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MEDICAL BILLING
BILLING DEFINITIONS
| Term | Definition |
|---|---|
| Health insurance claims | documentation that is electronically or manually submitted to a third party or government program requesting reimbursement |
| hold harmless cause | the patient is not responsible for what the insurance plan denies, is not in all insurances |
| no balance billing | the patient is only responsible for copays, coinsurance amounts and deductibles |
| health care provider | physician or health care practitioner e.g. physician assistance |
| provider-managed care | sets clauses requirement and reimbursement regulations each one set separate rules |
| centers for medicare and medicaid services | agency within the federal department of health and human services which coders are required to stay up to date on rules |
| coding | the process of assigning ICD-10-CM,ICD-10-PCS,CPT and HCPCS CODES TO DIAGNOSIS, procedures and supplies |
| diagnoses | documented conditions or disease process example- hypertension |
| procedures | preformed for diagnostic ,therapeutic and services to evaluate patients care |
| coding systems | ICD-10-CM, ICD-10-PCS, CPT AND HCPCS |
| ICD-10-CM | International classification of diseases,10th revision , clinical modification |
| ICD-10-PCS | INTERNATIONAL classification of diseases, 10th revision ,procedural coding system |
| HCPCS (hick picks) | healthcare common procedural coding system 2 levels |
| CPT | Current Procedural Technology (AMA) |
| AMA | American Medical Association |
| accreditation | voluntary process that a health care facilityy or organization(e.g.hospital or care plan) undergoes to demonstrate that it has met standarrds |
| advanced alternative payment models | includes new ways for CMS to reimburse health care providers for care provided to Medicare beneficiaries |
| advanced APMs | advanced alternative payment models |
| alternative payment models | payment approach that includes incentive payments to provide high quality and cost efficient care |
| APMs | alternative payment models |
| benchmarking | care practice that allows an entity to measure and compare its own data against that of it other agencies and organizations for the purpose of continuous |
| cafeteria plan | also called triple option ,provides different health benefit plans and extra coverage options |
| capitation | prospective payment per patient for a prescribed period of time |
| carve -out plan | arrangement provided by a health insurance company to offer a specific health benefit that is managed separately from the health insurance plan |
| case manager | submits written confirmation, authorizing treatment to the provider; include nurses and social workers who help patients |
| clinical practice guidelines | define modalities for the diagnoses, management and treatment of patients and they include recommendations based on a |
| CMS-1500 claim | claim submitted for reimbursement of physician office procedures and services, electronic version is called ANSI ASC X12N 837P. |
| COINSURANCE | the percentage the patient pays for covered services after the deductible has been met and |
| COMPETITIVE MEDICAL PLAN(CMP) | an HMO THAT MEETS FEDERAL ELIGIBIBILITY requirements for a Medicare risk contract but is not licensed as a federally qualified plan |
| CMP | competitive medical care plan |
| consumer-directed health plan(CDHP) | define employer contributions and ask employees to be more responsible for health care decisions and cost sharing |
| continuity of care | documenting patient care services so that others who have a source of information on which to base additional care |
| copayment (copay) | provision in an insurance policy that requires the policy holder or patient to pay a specificied amount per service |
| covered services | see schedule of benefits |
| CDHP | consumer-directed health plan |
| copay | copayment |
| deductible | amount for by which the patient is responsible for before the insurance policy provides reimbursement |
| electronic clinical quality measurements | processes, observations, treatments and outcomes that quantify the quality of care provided by the health care systems |
| enrollee | subscriber |
| excess insurance | see stop-loss insurance |
| exclusive provider organization (EPO) | managed care plan that provides benefits to subscribers if the receive services from network providers |
| EPO | exclusive provider organization |
| express contract | provisions stated in a health insurance contract |
| external quality review organization | responsible for reviewing health care provided by managed care organizations |
| EQRO | External quality review organization |
| fee schedule | list of predetermined payments for health care services provided to patients (e.g. a fee is assigned to each CPT code |
| fee-for-service | reimbursement methodology that increases payment if the health care service fees increases |
| fee for service plans | reimburses providers according to a fee schedule after covered procedures and services have been provided |
| gag clause | provents providers from discussing all treatment options with patients, whether or not the plan would provide reimbursement for |
| flexible spending account(FSA) | consumer -directed health plan that allows accounts created by employees for the purpose of paying health care bills |
| FSA | FLEXIBLE SPENDING ACCOUNT |
