Billing/Coding Terms Flashcards
Account Payable
A/P
Money Owed BY the business
Account Receivable
A/R
Income or money owed TO the business
Guarantor
The Patient, Caregiver, power of attorney, or other entity responsible for the payment of the healthcare bill
Clearinghouse
A group that takes non-standard medical billing software formats and translate them into the standard EDI formats for submission to insurance payers
AMA
American Medical Association.
This organization manages and maintains the yearly CPT code list
Centers for Medicare and Medicaid services (CMS)
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
Healthcare provider
Someone who provides medical services, such as doctors, hospitals, or labs.
CMS – 1450
UB – 04. Uniform Bill, formally known as UB – 92,
used for institutional billing also known as hospital visits.
CMS – 1500
The standard claim form used my health plans on which to consider payment to the medical provider.
Date of service (DOS)
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.
Co-pay
Agreed amount of the charges for medical services that patients or guarantors must pay.
Co- insurance
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%
Deductible
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.
Superbill
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
Demographics
Physical characteristics of a patient such as age, sex, address etc.
Necessary for filing a claim
Subscriber
Identifies the individual who holds the insurance policy for coverage.
Also known as the insured person, insured, or policyholder.
Assignment of benefits
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.
In-networking
And insurance plan which a provider signed a contract to participate in.
The provider agrees to except a discounted rate for procedures.
Claim
Medical bill that is sent to an insurance company for processing.
In patient (IP)
Patient who stay overnight in the hospital
Outpatient
Patient who does not need to stay overnight in the hospital.
Outpatient services include labs, x-rays and some surgeries.
Actual charge or charge
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.
Clean Claim
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.
Untimely Submission
Medical claim submitted after the time frame allowed by the insurance payer.
Claims submitted after this date are denied.
Allowed Amount
The amount of the billed charge the insurance company deems is payable.
Contractual adjustments
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.
Electronic remittance advice (ERA)
This is an electronic version of an insurance EOB that provides details of insurance payments.
Explanation of benefits (EOB)
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.
Patient responsibility
The amount the patient is responsible for paying that is not covered by the insurance plan.
Amount paid
The dollar amount paid for the doctor or hospital visit.
Ordering physician
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.
Facility
A location where services are rendered outside of the practice location
Federal tax ID number
A number assigned by the federal government to doctors and hospitals for tax purposes.
Physician extenders
Also called mid level service providers. Include licensed nurse practitioners and/or licensed physician assistance. They coordinate patient care under a doctors supervision.
Physician practice
A group of doctors, nurses, and physician assistance who work together.
Primary care physician (PCP)
Usually the physician who provides initial care and coordinate additional care if necessary.
CPT codes
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
ICD 10 code
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.
Referring physician
A physician who requests an item or service for beneficiary for which payment may be made.
Revenue code
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.
Specialist
A Doctor Who specializes in treating certain parts of the body or specific medical conditions.
Supervising physician
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.
Taxonomy code
Specialty standard codes used to indicate a providers specialty.
Sometimes required to process a claim.
Modifier
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.
National provider identifier (NPI) number
A unique 10 digit identification number required by HIPAA and assigned through the national plan and provider enumeration system (NPPES).
Durable medical equipment (DME)
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.
