Those in healing billing and coding careers have a terminology of unique terms and abbreviations. Below are some of the more oftentimes used healing Billing terms and acronyms. Also included is some healing coding terminology.
Aging - Refers to the unpaid guarnatee claims or inpatient balances that are due past 30 days. Most healing billing software's have the quality to create a separate description for guarnatee aging and inpatient aging. These reports typically list balances by 30, 60, 90, and 120 day increments.
Health Check
Appeal - When an guarnatee plan does not pay for treatment, an appeal (either by the provider or patient) is the process of formally objecting this judgment. The insurer may require additional documentation.
Applied to Deductible - Typically seen on the inpatient statement. This is the estimate of the charges, thought about by the patients guarnatee plan, the inpatient owes the provider. Many plans have a maximum each 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 service that transmits claims to guarnatee carriers. Prior to submitting claims the clearinghouse scrubs claims and checks for errors. This minimizes the estimate of rejected claims as most errors can be really corrected. Clearinghouses electronically transmit claim data that is compliant with the spoton Hippa standards (this is one of the healing billing terms we see a lot more of lately).
Cms - Centers for Medicaid and Medicare Services. Federal agency which administers Medicare, Medicaid, Hippa, and other health programs. Once known as the Hcfa (Health Care Financing Administration). You'll notice that Cms it the source of a lot of healing billing terms.
Cms 1500 - healing claim form established by Cms to submit paper claims to Medicare and Medicaid. Most commercial guarnatee carriers also require paper claims be submitted on Cms-1500's. The form is distinguished by it's red ink.
Coding -Medical Billing Coding involves taking the doctors notes from a inpatient visit and translating them into the proper Icd-9 code for determination and Cpt codes for treatment.
Co-Insurance - ration or estimate defined in the guarnatee plan for which the inpatient 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 inpatient pays 20%.
Co-Pay - estimate paid by inpatient at each visit as defined by the insured plan.
Cpt Code - Current Procedural Terminology. This is a 5 digit code assigned for reporting a policy performed by the physician. The Cpt has a corresponding Icd-9 determination code. Established by the American healing Association. This is one of the healing billing terms we use a lot.
Date of service (Dos) - Date that health care services were provided.
Day Sheet - overview of daily inpatient treatments, charges, and payments received.
Deductible - estimate inpatient must pay before guarnatee coverage begins. For example, a inpatient could have a 00 deductible per year before their health guarnatee will begin paying. This could take several doctor's visits or prescriptions to reach the deductible.
Demographics - physical characteristics of a inpatient such as age, sex, address, etc. Principal for filing a claim.
Dme - Durable healing tool - healing supplies such as wheelchairs, oxygen, catheter, glucose monitors, crutches, walkers, etc.
Dob - Abbreviation for Date of Birth
Dx - Abbreviation for determination 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 standard 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 medicine needs.
Emr - Electronic healing Records. healing records in digital format of a patients hospital or provider treatment.
Eob - Explanation of Benefits. One of the healing billing terms for the statement that comes with the guarnatee enterprise cost to the provider explaining cost details, covered charges, write offs, and inpatient 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 agreeing to the Hipaa X12N 835 standard.
Fee agenda - Cost associated with each medicine Cpt healing billing codes.
Fraud - When a provider receives cost or a inpatient 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 tasteless policy Coding System. (pronounced "hick-picks"). This is a three level principles of codes. Cpt is Level I. A standardized healing coding principles used to recite specific items or services in case,granted when delivering health services. May also be referred to as a policy code in the healing billing glossary.
The three Hcpcs levels are:
Level I - American healing Associations Current Procedural Terminology (Cpt) codes.
Level Ii - The alphanumeric codes which include mostly non-physician items or services such as healing 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 inexpressive insurers for specific areas or programs.
Hipaa - health guarnatee Portability and responsibility Act. several federal regulations intended to improve the efficiency and effectiveness of health care. Hipaa has introduced a lot of new healing 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 principles used to assign codes to inpatient 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 additional digits to allow more ready codes. The U.S. agency 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 estimate 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 administrative and clinical duties to keep a health care provider such as a physician, physicians assistant, nurse, or nurse practitioner.
Medical Coder - Analyzes inpatient charts and assigns the spoton Icd-9 determination codes (soon to be Icd-10) and corresponding Cpt medicine codes and any associated Cpt modifiers.
