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Acute Care Facility
A health care facility that provides continuous professional medical care to patients with acute conditions or illnesses.
A part of HIPAA that requires the healthcare industry to use certain standards for electronic data exchange. Under Title II.
Ambulatory Surgical Center
A Health care facility providing surgical services only on an outpatient basis.
Centers for Medicare and Medicaid Services
Federal agency within the Dept. of Health and Human Services and runs Medicare, Medicaid Clinical Laboratories. Formerly Heath Care Financing Administration.
The portion of charges that an insured person must pay for health care services after payment of the deductible amount; usually stated as a percentage
Consumer Driven Health Plan (CDHP)
Type of medical insurance that combines a high-deductible health plan with a medical savings plan which covers some out-of-pocket expenses.
The method medicare initially used to pay health care facilities for services furnished to beneficiaries. payment was based on providers cost as reported annually.
A health plan, a healthcare clearinghouse, or a healthcare provider who transmits any health information in electronic form in connection with a transaction
An amount that an insured person must pay, usually on an annual basis, for health care services before a health plan's payment begins.
De-indentified health information
Medical data from which individual identifiers have been removed; also known as a redacted or blinded record.
Health Insurance Portability and Accountability Act (HIPPA)
Federal act that set forth the guidelines for standardizing the electronic data interchange of administrative and financial transactions, exposing fraud and abuse in government programs, and protecting the security and privacy of health information.
Health Maintenance Organization (HMO)
A managed health care system in which providers agree to offer health care to the organization's members for fixed periodic payments from the plan; usually members must receive medical services only from the plan's providers.
HIPPA Electronic Health Care Transactions and Code Sets (TCS)
HIPPA stsndards governing the electronic exchange of health information using standard formats and standard code sets.
HIPPA Privacy Rule
Law that regulates the use and disclosure of patient's protected health information (PHI)
HIPPA Security Rule
Security standards that require appropriate administrative, physical and technical safeguards to protect the privacy of protected health information against unintended disclosure through breach of security.
Home Health Agency (HHA)
Healthcare provider licensed under state or local law that provides skilled nursing and other therapeutic services (visiting nurses associations and hospice based home care programs)
Care for the terminally ill that emphasizes emotional support and coping with pain and death
Insurance company's agreement to reimburse a policy holder a predetermined amount for covered losses
intermediate Care Facility( ICF)
A health care facility providing care to patients who do not require professional medical or skilled nursing services.
Minimum Necessary Standard
Principle that individually identifiable health information should be disclosed only to the extent needed to support the purpose of the disclosure.
A person who receives health care in a medical setting without overnight admission; the length of the stay is generally less than 23 hours.
A payment method that reimburses a set rate for each inpatient day according to the case category.
Preferred Provider Organization(PPO)
A managed care organization structured as a network of health care providers who agree to perform services for plan members at discounted fees; usually, plan members can receive services from non-network providers for a higher charge.
Method of payment that sets a predetermined rate for each category of patient illness or for services provided for a standard type of case.
Protected health Information (PHI)
Individually identifiable health information that is transmitted or maintained by electronic media.
A person or entity that supplies medical or health services and bills for or is paid for the services in the normal course of business. A provider may be a professional member of the health care team, such as a physician, or a facility, such as a hospital or skilled nursing home.
Skilled Nursing Facility (SNF)
A health care facility that provides skilled nursing care and related services for patients who need nursing care or rehabilitation services
Treatment, Payment and Health care Operations (TPO)
Under HIPPA, the rule that patient's protected health information may be shared without authorization for the purposes of treatment, payment and operations.
An amount (positive or negative) entered in a patient billing program to change a patient's account balance
Fees for service other than room and board provided during a patient's hospitalization, such as anesthesia, pharmacy,supplies, and therapies.
The clinician primarily responsible for the care of the patient from the hospital admission through discharge or transfer.
A billing system feature that stores all charges for particular servies; when a service is provided, the system automatically bills all of its component charges.
