Refers to an individual who receives medical or disability benefits fits from both Medicare and Medicaid programs; some times referred to as a Medi-Medi case or crossover.
A provider who decides not to accept the determined allowable charge from the insurance plan as full fee for care. Payment goes directly to the patient in this case, and the patient is usually responsible for paying the bill in full.
were doctors charge PRIVATE insurance subscribers extra for one session, unnecessary charges, and billing without an actual visit
incidents or practices, not usually considered fraudulent, but are inconsistent with generally accepted behavior
Account number sequence
The next base account number available to be assigned to a new guarantor., for example, if account 1-30 have been assigned, the next available sequential number is 31. (2) The next account number siffix to be assinged to a dependent of an account, example if an account has the number 30.0 and 30.1, the next account number sequence to be assigned to a dependent of this account is 30.2
The process by which an account information is retrieved from the database. There are several methods to retrieve an account. From any account retrieval window, for example, one may use just the question mark (?), the question mark with the first letter of the guarantor's name (?C), or key in the full account number.
accounts receivable management
Refers to functions required for the monitoring and follow-up on outstanding accounts to ensure that reimbursement is received in a timely manner.
An unfavorable, detrimental , or pathologic reaction to a drug that occurs when appropriate doses are given to humans for prophylaxis (prevention of disease), diagnosis, and therapy
The procedure of systematically arranging the accounts receivable, by age, from the date of service
In-depth information about an illness or injry that is always required for Workers' Compensation claims and sometimes needed for other claims. This is also the name of a screen found in the Procedure Entry phase of The Medical Manager software. Ailment Detail can be thought of as the "other information" needed on the CMS-1500 form.
alternative billing codes (ABCs)
A code system for integrative health care products and services consisting of five-character alphabetic symbols with appended two-character practitioner modifiers that represent the practitioner type
AMA Code of Medical Ethics
A code of medical ethics formulated by the American Medical Association and adopted in 1847
American Health Information Management Association (AHIMA)
A national professional organization for promoting the art and science of medical record management and improving the quality of comprehensive health information for the welfare of the public.
American Medical Association (AMA)
The national professional membership organization for physicians that distributes scientific information to its members and the public, informs members of legislation related to health and medicine, and represents the medical profession's interests in national legislative matters; maintains and publishes the Current Procedural Terminology (CPT) coding system
ambulatory payment classifications-- A system of outpatient hospital reimbursement based on procedures rather than diagnoses.
An agreement by which a patient assigns to another party the right to receive payment from a third party for the services the patient has received.
Assignment of benefits
The act by which a patient assigns in writing to their physician the right to receive payment directly from the patient's insurance carrier. Also see Assignment of claim
A type of HMO in which a program administrator contracts with a number of physicians who agree to provide treatment to subscribers in their own offices. Physicians are not employees of the managed care organizataion(MCO) and are not paid salaries. They receive reimbursement on a CAPITATION or FEE-FOR-SERVICE basis; also known as a medical capitation plan.
A medical staff member who is legally responsible for the care and treatment given to a patient
A document signed by the patient that is needed for use and disclosure of protected health information for purposes other than treatment, payment or health care operations
A court order that goes into effect once a bankruptcy petition is filed; all other legal actions such as attachments and forclosures, are halted
An abnormal growth that does not have the properties of invasion and metastasis and is usually surrounded by a fibrous capsule; also called a neoplasm
Comprehensive group insurance coverage through plans sponsored by professional associations for their members
An insurance contract by which, in return for a stated fee, a bonding agency guarantees payment of a certain sum to an employer in the event of a financial loss to the employer by the act of a specified employee or by some contingency over which the employer has no control
Breach of Confidential Communication
unauthorized release of information, a HIPAA violation - breacher is required to mitigate harmful effects of the breach
A person, who on behalf of the covered entity, performs or assists in the performance of a function or activity involving the use or disclosure of individually identifieable health information.
A provision allowing the insurer to cancel the policy at any time or at the end of a policy period with no guarantees of continuation of the policy.
System of payment used by managed care plans in which physicians and hospitals are paid a fixed, per capita amount for each patient enrolled over a stated period regardless of the type and number of services provided; reimbursement to the hospital on a per-member/per-month basis to cover costs for the members of the plan.
A system of payment used by managed care plans where health care providers are reimbursed a fixed amount per capitation (per person) enrolled over a given or contracted period of time, regardeless of the type or number of services rendered. A variety of capitation plans ranging from fixed payments per procedure code to a fixed amount paid per claim.
A reimbursement method utilized that provides a set payment rate to the hospital for a case. The payment rate is based on the type of case and resources utilized to treat the patient.
Conversion Factor, a national dollar amount that is applied to all services paid on the basis of the Medicare Fee Schedule
Part of the dialy close function that lists all checks posted during 1 day. All checks posted for each doctor. The check register would include the check number, amount, and from whom the payment was posted into the system.
chief complaint (CC)
A patient's statement describing symptoms, problems, or conditions as the reason for seeking health care services from a physician
Request for payment of a covered medical expense, sent to the insurance company, may be submitted by the insured or by the agency or individual that provided the medical care.
