medical Billing Terms and medical Coding Terminology
Those in curative billing and coding careers have a terminology of unique terms and abbreviations. Below are some of the more often used curative Billing terms and acronyms. Also included is some curative coding terminology.
medical Billing Terms and medical Coding Terminology
Aging - Refers to the unpaid guarnatee claims or patient balances that are due past 30 days. Most curative billing software's have the ability to originate a separate description for guarnatee aging and patient aging. These reports typically list balances by 30, 60, 90, and 120 day increments.
Appeal - When an guarnatee plan does not pay for treatment, an motion (either by the victualer or patient) is the process of formally objecting this judgment. The insurer may want further documentation.
Applied to Deductible - Typically seen on the patient statement. This is the number of the charges, considered by the patients guarnatee plan, the patient owes the provider. Many plans have a maximum every year deductible that once met is then covered by the guarnatee provider.
Assignment of Benefits - guarnatee payments that are paid to the physician or hospital for a patients treatment.
Beneficiary - man or persons covered by the health guarnatee plan.
Clearinghouse - This is a assistance that transmits claims to guarnatee carriers. Prior to submitting claims the clearinghouse scrubs claims and checks for errors. This minimizes the number of rejected claims as most errors can be beyond doubt corrected. Clearinghouses electronically transmit claim data that is compliant with the correct Hippa standards (this is one of the curative billing terms we see a lot more of lately).
Cms - Centers for Medicaid and Medicare Services. Federal group which administers Medicare, Medicaid, Hippa, and other health programs. Once known as the Hcfa (Health Care Financing Administration). You'll consideration that Cms it the source of a lot of curative billing terms.
Cms 1500 - curative claim form established by Cms to submit paper claims to Medicare and Medicaid. Most industrial guarnatee carriers also want paper claims be submitted on Cms-1500's. The form is mighty by it's red ink.
Coding -Medical Billing Coding involves taking the doctors notes from a patient visit and translating them into the permissible Icd-9 code for diagnosis and Cpt codes for treatment.
Co-Insurance - division or number defined in the guarnatee plan for which the patient is responsible. Most plans have a ratio of 90/10 or 80/20, 70/30, etc. For example the guarnatee carrier pays 80% and the patient pays 20%.
Co-Pay - number paid by patient at each visit as defined by the insured plan.
Cpt Code - Current Procedural Terminology. This is a 5 digit code assigned for reporting a procedure performed by the physician. The Cpt has a corresponding Icd-9 diagnosis code. Established by the American curative Association. This is one of the curative billing terms we use a lot.
Date of assistance (Dos) - Date that health care services were provided.
Day Sheet - summary of daily patient treatments, charges, and payments received.
Deductible - number patient must pay before guarnatee coverage begins. For example, a patient could have a 00 deductible per year before their health guarnatee will begin paying. This could take some doctor's visits or prescriptions to reach the deductible.
Demographics - corporal characteristics of a patient such as age, sex, address, etc. Valuable for filing a claim.
Dme - Durable curative tool - curative supplies such as wheelchairs, oxygen, catheter, glucose monitors, crutches, walkers, etc.
Dob - Abbreviation for Date of Birth
Dx - Abbreviation for diagnosis code (Icd-9-Cm).
Electronic Claim - Claim data is sent electronically from the billing software to the clearinghouse or directly to the guarnatee carrier. The claim file must be in a suitable electronic format as defined by the receiver.
E/M - evaluation and supervision section of the Cpt codes. These are the Cpt codes 99201 thru 99499 most used by physicians to access (or evaluate) a patients treatment needs.
Emr - Electronic curative Records. curative records in digital format of a patients hospital or victualer treatment.
Eob - Explanation of Benefits. One of the curative billing terms for the statement that comes with the guarnatee firm payment to the victualer explaining payment details, covered charges, write offs, and patient responsibilities and deductibles.
Era - Electronic Remittance Advice. This is an electronic version of an guarnatee Eob that provides details of guarnatee claim payments. These are formatted in according to the Hipaa X12N 835 standard.
Fee agenda - Cost linked with each treatment Cpt curative billing codes.
Fraud - When a victualer receives payment or a patient obtains services by deliberate, dishonest, or misleading means.
Guarantor - A responsible party and/or insured party who is not a patient.
Hcpcs - health Care Financing supervision base procedure Coding System. (pronounced "hick-picks"). This is a three level ideas of codes. Cpt is Level I. A standardized curative coding ideas used to retell exact items or services provided when delivering health services. May also be referred to as a procedure code in the curative billing glossary.
The three Hcpcs levels are:
Level I - American curative Associations Current Procedural Terminology (Cpt) codes.
Level Ii - The alphanumeric codes which include mostly non-physician items or services such as curative supplies, ambulatory services, prosthesis, etc. These are items and services not covered by Cpt (Level I) procedures.
Level Iii - Local codes used by state Medicaid organizations, Medicare contractors, and hidden insurers for exact areas or programs.
Hipaa - health guarnatee Portability and responsibility Act. some federal regulations intended to enhance the efficiency and effectiveness of health care. Hipaa has introduced a lot of new curative billing terms into our vocabulary lately.
Hmo - health Maintenance Organization. A type of health care plan that places restrictions on treatments.
Icd-9 Code - Also know as Icd-9-Cm. International Classification of Diseases classification ideas used to assign codes to patient diagnosis. This is a 3 to 5 digit number.
