Abstractor
hospital employee who converts documented procedurs and diangoses into medical codes
Abuse
coding practices that lead to improper
... [Show More] reimbursement by error because they do not meet medical necessity, ex. changing diagnosis to be covered by insurance
Accreditation
an examination process the healthcare facility goes through to evaluate the facilities policies, procedures, and performance to meet higher standards.
Accredited
Having seal of approval after being evaluated and demonstrating quality standards
Act/ Law/ Statute
Legislation passed through Congress and signed by President or passed over his veto
Actual Charge
The amount the provider charges for medical services or supplies. Not always paid in full.
Additional Benefits
Health care services not covered by Medicare and are offered through the Medicare Advantage Organization for no additional premium. The benefits must equal the ACR (Adjusted Community Rating)
Adjudication
Health Insurance Claims process at the insurance company
Adjusted Average Per Capita Cost (AAPCC)
Estimate of how much Medicare will spend in a year for an average beneficiary
Administrative Code Sets
Non medical code sets that characterize a general business situation rather than a medical condition.
Administrative Costs
Medicare, Medicaid, CMS refer to this as their expenses to have the program, operating expenses, program management, etc.
Administrative Data
Health insurance information stored in automated information system about enrollment, eligibility, claims, etc.
Administrative Law Judge (ALJ)
hearing officer who presides over appeal conflicts between providers or beneficiaries, and Medicare contractors (MAC's)
Administrative Simplification
Part of HIPAA authorizing HHS (Health and Human Services) to 1. adopt standards for transactions & code sets; 2. adopt standard identifiers for health plans; 3. adopt standards to protect security & privacy of personally identifiable health information.
Administrative Simplification Act
Signed 12/17/01 allows HHS (Health & Human Services) to exclude providers from Medicare for HIPAA non-compliance of electronic claims and prohibit paper claims except in certain situations
Admission Date
The date the patient was admitted for inpatient care, outpatient, or start of care.For hospice, enter effective date of election of hospice benefits.
Admitting Diagnosis
Diagnosis code indicating patient's diagnosis at admission
Admitting Physician
The doctor responsible for admitting a patient to the hospital or other inpatient health facility
Advance Beneficiary Notification (ABN)
A notice from provider to patient that Medicare may deny payment. Patient must sign before services are provider, otherwise patient is not responsible if Medicare does not cover.
Advanced Directive
Statement written by patient on how they want medical decisions to be made. May include a Living Will or Durable Power of Attorney for healthcare.
Allowed Charge
Individual charge determination by carrier for a covered service or supply.
Ambulatory Care
All types of health services that do not require an overnight stay.
Ambulatory Care Sensitive Conditions (ACSC)
Medical condtions that if treated immediatly and managed properly should not require hospitalization.
Ambulatory Payment Classification (APC)
Medicare's outpatient prospective payment system in which services are grouped based on the resources needed and payment is fixed within each group
Ambulatory Surgery Center (ASC)
Outpatient surgery center not located in the hospital. Patient's may stay a few hours up to 1 night.
American Hospital Association (AHA)
Represents concerns of instituitional providers. They host the National Uniform Billing Committee (NUBC) which consults under HIPAA
American Medical Association (AMA)
Professional organization maintains CPT code sets, secretariat to National Uniform Claim Committee (NUCC) which consults under HIPAA. ASC payment group rate.
ASHIM
American Society of Health Informatics Managers, Inc. is a non-profit group of computer professionals that specialize in health information technology (HIT). They are certified through Certified Health Informatics System Professionals (CHISP)
Ancillary Services
Professional services by a hospital or inpatient facility. Xrays, drugs, labs, etc.
Appeal
Complaint by hospital or patient about a health care payment
Approved Amount
The fee Medicare sets as reasonable and pays to the provider.
Assigned Claim
Claim submittted by a provider who accepts Medicare
Assignment
Agreeing to acccept Medicare fees as payment in full
Attending Physician
Licensed physician who certifies the patient services via medical necessity and is primarily responsible for the patient's medical care and treatment.