| gatekeeper | primary care provider for essentail health services at lowest possible cost , avoiding nonesssential cost and referring patients to specialist |
| group health insurance | private health insurance model that provides coverage which is subsidized by employers and other organizations |
| Guaranteed renewal | a provision, when included in a health insurance contract, that requires a health insurance company to renew the policy a long premiums are paid |
| health care | expands definition of medical care to include preventive services |
| health care reimbursement account(HCRA) | tax; exempt account used to pay for health care expenses individual, decides in advance , how much money to deposit into HCRA |
| HCRA | health care reimbursement account |
| health insurance | contract between a policyholder and a third party payer or government program to reimburse the policyholder for all or a portion or the cost of |
| health insurance exchange | method Americans use to purchase health coverage that fits their budget and meet their needs |
| health insurance marketplace | see health insurance exchange |
| health maintenance organization(HMO) | responsible for providing health services to subscribers in a given geographical area for a fixed fee, (requires providers be in network) |
| HMO | health maintenance organization |
| health reimbursement arrangement(HRA) | tax exempt accounts by employers which individuals use to pay health care bills |
| HRA | health reimbursement arrangements |
| Health savings account(HSA) | participants enroll in relatively inexpensive high deductible plan and a tax deductable savings account is opened to cover current and future needs |
| HSA | health insurance saving account |
| healthcare effectiveness Data and information set (HEDIS) | created standards to assess managed - care systems that are collected evaluated and published to compare the |
| HEDIS | healthcare effectiveness data and information set |
| implied contract | results from the actions taken by the health care provider, such as registering a patient to provide treatment |
| indemnity plan | allows patients to seek health care from any provider and the provider receives reimbursement according to a fee schedule |
| individual health insurance | PRIVATE HEALTH INSURANCE POLICY PURCHASED by individuals or families who do not have access to group insurance |
| integrated delivery system (IDS) | organization of affiliated provider sites (e.g. hospitals) that offer joint health care services |
| IDS | integrated delivery system |
| legislation | federal ,state ,county and municipal laws, which are rules of conduct enforced by threat |
| lifetime maximum amount | maximum benefit payable to a health plan participant,such as annually or during a lifetime |
| mandates | official directive,instruction or order to take or perform a certain action such as regulations written by federal government |
| medical care | includes the identification of disease and prevision of care and treatment as provided by memmbers of the health care team to the patient |
| MIPS value pathways (MVPs) | allow for a more cohesive provider participation experiance by connecting activities and mesures for four merit based |
| National Committee for Quality Assurance | a private, not for profit organization that asssesses the quality of managed care plans in the United States and releases data to the public |
| network provider | physician ,other health care provider or health care facility under contract with the insurance company to |
| payer mix | different types of health insurance made to providers for patient services |
| performance measurements | strengthen organization accountability and support performance improvement initiatives by assessing the degree |
| personal health record | web based application that allows individuals to maintain and manage their health information |
| physician incentive plan | requires managed care plans that contract with Medicare and Medicaid to disclose information about physician incentives |
| physician incentives | payments made either directly or indirectly to health care providers to serve as encouragement to reduce or limit healthcare cost |
| physician referral | written order by a primary care provider that facilitates patient evaluation and treatment by a physician specialist |
| point - of- service plan | delivers health care services using both managed care network and traditional indemnity coverage so patients can seek care outside |
| policy holder | a person who signs a contract with a health insurance company and thus, owns the health insurance policy |
| preferred provider network | network of physicians, other health care practitioners and hospitals that have joined together to contract with insurance companies |
| premium | amount paid for a health insurance policy |
| prepaid health plan | capitation contract between a health care plan and providers who manage all of the health care for a patient population and |
| prescription management | controls medication cost using a variety of strategies, which include pharmacy benefit managers, cost sharing copayments or |
| preventive services | designed to help individuals avoid problems with health and injuries |
| primary care provider | responsible for supervising and coordinating health services for enrollees and preauthorizing referrals to specialist |
| Promoting Interoperability programs | focus on improving patient health information and reducing the time and cost required of providers to comply with the programs' |
