Key Terms Flashcards
(325 cards)
1
Q
AAPC (American Academy of Professional Coders)
A
Professional association established to provide a national certification and credentialing process, to support the national and local membership by providing educational products and opportunities to networks, and to increase and promote national recognition and awareness of professional coding.
2
Q
AAMA (American Association of Medical Assistants)
A
enables medical assisting professionals to enhance and demonstrate the knowledge skills and professionalism required by employers and patience, as well as protect medical assistance, rights to practice.
3
Q
AHIMA (American Information Management Association)
A
Found it in 1928 to improve the quality of medical records, and currently advances the health information management profession toward an electronic and global environment, including implementation of ICD – 10 – CM and ICD – 10 – PCS in 2013.
4
Q
Bonding insurance
A
And insurance agreement that guarantees repayment for financial losses, resulting from the act or failure to act of an employee. It protects the financial operations of the employer.
5
Q
Business liability insurance
A
Protect business assets and covers the cost of lawsuits resulting from bodily injury, personal injury, and false advertising.
6
Q
CMS (Centers for Medicare and Medicaid Services)
A
Formally known as the healthcare financing administration (HCFA); an administrative agency within the federal department of health and human services (DHHS).
7
Q
Claims examiner
A
Employed by third-party payers to review health related claims to determine whether the charges are reasonable and medically necessary based on the patient’s diagnosis.
8
Q
Coder coding
A
Process of reporting diagnoses, procedures, services and supplies as numeric and alpha numeric characters (called codes) on the insurance claim.
9
Q
Embezzle
A
The illegal transfer of money or property as a fraudulent action; steal money from an employer.
10
Q
Errors and omissions insurance aka professional liability insurance
A
Provides protection from liability as a result of errors and submissions when performing their professional.
11
Q
Ethics
A
Principle of right or good conduct; rules that govern the conduct of members of a profession.
12
Q
Healthcare provider
A
Physician or other healthcare practitioner (eg physicians assistant).
13
Q
Health information technicians
A
Professional human manage, patient health information and medical records, administer computer information systems, and code diagnoses and procedures for healthcare services provided to patients.
14
Q
Health insurance claim
A
Documentation that is electronically or manually submitted to an insurance plan requesting reimbursement for healthcare procedures, and services provided.
15
Q
Health insurance specialist aka reimbursement specialists
A
Person who reviews health related claims to match medical necessity to procedures or services performed before payment (reimbursement) is made to the provider.
16
Q
Hold harmless clause
A
Policy that the patient is not responsible for pain with the insurance plan denies.
17
Q
Independent contractor
A
Defined by the lectric law library’s lexicon as “a person who performed services for another under an express or implied agreement, and who is not subject to the others control, or right to control, of the manner and means of performing the services. The organization that hires an independent contractor is not liable for the ax or emissions of the independent contractor.”
18
Q
Internship
A
Nonpaid professional practice experience that benefits, students and facilities that accept students for placement; students receive on the job experience prior to graduation, and the internship assist them in obtaining permanent employment.
19
Q
Medical assistant
A
Employed by a provider to perform administrative and clinical tasks that keep the office or clinic running smoothly.
20
Q
Medical malpractice insurance
A
A type of liability insurance that covers physicians and other healthcare professionals for liability claims arising from patient treatment.
21
Q
Medical necessity
A
Involves linking every procedure or service code reported on an insurance claim to a condition code that justifies the need to perform that procedure or service.
22
Q
Professionalism
A
Conduct or qualities that characterize a professional person.
23
Q
Property insurance
A
Protects business, contents against fire, theft, or other risks.
24
Q
Respondeat superior
A
Latin for let the master answer; legal doctrine, holding that the employer is liable for the actions and emissions of employees performed, and committed within the scope of their employment.
25
Scope of practice
Healthcare services determined by the state that an NP and a PA can perform.
26
Workers’ compensation insurance
Insurance program, mandated by federal and state governments that requires employers to cover medical expenses and loss of wage for workers who are injured on the job or who have developed job-related disorders.
27
Accreditation
Voluntary process that a health care facility or organization undergoes to demonstrate that it has met standards beyond those required by law.
28
Advanced alternative payment models (advanced APMs)
Include new ways for CMS to reimburse healthcare providers for care provided to Medicare beneficiaries; providers who participate in an advanced 8 PM through Medicare part B may earn an incentive payment for participating in the innovative payment model.
29
Alternative payment models (APMs)
Payment approach that includes incentive payments to provide high-quality and cost efficient care; APMs can apply to a specific clinical condition, a care episode, or a population.
30
Benchmarking
Practice that allows an entity to measure and compare its own data against that of other agencies and organizations for the purpose of continuous improvement (ie coding error rates)
31
Cafeteria plan
Also called triple option plan; provides different health, benefit plans and extra coverage options through an insurer or third-party administrator.
32
Capitation
prospective payment per patient for a prescribed period of time; provider accepts pre-established payments for providing healthcare services to enrolleyes over a specified period of time (usually one year or monthly).
33
Carve-out plan
Arrangement provided by a health insurance company to offer a specific health benefit that is managed separately from the health insurance plan.
34
Case manager
Cements written confirmation, authorizing treatment, to the provider; include nurses and social workers who help patients and families navigate complex, healthcare and support systems; also coordinate health care services to improve patient outcomes while considering financial implications as part of severity of illness and intensity of services (SI/IS) to dress the balance of medical necessity, procedures/services provided, and level of care needed.
35
Clinical practice guidelines
Define modalities for the diagnosis, management, and treatment of patients, and they include recommendations based on a methodical and meticulous evaluation, and synthesis of published medical literature; the guidelines are not protocols that must be followed, and instead are to be concerned.
36
CMS-1500 claim
Claim submitted for reimbursement of physician, office procedures in Services; electronic version is called ANSI ASC X12N 837P.
37
Coinsurance
Also called coinsurance payment; the percentage that patient pays for covered services after the deductible has been met, and the copayment has been made.
38
Competitive medical plan (CMP)
An HMO that meets federal eligibility requirements for a Medicare risk contract, but it’s not licensed as a federally qualified plan.
