UHB Ch 1

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49 terms · Understanding Hospital Billing and Coding second edition

Accounts Recievable

The term that describes monies owed to the hospital from patients, insurance companies, and government programs

Acute Care Facility

A facility designed to treat patients who have a sudden onset of condition, illness, or disease

Ambulatory Surgery

A surgery that is performed on the same day the patient is released

American College of Surgeons (ACS)

Organization formen in 1913 for the purpose of developing hospital standards by collection patient care data

American Hospital Association (AHA)

Organization formed in 1906 to promote public welfare by improving health care provided in hospitals

American Medical Association (AMA)

Organization formed in 1847, with a mission to improve standards of medial education

Blue Cross

Organizatin that introduced one the the first prepaid health plans in 1929 to provide coverage forr hospital care

Coding

The process of translating written descriptions of diagnoses, services, and items into numeric or alphanumeric codes

Community Hospital

A hoopital that prvides care to members of a specific community

Demographic Information

Specific characteristic information about a patient including: name, address, date of birth, sex and Social Security number

Diagnosis Related Group (DRG)

A reimbursement method implemented under PPS that pays hospitals a fixed amount for a hospital inpatient stay regardless of the amount of charge accrued

Diagnostic Service

A sevice performed to diagnose a patients's condition

Emergency Department

Services are provided to patients who present with conditions that they believe require immediate attention

Evaluation and Management (E/M)

A service performed to evaluate and managed a patient's condition, which includes a history, exam, and medical decision making by the provider

Fee-for-service

A payment method used by various payers that reimburses providers based on carges submitted

General Hospital

Designed to provide medical, surgical, and emergency services required to treat a wide range of illness and injury

Group Health Insurance

Health insurance to provide coverage for medical services to members of a group. Group health insurance is often sold to emplyer groups or associations

Hill-Burton Act

Legislation implemented in 1946 that made funding available to modernize existing hospitals and build new ones

Hospital

A facility where patients with health care problems can go to seek diagnosis and treatment of their condition(s)

Hospital Standardization Program

Program designed by the American College of Surgeons (ASC) in 1913 to establish standards for hospital medical care

Indigent

A person who has no means of paying for medical services or treatments and who is not eligible for benefits under Medicaid or other public assistance program

Inpatient

Patient care services are provided to a patient who is admitted to the hospital for more than 24 hours

Insurance Information

Information regarding the insurance plan or government program that the patient is insured under including: plan name and number, identification number, and group name

Integrated Delivery System

An organization consisting of a network or providers that are affiliated within the system to offer patients a full range of managed health care services

Joing Commission of Accreditation of Healthcare Organization (JCAHO)

A national commissin formed in1952 to develop guidelines for hospitals and other health care organizations. JCAHO evaluates and accredits health care organizations based on estabilihed standards of quality for operations and medical services.

Managed Care Plans

Prepaid health insurance plans that incorporate the provision of coordinated health care services and cost containment measures to monitor and manage health care services provided to members of the plan.

Medicaid

Federal program administered at the state level established unter title XlX of the SSA to provide healthcare benefits for medically indigent people.

Medicare

A government program that provides coverage for health expenses to individuals over the age of 65 and other eligible groups such as the disabled.

Non-patient

A laboratory or pathology service is performed on specimens received at the hospital. The patient is not present when the service is performed.

Observation

A petient is admitted to a facility for the purpose of being observed and is generally released within 24 hours.

Outpatient

Patient care services are provided and the patient is released with 24 hours.

Palliative Service

A service provided to chronically ill patients to help alleviate symptoms of their illness.

Payer

Insurance company or government program that pays health benefits for patient care services.

Peer Review

A review of a medical case conducted by a physician to determine or assess the medical services.

Peer Review Organization (PRO)

An organizaton that conducts medical reviews to determine whether the quality of care, medical necessity, and appropriateness of service criteria were met.

Per Diem

A payment method used by various payers that reimburses providers for a daily rate for services.

Percentage of Accured Charges

A reimbursement method that calculates payment based on a percentage of total charges submitted.

Prepaid Health Plan

A Health plan that provides health benefits for specific medical servies in exchange for prepayment of an annual or monthly premium.

Preventive Service

A sevice provided to promote wellness and prevent illness.

ACS

American College of Surgeons

AHA

American Hospital Association

AMA

American Medical Association

DR

Diagnosis Related Group

E/M

Evaluation and management

JCAHO

Joint Commission on Accreditation of Healthcare Organizations

PPS

Prospective Payment System

PRO

Peer review organization

UM

Utilization management

UR

Utilization review

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