Automated Claim Review
Claim review and etermination via system edits and don't require human intervention
Basic Benefit
Includes Medicare covered benefits (except hospice) and additional benefits
Beneficiary
The name of a person who has health care insurance through the insurance program
Benefit Payment
Amount paid by insurance after the deductible and coinsurance have been deducted
Benefit Period
Episode of care within hospitals & skilled nursing facilities (SNF). Begins on admission and ends 60 days after care has ended
Benefits
The money or services provided through an insurance policy
Board Certified
Doctor specializing in certain area of medicine and who passes an advanced exam. Primary care and specialists can both be board certified
Business Associate
Someone performs a function on behalf of a covered entity but is not part of the covered entity's workforce, outside business manager.
Capitation
Specified amount of money is paid to a health plan or doctor regardless of the services rendered in that period. One lump sum.
Care Plan
Written plan of services patient will receive to ensure the patient's best care physically, mentally & socially
Caregiver
Someone who cares for a patient who is ill, disabled, or aged. Can be relatives, friends or someone who is paid.
Case Management
Physician, nurse, or other person tracks use of facilities and resources of a patient to be sure they are receiving the care they need.
Case Mix
Distribution of patients into categories reflecting severity of illness or resource uses.
Case Mix Index
The average Diagnostic Related Groups (DRG) relative weight for all Medicare admissions
Catastrophic Illness
Serious and costly health problem that could be life-threatening or cause disability. Costs can cause patient financial hardship.
Catastrophic Limit
The highest amount a beneficiary is required to pay out of pocket during a certain period of time for certain covered charges.
Center for Disease Control and Prevention (CDC)
Organization that protects public health through monitoring disease trends, investigation outbreaks, implementing illness, and injury control.
Center for Medicare & Medicaid Services (CMS)
The Heath & Human Services (HHS) agency responsible for Medicare & parts of Medicaid. Maintains UB-04, oversight of HIPAA and maintains HCPCS code set & Medicare remittance advice (RA) remark codes. They promote higher quality care
Certification
the hospital passed a survey done by a state government agency. Medicare only covers hospital stays in hospitals that are certified or accredited.
Civilian Health and Medical Program (CHAMPUS)
Run by department of defense. Used to give medical care to active duty but now this is called TRICARE
Charge Description Master (CDM)
Electronic billing table where charge amounts are kept in a centralized place.
Claim
Request for payment for services or benefits received. Claims are called bills through Medicare Part A
Claim Adjustment Reason Codes
Identifies the reason for any difference in charge and payment. This code set is used in the X12 835 Claim Payment & Remittance Advice and the X12 837 Claim transactions and is maintained by Health Care Code Maintenance Committee
Claim Status Code
Identifies the status of a claim. This code set is used in the X12N 277 Claim Status Inquiry and Response transactions and is mainted by the Health Care Code Maintenance Committee
CMS Agent
State survey agency who participates in Medicare surveys and certification process. ex. private physician consulting with the State Agency (SA) or CMS regional office.
UB-04
Claim form used by hospitals and facilities for billing procedures and services.
CMS1500
Claim form used for billing physiicans and other services, ex physical therapy.
Code of Federal Regulations
Official compiliation of federal rules and requirements
Code Set
Set of codes used to encode data elements terms, codes, concepts, required under HIPAA
Coinsurance
Percentage of medical bill the beneficiary is responsible for paying.
Community Mental Health Services
Facility provides outpatient services for children, elderly, chronically ill, & residents discharged from inpatient treatment at a mental health facility. 24 hour day emergency care, partial hospitalization or psychosocial rehab, & screening for admission to inpatient facility.
Comprehensive Inpatient Rehabilitation Facility
Inpatient rehabilitation to patient's with physical disabilities.
Comprehensive Outpatient Rehabilitation Facility (CORF)
Outpatient rehabilitation
Conditional Payment
A payment made by Medicare in which another payer is responsible. Ex,, Auto is in litigation, if they pay, then Medicare will be reimbursed
Consolidated Omnibus Budget Recondiliation Act (COBRA)
A law that helps keep people covered by employer groups after coverage ended due to death of a spouse, losing a job, reduced hours, leaving voluntarily, or getting a divorce. The beneficiary may have to pay the premium however there is no administrative fee.
Coordination of Benefits
The process of determining which policy is first when a patient has 2 health care plans. [Show Less]