39
Consumer-directed health plan (CDHP)
Define employer contributions and asking employees to be more responsible for healthcare decisions, and cost sharing.
40
Continuity of care
Documenting patient care services so that others who treat the patient have a source of information on which to base additional care and treatment.
41
Copayment (copay)
Provision in an insurance policy that requires the policyholder or patient to pay a specified dollar amount to a healthcare provider for each visit or medical service received.
42
Covered services (aka schedule of benefits)
Outline services covered by a health insurance plan.
43
Deductible
An amount for which the patient is financially responsible before an insurance policy provides reimbursement to the provider.
44
Electronic clinical quality measures (eCQMs)
Processes, observations, treatments, and outcomes that quantify the quality of care provided by healthcare systems; measuring such data helps ensure that car is delivered safely, effectively, equitably, and timely.
45
Enrollee (aka subscriber)
Individual who joins a managed care plan; subscribers also purchased traditional health insurance plans.
46
Excess insurance (aka stop-loss insurance)
Provides protection against catastrophic or unpredictable losses, and includes aggregate stop loss, plans and specific stop loss plans.
47
Exclusive provider organization (EPO)
Managed care plan that provides benefits to subscribers if they receive services from network providers.
48
Express contract
Provisions that are stated in a health insurance contract.
49
External quality review organization (EQRO)
Responsible for reviewing health care provided by managed care organizations.
50
Fee schedule
List of predetermined payments for healthcare services provided to patients (Ie a fee is assigned to each CPT code).
51
Fee-for-service
Reimbursement methodology that increases payment if the healthcare service fees increase, if multiple units of service are provided, or if more expensive services are provided instead of less expensive services (ie brand name vs generic prescription medication).
52
Fee-for-service plans
Reimburses providers according to a fee schedule after covered procedures and services have been provided to patients.
53
Flexible spending accounts (FSA)
Consumer directed health plan that allows tax exempt accounts to be created by employees for the purpose of paying healthcare bills.
54
Gag clause
Prevents providers from discussing all treatment options with patients, whether or not the plan would provide reimbursement for services.
55
Gatekeeper
Primary care provider for essential healthcare services at the lowest possible cost, avoiding non-essential care, and referring patients to specialist.
56
Group health insurance
Private health insurance model that provides coverage, which is subsidized by employers and another organizations (ie labor unions, rural and consumer health cooperatives) whereby part all of premium costs are paid for and or discounted group rates are offered to eligible individuals.
57
Guaranteed renewal
A provision, when included in a health insurance contract, that requires a health insurance company to renew the policy as long as premiums continue to be paid.
58
Health care
Expands the definition of medical care to include preventative services.
59
Health care reimbursement account (HCRA)
Tax exempt account used to pay for healthcare expenses; individual decides in advance how much money to deposit in an HCRA (and unused funds are lost)
60
Health insurance
Contract between a policyholder and a third-party payer or government program to reimburse the policy holder for all or a portion of the cost of medically necessary, treatment or preventative care by healthcare professionals.
61
Health insurance exchange (aka health insurance marketplace)
Method Americans used to purchase health coverage that fits their budget and meets their needs, effective October 1 2013, as a result of passage of the affordable care act.
62
Health maintenance organization (HMO)
Responsible for providing healthcare services to subscribers in a given geographical area for a fixed fee.
63
Health reimbursement arrangement (HRA)
Tax-exempt account funded by employers, which individuals used to pay healthcare bills.
64
Health savings account (HSA)
Participants enroll in a relatively inexpensive, high deductible health plan (HDHP) and a tax deductible. Savings account is open to cover current and future medical expenses.
65
Health case effectiveness data and information set (HEDIS)
Created standards to assess managed care systems using data elements that are collected, evaluated, and published to compare the performance of manage healthcare plans.
66
Implied contract
Results from actions taken by the healthcare facility or provider, such as registering a patient to provide treatment.
67
Indemnity plan
Allows patient to see healthcare from any provider, and the provider receives reimbursement, according to a fee schedule; indemnity plans are sometimes called fee for service plans.
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Individual health insurance
Private health insurance policy purchased by individuals or families who do not have access to group health insurance coverage; applicants can be denied coverage, and they can also be required to pay higher premiums due to age, gender, and/or pre-existing medical conditions.
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Integrated delivery systems (IDS)
Organization of affiliated provider sites that offer joint healthcare services to subscribers.
70
Legislation
Federal state county, and municipal laws which are rules of conduct enforced by a threat of punishment if violated.
71
Lifetime maximum amount
Maximum benefit payable to a health plan, participant, such as annually or during a lifetime.
72
Major medical insurance
Coverage for catastrophic prolong illnesses and injuries, which can include hospital, medical common surgical benefits, that supplement basic coverage benefits.
73
Managed care
Health care delivery system organized to manage health care costs, utilization, and quality.
74
Managed care organization (MCO)
Responsible for the health of a group of enrollees; can be a health plan, hospital physician group or health system.
75
Mandates
Official directive, instruction, or order to take her perform a certain action, such as regulations written by federal government administrative agencies; they are also authoritative commands, such as by courts, governors, and legislatures.
76
Medical care
Includes the identification of disease and the provision of care and treatment as provide provided by members of the healthcare team to persons who are sick injured or concerned about their health status.
77
MIPS value pathways (MVPs)
Allow for a more cohesive provider, participation experience by connecting activities and measures from four merit-based incentive payment systems (MIPS) performance categories, irrelevant to a specialty, medical condition, or episode of care; MVP performance categories include quality, performance, improvement, activities, cost, and foundational layer (ie population health measures, promoting interoperability); see also traditional merit based incentive payment system (MIPS), which is the basis of MVPs.
78
National Committee for Quality Assurance (NCQA)
A private, not-for-profit organization, that assesses the quality of managed care plans in the United States and releases the data to the public for its consideration when selecting a managed care plan.
79
Network provider
Physician, healthcare practitioner, or healthcare facility under contract to the manage care plan.
80
Payer mix
Different types of health insurance payments made to providers for patient services.
