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Career Step IP/OP Medical Billing and Coding


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

Account retrieval

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 (A/R)

The total amount of money owed for professional services rendered

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.


gotten through environmental forces


A medical condition that runs a short but relatively severe course

adverse effect

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

age analysis

The procedure of systematically arranging the accounts receivable, by age, from the date of service


American Hospital Association; American Heart Association


American Health Information Management Association

Ailment Detail

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


deviation from the normal order, form, or rule; abnormality


ambulatory payment classifications-- A system of outpatient hospital reimbursement based on procedures rather than diagnoses.


person applying for insurance coverage.


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

association (IPA)

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.


having no symptoms of illness or disease


having no symptoms of illness or disease

attending physician

A medical staff member who is legally responsible for the care and treatment given to a patient


the process of giving someone permission to do or have something

Authorization Form

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

automatic stay

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 amount owed on a credit transaction; AKA: outstanding or unpaid balance


A condition under which a person or corporation is declared unable to pay debts

benign tumor

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


When coding surgical procedures, this term refers to both sides of the body

Blanket Contract

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

bundled codes

To group more than one component (service or procedure) into one CPT code

Business Associate

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.

Case Rate

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.

Cash Flow

The amount of actual money available to the practice at any given time


Charge Description Master--a hospital's list of the codes and charges for its services


Conversion Factor, a national dollar amount that is applied to all services paid on the basis of the Medicare Fee Schedule

Check register

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


A medical condition persisting over a long period of time

Chronic Disease

a disease that develops gradually and continues over a long period of time


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.

Code of Medical Ethics

A code of medical ethics written by Thomas Percival in 1803

Code Sequence

The correct order of diagnostic codes when submitting an insurance claim that affects maximum reimbursement.

Code Set

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

collection ratio

The relationship between the amount of money owed and the amount of money collected in reference to the doctor's accounts receivable

combination code

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

Comment field

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.

Communicable Disease

a disease that can be communicated from one person to another


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


acting according to certain accepted standards

Compliance Plan

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

comprehensive (C)

A term used to describe a level of history or physical examination

comprehensive code

A single procedural code that describes or covers two or more CPT component codes that are bundled together as one unit

concurrent care

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

Conditionally Renewable

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

Confidential communication

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


present at birth but not necessarily hereditary


the granting of permission by the patient for another person to perform an act.


Under the HIPAA Privacy rule, the patient gives consent to the use of his or her protected health information by the medical practice for purposes of treatment, payment, and operation of the health care practice. The patient does this by signing a consent form or signing an acknowledgment that they have received a copy of the office's privacy policy

Consent Form

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

consulting physician

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

conversion factor

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.

Cost Outlier

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

Covered Entity

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

credit card

A card issued by an organization and devised for the purpose of obtaining money, property, labor, or services on credit


A person to whom money is owed

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

customary fee

The amount that a physician usually charges most of her or his patients

cycle billing

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

Daily report

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 report that provides information on practice activities for a twenty four hour period

debit card

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 legal obligation to pay money


A person owing money


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.

Demographic Information

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.

detailed (D)

A term used to describe a level of history or physical examination

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

DRG Creep

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

dun messaages

A message or phrase to inform or remind a patient about a delinquent account

E codes

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


to modify a record

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.

elective surgery

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

Electronic Media

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 signature

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.

emancipated minor

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


A willful act by an employee of taking possession of an employer's money

emergency care

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

encounter form

A form that is used to record information about the procedures performed during a patient's visit

Encounter form

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

established patient

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

estate administrator

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

estate executor

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)


The cause of disease; the study of the cause of a disease


standards of professional behavior that physicians use for conduct with other physicians


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

expanded problem focused (EPF)

A phrase used to describe a level of history or physical examination

expressed contract

a written or oral agreement in which all terms are explicitly stated


To carry forward the balance of an individual financial accounting record

external audit

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

facsimile (FAX)

An electronic process for transmitting graphic and written documents over telephone lines; AKA fax

Family History

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

Federal Register

An official document, published every weekday, which lists the new and proposed regulations of executive departments and regulatory agencies.

fee schedule

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

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