Medical Billing expert - The man who processes guarnatee claims and inpatient payments of services performed by a physician or other health care provider and vital to the financial execution of a practice. Makes sure healing billing codes and guarnatee data are entered correctly and submitted to guarnatee payer. Enters guarnatee cost data and processes inpatient statements and payments.
Medical Necessity - healing service or policy performed for medicine of an illness or injury not thought about investigational, cosmetic, or experimental.
Medical Transcription - The conversion of voice recorded or hand written healing data dictated by health care professionals (such as physicians) into text format records. These records can be whether electronic or paper.
Medicare - guarnatee in case,granted by federal government for citizen over 65 or citizen under 65 with positive restrictions. Medicare has 2 parts; Medicare Part A for hospital coverage and Part B for doctors office or inpatient care.
Medicare Donut Hole - The gap or difference in the middle of the introductory limits of guarnatee and the catastrophic Medicare Part D coverage limits for designate drugs.
Medicaid - guarnatee coverage for low wage patients. Funded by Federal and state government and administered by states.
Modifier - Modifier to a Cpt medicine code that contribute additional data to guarnatee payers for procedures or services that have been altered or "modified" in some way. Modifiers are foremost to explicate additional procedures and gather repayment for them.
Network provider - health care provider who is contracted with an guarnatee provider to contribute care at a negotiated cost.
Npi estimate - National provider Identifier. A unique 10 digit identification estimate required by Hipaa and assigned through the National Plan and provider Enumeration principles (Nppes).
Out-of Network (or Non-Participating) - A provider that does not have a ageement with the guarnatee carrier. Patients ordinarily responsible for a greater part of the charges or may have to pay all the charges for using an out-of network provider.
Out-Of-Pocket Maximum - The maximum estimate the inpatient is responsible to pay under their insurance. Charges above this limit are the guarnatee clubs obligation. These Out-of-pocket maximums can apply to all coverage or to a specific benefit type such as prescriptions.
Outpatient - Typically medicine in a physicians office, clinic, or day surgical operation premise chronic less than one day.
Patient responsibility - The estimate a inpatient is responsible for paying that is not covered by the guarnatee plan.
Pcp - primary Care physician - ordinarily the physician who provides introductory care and coordinates additional care if necessary.
Ppo - adored provider Organization. guarnatee plan that allows the inpatient to opt 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 primary care physician to fill in the inpatient guarnatee carrier of positive healing procedures (such as inpatient surgery) for those procedures to be thought about a covered expense.
Premium - The estimate the insured or their owner pays (usually monthly) to the health guarnatee enterprise for coverage.
Provider - physician or healing care premise (hospital) that provides health care services.
Referral - When a provider (typically the primary Care Physician) refers a inpatient to someone else provider (usually a specialist).
Self Pay - cost made at the time of service by the patient.
Secondary guarnatee Claim - guarnatee claim for coverage paid after primary guarnatee makes payment. Typically intended to cover gaps in guarnatee coverage.
Sof - Signature on File.
Superbill - One of the healing billing terms for the form the provider uses to document the medicine and determination for a inpatient visit. Typically includes several generally used Icd-9 determination and Cpt procedural codes. One of the most oftentimes used healing billing terms.
Supplemental guarnatee - additional guarnatee policy that covers claims fro deductibles and coinsurance. oftentimes used to cover these expenses not covered by Medicare.
Taxonomy Code - Code for the provider specialty sometimes required to process a claim.
Tertiary guarnatee - guarnatee paid in increasing to primary and secondary insurance. Tertiary guarnatee covers costs the primary and secondary guarnatee may not cover.
Tin - Tax Identification Number. Also known as owner Identification estimate (Ein).
Tos - Type of Service. description of the type of service performed.
Ub04 - Claim form for hospitals, clinics, or any provider billing for premise fees similar to Cms 1500. Replaces the Ub92 form.
Unbundling - Submitting more than one Cpt medicine code when only one is appropriate.
Upin - Unique physician Identification Number. 6 digit physician identification estimate created by Cms. Discontinued in 2007 and supplanted by Npi number.
Write-off (W/O) - The difference in the middle of what the provider charges for a policy or medicine and what the guarnatee plan allows. The inpatient is not responsible for the write off amount. May also be referred to as "not covered" in some glossary of billing terms.
curative Billing Terms and curative Coding Terminology