81
Performance measurements
Strengthen organization, accountability, and support performance improvement initiatives by assessing the degree to which evidence based treatment guidelines are followed, and include in evaluation of results of care.
82
Personal health record (PHR)
Web-based application that allows individuals to maintain and manage their health information(and that of others for whom they are authorized, such as family) in a private, secure, and confidential environment.
83
Physician incentive plan
Requires managed care plans that contract with Medicare or Medicaid to disclose information about physician incentive plans to CMS or state medicate agencies before a new renewed contract receives final approval.
84
Physician incentives
Include payments made directly or indirectly to healthcare providers to service encouragement to reduce our limit (ie discharge an inpatient from hospital more quickly) to save money for the managed care plan.
85
Physician referral
Written order by a primary care provider that facilitates patient evaluation and treatment by a physician specialist.
86
Point-of-service plan (POS)
Delivers healthcare services using both managed care network and traditional indemnity coverage so patient can see care outside the managed care network.
87
Policyholder
The person who signs a contract with a health insurance company and who, thus, owns the health insurance policy.
88
Preferred provider organization (PPO)
Network of physicians, or healthcare practitioners, and hospitals that have joined together to contract with insurance companies, or employers or other organizations to provide healthcare subscribers for a discounted fee.
89
Premium
Amount paid for a health insurance policy.
90
Prepaid health plan
Captation contract between a health plan and providers who manage all of the healthcare for a patient population and are reimbursed a predetermined amount of money either monthly or annually.
91
Prescription management
Controls medication costs using a variety of strategies, which include pharmacy, benefit, managers, cost, sharing, copayments or coinsurance, disease, management programs, electronic prescribing, drug formulas, drug utilization review, generic substitution, manufacturer, drug, rebates, negotiated prices, and prescription mail services.
92
Preventive services
Designed to help individuals avoid problems with health and injuries.
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Primary care provider (PCP)
Responsible for supervising and coordinating health care services for enrolling and pre-authorizing referrals to specialist and inpatient hospital admissions (except in emergencies).
94
Promoting interoperability programs (PI)
Focus on improving patient access to health information and reducing the time cost required of providers to comply with the programs requirement; previously called EHR incentive programs.
95
Public health insurance
Federal and state government health programs (ie Medicare, Medicaid, CHIP, TRICARE) available to eligible individuals.
96
Quality assessment and performance improvement (QAPI) program
Program implemented so the quality assurance activities are performed to improve the functioning of Medicare advantage organizations.
97
Quality assurance program (aka quality management program)
Activities that assess the quality of care provided in a healthcare setting.
98
Quality improvement (QI)
Involves continuous and systematic actions that result in measurable improvement in the provision of healthcare services in the health status of targeted patient groups.
99
Quality improvement organizations (QIO)
Perform utilization and quality control review of healthcare furnished, or to be furnished to medical beneficiaries.
100
Quality improvement system for managed care (QISMC)
Established by Medicare to ensure that accountability of managed care plans in terms of objective, measurable standards.
101
Quality payment program (QPP)
Helps providers for us on quality of patient care and making patients healthier; includes advanced alternative payment models (Advanced APMs) and merit-based incentive payment system (MIPS); replaced the EHR Incentive Program (or Meaningful Use), Physician Quality Reporting System, and Value-Based Payment Modifier program.
102
Record linkage
Allows patient information to be created at different locations according to unique patient identifier or identification number.
103
Report card
Contains data regarding a managed, care, plans, quality, utilization, customer, satisfaction, administrative effectiveness, financial stability, and cost control.
104
Rider
Special contract clause stipulating additional coverage above the standard contract.
105
Risk adjustment program
Lessons or eliminate the influence of risk selection on premiums charged by health plans and includes the risk adjustment model and risk transfer formula.
106
Risk contract
An arrangement among providers to provide capitated (fixed, prepaid basis) healthcare services to Medicare beneficiaries.
107
Schedule of benefits
Outlines services covered by a health insurance plan.
108
Second surgical opinion (SSO)
Second physician is asked to evaluate the necessity of surgery and recommend the most economical, appropriate facility in which to perform the surgery.
109
Self-insured (or self-funded) employer-sponsored group health plans
Allows a large employer, to assume the financial risk for providing healthcare benefits to employees; employer does not pay a fixed premium to a health insurance, payer, but establishes a (of employer and employee contributions) out of which claims are paid.
110
Self-referral
Enrollee who sees a non-HMO panel specialist without a referral from the primary care physician
111
Single-payer health system
National health service model adopted by some western nations (ie Canada, Great Britain) and funded by taxes. The government pays for each residence healthcare, which is considered a basic social service.
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Socialized medicine
Type of single pair system in which the government owns an operates healthcare facilities, and providers (ie physicians) receive salary; the VA healthcare program is a form of socialized medicine.
113
Standards
Requirements established by accreditation organizations.
114
Stop-loss insurance
Provide provides protection against catastrophic or unpredictable losses, and include aggregate stop loss, plans and stop specific plans.
115
Third-party administrators (TPAs)
Company that provides health benefits, claims administration and other outsourcing services (or employee benefits management) for self insured companies; provides administrative services to healthcare plans; specializes in mental health case management; and processes claims, serving as a system of checks and balances for labor – management.
116
Third-party payer
The health insurance company that provides coverage, such as Blue Cross Blue Shield.
117
Total practice management software (TPMS)
Used to generate the EMR, automating medical practice functions of registering patients, scheduling appointments, generating insurance claims and patient statements, processing payments from patients in third-party payers, and producing administrative in clinical reports.
118
Traditional merit-based incentive payment system (MIPS)
Allows providers to earn a performance based payment adjustment that considers quality, resource use, clinical practice, improvement, and promoting interoperability; see also MIPS value pathways which evolved from traditional MIPS to allow for a more cohesive power participation experience.
119
Triple option plan
Usually offered by either a single insurance plan or as a joint venture among two or more third-party payers, and provide subscribers or employees with a choice of HMO, PPO, or traditional health insurance plans; also called cafeteria plan or flexible benefit plan.
