Common Medical Billing and Coding Terminology

Question 1

When a healthcare provider accepts as full payment the amount paid on a claim by the insurance company. This excludes patient responsible amounts such as coinsurance or copay.

Answer 1

Accept Assignment

Question 2

When a claim is corrected which results in a credit or payment to the provider.

Answer 2

Adjusted Claim

Question 3

The reimbursement amount an insurance company will pay for a healthcare procedure. This amount varies depending on the patients insurance plan. For 80/20 insurance, the provider accepts 80% of the allowed amount and the patient pays the remaining 20%.

Answer 3

Allowed Amount

Question 4

One of the medical billing terms referring to the unpaid insurance claims or patient balances that are due past 30 days. Most medical billing software’s have the ability to generate a separate report for insurance aging and patient aging. These reports typically list balances by 30, 60, 90, and 120 day increments.

Answer 4

Aging

Question 5

These are typically services a patient requires in a hospital setting that are in addition to room and board accommodations – such as surgery, lab tests, counseling, therapy, etc.

Answer 5

Ancillary Services

Question 6

When an insurance plan does not pay for treatment, an appeal (either by the provider or patient) is the process of objecting this decision. The insurer may require documentation when processing an appeal and typically has a formal policy or process established for submitting an appeal. Many times the process and associated forms can be found on the insurance providers web site.

Answer 6

Appeal

Question 7

You typically see these medical billing terms on the patient statement. This is the amount of the charges, determined by the patients insurance plan, the patient owes the provider. Many plans have a maximum annual deductible that once met is then covered by the insurance provider.

Answer 7

Applied to Deductible (ATD)

Question 8

Insurance payments that are paid directly to the doctor or hospital for a patients treatment. This is designated in Box 27 of the CMS-1500 claim form.

Answer 8

Assignment of Benefits(AOB)

Question 9

When a patient requires permission (or authorization) from the insurance company before receiving certain treatments or services.

Answer 9

Authorization

Question 10

Person or persons covered by the health insurance plan and eligible to receive benefits.

Answer 10

Beneficiary

Question 11

An organization of affiliated insurance companies (approximately 450), independent of the association (and each other), that offer insurance plans within local regions under one or both of the association’s brands (Blue Cross or Blue Shield). Many local BCBS associations are non-profit BCBS sometimes acts as administrators of Medicare in many states or regions.

Answer 11

Blue Cross Blue Shield (BCBS)

Question 12

A fixed payment paid per patient enrolled over a defined period of time, paid to a health plan or provider. This covers the costs associated with the patients health care services. This payment is not affected by the type or number of services provided.

Answer 12

Capitation

Question 13

Simply the insurance company or “carrier” the patient has a contract with to provide health insurance.

Answer 13

Carrier

Question 14

Codes for medical procedures or services identified by the 5 digit CPT Code.

Answer 14

Category I Codes

Question 15

Optional performance measurement tracking codes which are numeric with a letter as the last digit (example: 9763B).

Answer 15

Category II Codes

Question 16

Temporary codes assigned for collecting data which are numeric followed by a letter in the last digit (example: 5467U).

Answer 16

Category III Codes

Question 17

Civilian Health and Medical Program of the Uniformed Services. Recently renamed TRICARE. This is federal health insurance for active duty military, National Guard and Reserve, retirees, their families, and survivors.

Answer 17

CHAMPUS

Question 18

Medical billing term for 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.

Answer 18

Clean Claim

Question 19

This is a service that transmits claims to insurance carriers. Prior to submitting claims the clearinghouse scrubs claims and checks for errors. This minimizes the amount of rejected claims as most errors can be easily corrected. Clearinghouses electronically transmit claim information that is compliant with the strict HIPAA electronic format standards.

Answer 19

Clearinghouse

Question 20

Centers for Medicaid and Medicare Services. Federal agency which administers Medicare, Medicaid, HIPAA, and other health programs. Formerly known as the HCFA (Health Care Financing Administration). You’ll notice that CMS it the source of a lot of medical billing terms.