| public health insurance | federal and state government heath program( e.g. Medicare ,Medicaid, CHIP ,TRICARE)available to eligible individuals |
| Quality assessment and performance improvement program(QAPI) | program implemented so that quality assurance activities are performed to improve the functioning of Medicare Advantage |
| quality assurance program | activities that assess the quality of care provided in a health care setting |
| quality assurance(QI) | involves continuous and systematic actions that result in measurable improvement in the provision of health care services and the |
| Quality improvement organizations (QIO) | preforms utilization and quality control review of health care furnished or to be furnished to Medicare |
| Quality Improvement System for Managed Care (QISMC) | established by Medicare to ensure the accountability of managed care plans in terms of objective measurable |
| quality management program | see quality assurance program |
| quality payment program (QPP) | helps providers focus on quality of patient care and making healthier includes advanced alternative payment models |
| record linkage | allows patient information to be created at different locations according to a unique patient identifier or identification number |
| report card | contains data regarding a managed care plan's quality,utilization ,customer satisfaction, administrative effectiveness |
| rider | special contract clause stipulating additional coverage above the standard contract |
| risk adjustment program | lessens or eliminates the influence of risk selection on premiums charged by health plans and includes the risk adjustment model and |
| risk contract | an arrangement among providers to provide capitated (fixed, prepaid basis) health services to Medicare |
| schedule of benefits | outlines services covered by a health insurance plan |
| second surgical opinion | second physician asked to evaluate the necessity of surgery and recommend the most economical appropriate facility in |
| self- insured(or self-funded) employer- sponsored group health plans | allows a large employer to assume the risk for providing health care benefit to |
| self -referral | enrollee who sees a non-HMO panel specialist without a referral from the primary care physician |
| singer- payer health system | national health service model adopted by some western nations and funded by taxes |
| socialized medicine | the type of single payer system in which the Government owns and operates health care facilities and providers |
| standards | requirements established by accreditation organizations |
| STOP-LOSS INSURANCE | provides protection against catastrophic or unpredictable losses and includes aggregate stop-loss plans and specific stop-loss plans |
| subscriber | individual who joins either a managed care plan or traditional health insurance plans |
| enrollee | individual who joins either a managed care plan or traditional health insurance plans |
| third party administrators (TPAs) | company that provides health benefits clams administration and other outsourcing employee benefits |
| third -party payer | A HEALTH INSURANCE COMPANY THAT PROVIDES COVERAGE SUCH AS BLUE CROSS |
| total practice management software (TPMS) | used to generate the EMR, automating medical practice functions of registering patients |
| traditional merit- based incentive payment system (MIPS) | allows providers to earn a proformaced based payment adjustment that condiders quality |
| triple option plan | usually offered by either a single plan or as a joint venture among two or more third party payers and provides subscribers |
| universal health insurance | goal of providing every individual access to health coverage, regardless of the system implemented to achieve that goal. |
| utalization review organization utilization review organization(URO) | entity that establishes a utilization managerment program and performs external utilization review services. |
| value-based reimbursement methodology | compensates providers for the quality of care provided to patients as measured by patient outcomes |
| managed health care | health care delivery system organized to manage health care cost, utilization and quality . |
| managed care | health care delivery system organized to manage health care cost, utilization and quality . |
| gag causes | prevents providers from discussing all treatment options with patients, whether or not then plan would provide reimbursement for |
| consumer- directed health plans (CDHPs) | define employer contributions and ask employees to be more responsible for health care decisions and cost sharing |
| alternative payment model (APM) | payment approach that includes that includes incentive payments to provide high quality and cost efficient care, APMs can apply to a specific condition |
| the traditional merit based incentive payment system (traditional NIPS) | allows provider to earn a performance based payment adjustment that considers quality resource use ,clinical practice improvement. |
| AAPC | professional association previously known as the American Academy of professional Coders established to provide a national certificate and credentialing process,to support the national and local membership by providing educational products and opportuniti |
| 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. |