120
Universal health insurance
Goal of providing every individual with access to health coverage, regardless of the system implemented to achieve that goal
121
Utilization review organization
Entity that establishes a utilization management program and performs external utilization review services.
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123
Revenue management
The process by which healthcare facilities and providers ensure their financial viability by increasing revenue, improving cash flow and enhancing the patient’s experience. A.k.a. accounts receivable accounts, payable and quality of patient care.
124
Revenue cycle management
A revenue cycle process that typically begins upon appointment scheduling or physician order for an inpatient hospital admission and it concludes when reimbursement obtained through collections has been posted. A.k.a. accounts receivable management.
125
Institutional billing (aka facility billing)
Involves generating UB – 04 claims for charges generated for inpatient and outpatient services provided by healthcare facilities, which, according to CMS includes hospitals, long-term care, facilities, skilled nursing facilities, home health, agencies, hospice, organizations, and stage renal disease providers, outpatient physical therapy Services, comprehensive outpatient, rehab, facilities, community, mental health centers, critical access, hospitals, federally, qualified health centers, history, compatibility, laboratories, Indian health, service, facilities, Oregon procurement organizations, religious, non-medical, healthcare, institution, and rural health clinics.
126
Professional billing
Involves generating CMS – 1500 claims for charges generated for professional services and supplies provide provided by physicians and non-physician practitioners, which, according to CMS include nurse practitioners, physician, assistance, clinical nurse, midwives, certified registered, nurse anesthetists, and clinical nurse specialist.
127
Discharged not final fill coded (DNFC) and discharged not final billed (DNFB)
Involve patient claims that are not finalized because of coding delays in incomplete documentation or billing delays.
128
Claims rejections vs claims denials
Rejections are unpaid claims that failed to meet certain data requirements, such as missing data rejected claims can be corrected and resubmitted for processing. Denial are unpaid claims that contain beneficiary, identification errors, coding errors diagnoses that do not support the medical necessity of procedures or services performed, duplicate claims, global global delays of surgery, coverage issues, and other patient issues.
129
Integrated revenue cycle (IRC)
In case in utilization management, clinical documentation improvement, coding and health information and management are coordinated as part of the revenue management process.
130
Patient portal
Secure online website or cell phone application that provides patients with 24 hour online access to patient health information, appointment scheduling, messaging, and payment methods.
131
Guarantor
Person responsible for paying charges.
132
Participating provider (PAR)
Provider that contracts with the health insurance plan and accept whatever the pay reimburses for procedures or services performed. Participating providers are not allowed to bill patients for the difference between the contracted rate and their normal fee.
133
Non-participating provider (nonPAR)
Also called an out of network provider. Does not contract with the insurance plan, and the patients who like to receive care from non-participating providers will encourage higher out-of-pocket expenses. The patient is usually expected to pay the difference between the insurance admin and the providers fee, which is referred to as balance billingbalance billing is prohibited by state workers compensation plans in federal government programs, such as Medicaid Medicare TRICARE.
134
Single-path coding
Combined p professional and institutional coding to improve productivity and ensure the submission of clean claims, leading to improved reimbursement.
135
Encounter form
The financial record source document used by healthcare providers and other personnel to record treated diagnoses and services rendered to the patient during the current encounter. In the physicians office, it is also called a super Bill; in the hospital it’s called a charge master.
136
Chargemaster (aka charge description master CDM)
A document that contains a computer-generated encounter form that includes a list of procedures, Services, supplies and revenue codes with charges for each.
137
Revenue code
A four-digit code pre-printed on a facilities charge master to indicate the location or type of service provided to an institutional patient. Revenue codes are reported in form locator 42 of the UB – 04 claim.
138
Accept assignment
The provider agrees to accept with the insurance company allows or approved his payment info for the claim. The patient is responsible for paying any copayment and or coinsurance amounts.
139
Assignment of benefits
The patient and/or insured authorize the pay to reimburse the provider directly.
140
Out-of-pocket payment
Established by health insurance companies for a health insurance plan usually has limits of $1000 or $2000; when the patient has reached the limit of an out-of-pocket payment for the year appropriate patient reimbursement to the provider is determined; not all health insurance plans include an out-of-pocket payment provision.
141
Patient ledger or a patient account record
A permanent record of all financial transactions between the patient and the practice the charges along with personal or third-party payments are posted on the patient’s account. Each transaction must be individually described when entered on the patient ledger/account record.
142
Day sheet
Called manual daily accounts, receivable journal; chronological summary used to manually track all transactions posted to individual patient ledgers/accounts on a specific day.
143
Quarterly provider update updates (QPU’s)
Simplify the process of understanding, proposed or changes to its programs (Medicaid/medicare/Chip)
144
Utilization management aka utilization review
A method of controlling healthcare costs and quality of care by reviewing the appropriateness and medical necessity of care provider to patients prior to the administration of care or aftercare has been provided.
145
Case management
Involves the development of patient care plans for the coordination and provision of care for complicated cases in a constant effective manner.
146
Revenue monitoring
Involves assessing the revenue cycle to ensure financial viability and stability using the following metrics which are standards of measurement: cash flow, days and accounts receivable percentage of accounts receivable older than 30, 60, 90 and 120 days net collection rate and denial rate.
147
Revenue auditing
Assessment process that is conducted as a follow up to revenue monitoring so that areas of poor performance can be identified and corrected.
148
CMS-1500
Insurance claim used to report, professional and technical services
149
Resource allocation
Distribution of financial resources among competing groups.
150
Data analytics
Tools and systems that are used to analyze, clinical and financial data, conduct research, and evaluate the effectiveness of disease treatments.
151
Claims management
Performed to complete, submit and follow up on claims for procedures and services provided.
152
Claim submission
The electronic or manual transmission of claims stated to payers, clearing houses, or third-party administrators for processing. Prior submission claim scrubber software is used to review medical claims for coding and billing accuracy and other possible errors before submitting them.
153
Clearinghouse
An agency organization, that collects, processes, and distributes claims.
154
Explanation of benefits (EOB)
Details about the results of claim processing, such as provider charge, pay your fee scheduled, payment made by the pay, and patient financial responsibility.