Claims Assistance Professional (CAP)
A practitioner who works for the consumer and helps patient organize, complete, file, and negotiate health insurance claims of all types to obtain maximum benefits as well as tell patients what checks to write to providers to eliminate overpayment.
a service company that recieves electronic or paper claims from the provider, checks and prepares them for processing, and transmits them in HIPAA-complaint format to the correct carriers
The universally accepted claim form utilized to submit charges for physician and outpatient services.
The correct order of diagnostic codes when submitting an insurance claim that affects maximum reimbursement.
under HIPAA, terms that provide for uniformity and simplification of health care billing and record keeping
Is the amount of money the insured splits with their insurance carier Instance, if your health plan has an 80/20 coinsurance rate (coinsurance rates of 70/30 90/10, and flat rates of $5.00 to $20.00 per doctor's office visit are also common). your insurance plan pays for 80% of your eligible medical expenses and you're responsible for the remaining 20%.
Any possession such as an automobile, furniture, stocks, or bonds that secures or guarantees the discharge of an obligation
The relationship between the amount of money owed and the amount of money collected in reference to the doctor's accounts receivable
A code from one section of the procedural code book combined with a code from another section that is used to completely describe a procedure performed; in diagnostic coding, a single five-digit code used to identify etiology and secondary process (manifestation) or complication of a disease
A field on the Ailment Detail screen that allows the user to enter a specific comment about why the Ailment Detail is being created for the patient. For example, if a patient is being treated for a work-related injury (such as a back injury) that will be billed to the patient's employer's Workers' Compensation Policy, it will be necessary for the physician to enter a complete Ailment Detail for the patient. In the Comment field on the Ailment Detail screen, the physician may enter "WC Back" to indicate that this is a back injury that will be billed to Workers' Compensation.
An ongoing condition that exists along with the condition for which the patient is receiving treatment; in regard to DRGs, a preexisting condition that, because of its presence with a certain principal diagnosis, will cause an increase in length of stay by at least 1 day in approximately 75% of cases. AKA substantial comorbidity
Competitive Medical Plan (CMP)
a state licensed health plan similar to a health maintenance organization that delivers comprehensive, coordinated services to voluntary enrolled members on a prepaid capitation
A medical practice's written plan for (a) the appointment of a compliance officer and committee, (b) a code of conduct for physicians' business arrangements and employees' compliance, (c) training plans, (d) properly prepared and updated coding tools such as job reference aids, encounter forms, and documentation templates, (e) rules for prompt identification and refunding of overpayments, and (f) ongoing monitoring and auditing of claim preparation.
A disease or condition arising during the course of, or as a result, another disease modifying medical care requirements
A single procedural code that describes or covers two or more CPT component codes that are bundled together as one unit
The provision of similar services (EG hospital visits) to the same patient by more than one physician on the same day. Usually a separate physical disorder is present
An insurance policy renewal provision that grants the insurer a limited right to refuse to renew a health insurance policy at the end of a premium payment period
A privileged communication that may be disclosed only with the patient's permission.
the act of holding information in confidence, not to be released to unauthorized individuals
document signed by the patient or legal guardian giving permission for medical or surgical care
Services rendered by a physician whose opinion or advice is requested by another physician or agency in the evaluation or treatment of a patient's illness or suspected problem
A provider whose opinion or advice about a working professional and intended to improve or maintain professional competence
continuity of care
When a physician sees a patient who has receive treatment for a condition and is referred by the previous doctor for treatment of the same condition
agreement between an insurance company and an individual in which the insurance company agrees to provide insurance coverage in exchange for a premium
Rules or principles for determining a diagnostic code when using diagnostic code books such as each space, typefaces, indentations, punctuation marks, instructional notes, abbreviations, cross-reference notes, and specific usage of the words and, with, and due to. These rules assist in the selection of correct codes for the diagnoses encountered
The dollars and cents amount that is established for one unit as applied to a procedure or service rendered. This unit is then used to convert various procedures into fee-schedule payment amounts by multiplying the relative value unit by the conversion factor
Coordination of Benefits (COB)
When a patient and a spouse (or parent) are covered under the two separate employer groups of policies, the total benefits an insured can receive from both group plans are limited to not more than 100% of the allowable expenses, preventing the policy holders from a profit on health insurance claims. The primary plan pays benefits up to its limits, and then the secondary plan pays the difference, up to its limits.
Exceptionally high costs associated with inpatient care when compared with other cases in the same diagnosis-related group
A discussion between the physician and a patient, family, or both concerning the diagnosis, recommended studies or tests, prognosis, risks, and benefits of treatment, treatment options, patient and family education, and so on
An entity that transmits health information in electronic form in connection with a transaction covered by HIPAA. The covered entity may be a helath care coverage carrier such as Blue Cross, a health care clearinghouse through which claims are submitted, or a health care provider such as the primary care physician.
