coding practices that lead to improper reimbursement by error because they do not meet medical necessity, ex. changing diagnosis to be covered by insurance
an examination process the healthcare facility goes through to evaluate the facilities policies, procedures, and performance to meet higher standards.
Act/ Law/ Statute
Legislation passed through Congress and signed by President or passed over his veto
The amount the provider charges for medical services or supplies. Not always paid in full.
Health care services not covered by Medicare and are offered through the Medicare Advantage Organization for no additional premium. The benefits must equal the ACR (Adjusted Community Rating)
Adjusted Average Per Capita Cost (AAPCC)
Estimate of how much Medicare will spend in a year for an average beneficiary
Administrative Code Sets
Non medical code sets that characterize a general business situation rather than a medical condition.
Medicare, Medicaid, CMS refer to this as their expenses to have the program, operating expenses, program management, etc.
Health insurance information stored in automated information system about enrollment, eligibility, claims, etc.
Administrative Law Judge (ALJ)
hearing officer who presides over appeal conflicts between providers or beneficiaries, and Medicare contractors (MAC's)
Part of HIPAA authorizing HHS (Health and Human Services) to 1. adopt standards for transactions & code sets; 2. adopt standard identifiers for health plans; 3. adopt standards to protect security & privacy of personally identifiable health information.
Administrative Simplification Act
Signed 12/17/01 allows HHS (Health & Human Services) to exclude providers from Medicare for HIPAA non-compliance of electronic claims and prohibit paper claims except in certain situations
The date the patient was admitted for inpatient care, outpatient, or start of care.For hospice, enter effective date of election of hospice benefits.
The doctor responsible for admitting a patient to the hospital or other inpatient health facility
Advance Beneficiary Notification (ABN)
A notice from provider to patient that Medicare may deny payment. Patient must sign before services are provider, otherwise patient is not responsible if Medicare does not cover.
Statement written by patient on how they want medical decisions to be made. May include a Living Will or Durable Power of Attorney for healthcare.
Ambulatory Care Sensitive Conditions (ACSC)
Medical condtions that if treated immediatly and managed properly should not require hospitalization.
Ambulatory Payment Classification (APC)
Medicare's outpatient prospective payment system in which services are grouped based on the resources needed and payment is fixed within each group
Ambulatory Surgery Center (ASC)
Outpatient surgery center not located in the hospital. Patient's may stay a few hours up to 1 night.
American Hospital Association (AHA)
Represents concerns of instituitional providers. They host the National Uniform Billing Committee (NUBC) which consults under HIPAA
American Medical Association (AMA)
Professional organization maintains CPT code sets, secretariat to National Uniform Claim Committee (NUCC) which consults under HIPAA. ASC payment group rate.
American Society of Health Informatics Managers, Inc. is a non-profit group of computer professionals that specialize in health information technology (HIT). They are certified through Certified Health Informatics System Professionals (CHISP)
Professional services by a hospital or inpatient facility. Xrays, drugs, labs, etc.
Licensed physician who certifies the patient services via medical necessity and is primarily responsible for the patient's medical care and treatment.
Automated Claim Review
Claim review and etermination via system edits and don't require human intervention
Episode of care within hospitals & skilled nursing facilities (SNF). Begins on admission and ends 60 days after care has ended
Doctor specializing in certain area of medicine and who passes an advanced exam. Primary care and specialists can both be board certified
Someone performs a function on behalf of a covered entity but is not part of the covered entity's workforce, outside business manager.
Specified amount of money is paid to a health plan or doctor regardless of the services rendered in that period. One lump sum.
Written plan of services patient will receive to ensure the patient's best care physically, mentally & socially
Someone who cares for a patient who is ill, disabled, or aged. Can be relatives, friends or someone who is paid.
Physician, nurse, or other person tracks use of facilities and resources of a patient to be sure they are receiving the care they need.
Case Mix Index
The average Diagnostic Related Groups (DRG) relative weight for all Medicare admissions
Serious and costly health problem that could be life-threatening or cause disability. Costs can cause patient financial hardship.
The highest amount a beneficiary is required to pay out of pocket during a certain period of time for certain covered charges.
Center for Disease Control and Prevention (CDC)
Organization that protects public health through monitoring disease trends, investigation outbreaks, implementing illness, and injury control.