155
Remittance advice - aka remit
Sent to providers by third-party payers that contains details about claims adjudication, including information about payments, deductibles and copayments, adjustments, denial, missing or inaccurate data, refunds, and claims, without due to secondary payer, third-party liability or penalty situations.
156
Electronic file format a.k.a. electronic media claim
Series of fixed length records submitted to payers as a bill for healthcare services
157
Electronic data interchange (EDI)
The computer to computer transfer data between providers and third-party payers in a data format agreed-upon by sending and receiving parties. The three formats acceptable are UB – 04 flat file format, national standard format. (NSF), or ANSI ASC X 12N 837 format.
158
Covered entities
Process electronic claims and include all private sector health plans
159
Clean claim
Correctly completed standardized claim (ie CMS-1500 claim).
160
Claims attachment
A set of supporting documentation or information associated with a healthcare claim or patient encounter. These are used for a medical evaluation for payment, past payment, audit, or review, and quality control to ensure access to care and quality of care.
161
Coordination of benefits (COB)
A provision in group health insurance policies intended to keep multiple insurance from paying benefits, covered by other policies.
162
Claims processing
Sorting claims upon submission to collect and verify information about the patient and provider.
163
Claims adjudication
Comparing a claim to pair edits, and the patient’s health plan benefits to verify that required information is available to process the claim, the claim is not a duplicate, pay rules and procedures have been followed, and procedures performed, and service is provided our covered benefits.
164
Common data file
Summary abstract report of all recent claims filed on each patient
165
Downcoding
Assigning lower-level codes than documented in the record.
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Unbundling a.k.a. fragmentation
Submitting multiple CPT codes when one code should be submitted
167
Upcoding
Assignment of an ICD – 10 – CM diagnosis code that does not match patient record documentation for the purpose of illegally increasing reimbursement.
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169
Source document
The routing slip, charge slip, encounter form, or super Bill form which the insurance claim was generated.
170
Open claims
Submitted to the pay, but processing is not complete.
171
Closed claims
Claims for which all processing, including appeals, has been completed.
172
Unassigned claims
Generated for providers who do not accept assignment; organized by year
173
Denied claims
Claim returned to the provider by payers due to coding errors, missing information, and paging coverage issues.
174
Claims adjustment reason codes (CARC)
Reasons for denied or rejected claims as reported on the remittance advisor explanation of benefits.
175
Remittance advice remark codes (RARC)
Additional explanation of reasons for denied claims.
176
Appeal
Documented as a letter and signed by the provider to explain why a claim should be reconsidered for payment.
177
Peer review
Appeal process performed to determine whether to reverse a pulled claims denial. Evaluation of the appeal is performed by a medical reviewer or a medical Director and if appeal is escalated and independent, external review may assess the appeal.
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Statutes aka statutory law
Lost passed by legislative bodies (federal, Congress and state legislatures).
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Regulations aka regulatory law
Mandated guidelines written by administrative agencies. An official directive, instruction, or order to take or perform a certain action such as a federal regulation. mandates are also authoritative command, such as by courts, governors and legislatures.
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Case law aka common law
Based on court decisions that establish a precedent. Court supply president law in the same manner to cases with the same facts the president serves as the standard for similar cases.
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Precedent
Based on a court decision that is legally binding and follows the doctrine of stare decisis for deciding subsequent cases involving identical or similar facts; state decides is Latin for the thing speaks for itself, which means it require courts to apply president law at the same amount of cases with the same facts.
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Civil law
Deals with all areas of the law that are not classified as criminal law.
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Criminal law
A public law that defines crimes in their prosecution.
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Subpoena
And order the car that requires a witness to PT appear at a particular time and place to testify.
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Subpoena deuces tecum
Requires documents to be produced.
186
Deposition
Legal proceeding during which a party answers questions on your oath, but not an open court
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Interrogatory
A document containing a list of questions that must be answered in writing.
188
Qui tam
An abbreviation for Latin term qui tam pro domino rege quam pro sic ipso in hoc parte sequitar, meaning “who as well for the king as for himself sues in this matter”. It is a provision of the false claims act that allows a private citizen to file lawsuit in the name of the US government, charging fraud by government contractors and other entities.
189
Federal register
Legal newspaper published dairy business day by the national archives and records administration (NARA).
190
CMS transmittals
Document published by Medicare containing new and changed policies and our procedures that are to be incorporated into a specific CMS program manual; cover page summarizes, new, and change material, and some pages provide details.
191
CMS quarterly provider update (QPU)
An online CMS publication that contains information about regulations and major major policies, currently underdevelopment, regulations and major policies completed or canceled, and new or revised manual instructions.
192
Medicare administrative contractor (MAC)
An organization that contracts with CMS to process claims and perform program integrity tasks for Medicare, part a Medi card, part B, and DMEPOS; each contractor makes program coverage decisions and publishes a newsletter, which is sent to providers who receive Medicare reimbursement. Medicare transitioned fiscal intermediaries and carries to create Medicare administrative contractors.
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Conditions of participation (CoP)
Health and safety regulations that healthcare organizations, such as hospitals, must meet in order to begin and continue participating in the Medicare Medicaid programs.
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Conditions for coverage (CfC)
Health and safety regulations that healthcare organizations, such as end-stage renal disease facilities, must meet in order to begin and continue participating in the Medicare and Medicaid programs.
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Record retention
Storage of documentation for an established period of time, usually mandated by federal and or state law; it’s purposes to ensure the availability of records for used by government in Jesus disease and other third parties. 
196
Audit
Objective evaluation to determine the accuracy of submitted financial statements.
197
Compliance program
Internal policies and procedures that in organization follows to meet mandated requirements. Love you can change it I’m working. 
198
Medicare integrity program (MIP)
Authorize CMS, to enter into contracts with entities to perform cost report auditing, medical review, antifraud, activities, and the Medicare secondary payer program.
199
Medicare review
Defined by CMS as a review of claims to determine whether services provided our medically reasonable and necessary, as well as to follow up on the effectiveness of previous corrective actions. 