Trust in regard to financial obligation. Accounting entry reflecting payment by a debtor (patient) of a sum received on his or her account
A card issued by an organization and devised for the purpose of obtaining money, property, labor, or services on credit
Current Procedural Terminology (CPT)
A reference procedural code book using a five-digit numerical system to identify and code procedures established by the American medical Association
A system of billing accounts at spaced intervals during the month based on breakdown of accounts by alphabet, account number, insurance type, or date of first service
An end-of-day report detailing all of the transactions that were posted during the day. Also called Daily close. you may run a trial Daily Close to check that the informatin you entered was correctly posted, and run the final Daily Close to actually close the day's business.
Date of Service
from date/to date (DOS) can be entered for repetitive procedures, such as allergy shots given weekly or on an ongoing basis over time
Date of Service (DOS)
a date that is entered for repetitive procedures, such as allergy shots given weekly or on an ongoing basis over time. This is accomplished by typing the first date and pressing ENTER for the From Date and then keying the second date and pressing Enter for the to Date.
A card permitting bank customers to withdraw from any affiliated automated teller machine (ATM) and make cashless purchases from funds on deposti without incurring revolving finance charges for credit
a clause in an insurance policy that relieves the insurer of responsibility to pay the initial loss up to a stated amount
This is the amount the patient is expected to pay before the insurance plan will begin paying. This is used when a patient is expected to pay a portion of their medical expenses. For example, the charges for a patient's visit may total $120.00 However, because the patient's deductible for this plan is $100.00 anually, the insurance company will be billed only for the remaining $20.00, where as the patient will have to pay the $100.00 deductible amount.
Personal information about the patient; the name, address, and telephone number of the guarantor's employer; the names, addresses, and policy numbers of all health insurance plans covering the patient; the name of the referring physician; and information about any dependents.
disability income insurance
pays money to the insured patient when they are disabled, but not due to a work-related accident or condition
Defined as doing any action by the entity holding the information so that the information is outside the entity.
A reduction of a normal charge based on a specific amount of money or a percentage of the charge
A chronologic detailed recording of pertinent facts and observations about a patient's health as seen in chart notes and medical reports; entries in the medical record such as prescription refills, telephone calls, and other pertinent data. For computer software, a usuer's guide to a program or piece of equipment
This occurs when the coding system used by the physician's office on a claim does not match the coding system used by the insurance company receiving the claim. The insurance company computer system converts the code submitted to the closest code in use, which is usually down one level from the submitted code, generating decreased payment
An increase in a case-mix index that occurs through the coding of higher-paying principal diagnoses and of more complications and comorbidities, even though the actual severity level of the patient population did not change
Diagnostic related groups that pay providers of care for medicare patients a set amount regardless of actual cost
A classification of ICD-9-CM coding used to describe environmental events, circumstances, and conditions as the external cause of injury, poisoning, and other adverse effects. Also used in coding adverse reactions to medications
Edit ailment records
A procedure that is used to modify or delete the patient's CONDITION/DIAGNOSIS detail from when it was originally created. For example, as when a patient's condition improves, this function opens the edit ailment detail screen to edit/enter beginning and end dates for the diagnosis.
e-health information management (e-HIM)
Any and all transations in which health care information is accessed, processed, stored, and transferred using electronic technologies.
A surgical procedure that may be scheduled in advance, is not an emergency, and is discretionary on the part of the physician and patient
electronic health record (EHR)
A patient record that is created using a computer with software. A template is brought up and by answering a series of questions data are entered
Means of electronic transmission, including the Internet, private networks, dial-up phone lines, and fax modems; includes information moved from one place to another while stored on an electronic device.
Electronic approval of a document that has the same legal status as a written signature.
Qualifying factors that must be met before a patient receives benefits under a specified insurance plan, government program, or managed care plan.
Person younger than 18 years of age who lives independently, is totally self-supporting, is married or divorced, is a parent even if not married, or is in the military and possesses decision-making rights.
the fraudulent appropriation of funds or property entrusted to your care but actually owned by someone else
Health care services provided to prevent serious impairment of bodily functions or serious dysfunction to any body organ or part.
electronic medical record, an electronic file wherein patients health information is stored in a computer system
A form that is used to record information about the procedures performed during a patient's visit
This is a printed list of the most common procedures and treatments performed by the doctor. The doctor uses this paper form to indicate the procedures or treatmetn performed for the patient as well as the diagnosis for the patient's condition, also see superbill.