Center for Medicare & Medicaid Services (CMS)
The Heath & Human Services (HHS) agency responsible for Medicare & parts of Medicaid. Maintains UB-04, oversight of HIPAA and maintains HCPCS code set & Medicare remittance advice (RA) remark codes. They promote higher quality care
the hospital passed a survey done by a state government agency. Medicare only covers hospital stays in hospitals that are certified or accredited.
Civilian Health and Medical Program (CHAMPUS)
Run by department of defense. Used to give medical care to active duty but now this is called TRICARE
Charge Description Master (CDM)
Electronic billing table where charge amounts are kept in a centralized place.
Request for payment for services or benefits received. Claims are called bills through Medicare Part A
Claim Adjustment Reason Codes
Identifies the reason for any difference in charge and payment. This code set is used in the X12 835 Claim Payment & Remittance Advice and the X12 837 Claim transactions and is maintained by Health Care Code Maintenance Committee
Claim Status Code
Identifies the status of a claim. This code set is used in the X12N 277 Claim Status Inquiry and Response transactions and is mainted by the Health Care Code Maintenance Committee
State survey agency who participates in Medicare surveys and certification process. ex. private physician consulting with the State Agency (SA) or CMS regional office.
Community Mental Health Services
Facility provides outpatient services for children, elderly, chronically ill, & residents discharged from inpatient treatment at a mental health facility. 24 hour day emergency care, partial hospitalization or psychosocial rehab, & screening for admission to inpatient facility.
Comprehensive Inpatient Rehabilitation Facility
Inpatient rehabilitation to patient's with physical disabilities.
A payment made by Medicare in which another payer is responsible. Ex,, Auto is in litigation, if they pay, then Medicare will be reimbursed
Consolidated Omnibus Budget Recondiliation Act (COBRA)
A law that helps keep people covered by employer groups after coverage ended due to death of a spouse, losing a job, reduced hours, leaving voluntarily, or getting a divorce. The beneficiary may have to pay the premium however there is no administrative fee.
Coordination of Benefits
The process of determining which policy is first when a patient has 2 health care plans.
A period of time where the employer group health will pay first on the bill and Medicare will pay 2nd.
Ratio of cost of the program on an incurrerd basis during a year to the taxable payroll for the year.
Report required from providers on an annual basis in order to make proper determination of amounts payable under Medicare program.
A health service or item that is included in the health plan and paid for partially or in full.
Under HIPAA, this is a health plan, clearninghouse, or provider who transmits any health information in electronic format in connection with HIPAA transaction.
Services for which a carrier pays as defined and limited by coverage or statute. physician care, outpatient hospitals, diagnostic tests, DME, ambulance, and other health services.
Critical Access Hospital
Small facility that gives limited outpatient and inpatient hospital services in rural areas
Current Dental Terminology (CDT)
Medical code set of dental procedures maintained and copyrighted by American Dental Association (ADA) and adopted by the secretary of Health and Human Services (HHS) as a standard for reporting dental services and transactions
Current Procedural Terminology (CPT)
Medical code set of physician and other services, maintained and copyrighted by American Medical Association (AMA) and adopted as a standard for reporting physician and other services.
Non-skilled personal care attendance (PCA) to help with Activities of Daily Living (ADL) like eating, bathing, etc.
Custodial Care Facility
Provides room and board, and other personal assistance on a long term basis but does not include medical care.
An annual amount or out of pocket expense the subscriber must pay either individually or per family.
The amount a beneficiary must pay for health care before Medicare begins to pay, either Part A or Part B. These amounts vary every year.
Describes the characteristics of the enrollee populations within a managed care entity, age, sex, race, etc
Projects and contracts that CMS has signed with various health care organizations. Used to evaluate the effects and impact of various health care initiatives and the cost of implications to the public.
Department of Health and Human Services (DHHS)
Administers many of the social programs at the federal level dealing with the health and welfare of citizens of the United States. (Parent of CMS)
Designated Code Set
Medical code set or administrative code set required to be used by the adopted implementation specification for standard transaction
Disease, signs, or symptoms that indicate the patient's condition and support medical necessity for services provided.