200
Medicaid integrity program (MIP)
Combat fraud, waste, and abuse in the Medicaid program; Congress requires annual reporting by CMS about the use and effectiveness of funds appropriate for the MIP.
201
Medicaid integrity contractors (MICs)
CMS-contracted entities that review provider claims, audit providers, and others, identify over payments, and educate providers, manage care, entities, beneficiaries, and others with respect to integrity and quality of care.
202
Medicaid fraud control units (MFCUs)
Investigates and prosecute Medicaid provider fraud as well as patient abuse or neglect in healthcare facilities in boarding care, facilities, and all 50 states, the District of Columbia, Puerto Rico, and the US Virgin Islands.
203
Recovery and audit contractor program (RAC)
Mandated by the Medicare prescription drug, improvement, and modernization act of 2003 to find incorrect improper Medicare payments paid to healthcare providers participated in fee for service Medicare.
204
Healthcare fraud prevention and enforcement action team (HEAT)
 Joint effort between the department of health and human services and the department of justice to fight healthcare fraud by increasing coordination, intelligent, sharing, and training among investors, agents, prosecutors, analyst, and policy makers; implemented as a result of the patient protection and affordable care act.
205
Medicare shared savings program
Mandated by the patient protection and portable care act to facilitate coordination and cooperation among providers to improve quality of care for Medicare fee for service beneficiaries and to reduce unnecessary costly the creation of accountable care organizations.
206
Health insurance portability, and accountability act (HIPAA)
Mandates regulations that govern privacy, security, and electronic transaction standards for healthcare information.
207
Health insurance, portability, and accountability act (HIPAA)
Mandates regulations that govern privacy, security and electronic transaction standards for healthcare information. 
208
Fraud
An intentional deception or misrepresentation that someone makes knowing it as false that could resolve in an unauthorized payment.
209
Abuse
Involves actions that are inconsistent with accepted sound medical business or fiscal practices, abuse directly or indirectly results in unnecessary cost to the program through improper payments. The difference between fraud and abuse is the individuals intent.
210
National individual identifier (patient identifier)
Unique identifier to be assigned to patients has been put on hold. Several bills in Congress would eliminate the requirements to establish a national individual identify.
211
National provider identifier (NPI)
Unique identifier assigned to healthcare providers as 10 digit numeric identifier, including a check digit in the last position.
212
National standard employer, identification number (EIN)
Unique identifier assigned to employers who, as sponsors of health insurance for their employees, need to be identified in healthcare transactions; it is the federal employer identification number assigned by the IRS and has nine digits with a EIN assignment by the IRS began in January 1998.
213
National plan and provider enumeration system (NPPES)
Developed by CMS to assign unique identifiers to healthcare providers.
214
Electronic transaction standards, a.k.a. transactions rule
A uniform language for electronic data interchange.
215
Digital
Application of a mathematical function to an electronic document to create a computer code that can be encrypted (encoded).
216
Unique bit string
Computer code that creates an electronic signature message digest that is encrypted and appended (attached) to an electronic document.
217
Message digest
Representation of text as a single string of digits, which was created using a formula; for the purpose of electronic signatures, the message digest is encrypted and appended to an electronic document.
218
Encrypt
To convert information to secure language format for transmission.
219
Decrypts
To decode and encoded computer file so that it can be viewed; convert data to a language that can be read.
220
ANSI ASC X12N 837
Electronic format, supported for healthcare claim transactions
221
UB-04 flat file
Series of fixed length records used to build institutional services, such as services performed in hospitals.
222
National standard format (NSF)
Flat file format used to build provider and non-institutional services, such as services reported by a general practitioner on a CMS-1500 claim.
223
Privileged communication
Private information shared between a patient and healthcare provider; disclosure must be in accordance with HIPAA and or individual state provisions regarding the privacy and security of protected health information (PHI).
224
Protected health information (PHI)
Information that is identifiable to an individual such as name, address, telephone numbers, date of birth, Medicaid ID number, medical record number, Social Security number, and name of employer.
225
Authorization
Document that provides official instruction, such as the customized document that gives covered entities permission to use specified protected health information for specified purposes, or to disclose PHI to a third-party specified by the individual.
226
Privacy
Right of individuals to keep their information from being disclosed to others.
227
De-identification of protected health information
Process that removes identifiers from health information to mitigate privacy risk for individuals, and thus supports the secondary use of data for comparative effectiveness, studies, policy assessment, life, sciences, research, and other endeavors.
228
Confidentiality
Restricting patient information access to those with proper authorization and maintaining the security of patient information.
229
Security
Involves the safekeeping of patient information by controlling access to hardcopy and computerized records; protecting patient information from alteration, destruction, tampering, or loss; providing employee training in confidentiality of patient information; and requiring employees to sign a confidentiality statement that details, the consequences of not maintaining patient confidentiality.
230
Breach of confidentiality
Unauthorized release of patient information to a third-party.
231
HIPAA privacy rule
HIPAA provision that creates national standards to protect individuals, medical records and other personal health information.
232
Treatment, payment, and healthcare operation (TPO)
Activities defined by the HIPAA privacy rule, including treatment, payment, and healthcare operations.
233
Notice of privacy practices (NPP)
Document that includes an individual’s health privacy rights related to protected health information and communicates how health information may be used and shared.
234
Minimum necessary standard
Key protection of the HIPAA privacy rule, based on sound current practice that protected health information should not be used or disclosed when it is not necessary to satisfy a particular purpose or carry out of function.
235
Designated record set
Group of records maintained by or for a covered entity and includes medical and billing records about individuals maintained by or for a covered healthcare provider; enrollment, payment, claims, adjudication, and case or medical management record systems maintained by or for a health plan; or other records that are used by or for the covered entity to make decisions about individuals.
236
HIPAA security rule
HIPAA standards and safeguards that protect health information collected, maintained, used, or transmitted electronically; covered entities affected by this rule. Include health plans, healthcare, clearing, houses, and certain healthcare providers.
237
Breach notification
HPA rule that requires covered entities in their business associates to provide patient notification following a breach of unsecured protected health information.