The name of a disease, anatomic structure, operation, or procedure, usually derived from the name of a place where it first occurred or a person who discovered or first described it
An individual who has received professional services within the past 3 years from the physician or another physician of the same specialty who belongs to the same group practice
One who takes possession of the assets of a decedent, pays the expenses of administration and the claims of creditors, and disposes of the estate in accordance with the statues governing the distribution of decedents' estates
One who takes possession of the assets of a decedent, pays the expenses of administration and the claim of creditors, and disposes of the balance of an estate in accourdance with the decedent's will
code of conduct for medical professionals. Basic principle usually include showing respect for the patient autonomy, not infliction harm on the patient, contributing to the welfare of patients, and providing justice and fair treatment of patients (not to guage legal and illegal activites)
provisions written into the insurance contract denying coverage or limiting the scope of coverage, for certain conditions or services
exclusive provider organization (EPO)
Plan in which participants must use providers in the network of coverage or no payment will be made
A review done after claims have been submitted (retrospective review) of medical and financial records by an insurance company or Medicare representative to investigate suspected fraud or abusive billing practices
An electronic process for transmitting graphic and written documents over telephone lines; AKA fax
part of a patient's medical history in which questions are asked in an attempt to find out whether the patient has hereditary tendencies toward particular diseases
family history (FH)
A review of medical events in the patient's family including diseases that may be hereditary or place the patient at risk
An official document, published every weekday, which lists the new and proposed regulations of executive departments and regulatory agencies.
A list of charges or established allowances for specific medical services and procedures
financial accounting record
An individual record indicating charges, payments, adjustments, and balances owed for services rendered; AKA ledger
foundation for medical care(FMC)
An organization of physicians sponsored by a state or local medical association concerned with the development and delivery of medical services and the cost of health care.
Any fraud that involves an insurance company, whether committed by consumers, insurance company employees, producers, health care providers, or anyone else connected with and insurance transaction. ILLEGAL usually performed against the GOVERNMENT.
The overall financial accounting for the entire practice. This includes the accounts receivable, the accounts payable, the payroll, and other accounting stages, The Medical Manager software is the accounts receivable portion of a general ledger.
global surgery policy
A Medicare policy relating to surgical procedures in which preoperative and postoperative visits (24 hours before major and day of minor), usual, intraoperative services, and complications not requiring additional trips to the operating room are included in one fee
(group name) Identifies the group purchasing the insurance. Often, this is the person's employer.
A clause in an insurance policy that means the insurance company must renew the policy as long as premium payments are made. However, the premium may be increased when it is renewed. These policies may have age limits of 60, 65, or 70years or may be renewable for life
An individual who promises to pay the medical bill by signing a form agreeing to pay or who accepts treatment, which constitutes an expressed promise
Health Care Provider
is a person trained and licensed to provide care to a patient care to a patient, and a place that is licensed to give health care
A contract between the policy holder or member and insurance carrier or government program to reimburse the policy holder or member for all or portion of the cost of medical care rendered by health care professionals
health maintenance organization (HMO)
The oldest of all prepaid health plans. A comprehensive health care financing and delivery organization that provides a wide range of health care services with an emphasis on preventive medicine to enrollees within a geographic area through a panel of providers. Primary care physicians "gatekeepers" are usually reimbursed via CAPITATION. In general, enrollees do not receive coverage for the services from providers who are not in HMO network, except for emergency services.
health record/medical record
Written or graphic information documenting facts and events during the rendering of patient care. AKA medical record
Healthcare Common Procedure Coding System (HCPCS)
The CMS's Common Procedure Coding System. A three-tier national uniform coding system developed by the Centers for Medicare and Medicaid Services (CMS), formerly HCFA, used in reporting physician or supplier services and procedures under the Medicare program. Level l: national CPT codes. Level II: HCPCS national codes used to report items not covered under CPT. Level III: are HCPCS regional or local codes used to identify new procedures or items for which there is no national code
Electronic Health Record: An integration of all medical documentation into electronic format
The Health Insurance Portability and Accountability Act, a federal law protecting the privacy of patient-specific health care information and providing the patient with control over how this information is used and distributed
history of present illness (HPI)
A chronologic description of the development of the patient's present illness from the first sign or symptom or from the previous encounter to the present
International Classification of Diseases-9th Revision Clinical Modification, a publication containing the HIPAA-mandated standardized classification system for disease and injuires; developed by the World Health Organization and modified for use in the United States.
A contract between physician and patient not manifested by direct words but implied or deduced from the circumstance, general language, or conduct of the patient. Most contracts are implied.
A description applied to a malignant growth condined to the site of origin witt invasion of neighboring tissues
Individually Identifiable Health Information (IIHI)
According to HIPAA privacy provisions, that information which specifically identifies the patient to whom the information relates, such as age, gender, date of birth, and address
insurance balance billing
A statement sent to the patient after his or her insurance company has paid its portion of the claim
Insurance Billing Specialist
An individual who processes health insurance claims in accordance with legal, professional, and insurance company guidelines and regulations.
Insurance Coverage Priority
This is information set in the Insurance Coverage Priority screen in the system that establishes the insurance policy or policies a patient is covered by. This determines which plan is to be billed first for the patient's charges and, if applicable, which plan is to be billed for the remaining charges. Dependent's insurance coverage priority may often be different from the coverage the guarantor of the account has.
An individual or organization protected in case of loss under the terms of an insurance policy.
