Primary Care Providers - curative Billing Terms and curative Coding Terminology.
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Those in medical billing and coding careers have a terminology of unique terms and abbreviations. Below are some of the more oftentimes used medical Billing terms and acronyms. Also included is some medical coding terminology.
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Aging - Refers to the unpaid guarnatee claims or outpatient balances that are due past 30 days. Most medical billing software's have the quality to generate a isolate record for guarnatee aging and outpatient aging. These reports typically list balances by 30, 60, 90, and 120 day increments.
Appeal - When an guarnatee plan does not pay for treatment, an motion (either by the provider or patient) is the process of formally objecting this judgment. The insurer may want supplementary documentation.
Applied to Deductible - Typically seen on the outpatient statement. This is the estimate of the charges, considered by the patients guarnatee plan, the outpatient owes the provider. Many plans have a maximum annual deductible that once met is then covered by the guarnatee provider.
Assignment of Benefits - guarnatee payments that are paid to the doctor or hospital for a patients treatment.
Beneficiary - person or persons covered by the health guarnatee plan.
Clearinghouse - This is a service that transmits claims to guarnatee carriers. Prior to submitting claims the clearinghouse scrubs claims and checks for errors. This minimizes the estimate of rejected claims as most errors can be well corrected. Clearinghouses electronically send claim information that is compliant with the correct Hippa standards (this is one of the medical billing terms we see a lot more of lately).
Cms - Centers for Medicaid and Medicare Services. Federal agency which administers Medicare, Medicaid, Hippa, and other health programs. Once known as the Hcfa (Health Care Financing Administration). You'll consideration that Cms it the source of a lot of medical billing terms.
Cms 1500 - medical claim form established by Cms to submit paper claims to Medicare and Medicaid. Most market guarnatee carriers also want paper claims be submitted on Cms-1500's. The form is remarkable by it's red ink.
Coding -Medical Billing Coding involves taking the doctors notes from a outpatient visit and translating them into the proper Icd-9 code for analysis and Cpt codes for treatment.
Co-Insurance - division or estimate defined in the guarnatee plan for which the outpatient is responsible. Most plans have a ratio of 90/10 or 80/20, 70/30, etc. For example the guarnatee carrier pays 80% and the outpatient pays 20%.
Co-Pay - estimate paid by outpatient at each visit as defined by the insured plan.
Cpt Code - Current Procedural Terminology. This is a 5 digit code assigned for reporting a policy performed by the physician. The Cpt has a corresponding Icd-9 analysis code. Established by the American medical Association. This is one of the medical billing terms we use a lot.
Date of service (Dos) - Date that health care services were provided.
Day Sheet - summary of daily outpatient treatments, charges, and payments received.
Deductible - estimate outpatient must pay before guarnatee coverage begins. For example, a outpatient could have a 00 deductible per year before their health guarnatee will begin paying. This could take several doctor's visits or prescriptions to reach the deductible.
Demographics - bodily characteristics of a outpatient such as age, sex, address, etc. Vital for filing a claim.
Dme - Durable medical equipment - medical supplies such as wheelchairs, oxygen, catheter, glucose monitors, crutches, walkers, etc.
Dob - Abbreviation for Date of Birth
Dx - Abbreviation for analysis code (Icd-9-Cm).
Electronic Claim - Claim information is sent electronically from the billing software to the clearinghouse or directly to the guarnatee carrier. The claim file must be in a acceptable electronic format as defined by the receiver.
E/M - evaluation and supervision section of the Cpt codes. These are the Cpt codes 99201 thru 99499 most used by physicians to way (or evaluate) a patients treatment needs.
Emr - Electronic medical Records. medical records in digital format of a patients hospital or provider treatment.
Eob - Explanation of Benefits. One of the medical billing terms for the statement that comes with the guarnatee enterprise payment to the provider explaining payment details, covered charges, write offs, and outpatient responsibilities and deductibles.
Era - Electronic Remittance Advice. This is an electronic version of an guarnatee Eob that provides details of guarnatee claim payments. These are formatted in according to the Hipaa X12N 835 standard.
Fee schedule - Cost associated with each treatment Cpt medical billing codes.
Fraud - When a provider receives payment or a outpatient obtains services by deliberate, dishonest, or misleading means.
Guarantor - A responsible party and/or insured party who is not a patient.
Hcpcs - health Care Financing supervision coarse policy Coding System. (pronounced "hick-picks"). This is a three level theory of codes. Cpt is Level I. A standardized medical coding theory used to quote definite items or services in case,granted when delivering health services. May also be referred to as a policy code in the medical billing glossary.
The three Hcpcs levels are:
Level I - American medical Associations Current Procedural Terminology (Cpt) codes.
Level Ii - The alphanumeric codes which comprise mostly non-physician items or services such as medical supplies, ambulatory services, prosthesis, etc. These are items and services not covered by Cpt (Level I) procedures.
Level Iii - Local codes used by state Medicaid organizations, Medicare contractors, and secret insurers for definite areas or programs.
Hipaa - health guarnatee Portability and responsibility Act. several federal regulations intended to enhance the efficiency and effectiveness of health care. Hipaa has introduced a lot of new medical billing terms into our vocabulary lately.
Hmo - health Maintenance Organization. A type of health care plan that places restrictions on treatments.
Icd-9 Code - Also know as Icd-9-Cm. International Classification of Diseases classification theory used to assign codes to outpatient diagnosis. This is a 3 to 5 digit number.