238
Medical identity theft
Occurs when someone uses another person’s name and or insurance information to obtain medical and or surgical treatment, prescription drug, and medical durable equipment; it can also occur when dishonest people who work in a medical setting use another person’s information to submit false bills to healthcare plans.
239
Accounting of disclosures
HIPAA regulations that require requires health healthcare organizations to track medical information provide provided to third parties so that patients can be notified if there has been an inappropriate release of their medical information.
240
Release of information (ROI)
ROI by a covered entity about protected health information requires the patient to sign an authorization to release information, which is reviewed for authenticity and processed within a HIPAA mandated 60 day time limit; request for our O, I include those from patients, physicians, and other healthcare providers; third-party pairs; Social Security, disability, attorneys; and so on.
241
Release of information log
Used to document patient information released to authorized requested; data is entered manually or using ROI tracking software.
242
International classification of diseases, 10th revision, clinical modification (ICD10-CM)
Coding system to be implemented on October 1 2015, and used to report diseases, injuries, and other reasons for impatient and outpatient encounters.
243
International classification of diseases, 10th revision, procedure coding system (ICD-10-PCS)
 Coding system to be implemented on October 1 2015, and used to report procedures and services on inpatient claims.
244
Physician query process
When coders have questions about documented diagnoses or procedures/services, they contact the responsible physician to request clarification about documentation and the code(s) to be assigned.
245
Encoders
Automate the coding process using computerized or web-based software; instead of manually looking up conditions in the Code manual’s index, the coder uses a software search feature to locate and verified diagnosis and procedure codes.
246
ICD-10-CM/PCS Coordination and Maintenance Committee
Responsible for oversee And Al changes and modifications to ICD – 10 – CM and ICD – one zero – PCS codes; discuss his issues such as the creation and update of general equivalent mappings.
247
Computer assisted coding (CAC)
Uses a natural language processing engine to read patient’s records and generate ICD – 10 – CM and hcpCS/CPT codes.
248
Evidence-based coding
Coding auditor clicks on codes that CAC software generates to review electronic health record documentation used to generate the code.
249
Laterality
ICD – 10 – CM specifically classified conditions that occur on the left, right or bilaterally.
250
International classification of diseases, 11th revision (ICD-11)
Developed by the world, health organization and released in 2018 to begin the inflammation (translation into language languages other than English).
251
ICD-10-CM Index to diseases and injuries
An alphabetical listing of terms and corresponding codes which include: specific illnesses, injuries, eponyms, abbreviations, other descriptive diagnostic terms. It is subdivided index to the diseases and injuries with table and neoplasm and table of drugs and chemicals, then index of external causes of injury
252
Main terms
Boldface term located in the ICD – 10 – CM index; listed in alphabetical order with sub terms and qualifiers, and then below each main term.
253
Non-essential modifiers
Supplementary words located in parentheses after an ICD – 10 – CM main term that do not have to be included in the diagnostic statement for the code number to be assigned
254
Qualifiers
Supplementary terms in the ICD – 10 – CM index to disease diseases and injuries that further modify sub terms and other qualifiers.
255
Subterms aka essential modifiers
Qualifies the main term by listing alternative sites, etiology or clinical status; it is indented two spaces under the main term.
256
Primary malignancy, a.k.a. original Cancer site
The original tumor site.
257
Secondary malignancy
Tumor has metastasized to a secondary site, either adjacent to the primary site or to a remote region of the body.
258
Carcinoma (Ca) in situ
A malignant tumor that is localized, circumcised, encapsulated, and non-invasive (has not spread to deeper or adjacent tissues or organs).
259
Benign
Not cancerous
260
Uncertain behavior
It is not possible to predict, subsequent morphology or behavior from the submitted specimen.
261
Unspecified nature
Neoplasm is identified, but no further indication of the histology or nature of the tumor is reflected in the documented diagnosis.
262
Contiguous or overlapping sites
Occurs when the origin of the tumor involves two adjacent sites.
263
Poisoning: accidental (unintentional)
Poisoning that results from an inadvertent overdose, wrong substance administered/taken, or Inox medication that includes combining prescription drugs with non-prescription drugs or alcohol.
264
Poisoning: intentional self-harm
Poisoning that results from a deliberate overdose, such as a suicide attempt of substances administered/taken or intoxication that includes purposely combining prescription drugs with non-prescription drugs or alcohol.
265
Poisoning: assault
Poisoning inflicted by another person who intended to kill or injure the patient.
266
Poisoning: undetermined
Sub category used if the medical record does not document whether the poisoning was intentional or accidental.
267
Adverse effect
Development of a pathological condition that results from a drug or chemical substance that was administered or taken.
268
Underdosing
Taking less of a medication than is prescribed by a provider or a manufacturers instruction.
269
ICD – 10 – CM index of external causes of injury
Arranged alphabetical order by main term, indicating the event; are secondary codes for use in any healthcare setting; capture how the injury your health condition happened, the intent, the place where the event occurred, the activity of the patient at the time of the event and the persons status.
270
Eponyms
Diseases and procedures name for people such as Barlows disease.
271
Main terms
Boldface term located in the ICD – 10 – CM index; listed in alphabetical order with sub terms and qualifiers indented below each main term.
272
Non-essential modifiers
Supplementary words located in parentheses after an ICD – 10 – CM main term that do not have to be included in the diagnostic statement for the code number to be assigned.
273
Qualifiers
Supplementary terms in the ICD – 10 – CM index two disease is an injuries that further modify sub terms and other qualifiers.
274
Sub terms aka essential modifiers
Qualifies the main term by listing alternative sites, etiology, or clinical status; it is indented two spaces under the main term.
275
Primary malignancy
Original cancer site.
276
Secondary malignancy
Tumor has metastasized to a secondary site, either adjacent to the primary site or to remote region of the body.
277
Carcinoma in situ (Ca)
A malignant tumor that is located, circumscribed, encapsulated, and non-invasive.
278
Benign
Not cancerous.
279
Uncertain behavior
It is not possible to predict, subsequent morphology or behavior from the submitted specimen.
280
Continuous sites, a.k.a. overlapping sites
Occurs when the origin of the tumor involves to adjacent sites.