Insured party file
A file which provides the detailed dinformation of the insured party including their name, address, and insurance ID number
The process of going over financial documents before and after billing to insurance carriers to determine documentation deficiencies or errors
International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM)
A diagnostic code book that uses a system for classifying diseases to assist collection of uniform and comparable health information. Two volumes
International Classification of Diseases, Tenth Revision, Procedural Coding System (ICD-10-PCS)
Procedural code system; A build-your-own book
A diagnostic coding term that relates to an adverse effect rather than a poisoning when drugs such as digitals, steroid agents, and so on are involved
A diagnostic code in ICD-9-CM, Volume 1, Tabular list, that may never be sequenced as the principal diagnosis
A detailed summary of all detailed charges, payments (copayments and deductibles), date the insurance claim was submitted, adjustments, and account balance
An inactive residual effect or condition produced after the acute phase of an illness or injury has ended
A claim on the property of another as security for a debt. In litigation cases, it is a legal promise to satisfy a debt owed by the patient to the physician out of any proceeds received on the case
telephone technique, creating warm and reassuring environment, writing and responding to telephone messages, patient education, assisting with billing issues
low complexity (LC)
Phrase used to describe a type of medical decision making when a patient is seen for an E/M service
A health insurance policy designed to offset heavy medical expenses resulting from catastrophic or prolonged illness or injury.
a dangerous cancerous growth that sheds cells into body fluids and spreads to new locations to start new cancer colonies
An abnormal growth that has the properties of invasion and metastasis (EG transfer of diseases from one organ to another)
Processing statements by hand, may involve typing statements or photocopying the patient's financial accounting record and placing it in a window envelope, which then becomes the statement
This is a financial assistance program sponsored jointly by the federal government and the states to provide health care for the poor. Medicaid generally pays the deductible amount charged under Medicare (explained below), as well as the 20 percent of charges not covered by Medicare medical insurance for eligible patients. In general, Medicaid patients do not have to pay for health care services.
A federally aided, state-operated, and state-administered program that provides medical benefits for certain low-income persons in need of health and medical care. California's Medicaid program is also known as Medical
medical decision making (MDM)
Health care management process done after performing a history and physical examination on a patient that results in a plan of treatment. It is based on establishing one or more diagnosis and/or selecting a management or treatment option, amount of data or complexity of data reviewed, and complication and/or morbidity or mortality
The performance of services and procedures that are consistent with the diagnosis in accordance with standards of good medical practice, performed at the proper level, and provided in the most appropriate setting.
A process insurance companies use to verify whether or not a procedure was medically necessary to treat the patients complaint/problem.
A permanent, legal document (letter or report format) that formally states the consequences of the patient's examination or treatment
A program added to the Social Security system in 1965 that provides hospitalization insurance for the elderly and permits older Americans to purchase inexpensive coverage for doctor fees and other health expenses. Also includes people with ESRD.
This is an insurance program sponsored by the federal government to protect the elderly and disabled population. Medicare medical insurance pays 80 percent of reasonable physician's fees and related medical charges, minus a deductible amount. Medicare hospital insurance pays for most but not all of a patient's hospital treatment and related expenses.
A nationwide health insurance program for persons age 65 years of age and older and certain disabled or blind persons regardless of income, administered by HCFA. Local Social Security offices take applications and supply information about the program.
Medicare Part A
The part of the Medicare program that pays for hospitalization, care in a skilled nursing facility, home health care, and hospice care.
Medicare Part B
The part of the Medicare program that pays for physician services, outpatient hospital services, durable medical equipment, and other services and supplies.
Medicare Part C
managed care health plans offered to medicare beneficiaries under the medicare advantage program
Person covered under an insurance program's contract, including(1) the subscriber or contract holder who is the person named on the membership identification card and (2) in the case of (a) two person coverage, (b) one adult-one child coverage, or (c) family coverage, the eligible family dependents enrolled under the subscriber's contract.
moderate complexity (MC)
A phrase used to describe a type of medical decision making when a patient is seen for and E/M service
In CPT coding, a two-digit add-on number placed after the usual procedure code number to indicate a procedure or service that has been altered by specific circumstances. In HCPCS level II coding, one-digit or two-digit add-on alpha characters, placed after the usual procedure code number
Medicare Severity Diagnosis Related Groups, implemented in 1983., classification that is based on diagnoses, procedures, other demographic information & the presence of complications & comorbidities
Multiskilled health practitioner (MSHP)
An individual cross-trained to provide more than one function
destruction of heart tissue resulting from obstruction of the blood supply to the heart muscle
A spontateous new growth of tissue forming an abnormal mass that is also known as a tumor. May be benign or malignant.
Evaluating a collection agency's performance by taking the amount of monies collected and subtracting the agency's fees
new patient (NP)
An individual who has not received any professional services from the physician or another physician of the same specialty who belongs to the same group practice within the past 3 years
An insurance policy clause that means the insurance company cannot increase premium rates and must renew the policy until the insured reaches the age stated in the contract. Some disability income policies have noncancelable terms.
