Billing/Coding Terms

Question 1

Account Payable

A/P

Answer 1

Money Owed BY the business

Question 2

Account Receivable

A/R

Answer 2

Income or money owed TO the business

Question 3

Guarantor

Answer 3

The Patient, Caregiver, power of attorney, or other entity responsible for the payment of the healthcare bill

Question 4

Clearinghouse

Answer 4

A group that takes non-standard medical billing software formats and translate them into the standard EDI formats for submission to insurance payers

Question 5

AMA

Answer 5

American Medical Association.

This organization manages and maintains the yearly CPT code list

Question 6

Centers for Medicare and Medicaid services (CMS)

Answer 6

The federal agency that runs the Medicare program. In addition, CMS works with the states to run the Medicaid program.

CMS works to make sure that the beneficiaries in these programs are able to get high quality healthcare

Question 7

Healthcare provider

Answer 7

Someone who provides medical services, such as doctors, hospitals, or labs.

Question 8

CMS – 1450

Answer 8

UB – 04. Uniform Bill, formally known as UB – 92,

used for institutional billing also known as hospital visits.

Question 9

CMS – 1500

Answer 9

The standard claim form used my health plans on which to consider payment to the medical provider.

Question 10

Date of service (DOS)

Answer 10

The beginning and end dates of the health related service you received from the provider.

If the claim is for a doctor visit, the beginning and end dates will be the same.

Question 11

Co-pay

Answer 11

Agreed amount of the charges for medical services that patients or guarantors must pay.

Question 12

Co- insurance

Answer 12

Percentage or amount defined in the insurance plan for which the patient is responsible. Most plans have a ratio of 90/10, 80/20, or 70/30 etc.

For example- the insurance carrier pays 80% and the patient pays 20%

Question 13

Deductible

Answer 13

How much cost sharing one must pay for medical services, often before insurance company starts to pay. The amount patient must pay before insurance coverage begins.

For example, the patient could have a $1000 deductible per year before their health insurance will begin paying. This could take several doctors visits or prescriptions to reach the deductible.

Question 14

Superbill

Answer 14

One of the medical billing terms for the form the provider uses to document the treatment and diagnosis for a patient visit.

Typically includes several commonly use ICD 10 diagnosis and CPT procedural codes.

One of the most frequently used medical billing terms

Question 15

Demographics

Answer 15

Physical characteristics of a patient such as age, sex, address etc.

Necessary for filing a claim

Question 16

Subscriber

Answer 16

Identifies the individual who holds the insurance policy for coverage.

Also known as the insured person, insured, or policyholder.

Question 17

Assignment of benefits

Answer 17

The patient or guardian sign the assignment of benefits form so that the medical provider will receive the insurance payment directly.

If this form is not signed, the patient or guardian will receive the insurance payment.

Question 18

In-networking

Answer 18

And insurance plan which a provider signed a contract to participate in.

The provider agrees to except a discounted rate for procedures.

Question 19

Claim

Answer 19

Medical bill that is sent to an insurance company for processing.

Question 20

In patient (IP)

Answer 20

Patient who stay overnight in the hospital

Question 21

Outpatient

Answer 21

Patient who does not need to stay overnight in the hospital.

Outpatient services include labs, x-rays and some surgeries.

Question 22

Actual charge or charge

Answer 22

Amount of money a doctor for supplier charges for a certain medical service or supply.

The amount is often more than the insurance plan approves.

Question 23

Clean Claim

Answer 23

A complete submitted insurance claim that has all the necessary correct information without any omissions or mistakes that allows it to be processed and paid promptly.

A claim that does not have to be investigated by insurance companies before they process it.

Question 24

Untimely Submission

Answer 24

Medical claim submitted after the time frame allowed by the insurance payer.

Claims submitted after this date are denied.

Question 25

Allowed Amount

Answer 25

The amount of the billed charge the insurance company deems is payable.

Question 26

Contractual adjustments

Answer 26

The amount of charges a provider for hospital agrees to write off and not charge the patient per the contract terms with the insurance company.

Question 27

Electronic remittance advice (ERA)

Answer 27

This is an electronic version of an insurance EOB that provides details of insurance payments.

Question 28

Explanation of benefits (EOB)

Answer 28

The notice one receipt from their insurance company after getting medical services from a doctor or hospital.

It explains what was billed, the payment amount approved by the insurance, the amount paid and what is still left to pay.

Question 29

Patient responsibility

Answer 29

The amount the patient is responsible for paying that is not covered by the insurance plan.

Question 30

Amount paid

Answer 30

The dollar amount paid for the doctor or hospital visit.

Question 31

Ordering physician

Answer 31

A physician, or when appropriate, a non-physician provider (NPP), who orders non-physician services for the patient.

Examples of services that might be ordered include diagnostic lab tests, clinical lab tests, pharmaceutical services, DME and services pertinent to that
physicians or NPP’s service.

Question 32

Facility

Answer 32

A location where services are rendered outside of the practice location

Question 33

Federal tax ID number

Answer 33

A number assigned by the federal government to doctors and hospitals for tax purposes.

Question 34

Physician extenders

Answer 34

Also called mid level service providers. Include licensed nurse practitioners and/or licensed physician assistance. They coordinate patient care under a doctors supervision.

Question 35

Physician practice

Answer 35

A group of doctors, nurses, and physician assistance who work together.

Question 36

Primary care physician (PCP)

Answer 36

Usually the physician who provides initial care and coordinate additional care if necessary.

Question 37

CPT codes

Answer 37

Current procedural terminology in. This is a five digit code assigned for reporting a procedure performed by the physician.

Established by the American medical Association.

A coding system use to describe what treatment or services were given to you by the doctor

Question 38

ICD 10 code

Answer 38

10th revision of the international classification of diseases.

Uses 3to 7 digits. Includes additional digits to allow more available codes.

The US department of health and human services has set an implementation deadline of October 2015 for ICD 10.

Question 39

Referring physician

Answer 39

A physician who requests an item or service for beneficiary for which payment may be made.

Question 40

Revenue code

Answer 40

A billing code used to name a specific room, service, billing some.

A 3 digit number used on hospital bills to tell the insurer where the patient was when they received the treatment or what type of item a patient received.

Question 41

Specialist

Answer 41

A Doctor Who specializes in treating certain parts of the body or specific medical conditions.

Question 42

Supervising physician

Answer 42

A physician or, when appropriate, and NPP who oversees patient’s plan of care.

Examples of services might be for physical therapy, occupational therapy or speech language pathology services.

Question 43

Taxonomy code

Answer 43

Specialty standard codes used to indicate a providers specialty.

Sometimes required to process a claim.

Question 44

Modifier

Answer 44

Modifier to ECP to treatment code that provides additional information to insurance payers for procedures or services that have been altered or modified in someway.

Modifiers are important to explain additional procedures and obtain reimbursement for them.

Question 45

National provider identifier (NPI) number

Answer 45

A unique 10 digit identification number required by HIPAA and assigned through the national plan and provider enumeration system (NPPES).

Question 46

Durable medical equipment (DME)

Answer 46

Medical equipment that can be used many times, or special equipment ordered by the doctor for use at home such as wheelchairs, oxygen, catheter, glucose monitors, crutches, walkers, etc.