| American Health Information Management Association ( AHMA) | founded in 1928 to improve quality of medical records and currently advances the health information management ( HIM) |
| bonding insurance | an insurance agreement that guarantees repayment for financial loses resulting from the act or failure to act of an employee. It protects the financial operations of the employer |
| business liability insurance | protects business assets and covers the cost of lawsuits resulting from bodily injury , personal injury, and false advertising |
| lien | pledges or sources a debtor's property as a guarantee\ of payment for a debt, may be used in a potential liability case, but use varies on a federal and state level |
| claims examiner | employed by a third party to review health insurance claims to determine whether the charges are reasonable and medically necessary based on the patients diagnosis |
| coder coding | process of reporting diagnoses ,procedures services ,and supplies as numeric and alphanumeric characters (called codes) on the insurance claims |
| embezzle | the illegal transfer of money or property as a fraudulent action ; to steal money from an employer. |
| errors and omissions insurance | see professional liability insurance |
| ethics | principle of right or good conduct , rules that govern the conduct of members of a profession |
| litigation | legal action to recover a debt; usually a last resort for a medical practice |
| health information technicians | professionals who manage patients health information and medical records, administer computer code diagnoses and procedures for health care services provided to patients. |
| health insurance claim | documentation that is electronically or manually submitted to an health insurance plan requesting reimbursement for health care procedures and services provides e.g. CMS-1500 AND UB-04 |
| health insurance specialist | PERSON WHO REVIEWS HEALTH RELATED CLAIMS to match medical necessity to procedures or services preformed bbefore payment is made to the provider, see reimbursement specialist |
| hold harmless clause | policy that the patient is not responsible dor paying what the insurance denies |
| independent contractor | defined by the " Lectric Law Libarary's Lexicon as a person who performs services for another under express or implied agreement and who is not subject to the others |
| clinical document improvement (CDI) | ensures accurate and thorough documentation in patient records though the identification of discrepancies between provider documentation and codes to be assigned |
| coding compliance | conformity to established coding guidelines and regulations |
| coding compliance programs | developed by health information management departments and similiar areas ,such as the coding and billing section of a physician's practice ,to ensure coding accuracy and conformance with guidelines and regulations; includes written policies and procedur |
| coding for medical necessity | involves assigning ICD-10-CM codes to diagnoses and CPT/HCPCS LEVEL II CODES TO PROCEDURES /SERVICES And then matching an appropriate ICD-10-CM CODE with each CPT or HCPCS Level II code |
| compliance program guideline | documents published by the DHHS OIG to encourage the development and use of internal controls by health care organizations for the purpose of monitoring adherance to applicable statutes, regulations and program requirements. |
| local coverage determinations (LCDs) | formerly local medical review policy (LMRP) MEDICARE administrative contractors create edits for national coverage determination rules |
| medically managed | a particular diagnosis may not receive direct treatment during an office visit, but the provider had to consider that diagnosis when considering treatment for other conditions |
| medically unlikely edit | used to compare units of service(UOS) with CPT and HCPCS Level II codes reported on claims , indicates the maximum number of UOS allowable by the same provider for the same benificiary on the same date of service under most circumstances |
| Medicare code editor | software program used to deteect and report errors in ICD-10-CM/PCS CODED data during processing of inpatient hospital Medicare claims |
| auditing process | review of patients records and CMS-1500 (or UB-04) claims to access coding accuracy and whether documentation is complete |
| Medicare coverage data base | used by the Medicare administrative care industry professionals to determine whether a procedure or service is reasonable and necessary for the diagnoses of illness and injury, contains national determinations (NCDs)(LCDs)(NCAs) (CALs) (MedCAC) AND MED |
| narrative clinical note | using a paragraph format to document Health care |
| National Correct Coding Initiative (NCCI) program | developed by CMS to promote national correct coding methodologies and to eliminate improper coding practices |
| national coverage determinations(NCD) | rules developed by CMS that specify under what clinical circumstances a service or procedure is covered and correctly coded |
| operative reports | varies from a short narrative description of a minor procedure that is preformed in the physicians office to a more formal report dictated by the surgeon in a format required by the hospitals and ambulatory surgical centers(ASCs) |
| outpatient code editor(OCE) | sofetware that edits outpatient submitted claims byHealthcare facilities such as Hospitals , community mental healthcenters , comprehensive outpatient rehab, home health agencies , the software reviews submissions for coding validiity and coverage,OCE edi |