Icd 10 Code - 10th revision of the International Classification of Diseases. Uses 3 to 7 digit. Includes supplementary digits to allow more available codes. The U.S. agency of health and Human Services has set an implementation deadline of October, 2013 for Icd-10.
Inpatient - Hospital stay longer than one day (24 hours).
Maximum Out of Pocket - The maximum estimate the insured is responsible for paying for eligible health plan expenses. When this maximum limit is reached, the guarnatee typically then pays 100% of eligible expenses.
Medical Assistant - Performs administrative and clinical duties to keep a health care provider such as a physician, physicians assistant, nurse, or nurse practitioner.
Medical Coder - Analyzes outpatient charts and assigns the correct Icd-9 analysis codes (soon to be Icd-10) and corresponding Cpt treatment codes and any associated Cpt modifiers.
Medical Billing devotee - The person who processes guarnatee claims and outpatient payments of services performed by a doctor or other health care provider and vital to the financial operation of a practice. Makes sure medical billing codes and guarnatee information are entered correctly and submitted to guarnatee payer. Enters guarnatee payment information and processes outpatient statements and payments.
Medical Necessity - medical service or policy performed for treatment of an illness or injury not considered investigational, cosmetic, or experimental.
Medical Transcription - The conversion of voice recorded or hand written medical information dictated by health care professionals (such as physicians) into text format records. These records can be whether electronic or paper.
Medicare - guarnatee in case,granted by federal government for habitancy over 65 or habitancy under 65 with confident restrictions. Medicare has 2 parts; Medicare Part A for hospital coverage and Part B for doctors office or outpatient care.
Medicare Donut Hole - The gap or inequity in the middle of the initial limits of guarnatee and the catastrophic Medicare Part D coverage limits for prescribe drugs.
Medicaid - guarnatee coverage for low revenue patients. Funded by Federal and state government and administered by states.
Modifier - Modifier to a Cpt treatment code that supply supplementary information to guarnatee payers for procedures or services that have been altered or "modified" in some way. Modifiers are leading to clarify supplementary procedures and gather refund for them.
Network provider - health care provider who is contracted with an guarnatee provider to supply care at a negotiated cost.
Npi estimate - National provider Identifier. A unique 10 digit identification estimate required by Hipaa and assigned straight through the National Plan and provider Enumeration theory (Nppes).
Out-of Network (or Non-Participating) - A provider that does not have a ageement with the guarnatee carrier. Patients normally responsible for a greater measure of the charges or may have to pay all the charges for using an out-of network provider.
Out-Of-Pocket Maximum - The maximum estimate the outpatient is responsible to pay under their insurance. Charges above this limit are the guarnatee companies obligation. These Out-of-pocket maximums can apply to all coverage or to a definite benefit class such as prescriptions.
Outpatient - Typically treatment in a physicians office, clinic, or day surgery facility chronic less than one day.
Patient responsibility - The estimate a outpatient is responsible for paying that is not covered by the guarnatee plan.
Pcp - traditional Care doctor - normally the doctor who provides initial care and coordinates supplementary care if necessary.
Ppo - adored provider Organization. guarnatee plan that allows the outpatient to pick a doctor or hospital within the network. Similar to an Hmo.
Practice supervision Software - software used for the daily operations of a providers office. Typically includes appointment scheduling and billing functions.
Preauthorization - Requirement of guarnatee plan for traditional care doctor to acquaint the outpatient guarnatee carrier of confident medical procedures (such as outpatient surgery) for those procedures to be considered a covered expense.
Premium - The estimate the insured or their employer pays (usually monthly) to the health guarnatee enterprise for coverage.
Provider - doctor or medical care facility (hospital) that provides health care services.
Referral - When a provider (typically the traditional Care Physician) refers a outpatient to someone else provider (usually a specialist).
Self Pay - payment made at the time of service by the patient.
Secondary guarnatee Claim - guarnatee claim for coverage paid after traditional guarnatee makes payment. Typically intended to cover gaps in guarnatee coverage.
Sof - Signature on File.
Superbill - One of the medical billing terms for the form the provider uses to document the treatment and analysis for a outpatient visit. Typically includes several ordinarily used Icd-9 analysis and Cpt procedural codes. One of the most oftentimes used medical billing terms.
Supplemental guarnatee - supplementary guarnatee policy that covers claims fro deductibles and coinsurance. oftentimes used to cover these expenses not covered by Medicare.
Taxonomy Code - Code for the provider specialty sometimes required to process a claim.
Tertiary guarnatee - guarnatee paid in expanding to traditional and secondary insurance. Tertiary guarnatee covers costs the traditional and secondary guarnatee may not cover.
Tin - Tax Identification Number. Also known as employer Identification estimate (Ein).
Tos - Type of Service. record of the class of service performed.
Ub04 - Claim form for hospitals, clinics, or any provider billing for facility fees similar to Cms 1500. Replaces the Ub92 form.
Unbundling - Submitting more than one Cpt treatment code when only one is appropriate.
Upin - Unique doctor Identification Number. 6 digit doctor identification estimate created by Cms. Discontinued in 2007 and replaced by Npi number.
Write-off (W/O) - The inequity in the middle of what the provider charges for a policy or treatment and what the guarnatee plan allows. The outpatient is not responsible for the write off amount. May also be referred to as "not covered" in some glossary of billing terms.
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