One's total property (in bankruptcy cases) not falling in the exemption category; including money, automobile equity, and property, more than a specideied amount, depending on the state in which the person lives
non-physician practitioner (NPP)
Health care provider who meets state licensing requirements to provide specific medical services. (advance registered nurse practitioners (ARNPs), certified registered nurse practitioners, clinical nurse specialists (CNSs), licensed clinical social workers (LCSWs), physician assistants (PAs), nurse midwives)
Information consisting of ordinary facts unrelated to the treatment of the patient. The patient's authorization is not required to disclose the data unless the record is in a specialty hospital or in a special service unit of a general hospital, such as the psychiatric unit
not elsewhere classifiable (NEC)
This term is used in the ICD-9-CM diagnostic coding system when the code lacks the information necessary to code the term in a more specific category
not otherwise specified (NOS)
Unspecified. Used in ICD-9-CM diagnostic coding system when the code lacks the information necessary to code the term in a more specific category
Notice of privacy Practices
Under HIPAA, a document given to the patient at the first visit or at enrollment explaining the individual's rights and the physician's legal duties in regard to protected health information. Document optionally revised and/or distributed annually after initial distribution.
Services furnished on a hospital premises, use of a bed and monitoring. The length of an observation stay is 24-48hrs maximum.
Official Guidelines for Coding and Reporting
Rules of coding diagnosis codes (ICD-9-CM) published by the Editorial Advisory Board of Coding Clinic
An insurance policy renewal provision in which the insurer has the right to refuse to renew the policy on a date and may add coverage limitations or increase premium rates.
The physician ordering non-physician services for a patient (EG diagnostic laboratory tests) when an insurance claim is submitted by a non-physician supplier of services
operative procedures performed on clients who return home the same day, performed on patients of optimal health and who's recovery is expected to be uneventful
This is the practice scheduling more patients than the physician can see during a reasonable period of time. Overbooking may also be called double scheduling or double booking
participating provider (par)
One who accepts TRICARE assignment. Payment in this case goes directly to the provider. The patient must still pay the cost-share outpatient deductible and the cost of care not covered by TRICARE.
preadmission testing, routine test required for all patients before hospital admission to screen for abnormal findings that could interfere with the patient's hospital stay or scheduled procedure
patient registration form
A questionnaire designed to collect demographic data and essential facts about medical insurance coverage for each patient seen for professional services; also called patint information form.
Patient registration form
This is the form the patient completes when he or she first sets up his or her account at the medical practice. The Form typically contains the patient's full name, complete address and telephone number, social security number, date of birth, employement information, insurance plan information, and similar informatin for each of his or her dependents.
a reimbursement method that provides payment of a set rate, per day to the hospital, rather than payment based on total charges
Percentage of Revenue
the fixed percentage of the collected premium rate that is paid to the hospital to cover services
An insurance plan issued to an individual (or his or her dependents); also known as individual contarct.
physical examination (PE or PX)
Objective inspection or testing of organ systems or body areas of a patient by a physician
physician's fee profile
A compliation of each physician's charges and the payments made to him or her over a given period of time for each specific professional service rendered to a patient
Place of service (POS)
This field contains the number representing the place where the service was performed. Medical Manager has an internal, one digit code that corresponds to different coding systems used by different insurance companies & agencies. The codes are provided to an insurance company on an insurance form, they will automatically be cross-referenced to the correct code for that company.
A managed care plan in which members are given a choice as to how to receive services, whether through an HMO, PPO, or fee-for-service plan. The decision is made up at the time the service is necessary(at the point of service) sometimes referred to as open-ended HMOs, swing-out HMOs, self-referral options, or multiple option plans.
A condidtion resulting from an overdose of drugs or chemical substances or from the wrong drug or agent given or taken in error
This is the individual who owns the insurance policy. In other words, this is the person who brings the insurance policy to the family account. This person must be the guarantor or one of the dependents on the account. In general, this is also usually the guarantor.
The activity of recording business transactions such as the process of typing information from a source document, such as an encounter form, into the procedure Entery Screen, or typing in payments from an EOB to the Patient Payment window.
The activity of recording business transactions such as the process of typing information from a source document, such as an encounter from, into the Procedure Entry screen; or typing in payments from an EOB to the Patient Payments window.
The cost of insurance coverage paid annually, semianually, or monthly to keep the policy in force. This fee is updated annually to reflect changes in program costs.
primary care physician (PCP)
A physician who oversees the care of patients in a managed health care plan (HMO or PPO) and refers patients to see specialists for services as needed
Primary Care Physician (PCP)
This is a doctor who has contracted with a managed care plan and has agreed to be responsible for providing the health care for specific patients participating in the plan. Each patient with a managed care plan must choose a PCP from a list, or directory, of physicians who are providing services for the plan. Under the terms of most managed care plans, the patient must contact his or her PCP before he or she receives are form any other health care provider (exept in the case of an emergency). Because the PCP is required to monitor and administer the health care of the plan's patients, the PCP is often referred to as the "Gatekeeper" of managed care.
