconciliation Act. A portion of this Act requires employers to offer the opportunity for terminated employees to purchase continuation of health care coverage under the group’s medical plan.
a provision in a member’s coverage that limits the amount of coverage by the plan to a certain percentage, commonly 80 percent. Any additional costs are paid out of pocket by the member.
Coordination of Benefits
(COB) - a group health insurance policy provision designed to eliminate duplicate payments and provide the sequence in which coverage will apply (primary and secondary) when a person is insured under two contracts.
the portion of a claim or medical expense that member must pay out of pocket. Usually a fixed amount, such as $10 in many HMOs.
(Current Procedural Terminology) - Procedure codes (i.e. EKG).
that portion of a member’s health care expenses that must be paid out of pocket before any insurance coverage applies.
Abbreviation for diagnosis
(Durable Medical Equipment) - Medical equipment that can withstand repeated use and is used primarily to serve a medical purpose. For example, wheelchairs, crutches or nebulizers. These are specific billed using specific HCPCS codes called E codes.
(Doctor of Osteopathy) - Similar training to M.D., but focus on the body structure (bones, nerves and muscles) in the belief that problems with these are often the causes of illness and manipulation can be a cure. They attend specific osteopathic schools that cover much the same information as traditional medical schools, in addition to manipulative therapy, and are qualified to treat the same illnesses. Most D.O.s specialize in primary care disciplines and practice exactly like M.D.s while others concentrate on herbal and alternative remedies.
E Codes
Specific HCPCS codes used for DME.
(Evaluation and Management) Codes - Visit codes (i.e. level 3 office visit, newborn initial evaluation, etc.). E&M codes are a subset of CPT codes.
(otolaryngologist) - a physician who specializes in diseases of the ear, nose and throat.
(Explanation of Benefits) - a statement mailed to a member or covered insured explaining how or why a claim was paid or not paid.
(Early and Periodic Screening, Diagnosis and Testing) - Medicaid term referring to well visits, immunizations and other standard childhood wellness standards.
Family practitioner
a physician, a generalist who cares for the whole family regardless of age.
Fee Schedules
A list of all CPT and HCPCS codes and their corresponding charges. Can be variable based on insurance. Fee schedules are usually associated with a particular payor and reflect the reimbursement rates negotiated under the contract.
a physician, who specializes in diseases of the stomach and intestines.
an informal though widely used term that refers to a primary care physician management model health plan. In this model, all care from providers, other than in true emergencies, must be authorized by the primary care physician before care is rendered. This is a predominant feature of most HMOs.
The final responsible party on a bill after insurance (if applicable). It is essentially the person responsible for paying the balance due.
A physician who specializes in women’s health.
(Health Care Financing Administration) - Referred to as "hicfa", it is the government body that controls and directs legislation for government sponsored health coverage (Medicare, Medicaid). They are responsible for much of the direction in reimbursement including forms such as the HCFA-1500, as well as reimbursement rates upon which other payors will base theirs.
(1500) Form - The standard insurance claim form used by most insurances to submit paper claims. However, some have their own forms such as Medicaid in Illinois and Massachusetts.
More cmmonly known as the UB-92 (Universal Bill). This is also an insurance claim form, but is used for hospital visits and rural health claims. It is characterized by including more procedure level reporting lines, as well as place for information such as hospital days.
(Healthcare Common Procedural Coding System) - Codes for supplies, materials and injections (i.e. bandages, rubber gloves, penicillin). These are reported in the same parts of insurance forms as CPT codes (HCPCS as Level II CPT codes). There are specialized HCPCS codes such as E, J and L codes used for specific procedures or services.
a physician who specializes in the blood disorders.
(Health Insurance Portability and Accountability Act of 1996) - Federal legislation that improves access to health insurance when changing jobs by restricting certain preexisting condition limitations and guarantees availability and renewability of health insurance coverage for all employers regardless of claims experience or business size.
(Health Maintenance Organization) - A prepaid medical group practice plan that provides a comprehensive predetermined medical care benefit package. Most HMOs place at least some of the risk for medical expenses on the providers and most utilize primary care physicians as gatekeepers, but not all.
Abbreviation for history or history of.
health care facility or service providing medical care and support services such as counseling to terminally ill persons and their families.
a legally constituted institution having organized facilities for the care and treatment of sick and injured persons on an inpatient basis, including facilities for diagnosis and surgery under the supervision of a staff of one or more licensed physicians and which provides 24-hour nursing services.
(International Classification of Diseases) Codes - Diagnosis codes. For example, 401.1 represent benign hypertension. These codes have been color coded in tops Chart to represent the degree of specificity of the code. For example, red codes should be made more specific by adding more digits. In order to get the best reimbursement, the code should be carried out to the 4th or 5th digit whenever possible.
Indemnity Plans
in these traditional fee-for-service group health insurance plans, the patient chooses any doctor or hospital he or she wants to use. The employer pays premiums to the health insurance company to cover the costs of providing benefits and administering claims. The employee may pay a portion of the monthly insurance premiums, an annual deductible and /or co-payments per medical visit.