Answer 20

CMS

Question 21

Medical claim form established by CMS to submit paper claims to Medicare and Medicaid. Most commercial insurance carriers also require paper claims be submitted on CMS-1500’s. The form is distinguished by it’s red ink.

Answer 21

CMS 1500

Question 22

Medical Billing Coding involves taking the doctors notes from a patient visit and translating them into the proper diagnosis (ICD-9 or ICD-10 code) and treatment medical billing codes such as CPT codes. This is for the purpose of reimbursing the provider and classifying diseases and treatments.

Answer 22

Coding

Question 23

Percentage or amount defined in the insurance plan for which the patient is responsible. Most plans have a ratio of 90/10 or 80/20, 70/30, etc. For example the insurance carrier pays 80% and the patient pays 20%. Note This is AFTER the patient has met the deductible.

Answer 23

Co-Insurance

Question 24

This is in reference to the providers accounts receivable. It’s the ratio of the payments received to the total amount of money owed on the providers accounts.

Answer 24

Collection Ratio

Question 25

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

Answer 25

Contractual Adjustment

Question 26

When a patient is covered by more than one insurance plan. One insurance carrier is designated as the primary carrier and the other as secondary.

Answer 26

Coordination of Benefits (COB)

Question 27

Amount paid by patient at each visit as defined by the insured plan.

Answer 27

Co-Pay

Question 28

Current Procedural Terminology. This is a 5 digit code assigned for reporting a procedure performed by the physician. The CPT has a corresponding ICD-9 diagnosis code. Established by the American Medical Association. This is one of the medical billing terms we use a lot.

Answer 28

CPT Code

Question 29

This is an application process for a provider to participate with an insurance carrier. Many carriers now request credentialing through CAQH. The CAQH credentialing process is a universal system now accepted by insurance company networks.

Answer 29

Credentialing

Question 30

The balance that’s shown in the “Balance” or “Amount Due” column of your account statement with a minus sign after the amount (for example $50-). It may also be shown in parenthesis; ($50). The provider may owe the patient a refund.

Answer 30

Credit Balance

Question 31

When claim information is automatically sent from Medicare the secondary insurance such as Medicaid.

Answer 31

Crossover claim

Question 32

Date that health care services were provided.

Answer 32

Date of Service (DOS)

Question 33

Summary of daily patient treatments, charges, and payments received.

Answer 33

Day Sheet

Question 34

amount patient must pay before insurance coverage begins. For example, a patient could have a $1000 deductible per year before their health insurance will begin paying. This could take several doctor’s visits or prescriptions to reach the deductible.

Answer 34

Deductible

Question 35

Physical characteristics of a patient such as age, sex, address, etc. necessary for filing a claim.

Answer 35

Demographics

Question 36

Medical supplies such as wheelchairs, oxygen, catheter, glucose monitors, crutches, walkers, etc.

Answer 36

DME – Durable Medical Equipment

Question 37

Abbreviation for Date of Birth.

Answer 37

DOB

Question 38

When the insurance company reduces the code (and corresponding amount) of a claim when there is no documentation to support the level of service submitted by the provider. The insurers computer processing system converts the code submitted down to the closest code in use which usually reduces the payment.

Answer 38

Downcoding

Question 39

Request by an insurance company or group medical plan by another insurance company or medical plan to determine if other coverage exists.

Answer 39

Duplicate Coverage Inquiry (DCI)

Question 40

Abbreviation for diagnosis code (ICD-9 or ICD-10 code).

Answer 40

Dx

Question 41

Claim information is sent electronically from the billing software to the clearinghouse or directly to the insurance carrier. The claim file must be in a standard electronic format as defined by the receiver.

Answer 41

Electronic Claim

Question 42

An electronic paperless means of transferring money. This allows funds to be transferred, credited, or debited to a bank account and eliminates the need for paper checks.

Answer 42

Electronic Funds Transfer (EFT)

Question 43

Medical billing terms for the Evaluation and Management section of the CPT codes. These are the CPT codes 99201 thru 99499 most used by physicians to access (or evaluate) a patients treatment needs.