Release of a patient from a facility, including those who have died and those who are transferred to another facility.
DNFB (discharged/not final bill) list
A hospital list containing the accounts of patients who have been discharged but whose claoms have not yet been transmitted to payers used by hospitals to measure the timeliness of their billing process.
electronic health record (EHR) system
A running collection of health information that provides immediate electronic access by authorized users.
A listing of the services, procedures, and revenue departments for collecting charges for a patient's visit; also called a charge ticket or superbill
explanation of benefits (EOB)
A document from a payer sent to a patient that shows how the amount of a benefit was determined.
Surgical procedures which, due to their invasive nature and the need for a twenty-four-hour recovery time, Medicare has designated will only be paid for if performed on an inpatient basis.
Payment criterion of payers that requires medical treatments to be appropriate and provided in accordance with generally accepted standards of medical practice.
Prior authorization from a payer that must be received before elective hospital-based or out-patient surgeries are covered; also preauthorization or authorization
The work of physicians such as surgeons, anesthesiologists, and patients' private doctors that is billed to patients by the physician rather then by the facility.
Quality Improvement Organization (QIO)
An organization hired by CMS to determine the medical necessity, appropriateness, and quality of patients' treatments; formerly Peer Review Organization (PRO)
remittance advice (RA)
The document sent by a payer to a provider that itemizes the patients, claims, and explanations for payment decisions included in the attached payment
The total of the costs of all supplies that are customarily used to provide the service; items included in the routine charge should not be billed separately
A patient's balance that the billing department has determined cannot be collected from the debtor and is written off.
A formal review to determine the appropriateness and usage of hospital-based health care services delivered to a member of a plan; may be conducted on a prospective, concurrent, or retrospective basis.
Advance Beneficiary Notice Of Noncovearge (ABN)
A notice that a facility should give a Medicare beneficiary to sign if Medicare will probably not pay for the services that the patient will receive; used to establish the patient's responsibility for payment..
The method used by medicare to measure a beneficiary's use of hospital and skilled nursing facility services.
(1) An insurance company; (2) a private company that has a contract with Medicare to process Medicare Part B bills
The amount of a patient's payment that is applied to a patient's deductible for a particular health plan
Civilian Health and Medical Program of the Veterans Administration (CHAMPVA)
The Civilian Health and Medical Program of Veterans Administration (Dept of Veterans Affairs) that share health care costs for families of veterans w/100% service-connected disability and the serviving spouses and children of veterans who die
Under Medicare Part A, for the 61st thru 90th day of hospilization in a benefit period, a daily amount (equal to 25% of the inpatient hospital deductible) for which the beneficiary is responsible
coordination of benefits (COB)
A clause in an insurance policy that explains how the policy will pay if more than one insurance policy applies to the claim.
durable medical equipment (DME)
Medical term for reusable physical supplies such as wheelchairs, potty chairs, hospital beds, etc.
employer group health plans (EGHP's)
A health plan offered by an employer of more than 20 people that provide medical benefits to employees, former employees, and their families.
end stage renal disease (ESRD)
Permanent kidney failure that requires a regular course of dialysis or kidney transplantation to maintain life.
excluded (noncovered) services
Medical care that is not covered by a health plan; in medicare, most preventive care and services that are not medically necessary are excluded.
Hospital-Issued Notice of Noncoverage (HINN)
A hospital notice to a beneficiary that is provided to inform the patient that the inpatient care the beneficiary is receiving or about to receive is not covered.
lifetime reserve days (LSRD)
The 60 days of reduced-cost hospitalization coverage that medicare benefits allow a patient for use after a benefit period is used up; for each lifetime reserve day, Medicare pays all covered costs except a daily coinsurance.
local coverage determinations (LCDs)
Notice sent to providers with detailed and updated information about the coding and medical necessity of a specific Medicare service.
