Module 11 Flashcards
(29 cards)
Practice Management System (PMS)
Software used to electronically manage administrative functions.
Examples: scheduling appointments, integrating patient documentation for EHRs, coding, billing, and revenue cycle tasks such as running aging reports, managing accounts receivable
Centers for Medicare & Medicaid Services (CMS)
Federal agency that oversees the Medicare program and assists states with Medicaid programs
Real-time Adjudication (RTA)
A tool that allows for a submission of the coded visit to the insurance company by participating providers for reimbursement decisions by third party payers while the patient is present
Matrix
The designed time frame for appointments based on the method of appointment durations
Wave scheduling
Scheduling two or three patients during a designated hourly time period (last 30 min of the hour, patients seen in order of arrival)
Double booking
A type of scheduling in which two or more patients are scheduled within the same time slot
Clustering
Scheduling patients in groups with common medical needs
New patient
The initial patient appointment or the first encounter after a 3 year absence from the organization
Established patient
Patient who received same provider services within the last 3 years
Eligibility
Meeting the stipulated requirements to participate in the health care plan
Copayment
A set amount determined by the plan/payer that the patient pays for specified services, usually office visits and emergency departments visits
Specific time
Gives each patient an individual time for their appointment
After visit summary (AVS)
Information that includes follow up appointments, provider orders, instructions, educational resources, and financial account information
Deductible
The amount must be paid before benefits are paid by the insurance company
Coinsurance
The percentage of the allowed amount the patient will pay once the deductible is met
Notice of Privacy Practices (NPP)
Document that identifies how the provider will distribute and disclose a patient’s protected health information
Encounter form
A record of the diagnosis and procedures covered during the current visit; also known as superbill.
Precertification
A request to determine if a service is covered by the patient’s policy and what the reimbursement would be.
Preauthorization
Approval of insurance coverage and necessity of services prior to the patient receiving them
Medical necessity
Reasonable and appropriate services based on clinical standards per CMS and the OIG
CPT codes
Current Procedural Terminology codes that identify medical services and procedures performed by a provider
HCPCS codes
Healthcare Common Procedure Coding System codes that identify supplies and procedures not described by CPT codes
Diagnosis codes
International Classification of Diseases, 10th version, Clinical Modification (ICD-10-CM) codes based on the provider’s diagnosis (why the patient is needed for medical services)
Aging Report
A report that lists outstanding balances that have not been paid by either the patient or the insurance payer