| procedure to procedure(PTP0 code pairs edits | automated prepayment NCCI program edits that prevent improper payment when certain codes are submitted together for Medicare Part B covered services |
| SOAP note | outline format for documenting Health care: ACRONYM for Subjective, Objective, Assessment and plan |
| assessment | contains diagnosistic statement and may include providers rationale for the diagnosis |
| objective | documentation of measurable or objective observations made during physical examination and dianostic testing |
| plan | statement of the physician's future plans for the work-up and medical management of the case |
| subjective | part of the note that contains the chief complaint and the patient's description of the present problem |
| All- patient diagnosis -related groups | DG system adapted for use by 3rd party payers to reimburse hospitals for inpatient care provided to non-medicare beneficiaries,DRG assignment is based onthe intensity of resources |
| All-Patient Refined diagnosis- related groups (APR_DRGs) | system that classifies patients according to reason for admission, severity of illness, SOI) and risk of mortality |
| ambulance fee schedule | payment system for ambulance services provided to Medicare beneficiaries |
| ambulatory payment classification | prospective payment system used to calculate reimbursement for outpatient according to similar in clinical characteristics and in terms of the resources required |
| ambulatory surgical center (ASC) | state licensed,, Medicare certified supplier (not provider) of surgical health care services that must accept assignment on Medicare claims |
| bundled payment | predetermined amount for all services provided during an episode of care |
| case mix | the type and categories of patients treated by a health care facility or provider |
| case-mix index | relative weight assigned for a facility's patient population ,it is used in a formula to calculate health care reimbursement |
| case-mix management | allows health care facilities and providers to determine antcipated health care needs by reviewing data analytics about types and/or categories of patients treated |
| case rate | predetermined payment for an encounter, regardless of services provided or length of encounter |
| clinical laboratory fee schedule | data set based on local fee schedules (for outpatient clinical diagnostic laboratory services |
| conversion factors | dollar multiplier that converts relative value units (RVUs) into payments as part of the Medicare physician fee schedule ( MPFS) calculation formula |
| diagnosis- related groups (DRGs) | prospective payment system that reimburses hospitals for inpatient stays |
| disproportionate share hospital adjustment | policies in which treat a large number of low income patients receive increased Medicare payments |
| durable medical equipment prosthetic /orthotics and supplies (DMEPOS) fee schedule | Medicare reimburses *) percent of the actual charge for the item or the fee schedule amount whichever is lower |
| End stage Renal Disease prospective payment system (ESRD PPS) | provides a single pre treatment payment to ESRD that covers all resources used in providing outpatient dialysis treatments |
| episode of care | period of time during which care is provided for a particular condition |
| Federally Qualified Health Centers Prospective Payment System (FQHC PPC0 | national encounter based rate with geographic and other adjustments; established by the Affordable Care ACt and implemented in 2014; FQHCs include a payment code on claims submitted for payment and are paid80% of the lesser charges, based on FQHC paymen |
| global payment | one payment that covers all services rendered by multiple providers during an episode of care |
| grouper software | determines appropriate group (e.g. diagnosis- related group, home health resource group, and so on) to classify a patient after data about a patient is input |
| health insurance prospective payment system(HIPPS) code set | 5 digit alphanumerical codes that represent a case -mixed groups about which payment determinations are made for the HH PPS |
| Home assessment validation and entry (HAVEN) | data entry software used to collect OASIS assessment data to transmission to state data bases |
| Home Health Prospective payment system (HH PPS) | reimbursement methodology for home health agencies that uses a classification system called hone home health patient -driven grouping model(PDGM) which establishes a predetermined rate for home health care services provided to patients for each 60 day ep |
| Hospital acquired condition (HAC) | MEDICAL CONDITION OR COMPLICATIONS THAT WERE OBTAINED DURIN INPATIENT STAYS THAT WERE NOT PRESENT UPON ADMISSION |
| Hospital acquired condition (HAC) Reduction plan | encourages hospitals to reduce HACs by adjusting payments that rank > 25% with respect toHAC quality measures |
| hospital admissions reduction plan(HRRP) | requires CMS to reduce IPPS hospitals with excess admissions |
| incident to billing | Medicare regulation which permitted billing Medicare under the physician billing number to ancillary personal services |
| indirect medical education(IME) adjustment | approved teaching hospital receive increased medicare payments based on residents to beds and residents to average daily census |