281
Poisoning: accidental (unintentional)
Poisoning that results from an inadvertent overdose, wrong substance administered, or intoxication that includes combining prescription drugs with non-prescription drugs or alcohol.
282
Poisoning: intentional self harm
Poisoning that results from a deliberate overdose, such as a suicide, attempt, of substance taken or intoxication that includes purposely combining prescription drugs with non-prescription drugs or alcohol.
283
Poisoning: assault
Poisoning inflicted by another person who intended to kill or injured the patient.
284
Poisoning: undetermined
Sub category used if the medical record does not document whether poisoning was intentional or accidental.
285
Adverse effect
Development of a pathologic condition that results from a drug or chemical substance that was properly administered or taken.
286
ICD – 10 – CM tubular list of diseases and injuries
A chronological list of codes contained within 22 chapters, which are based on body systems or condition. These codes are organized within: major topic headings also called code block, and categories, sub, categories, and codes,
287
ICD – 10 – CM official guidelines for coding and reporting and ICD – 10 – PCS official guidelines for coding and reporting
Contains the guidelines and are approved by the Cooperating Parties for ICD – 10 – CM/PCS.
288
ICD – 10 – CM coding conventions
General coding rules that apply to the assignment of codes, independent of official coding guide guidelines.
289
Table of neoplasms
Alphabetical index of anatomic sites for which there are six possible codes, according to whether the neoplasm in question is malignant, benign, institute, of uncertain behavior, or unspecified nature.
290
Table of drugs and chemicals
Alphabetical index of medicinal, chemical and biological substances that result in poisoning, adverse effects, and underdosing.
291
Placeholder
Use of character X as a placeholder to allow for future expansion of certain codes; used when a code contains fewer than six character characters and seventh character applies.
292
NEC (not elsewhere classifiable)
Means other or other specified and identifies codes that are assigned with information needed to assign a more specific code cannot be located.
293
NOS (not otherwise specified)
Indicates that the code is unspecified; coders should ask the provider for more specific diagnosis before assigning the code.
294
colon
Used after an incomplete term and is followed by one or more mod (additional terms).
295
Parentheses
Enclose supplementary words that may be present or absent in the diagnostic statement, without affecting assignment of the code number.
296
Brackets
Used in the index to identify manifestation codes in the index and tubular list to enclose abbreviations, synonyms, alternative warning, or explanatory phrases.
297
Manifestation
Condition that occurs as the result of another condition; manifestations are always reported secondary codes.
298
Other codes, a.k.a. other specified codes
When this word appears in an ICD – 10 – CM tubular list, Code description, the code is assigned when patient record documentation provide provides detail for which a specific code does not exist.
299
Unspecified codes
When patient record documentation is insufficient to assign a more specific code, this unspecified code is a sign.
300
Includes note
Appear below certain tubular list categories to the further defined, clarify, or provide examples.
301
Trust the index
Concept that inclusion terms listed below codes in the tubular list are not meant to be exhaustive, and additional terms found only in the index may also be associated to a code.
302
Excludes1note
Appear excludes, which means not coded here, and in indicates mutually exclusive codes; and none of the words to conditions that cannot be reported together.
303
Excludes2note
Means not included here and indicates that although the excluded condition is not classified as part of the condition, it is excluded from, a patient may be diagnosed with all conditions at the same time; therefore may be acceptable to assign both the code and the excluded code together, if supported by medical documentation.
304
Use additional code
Indicates that the second code is to be reported to provide more information about the diagnosis.
305
Code first underlying disease
Appears when the code referred to be sequenced as a secondary code; the code, title, and instructions are italicized.
306
In diseases classified elsewhere
Indicates that the manifestation codes are component of the ideology/manifestation coding convention.
307
Code, if applicable, any casual condition first
Requires casual condition to be sequenced first if present; a casual condition as a disease that manifest another condition.
308
And
When two disorders are separated by the word “ and” It is interpreted as M/or an indicates that either of the two disorders is associated with the code number.
309
With
When codes combine one disorder with another, the providers diagnostic statement must clearly indicate that both conditions are present in a relationship exist between the conditions.
310
Due to
Located in the index in alphabetical order to indicate the presence of a cause and effect relationship between two conditions.
311
In
Located in alphabetical order below the main term; to a sign a code from the list of qualifiers below the word “in” the provider must document both conditions in the patient’s record; ICD – 10 – CM classify certain conditions if they were a cause-and-effect relationship present because they occur together much of the time, such as pneumonia in Q fever.
312
See
Cross reference that provides direction to a different index main term or main term and sub term.
313
See also
Cross reference that provides direction to an additional main term.
314
See category
Instruction directs the coder to the ICD – 10 – CM tubular list, where a code can be selected from the options provided there.
315
See condition
Directs the coder to the main term for a condition found in the index.
316
Code also
Instructional note in the ICD – 10 – CM tubular list instruction that includes two coats that may be required to fully describe a condition with sequencing, depending on circumstances of the encounter.
317
Default code
Listed next to a main term in the ICD – 10 – CM alphabetic index and represents the condition that is most commonly associated with the main term or is the unspecified code for the condition. 
318
ICD – 10 – CM diagnostic coding and reporting guidelines for outpatient services
Developed by the federal government, outpatient diagnoses that have been approved for used by hospital/providers, including and reporting hospital based outpatient services and provider based office visits.
319
Principal diagnosis
Condition determined, after study, that resulted in the patient’s admission to the hospital.
320
First listed diagnosis
Boarded on outpatient claims, it reflects the reason for the encounter and is often assign or symptom. 
321
Qualified diagnoses
Working diagnosis that is not yet proven or established; reported for inpatient cases only 
322
Secondary diagnoses
With the primary condition, has the potential to affect treatment of the primary condition, and is an active condition for which the patient is treated or monitored.
323
Comorbidity
Concurrent condition that coexist with the first listed diagnosis, has the potential to affect treatment of the first listing diagnosis, and is an active condition for which the patient is treated and/or monitored.
324
Complication
Condition that develops after outpatient care has been provided or during an inpatient admission
325
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