Code within the ICD-9 that explains the reason for the medical encounter and for underlying conditions that contribute to the patient's care and effect treatment receive or length of stay.
Diagnosis Related Groups (DRG's)
Classification system that groups patients according to diagnosis, type of treatment, age and other relevant criteria. Under the prospective payment system (PPS), hospitals are paid a set fee for treating patient's in a DRG category.
Process of deciding what a patient needs to move smoothly from one level of care to another, ex. hospital to nursing home.
Disproportionate Share Hospital
Large share of low income patients. States subside under Medicaid and Medicare inpatient payments are higher.
Reduce the value and code of a claim when documentation does not support the level of service billed by provider.
Durable Medical Equipment (DME)
Medical Equipment ordered by a doctor for use in the home. Must be reusable, ex. walker, wheelchair.
Durable Medical Equipment Regional Carrier (DMERC)
A private company that contracts with Medicare to pay bills for durable medical equipment (DME)
Electronic Data Interchange (EDI)
Exchange of transactions from one computer to another in a standard format
A software tool for accepting an EDI transmission and converting data into another format
Logic within Standard Claims Processing System that selects claim data and determines the payment
Emergency Room (Hospital)
Part of hospital where emergency diagnosis and treatment of illness is provided 24 hours a day
Emergency Medical Treatment and Active Labor Act (EMTALA)
Requires Medicare participating hospitals provide appropriate screening examination to any patient that requests such an exam. The patient must be stabilized before transferring care.
Detailed data about the patients services provided by a managed care entity. Similiar to that of a claim form. Sometimes called "shadow claims"
Episode of Care
Health care services given during a certain period of time, usually during a hospital stay.
Explanation of Benefits EOB(Remittance Advise (RA)- Medicare)
Explanation from insurance with details of payment, denials, etc.
Insurance companies pay less and charge a cost for the facility where services where rendered.
Daily publication for rules of federal agencies and organizations as well as executive orders and other presidential documents.
A private company that contracts with Medicare to pay Part A and some Part B claims. (Also called Intermediary)
Listing of prescription medications that are approved for use and/or covered by plans
Fraud and Abuse
Fraud is to purposely bill services not given or for higher reimbursement than give. Abuse is payment for services billed by mistake but should not have been paid for.
Freedom of Information Act (FOIA)
Law requiring US government to give information to the public when it receives a written request, only records of executive branch. NOT congress, federal courts, state or local governments or private groups.
Designation that all standards have been met and approved by Center for Medicare and Medicaid Services (CMS) without any other actions.
Developed by appropriate groups to assist providers with decisions in specific clinical situations.
Health Care Clearinghouse
Public or private entity that processes data from nonstandard to standard and/or receives standard transactions from another entity to convert
Health Care Code Maintenance Committee
Administered by Blue Cross Blue Shield Association (BCBSA) maintains coding schemes used in X12 transactions and elsewhere. They include claim adjustment reason codes, claims status category codes and claim status codes.
Health Care Prepayment Plan (HCPPP)
Managed care organization that pays for all in network services after a monthly premium, deductible and copayment. Out of network services are payable by the patient.
Health Care Provider
Person trained and licensed to give health care and has a licensed place to treat patients. Doctors, nurses, or hospitals are examples.
Health Care Quality Improvement Program (HCQIP)
Supports mission of CMS to assure health security for beneficiaries and improving quality of care.
Health Employer Data and Information Set (HEDIS)
Set of standard performance measures that give you information about the quality of a health plan. Center for Medicare and Medicaid Services (CMS) collects HEDIS data for Medicare patients.
Health Insurance Association of America (HIAA)
Represents the interest of commercial health care insurers. Participates in HCPCS Level II code data sets.
Health Insurance Claim Number (HICN)
Number assigned to insurance carrier/ beneficiary identifying them as the insurance subscriber.
Health Common Procedural Coding System (HCPCS)
Medical code set that identifies health care procedures, equipment and supplies for claim submission purposes. Level I is Current Procedural Terminology (CPT) maintained by the AMA. Level II is alpha numeric identifying items not found in CPT and maintained by Center for Medicare and Medicaid Services (CMS) and Blue Cross Blue Shield Association (BCBSA) and the Health Insurance Association of American (HIAA)