A federal and state assistance program that pays for health care services for people who cannot afford them
Medicare Administrative contractor (MAC)
New entities assigned by CMS to replace FIs and carriers that currently administer the Medicare Part A&B programs; fifteen of them will process and pay Medicare part A & B claims within specified multistate jurisdictions.
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 Secondary Payer (MSP)
Under MSP, Medicare does not pay for services if payment ha been made or can reasonably be expected to be made by another payer.
Medicare Summary Notice (MSN)
The explanaton of Part A and Part B benefits supplied by Medicare to beneficiaries in the Original Medicare Plan.
Medicare supplemental insurance sold by private companies to original medicare plan beneficiaries to fill the gaps of coverage.
national coverage determinations (NCDs)
Medicare plicy stating whether & under what circumstances a service is covered by Medicare program
The insurance carrier that pays benefits first when a patient is covered by more than one medical plan
Insurance plan that pays benefits after the primary payer when a patient is covered by more than one medical insurance plan
An insurance plan, such as Medigap that provides benefits for services which are not normally covered by a primary plan
The Civilian Health and Medical Program of the Uniformed Services that serves spouses and children of active duty service members, military retirees and their families, some former spouses, and survivors of deceased military members, formerly CHAMPUS.
A state or federal plan that covers medical care and other benefits for employees who suffer accidental injury or become ill as a result of employment.
Alphabetic and/or numeric representations for data; medical code sets are systems of medical terms that are required for HIPAA transactions; administrative (non-medical) code sets, such as taxonomy codes and zipcodes are also used in HIPAA transactions.
Admitted patient's coexisting condition that affects the length of the hospital stay of the course of treatment.
Under the CPT procedural coding system, most surgical codes represent groups of procedures that include all routine elements, such as the operation, local anesthesia, and routine follow-up care. Facilities report these codes to charge for their service associated with the procedure.
Condition an admitted patient develops after surgey or treatment that affects the length of hospital stay of the course of further treatment.
Typographic techniques or standard practices that provide visual guidelines for understanding printed material.
A comparison or map of the codes for the same or similar classifications under two coding systems; it serves as a guide for selecting the closest match.
Current Procedural Terminology (CPT)
Publication of the American Medical Association containing the HIPAA-mandated standardized classification system for reporting medical procedures and services.
Health Care Common Procedure Coding System (HCPCS)
Procedure codes for Medicare claims, made up of CPT codes (Level I) and national codes (Level II)
ICD-9 Official Guidelines for Coding and Reporting
Written by NCHS (National Center for Health Statistics) and CMS and approved by the cooperating parties, it provides rules for selecting and sequencing diagnosis codes in both the inpatient and the outpatient environments.
International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM
A publication that classifies diseases and injuries according to a system developed by the World Health Organization and modified for use in the United States
Two-digit character that is appended to a CPT code to report special circumstances involved with a procedure or service
patient's reason for visit
For unscheduled outpatient encounter, such as an emergency department visit, the condition the patient states is responsible for the hospital visit.
present on admission (POA)
Indicator required by Medicare that identifies whether a coded condition was present at time of hospital admission.
A diagnosis that represents the patient's major illness or condition for an encounter
The condition that after study is established as chiefly responsible for a patient's admission to a hospital
technical component (TC)
The technician's work and the equipment and supplies used in performing a procedure; billable by the facility rather than the physician.
an alphanumeric code in the ICD-9-CM that identifies factors that influence health status and encounters that are not due to illness or injury.
Improper billing practices, such as billing for a noncovered service or misusing codes on a claim.
Under the Medicare Inpatient Prospective Payment System , a number which is calculated based on a hospital's costs, wage index, and location, and is used in determining what a hospital will be paid for a particular DRG
To compare something against a standard, such as an activity looked at in an audit that is compared against a HIPAA standard.
case mix index (CMI)
The mix of patients treated in a facility based on a patient classification system such as DRG's.