| inpatient prospective payment system (IPPS) | system which Medicare reimburses hospitals for inpatient hospital services according to a predetermined rate upon patient discharge |
| Inpatient Psychiatric Facility Prospective Payment System( IPF PPS) | system in which Medicare reimburses inpatient psychiatric facilities according to the classification system that reflects differences in patient resources and costs: uses per diem system |
| Inpatient Rehabilitation Facility Prospective Payment System(RF PPS) | implemented as result of the BBA of 19977; utilizes information from a patient assessment instrument to classify patients into distinct groups based on clinical characteristic and expected resource needs |
| ancillary | proving neccessary support to the primary activities or operation |
| per diem | by the day |
| Inpatient Rehabilitation Validation and Entry (IRVIN) | computerized data entry system by inpatient rehabilitation facilities to create a standard format national electronic database to provide means to objectively measure and compare proformance and quality and to improve standards |
| Intensity of resources | relative volumes and types of diagnostic, therapeutic and inpatient bed services used to manage an inpatient disease |
| Intensity of services (IS) | determining whether the provided services are appropriate for the patients current or proposed level of care |
| IPPS 3-day payment window | require out patient preadmission services be provided up to 3 days prior to patients inpatient admission to be covered by IPPS DRG payment for diagnostic services and therapeutic services when diagnosis codes ICD-10-CM)precisely match |
| IPPS 72 hour rule | IPPS 3-day payment window |
| IPPS transfer rule | any patient with a diagnosis from one of ten CMS- determined DRGs who is dischsrged to a post acute provider, is treated as a transfer case; this means hospitals are paid a graduated per diem ratereimburses providers for services and procedures by classif |
| Limiting charge | maximum fee a nonparticipating provider who does not accept assignment may bill Medicare patients |
| long-term (acute) care hospital perspective payment system | classifies patients according to long -term care DRGs based on patients clinical characteristics and resource needs |
| major diagnostic category | organizes DRGs into mutually exclusive categories, loosely based on body systems |
| Medicare physician fee schedule (MPFS) payment system | reimburses providers for services and procedures by classifying services according to the relative value units (RVUs) |
| diagnosis-related groups | DRGs |
| Medicare severity diagnosis-related groups (MS-DRGs) | 2008 Medicare adaptation to improve recognizatioon of severity of illness and resouce consumption and reduce cost variation among DRGs, revaluated CC list to assign all ICD-!)_codes as nonCC,CC, or major CC status ,handles diagnosis differently based on |
| Medicare summary notice | notifies Medicare beneficiaries of action taken on claims |
| Never events | medical errors that should never occur and adverse events that are unambiguous ,serious and preventable |
| Outcomes and Assessment information Set (OASIS) | represents core items of a comprehensive assessment for adult home care patient and form the basis for measuring patient outcomes for purposes of outcome -based quality improvements |
| outlier | hospitals that treat unusually costly cases recieve increased Medicare payment |
| outpatient encounter | all outpatient procedures and services provided during one day to the same patient |
| outpatient prospective payment system (OPPS) | uses ambulatory payment classifications to calculate reimbursement, implemented for billing Medicare hospital outpatient claims |
| patient driven model(PDPM) | case-mixed reimbursement model that connects patients conditions and care needs instead of the volume of services provided |
| pay for performance(P4P) | initiatives that link reimbursement to performance criteria so that despite patient's ethnicity, gender ,geographic location and socioeconomic status ,patients receive the right care |
| unambiguous | clearly identifiable and measurable |
| CC | complications/comorbidities |
| payment system | reimbursement method the federal government uses to compensate providers for patient care. |
| present on admission (POA) | condition that exists at time of hospital admissions occur |
| price transparency | federal government requirement cost of health care items and services are available to patients prior to provision |
| prospective cost-based rates | rates established in advance, but based on proported health cost(charges ) from which a prospective payer prior to health care procedures and services |
| prospective payment system (PPS) | issues predetermined payment for services like bundled services ,capitation ,case rates and global payments |
| prospective price-based rates | rates established with specific a category of patient and established by the payer prior to provision of healthcare procedures and services |
| relative value units(RVUs) | standandized measures used to determine MPFS pricing amounts that are adjusted to reflect the variation of practice cost from area to area ,measures include physician work, practice expense and malpractice expense |
| Resident Assessment validation and entry(jRAVEN) | javased to enter MDS data about SNF patients and transmits asseswsments in CMS standard format to state or national databases |