Answer 43

E/M

Question 44

Electronic Medical Records. Also referred to as EHR (Electronic Health Records). This is a medical record in digital format of a patients hospital or provider treatment. An EMR is the patient’s medical record managed at the providers location. The EHR is a comprehensive collection of the patients medical records created and stored at several locations.

Answer 44

EMR

Question 45

Individual covered by health insurance.

Answer 45

Enrollee

Question 46

Explanation of Benefits. One of the medical billing terms for the statement that comes with the insurance company payment to the provider explaining payment details, covered charges, write offs, and patient responsibilities and deductibles.

Answer 46

EOB

Question 47

Electronic Remittance Advice. This is an electronic version of an insurance EOB that provides details of insurance claim payments. These are formatted in according to the HIPAA X12N 835 standard.

Answer 47

ERA

Question 48

Insurance where the provider is paid for each service or procedure provided. Typically allows patient to choose provider and hospital. Some policies require the patient to pay provider directly for services and submit a claim to the carrier for reimbursement. The trade-off for this flexibility is usually higher deductibles and co-pays.

Answer 48

Fee For Service

Question 49

Cost associated with each CPT treatment billing code for a providers treatment or services.

Answer 49

Fee Schedule

Question 50

The portion of the charges that are the responsibility of the patient or insured.

Answer 50

Financial Responsibility

Question 51

A Medicare representative who processes Medicare claims.

Answer 51

Fiscal Intermediary (FI)

Question 52

A list of prescription drug costs which an insurance company will provide reimbursement for.

Answer 52

Formulary

Question 53

When a provider receives payment or a patient obtains services by deliberate, dishonest, or misleading means.

Answer 53

Fraud

Question 54

Group Health Plan. A means for one or more employer who provide health benefits or medical care for their employees (or former employees).

Answer 54

GPH

Question 55

Name of the group or insurance plan that insures the patient.

Answer 55

Group Name

Question 56

Number assigned by insurance company to identify the group under which a patient is insured.

Answer 56

Group Number

Question 57

A responsible party and/or insured party who is not a patient.

Answer 57

Guarantor

Question 58

Health Care Financing Administration. Now know as CMS (see above in Medical Billing Terms).

Answer 58

HCFA

Question 59

Health Care Financing Administration Common Procedure Coding System. (pronounced “hick-picks”). Three level system of codes. CPT is Level I. A standardized medical coding system used to describe specific items or services provided when delivering health services. May also be referred to as a procedure code in the medical billing glossary.

Answer 59

HCPCS

Question 60

American Medical Associations Current Procedural Terminology (CPT) codes.

Answer 60

HCPCS levels Level I

Question 61

The alphanumeric codes which include mostly non-physician items or services such as medical supplies, ambulatory services, prosthesis, etc. These are items and services not covered by CPT (Level I) procedures.

Answer 61

HCPCS levels Level II

Question 62

Local codes used by state Medicaid organizations, Medicare contractors, and private insurers for specific areas or programs.

Answer 62

HCPCS levels Level III

Question 63

Also called Flexible Spending Account. A tax exempt account provided by an employer from which an employee can pay health care related expenses. The current limit is $2600 per year.

Answer 63

Health Savings Account

Question 64

Typically a physician, hospital, nursing facility, or laboratory that provides medical care services. Not to be confused with insurance providers or the organization that provides insurance coverage.

Answer 64

Heathcare Provider

Question 65

Health Insurance Claim. This is a number assigned by the the Social Security Administration to a person to identify them as a Medicare beneficiary. This unique number is used when processing Medicare claims.

Answer 65

HIC

Question 66

Health Insurance Portability and Accountability Act. Several federal regulations intended to improve the efficiency and effectiveness of health care and establish privacy and security laws for medical records. HIPAA has introduced a lot of new medical billing terms into our vocabulary lately.

Answer 66

HIPAA

Question 67

Health Maintenance Organization. A type of health care plan that places restrictions on treatments.

Answer 67

HMO

Question 68

Inpatient, outpatient, or home healthcare for terminally ill patients.

Answer 68

Hospice

Question 69

Also know as ICD-9-CM. International Classification of Diseases classification system used to assign codes to patient diagnosis. This is a 3 to 5 digit number.