CCI column 1/column 2 code pair edits
Medicare code edit under which CPT codes in column 2 will not be paid if reported for the same patient on the same day of service by the same provider as the column 1 code
CCI mutually exclusive edits
CCI edits for codes for services that could not have reasonably been done during a single patient encounter, so both will not be paid by Medicare. Only the lower-paid code is reimbursed.
CC and MCC lists
Medicare lists containing the ICD-9-CM codes for the secondary diagnoses that are considered significant acute diseases, or other chronic conditions that have an effect on the use of hospital resources and can therefore be assigned as CCs or MCCs inder the MS-DRG system.
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.
compliance program guidance
Guidance issued by the office of the Inspector General (OIG) for a specific covered entity with descriptions of what that entity should include in thier compliance plan in order to uncover and correct compliance problems connected with HIPAA violations, fraud, and abuse.
Correct Coding Initiative (CCI)
Medicare's national coding policy, under which mutually exclusive services and comprehensive/component edits are set up as the basis for computerized claim review.
diagnosis-related groups (DRGs)
A system of analyzing conditions and treatments for similar groups of patients used to establish Medicare fees for hospital inpatient services; patients are classified by their principal diagnosis, surgical procedure, age, and other factors.
Under the medicare inpatient prospective payment system, national relative amount assigned to each DRG that represents the average resources required to care for cases in that particular DRG relative to the average resources used to treat cases in all DRGs
A formal examination in which an agency, such as the OIG, selects certain records for review
A publication of the Office of the Federal Register (OFR), which is responsible for publishing federal laws, presidential documents, administrative regulations and notices, and descriptions of federal organizations, programs, and activities.
Under Medicare, fraud is an intentional misrepresentation that is known to be false and could result in unauthorized benefit, such as claiming costs for non-covered items and intentionally double billing for the same services.
A secondary condition developed during a hospital stay; for certain of these conditions, CMS will not assign a higher paying DRG for treatment unless it is documented as present on admission
Inpatient Prospective Payment System (IPPS)
Medicare payment system for hospital services; based on diagnosis-related groups (DRGs)
Self-audit conducted by a staff member or consultant as a routine check for compliance with reporting regulations
major CC (MCC)
Secondary diagnosis classified by the Inpatient Prospective payment system as severe when assigning the DRGs
major diagnostic category (MDC)
Under the inpatient prospective payment system, a classification of principal diagnoses based on groups of patients who are similar clinically and who require similar hospital resources
Medicare Common Working File (CWF)
CMS databases containing the histories of Medicare beneficiaries used by FIs and carriers to check eligibility, use of benefits, and other insurance coverage
A payer's determination that a claim is not ready for processing; the claim is returned to the sender for revision
The Medicare-required Part B (physician) claim form; also known as the Universal Health Insurance Claim form and formerly called the HCFA-1500
The Medicare-required Part A (hospital) claim form; also known as the UB-04 and formerly called the HCFA-1450
A character or symbol used in printed material to visually separate one group of words or values from another.
The fourth digit of a revenue code defines the detail description of the code; the general classification is indicated by a zero (such as 0430, the general classification for Occupational Therapy) and the detail-level codes- the numbers 1 through 9- represent different details for that particular revenue code (such as 0443 to report a group rate for Occupational Therapy)
The HIPAA (ASC X 12 N) professional claim transaction, used to file physicians' claims, The electronic claim form used to bill for a physician's services.
form locator (FL)
A numeric indicator that directs the reader to a specific box or space on a data collection form; there are 81 form locators on the UB-04 claim form
Generic term for the HIPAA X12N 837 institutional or professional health care claim transaction.
nsurance claim submitted to a payer as a printed or typed form; it can be an optical character recogniton (OCR) claim that is designed to be read by a scanner or a claim that is converted to electronic format by the payer
The uniform bill introduced in 2004 by the National Uniform Billing Committee (NUBC) for submitting Medicare Part A inpatient and outpatient claims to Medicare fiscal intermediaries; used by most other payers as well because it meets the billing requirements of many types of provider facilities. Officially replaced its predecessor, the UB-92, on March 1, 2007
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