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Understanding Hospital Billing and Coding Second Edition


The process by which an organization or agency performs an external review and grants recognition to a program of study or institution that meets certain predetermined standards.

Admitting Privileges

Granted to health care professionals to define what categories of patients can be seen by the professional along with the type of services and procedures that can be performed within the hospital.

Agency for Health Care Administration (AHCA)

A regulatory agency in Florida created in 1992 under the Health Care Reform Act fo 1992 for the purpose of ensuring that efficient quality health care services are accessible to all Floridians.

American Academy of Professional Coders (AAPC)

National organization founded for the purpose of elevating medical coding standards by providig ongoing education, networking opportunities, certification, and recognition of health insurance billing and coding professionals.

American Health Information Management Association (AHIMA)

National organization founded for the purpose of setting national standards in health information management and certification and providing support to health information management professionals.

American Osteopathic Association (AOA)

An organization established in 1997 for the purpose of advancing the philosophy and practice of osteopathic medicine.

Centers for Medicare and Medicaid Services (CMS)

Agency under the Department of Health and Human Services that oversees the federal responsibilities for the Medicare and Medicaid programs.CMS was formerly known as the Health Care Financing Administration (HCFA).

Civil Monetary Penalties Law (CMPL)

A law passed in 1983 for the purpose of prosecuting cases of Medicare and Medicaid fraud. Conditions for Participation (COP)Conditions established for providers to participate in the Medicare program. Medicare's COP
contains CMS rules and regulations that govern the Medicare program. Providers of service are required to follow regulations outlined in the COP implemented under the Code of Federal Regulations, Title 42.

Consolidated Omnibus Budget Reconciliation Act(COBRA)

Legislation passed to prevent in appropriate transfer or discharge of patients from one facility to another, commonly referred to as "dumping."Continuing education units (CEUs)Credits earned by individuals when they attend an educational function. Organizations generally grant 1 CEU for each hour attended.


The process followed by hospitals and other organizations for evaluating physicians to determine whether they should be granted admitting privileges.

Department of Health (DOH)

Agency within each state that is involved in the state's health care initiatives, including promoting public health and health safety of all state residents through disease prevention and ensuring that quality medical care is provided.

Department of Health and Human Services (DHHS)

Federal department responsible for health issues, including controlling the rising cost of health care, the health and welfare of various populations, occupational safety, and income security plans.

Emergency Medical Treatment and Labor Act (EMTALA)

Legislation passed by Congress to ensure public access to emergency services regardless of ability to pay.

Federal False Claims Act

Legislation passed to prevent overuse of services and uncover fraudulent activities in the Medicare and Medicaid programs.

Federal Register

The official publication in which federal regulations and legal notices are published.

Health, Education, and Welfare (HEW)

A governmental agency formed for the purpose of addressing issues related to health, education, and welfare of the people of the United States.

Health Information Management (HIM)

A hospital department responsible for the organization, maintenance, production, storage, retention, dissemination, and security of patient information.

Health Insurance Portability and Accountability Act (HIPAA)

Legislation implemented in phases from 1996 to 2008 to address several issues: continuity of health insurance, prevention and detection of fraud and abuse, limited coverage, access to long-term care, simplification of the administration of health insurance standards for the claims process, and protection of the privacy of health information.

Joint Commission on Accreditation of Healthcare Organizations (JCAHO)

A national commission formed to evaluate and accredit health care organizations based on established standards of quality for operations and medical services.


Federal program administered at the state level established under Title XIX
of the SSA to provide healthcare benefits for medically indigent people.


Government program created under Title XVIII of the Social Security Act that provides health care benefits for medical services provided to individuals over age 65, the disabled, and other qualified individuals.

Occupational Safety and Health Administration (OSHA)

Agency under the Department of Labor created under the OSHA Act for the purpose of developing standards and conducting site visits to determine compliance with safety standards.

Office of the Inspector General (OIG)

A federal agency under the DHHS that is responsible for protecting the integrity of DHHS programs, such as Medicare and Medicaid.

Patient Self-Determination Act (PDSA)

Legislation passed in 1990 for the purpose of ensuring that individuals are informed of their rights regarding health care decisions. The act requires facilities to provide patients with information regarding a living will, durable power of attorney, and advanced directives.

Professional Standards Review Organization (PSRO)

Organizations that contract with Medicare to conduct reviews to determine the appropriateness and medical necessity of services provided. PSROs have full authority to deny reimbursement for health care services provides to Medicare patients if the services are deemed inappropriate.


American Association of Healthcare Administrative Management


American Academy of Professional Coders


Agency for Health Care Administration


American Health Information Management Association


American Osteopathic Association


Certified Coding Associate


Certified Coding Specialist


Certified Coding Specialist-Physician


Continuing education units


Civil Monetary Penalties Law


Centers for Medicare and Medicaid Services


Consolidation Omnibus Budget Reconciliation Act


Conditions of Participation


Certified Professional Coder


Certified Professional Coder-Apprentice


Certified Professional Coder-Hospital


Department of Health and Human Services


Department of Health


Emergency Medical Treatment and Labor Act


Department of Health, Education, and Welfare


Health Information Management


Health Insurance Portability and Accountability Act


Occupational Safety and HealthAdministration


Office of Inspector General


Primary care physician


Patient Financial Services


Patient Self-Determination Act


Professional Standards Review Organization


Prospective Payment System


Registered Health Information Technician

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