| retrospective reasonable cost system | reimbursement system that doctors reported actual charges and get pay by fee schedule ,a percentage of billed charges or per diem basis |
| retrospective reimbursement methodology | same as retrospaective reasonable cost system |
| risk of mortality(ROM) (ROM is also shorthand for Range of motion) | risk of dying |
| severity of illness (SOI) | extent of physiological decompensation or organ system loss of function |
| skilled Nursing Facility prospective system | implemented to cover all costs (routine ,ancillary and capital 0 related to the services furnished to Medicare Part A beneficiaries and generating per diem case mix adjusted payments as part of a PDPM using minimal data and weights from staff time |
| split visit billing | shared visit billing |
| value -based purchasing (VBP) | CMS effort to link Medicare's inpatient prospective payment to a value-based system for promoting better clinical outcomes for patients by improving Health care quality |
| wage index | adjust payments to account for geographic variations in labor cost |
| miscellaneous codes | reported when DMEPOS dealer submits a claim for a product or service which has no existing permanent national code |
| modifiers | provide additional information about a procedure or service (e.g. left side procedure) |
| permanent national codes | maintained by the HCPCS National Panel |
| temporary codes | maintained by the HCPCS National Panel ; independent of permanent national codes |
| Healthcare Common procedural coding system | coding system that consist of of CPT, National Codes (level II) and local codes (level III):local codes were discontinued in 2003, previously HCFA common procedural coding system |
| Medicare pricing, data Analysis and coding PDAC contractor | responsible for providing suppliers and manufactures with assistance in determining HCPCS codes to be used, PDAXS replaced SADMERCS |
| national codes | commonly referred to as HCPCS level II codes |
| transitional pass though payments | temporary additional payments made for certain innovational medical devices, drugs and biologicals provided to Medical beneficiaries |
| NCPCS National Panel | composed of representatives from Blue Cross Blue Shield Association (BCBSA) the Health Insurance Association of America( HIAA) And CMS |
| CMS HCPCS Workgroup | develop and maintain HCPCS level II , composed of representatives from CMS, Medicare stat agencies, the veterans administration and PDAC contractors |
| DME MAC | process durable medical equipment claims for defined geographic areas |
| DME | durable medical equipment |
| DMEPOS | durable medical equipment ,prosthics ,orthotics and supplies |
| DMEPOS suppliers | submit claims to DME Medicare Administrative contractors MACS who are awarded contracts by CMS |
| established patient | been there in the last three years |
| Evaluation and Management | located at the beginning of CPT because these codes describe services (e.g. offices visits) that are most frequently provided by physicians and other health care practitionersa |
| face-to- face time | amount of time spent in office |
| global period | includes all services related to a procedure during a period of time depending on payer guidelines |
| global surgery | package concept or surgical package , includes all aspects of normal ,uncomplicated surgery |
| guidelines | define terms and explain the assignment of codes for procedures and services located in a particular CPT section |
| moderate (conscious ) sedation | administration of moderate sedation or analgesia, which results in a depression of consciousness |
| monitored anesthesia care | provision of local or regional anesthetic services with certain conscious- altering drugs administered by a physician, anesthesiologist, or medically directed CRNA , requires sufficient monitoring and continuous evaluation of vial physiologic functions |
| new patient | either has never seen provider or hasn't seen in three years |
| professional component | supervision of procedures ,interpretation , and writing of the report |
| technical component | use of equipment and supplies for services performed |
| telemedicine | remote care interactive audio and video telecommunications system that permits real time communication betwen you and the beneficiary , |
| transfer of care | occurs when a physician who is managing some or all of a patients problems releases the patient to the care of another physician who is not providing consultative services |
| exemptions to filing. the CMS-15OO Electronically part 1 | dental claims, disruption in electricity or communication only during the period of interruption Medicare beneficiaries can submit paper claims, Medicare demonstration project , Medicare secondary payer, roster billing for vaccines , |
| exemption to filing the CMS-1500 electronically part 2 | small scale provider ,less then 25 full time employees, facility, physician or supplier with fewer then ten FTE, durable Medicare equipment provider submits less then ten claims per month, non us provider |
| ANSI ASC X12N 837I | standard format for submission of electronic claims for institutional Health care claims |
| automobile insurance policy | car related insurance contract for premium which the policy available coverage includes medical personal injury protection and liability |
| disability insurance | reimbursement for income lost as a result of temporary or permanent illness or injury |
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