Intensive Care Unit (ICU)
a unit of a hospital especially designed and staffed to meet the specific needs of critically or seriously ill patients.
a physician who specializes in adult medicine (ages 18 and over).
J Codes
Specific HCPCS codes used for drugs administered other than oral method. For example, J0530 is and injection of penicillin.
Abbreviation for Last Menstrual Period
licensed practical nurse.
(Medical Assistant) - If certified, is referred to as CMA. Some clinics have similar positions known as Clinical Assistants. Used in most offices as a part of the nursing staff with responsibilities including working up patients, triaging and returning patient calls and assisting the provider in general.
Managed Care
health care programs that impose some controls on the utilization of health care services and providers who offer such care, and/or the fees charged for such services. Managed care can by provided through HMOs, PPOs, and managed indemnity plans. The primary goal is to deliver cost-effective health care without sacrificing quality or access.
administered by the Social Security Administration, Medicare is the U.S. federal government plan for paying certain hospital and medical expenses for those who qualify, primary those over age 65. Part A, Hospital insurance, provided for inpatient hospital and post hospital care. Part B pays for medically necessary doctors’ services and outpatient services.
Medicare Supplement Policy
a voluntary, contributory private insurance plan available to Medicare eligible to cover the costs of deductibles, coinsurance, physicians’ services and other medical and health services not covered by Medicare. Also, called Medigap policies.
Medical Doctor
A two-character code added to a CPT or HCPCS code that is used to help in the reimbursement process. For example, a modifier can be used to explain that a procedure not normally covered when billed on the same day as another is actually a separate and significant process, or that it is a rural health procedure that gets higher reimbursement. Up to 4 modifiers can be attached to each CPT, although in most cases only 1 or 2 are used.
Neonatal Intensive Care Unit (NICU)
A unit of a hospital, especially designed and staffed to care for critically ill newborns.
a physician who specializes in the treatment and diagnosis of newborns (up to 28 days of life).
a physician who specializes in diseases of the nervous system (e.g. multiple sclerosis, stroke).
a physician who specializes in surgery of the nervous structures; brain and spinal cord.
N.P. (Nurse Practitioner)
A mid-level provider. They are required to have a Bachelor's degree and then attend a rigorous 3-year training program mainly instructed by advanced nurses. Must be supervised by a physician. NPs can specialize much like physicians can, but are somewhat limited (i.e. pediatrics, family medicine, etc.).
a physician who specializes in delivering babies.
Occupational Therapist
a licensed allied health professional who specializes in creative activities that promote recovery and rehabilitation of patients.
physician who specializes in treatment of tumors/cancer.
a physician who specializes in diseases of the eye.
a licensed health professional (not a physician) who makes glasses and contacts.
a licensed health professional (not a physician) who specializes in examinations of the eye and prescribes eyeglasses and contacts for correction.
Orthopedist (orthopedic surgeon)
a physician who specializes in injuries and diseases of the bones.
Osteopath (DO)
a specialty that emphasizes the theory that the body can make its own remedies given normal structural relationships, environmental conditions and nutrition, Osteopathic physicians are granted the Doctor of Osteopathy (DO) degree.
Outpatient Services
medical and other services provided by a hospital or other qualified facility such as a mental health clinic, rural health clinic, mobile x-ray unit or freestanding dialysis unit. Services include outpatient patient physical therapy, diagnostic x-ray and laboratory tests and radiation therapy.
Outpatient Surgical Facility
a freestanding center within a hospital that is approved and licensed by the state to perform outpatient diagnostic services or surgical treatment of an illness or injury.
P.A. (Physician Assistant)
A mid-level provider. They are required to have a Bachelor's degree and then attend a rigorous 3-year training program mainly instructed by physicians. They are not physicians, but in most states have similar rights and privileges. However, they must be supervised by a physician.
Past Medical History
A list of a patient's past health problems, surgeries and specialists.
Patient Demographics
All the patient's pertinent information such as first and last name, SSN, DOB, insurance, etc.
Any party responsible for payment of services rendered, usually an insurance company.
Abbreviation for penicillin
PCP (Primary Care Physician)
Term used by insurance companies to describe the provider that will manage a patient's health. In most cases this is a family practitioner, internist, general practitioner or pediatrician. The PCP is responsible for obtaining referrals to specialists as needed.
a physician who specializes in children’s health (up to age 18).
Physical Therapist
a licensed allied health professional who treats diseases or injuries by physical means; exercise, manipulation, electricity, heat, cold and water.
Plastic Surgeon
a physician who specializes in the repair, restoration or improvement of lost, injured or defective body parts.
Podiatrist (doctor of podiatry)
a licensed health professional (not a physician) who specializes in treatment of the feet.
POS (Point-of-service) Plan
a health plan that allows members to choose to receive services from a participating or nonparticipating network provider, usually with a financial disincentive for going outside the network.
PPO (Preferred Provider Organization)
a plan that contracts with physicians at a discount for services. Providers exchanged discounts for increased volume and prompt payments. Participants’ out-of-pocket costs are usually lower than under an indemnity (fee-for-service plan.).