The condition considered to be the major health problem for the patient for the submitted claim. OUTPATIENT
Initial identification of the condition or chief complaint for which the patient is treated for outpatient medical care
A condidtion established after study that is chiefly responsible for the admission of the patient to the hospital
The main service performed for the condition listed as the principal diagnosis for a hospital inpatient.
Privacy Officer, Privacy Official (PO)
An individual designated ot help the provider remain in compliance by setting policies and procedures in place, and by training and managing the staff regarding HIPAA and patient rights; usually the contact person for questions and complaints.
Data related to the treatment and progress of the patient that can be released only when written authorization of the patient or guardian is obtained.
problem focused (PF)
A phrase used to describe a type of medical decision making when a patient is seen for an E/M service
The services the doctor provides to a patient are called procedures that are identified by a procedure code number. Typical procedures include office visits, injections, radiographs, appendectomy sutures, and other services.
procedure code numbers
Five-digit numeric codes that describe each serice the physician renders to a patient
A chronological listing of all procedures and associated diagnosis for the account.
professional component (PC)
That portion of a test or procedure (containing both a professional and technical component) which the physician performs
A discount or exemption from charges given to certain people at the discretion of the physician rendering the service. It is rarely used in current medicine
Professional Review Organization
Organization that focuses on the evaluation of nursing care provided in a health care setting. The quality, effectiveness, and appropriateness of nursing care for the client are the foci of evaluation.
A state service organization to assist children younger than 21 years of age who have conditions leading to health problems.
recent approach that attempts to prevent development of allergies. Someone who is known to be predisposed to the development of allergies is vaccinated shortly after birth.
The process of going over financial documents before billing is submitted to the insurance company to determine documentation deficiencies and errors
Protected Health Information
any information that identifies an individual and describes his health status, age, sex, ethnicity, or other demographic information
Protected Health Information (PHI)
Is an information about health status, provision of health care, or payment for health care that can be linked to an individual. This is interpreted rather broadly and includes any part of a patient's medical record or payment history.
provider sponsored organization;skips insurance company middleman and contracts directly with patient
Resource Based Relative Value Scale, Under this schedule a procedures relative value is the sum total of three elements. 1 work 2 overhead 3 malpractice. Payments are determined by multiplying a code's relative value by a constant dollar amount called the conversion factor ( multiplier ).
A charge is considered reasonable if it is deemed acceptable after peer review even though it does not meet the customary or prevailing criteria. This includes unusual curcumstances or complications requiring additional time, skill, or experience in connection with a particular service or procedure. In Medicare, the amount on which payment is based for participating physicians
Referring doctor file
This is a database file which contains all pertinent information about health care providers who refer their patients to your practice. This same file is also used by the PCP to refer their patients for further evauation or specialized treatment
A physician who sends the patient for testing or treatment noted on the insurance claim when it is submitted by the physician performing the service
Reviews health-related claims to determine the medical necessity for procedures or services performed before payment (reimbursement) is made to the provider.
relative value studies (RVS)
A list of procedure codes for professional serivces and peocedures that are assigned unit values that indicate the relative value of one procedure over another
relative value unit (RVU)
A monetary value assigned to each service on the basis of the amount of physician work, proctice expenses, and cost of professional liability insurance. There three RVUs are then adjusted according to geographic area and used in a formula to determine Medicare fees
A physician who has finished medical school and is performing one or more years of training in a specialty area on the job at a hospital (medical center)
resource-based relative value scale (RBRVS)
A system that ranks physician services by units and provides a formula to determine a Medicare fee schedule
an employer is vicariously liable for the behavior of an employee working within his or her scope of employment
The process of going over financial documents after billing an insurance carrier to determine documentation deficiencies and errors
review of systems (ROS)
An inventory of body systems obtained trough a series of questions used to identify signs or symptoms that the patient might be experiencing or has experienced
A reason subsequent to the primary diagnosis for an office or hospital encounter that may contribute to the condition or define the need for a higher lever of care but is not the underlying cause. There may be more than one secondary diagnosis
This is the insurance company that is billed for any remaining charges (minus copayments and deductibles) after the primary insurance company has been billed . It is not uncommon for patients to have secondary and sometimes even tertiary insurance coverage.