Icd 10 Code - 10th correction of the International Classification of Diseases. Uses 3 to 7 digit. Includes further digits to allow more available codes. The U.S. group of health and Human Services has set an implementation deadline of October, 2013 for Icd-10.
Inpatient - Hospital stay longer than one day (24 hours).
Maximum Out of Pocket - The maximum number the insured is responsible for paying for eligible health plan expenses. When this maximum limit is reached, the guarnatee typically then pays 100% of eligible expenses.
Medical Assistant - Performs executive and clinical duties to retain a health care victualer such as a physician, physicians assistant, nurse, or nurse practitioner.
Medical Coder - Analyzes patient charts and assigns the correct Icd-9 diagnosis codes (soon to be Icd-10) and corresponding Cpt treatment codes and any linked Cpt modifiers.
Medical Billing expert - The man who processes guarnatee claims and patient payments of services performed by a physician or other health care victualer and vital to the financial carrying out of a practice. Makes sure curative billing codes and guarnatee data are entered correctly and submitted to guarnatee payer. Enters guarnatee payment data and processes patient statements and payments.
Medical Necessity - curative assistance or procedure performed for treatment of an illness or injury not considered investigational, cosmetic, or experimental.
Medical Transcription - The conversion of voice recorded or hand written curative data dictated by health care professionals (such as physicians) into text format records. These records can be either electronic or paper.
Medicare - guarnatee provided by federal government for habitancy over 65 or habitancy under 65 with inevitable restrictions. Medicare has 2 parts; Medicare Part A for hospital coverage and Part B for doctors office or patient care.
Medicare Donut Hole - The gap or unlikeness in the middle of the first limits of guarnatee and the catastrophic Medicare Part D coverage limits for prescription drugs.
Medicaid - guarnatee coverage for low revenue patients. Funded by Federal and state government and administered by states.
Modifier - Modifier to a Cpt treatment code that furnish further data to guarnatee payers for procedures or services that have been altered or "modified" in some way. Modifiers are important to explain further procedures and collect reimbursement for them.
Network victualer - health care victualer who is contracted with an guarnatee victualer to furnish care at a negotiated cost.
Npi number - National victualer Identifier. A unique 10 digit identification number required by Hipaa and assigned through the National Plan and victualer Enumeration ideas (Nppes).
Out-of Network (or Non-Participating) - A victualer that does not have a contract with the guarnatee carrier. Patients ordinarily responsible for a greater measure of the charges or may have to pay all the charges for using an out-of network provider.
Out-Of-Pocket Maximum - The maximum number the patient is responsible to pay under their insurance. Charges above this limit are the guarnatee associates obligation. These Out-of-pocket maximums can apply to all coverage or to a exact advantage kind such as prescriptions.
Outpatient - Typically treatment in a physicians office, clinic, or day surgery factory chronic less than one day.
Patient responsibility - The number a patient is responsible for paying that is not covered by the guarnatee plan.
Pcp - traditional Care physician - ordinarily the physician who provides first care and coordinates further care if necessary.
Ppo - preferred victualer Organization. guarnatee plan that allows the patient to pick a physician or hospital within the network. Similar to an Hmo.
Practice supervision Software - software used for the daily operations of a providers office. Typically includes appointment scheduling and billing functions.
Preauthorization - Requirement of guarnatee plan for traditional care physician to clue the patient guarnatee carrier of inevitable curative procedures (such as patient surgery) for those procedures to be considered a covered expense.
Premium - The number the insured or their employer pays (usually monthly) to the health guarnatee firm for coverage.
Provider - physician or curative care factory (hospital) that provides health care services.
Referral - When a victualer (typically the traditional Care Physician) refers a patient to other victualer (usually a specialist).
Self Pay - payment made at the time of assistance by the patient.
Secondary guarnatee Claim - guarnatee claim for coverage paid after traditional guarnatee makes payment. Typically intended to cover gaps in guarnatee coverage.
Sof - Signature on File.
Superbill - One of the curative billing terms for the form the victualer uses to document the treatment and diagnosis for a patient visit. Typically includes some ordinarily used Icd-9 diagnosis and Cpt procedural codes. One of the most often used curative billing terms.
Supplemental guarnatee - further guarnatee procedure that covers claims fro deductibles and coinsurance. often used to cover these expenses not covered by Medicare.
Taxonomy Code - Code for the victualer specialty sometimes required to process a claim.
Tertiary guarnatee - guarnatee paid in addition to traditional and secondary insurance. Tertiary guarnatee covers costs the traditional and secondary guarnatee may not cover.
Tin - Tax Identification Number. Also known as employer Identification number (Ein).
Tos - Type of Service. description of the kind of assistance performed.
Ub04 - Claim form for hospitals, clinics, or any victualer billing for factory fees similar to Cms 1500. Replaces the Ub92 form.
Unbundling - Submitting more than one Cpt treatment code when only one is appropriate.
Upin - Unique physician Identification Number. 6 digit physician identification number created by Cms. Discontinued in 2007 and substituted by Npi number.
Write-off (W/O) - The unlikeness in the middle of what the victualer charges for a procedure or treatment and what the guarnatee plan allows. The patient is not responsible for the write off amount. May also be referred to as "not covered" in some glossary of billing terms.
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