General title for MD, D.O., NP, or P.A.. A provider of service. Most M.D.s and DOS don't like to be referred to as providers. Other providers are mental health professionals, chiropractic, etc.
the process of obtainingauthorization from the health plan for hospital admission or for certain outpatient procedures or tests, e.g. MRI. Failure to obtain precertification often results in a financial penalty or denial of payment for the admission or procedure.
Preexisting Condition
a physical and/or mental condition of an insured person that existed prior to the issuance of his or her policy. Some plans may cover these conditions after a waiting period of six months to a year.
Preventive Care
comprehensive care emphasizing priorities for prevention, early detection and early treatment of conditions, generally including routine physical examinations, immunizations and well-person care.
Primary Care
basic or general health care as opposed to specialist care.
a physician who specializes in disease of the anus, rectum and sigmoid colon.
a physician who specializes mental, emotional and behavioral disorders.
Psychologist (doctor of psychology)
a health professional (not a physician) who specializes in the mental or behavioral characteristics of an individual or group. Provides psychological testing for diagnosis of mental and behavioral disorders. Psychologists are granted a Doctor of Psychology degree.
RBRVS (Resource Based Relative Value Scale)
This is a scale of "weights" assigned to particular CPT codes that takes account of the relative amount of effort taken to perform a procedure based on the cost of supplies, the risk or difficulty and the time spent. For instance, brain surgery will have more RVUs than a wart removal. The RBRVS is controlled by HCFA.
Reasonable and Customary (R&C) charge
the prevailing charge made by physicians or similar expertise for a similar procedure in a particular geographic area. Also called Usual, Customary and Reasonable fees.
Some insurance companies require that on specific plans a referral must be obtained for certain procedures or visits to specialists. The referral is acquired by the primary care physician (PCP) by contacting the insurance company by phone or mail. This is a request for the service. The referral consists of an authorization code, a number of visits allowed (if applicable) and an expiration date. This information can be stored and referenced in tops Schedule and tops Bill.
Referring Provider
The provider that referred the patient to a specialist or for a specific procedure.
Renal (kidney) dialysis Center
a facility that furnishes the full spectrum of diagnostic, therapeutic and rehabilitative services (except transplantation) required for the care of dialysis patients.
Rendering/Performing Provider
The provider actually treating the patient.
Resident Physician
a physician who has graduated from medical school and is currently in specialty training (interns are now called 1st-year residents).
a physician who specializes in treatment of rheumatic diseases; inflammation of joints and muscles (e.g. rheumatoid arthritis).
registered nurse, a nurse with 2 to 4 years of training.
Rural Health Clinic (RHC)
A clinic that is contracted by HCFA to provide services to underserved populations. RHCs are reimbursed at a slightly higher level than the normal Medicare allowable. As is obvious, these are usually clinics in outlying rural areas where the government needs to encourage practitioners to have clinics, although some "rural" clinics are located in poorer parts of cities. RHCs are given a special status and when they bill particular procedures with QB (rural) or QU (urban) modifiers, they will get the higher rate. RHCs usually have to submit claims on a UB-92.
RVU (Relative Value Unit)
The weight within the RBRVS assigned to a particular CPT. The Total RVU for a CPT is made up of the Work RVU (the amount of time and effort it takes), the Practice Expense RVU (the overhead cost of that time), and the Malpractice RVU (the likelihood of complications)
Self-Insured Plan
A health, dental or vision plan in which the risk for cost is assumed by the company rather than an insurance company or managed care plan. In a sense, the employer is acting as an insurance company by paying claims with the money ordinarily earmarked for premiums.
the process whereby a patient seeks care directly from a specialist without seeking authorization from the primary care physician.
Skilled Nursing Facility (SNF)
a care setting for patients who no longer require hospital care, but need 24-hour nursing care and other health care services.
the right of an employer or insurance company to recover benefits paid to a plan participant through legal suit, if the action causing the medical expense was the fault of another individual.
Also known as an encounter form, route slip or fee slip. This is a paper charge capture tool used to document coding for a specific patient visit. It is a printed form with patient information at the top, and a subset of the provider's/practice's most commonly used ICD and/or CPT codes. The form travels with the patient through the clinic. Providers check off items when they see the patient, and the form then travels to the checkout desk or billing office where the codes are entered into the billing system.
a physician who specializes in treating disease and illness by surgery.
Abbreviation for symptoms
Tertiary Care
Specialized health care, needed by relatively few people, such as select rehabilitation services, highly technical medical procedures such as burn centers.
TPA (third-party administrator)
a firm that provides administrative functions (e.g. claims processing, membership, etc.) for a self-insured health plan.
the practice of a provider charging separately for services that normally are covered under one procedure code.
A standard 6 digit alphanumeric identifier assigned to providers. Can be used for single provider or a group/facility.
a physician who specializes in treatment of urinary tract and kidney.
Urgent Care Center
an ambulatory care facility that provides 24-hour service to treat minor conditions such as cuts, bruises, sprains and suture removal’ less costly than emergency room treatment