A debt (an amount owed) in which a debtor pledges certain property (collateral), in a written security agreement, to the repayment of the debt
An individual responsible for overseeing privacy policies and procedure and managing the organization's information security program
Under HIPAA, regulations related to the security of electronic protected health information that, along with regulations, related to electronic transactions and code sets, privacy, and enforcement, compose the Administrative Simplification provisions.
senior billing representative
The most experienced individual who processes health insurance claims in accordance with legal, professional, and insurance company guidelines and regulations and oversees medical billing specialists and representatives
A symbol used with a diagnostic code in ICD-9CM, Volume 2, Alphabetic Index, indiicating the code may never be sequenced as the principal diagnosis
a basis for comparison, a reference point against which other things can be evaluated; "they set the measure for all subsequent work"
State Disability Insurance (SDI)
Insurance that covers off-the-job injury or sickness and is paid for by deductions from a person's paycheck. This program is administered by a state agency.
if a state's privacy laws are stricter than HIPAA privacy standards, the state laws take precedence
If the patient's service are more than a certain amount, the physician can begin asking the patient to pay fee for service
Phrase used to describe a type of medical decision making when a patient is seen for an E/M service
Under penalty. A writ that commands a witness to appear at trial or other proceeding and give testimony
subpoena duces tecum
In his possession. A subpoena that required the appearance of a witness with his or her records. Sometimes the judge permits the mailing of records and it is not necessary for the physician to appear in court
The contract holder covered by an insurance program or managed care plan, who either has coverage through his or her place of employment or has purchased coverage directly from the plan or affiliate. This term is used primarily in Blue Cross and Blue Shield plans.
This term has two meanings; first, it refers to a person or organization who purchases the insurance and pays the premiums, and second, the person whose employment makes him or her eligible for membership in the plan.
A highly customizable form used by medical practitioners and clinicians that can be quickly completed and submitted by the patient to an insurance company or employer for reimbursement.
Support file maintenance
one of several selections on the file maintenance menu windows. When chosen, the option allows the user to add or modify a variety of files that directly support essential needs of the practice such as procedure code file.
Surgical procedure code numbers include the operation; local infiltration, digital blocl, or topical anesthesia; and normal, uncomplicated postoperatvice care. This is referred to as a PACKAGE, and one fee covers the whole package
Another name for a symptom complex (a set of complex signs, symptoms, or other manifestations resulting from a common cause or appearing in combination, presenting a distinct clinical picture of a disease or inherited abnormally)
A physician who is responsible for training and supervising medical students, interns, or residents and who takes them to the bedsides of patients in a teaching hospital to review course and treatment
technical component (TC)
Portion of a test or procedure (containing both a technical and a professional component) that pertains to the use of the equipment and the operator who performs it
The Civilian Health and Medical Program of the Department of Veterans Affairs (CHAMPVA)
a program for veterans with total, permanent, service-connected disabilities or surviving spouses and dependents of veterans who died of service-connected disabilities
Under HIPAA a structured set of data transmitted between two parties to carry out financial or administrative activities related to health care in medical billing program a financial exchange that is recorded such as a patients copayment or deposit of funds into the providers bank account.
Review of transfers to different areas of the same hospital that are exempted from prospective payment
Trial Daily Report
A function of the Daily Report selection of the Report menu, the Trial Daily Report allows the practice the ability to verify or correct the daily financial data entries before performing a Daily Close.
A three-option managed health care program offered to spouses and dependents of service personnel with uniform benefits and fees implemented nationwide by the federal government
Type of Service (TOS)
This is a series of standardized codes that indicate the type of service performed for the patient (e.g. Medical Care, Surgery). These codes are maintained in the support files of the system for ease of use and access
Paper hospital claim, formerly a Medicare-required Part A (hospital) for; also known as the CMS-1450 (UB-04)
Uniform Hospital Discharge Data Set-- 1974 standard for collecting data for Medicare/Medicaid programs
The practice of using numerous CPT codes to identify procedures normally covered by a single code; also known as ITEMIZING
conditions can only be coded to the highest degree of certainty. Don't code for:
Unemployment Compensation Disability (UCD)
Insurance that covers off-the-job injury or sickness and is paid for by deductions from a person's paycheck. This program is administered by a state agency.
The sharing, employment application, utilization, examination, or analysis of individually identifiable health information (IIHI) within an organization that holds such information
usual, cutomary, and reasonable (UCR)
A method used by insurance companies to establish their fee schedules in which three fees are considered in calculating payment: (1)the usual fee is the fee typincally submitted by the physician (2)The customary fee falls within the range of usual fees chaged by providers of similar training in a geographic area (3) the reasonable fee feets the aformentioned criteria or is considered justifiable because of special curcumstances.
Audit of health-care use and charges to identify which benefits are used and to make certain that care is necessary and costs are in line
A subclassification of ICD-9-CM coding used to identify health care encounters that occur for reasons other than illness or injury and to identify patients whose injury or illness is influenced by special circumstances or problems
Veterans Affairs (VA) outpatient clinic
A facility where medical and dental services are rendered to a veteran who has a service-related disability
Workers' compensation (WC) insurance
A contract that insures a person against on-the-job injury or illness. The employer pays the premium for his or her employees
This refers to a patient who is accommodated into the practice's appointment schedule, rather than having a scheduled appt. If a patient brings her child with her to the doctors during her normally scheduled appt because her child is ill, and encouter form will need to be created for that child. However, because the woucher numbers on encounter forms are generally preassigned to the patients scheduled to see the physicians that day, an encounter form with a sequentially assigned voucher number will not be available.