Answer 69

ICD-9 Code

Question 70

10th revision of the International Classification of Diseases. Uses 3 to 7 digit. Includes additional digits to allow more available codes. The U.S. Department of Health and Human Services has set an implementation deadline of October, 2013 for ICD-10.

Answer 70

ICD 10 Code

Question 71

Also referred to as fee-for-service. This is a type of commercial insurance were the patient can use any provider or hospital.

Answer 71

Indemnity

Question 72

An insurance plan in which a provider signs a contract to participate in. The provider agrees to accept a discounted rate for procedures.

Answer 72

In-Network (or Participating)

Question 73

Hospital care unit providing care for patients who need more than the typical general medical or surgical area of the hospital can provide. May be extremely ill or seriously injured and require closer observation and/or frequent medical attention.

Answer 73

Intensive Care

Question 74

Medicare Administrative Contractor.

Answer 74

MAC

Question 75

Insurance plan requiring patient to see doctors and hospitals that are contracted with the managed care insurance company. Medical emergencies or urgent care are exceptions when out of the managed care plan service area.

Answer 75

Managed Care Plan

Question 76

The maximum amount the insured is responsible for paying for eligible health plan expenses. When this maximum limit is reached, the insurance typically then pays 100% of eligible expenses.

Answer 76

Maximum Out of Pocket

Question 77

A provision of the 2009 HITECH act that provides stimulus money to providers who implement Electronic Health Records (EHR). Providers who implement EHR must show “Meaningful Use” and meet certain requirements defined in the act. The incentive is $63,750 over 6 years for Medicaid and $44,000 over 5 years for Medicare. Providers who do not implement EHR by 2015 are penalized 1% of Medicare payments increasing to 3% over 3 years.

Answer 77

Meaningful Use

Question 78

Medical service or procedure that is performed on for treatment of an illness or injury that is not considered investigational, cosmetic, or experimental.

Answer 78

Medical Necessity

Question 79

A unique number assigned by the provider or health care facility to identify the patient medical record.

Answer 79

Medical Record Number

Question 80

Medicare Secondary Payer.

Answer 80

MSP

Question 81

Tax exempt account for paying medical expenses administered by a third party to reimburse a patient for eligible health care expenses. Typically provided by employer where the employee contributes regularly to the account before taxes and submits claims or receipts for reimbursement. Sometimes also referred to in medical billing terminology as a Medical Spending Account.

Answer 81

Medical Savings Account

Question 82

The conversion of voice recorded or hand written medical information dictated by health care professionals (such as physicians) into text format records. These records can be either electronic or paper.

Answer 82

Medical Transcription

Question 83

Insurance provided by federal government for people over 65 or people under 65 with certain restrictions.

Answer 83

Medicare

Question 84

Medicare Hospital coverage

Answer 84

Medicare Part A

Question 85

Medicare Physicians visits and outpatient procedures

Answer 85

Medicare Part B

Question 86

Medicare Medicare insurance for prescription drug costs for anyone enrolled in Medicare Part A or B.

Answer 86

Medicare Part D

Question 87

Medical billing terminology for inpatient hospital coverage from day 61 to day 90 of a continuous hospitalization. The patient is responsible for paying for part of the costs during those days. After the 90th day, the patient enters “Lifetime Reserve Days.”

Answer 87

Medicare Coinsurance Days

Question 88

The gap or difference between the initial limits of insurance and the catastrophic Medicare Part D coverage limits for prescription drugs.

Answer 88

Medicare Donut Hole

Question 89

Insurance coverage for low income patients. Funded by Federal and state government and administered by states.

Answer 89

Medicaid

Question 90

Medicare supplemental health insurance for Medicare beneficiaries which may include payment of Medicare deductibles, co-insurance and balance bills, or other services not covered by Medicare.

Answer 90

Medigap

Question 91

Modifier to a CPT treatment code that provide additional information to insurance payers for procedures or services that have been altered or “modified” in some way. Modifiers are important to explain additional procedures and obtain reimbursement for them.

Answer 91

Modifier

Question 92

Non-Covered Charge. A procedure not covered by the patients health insurance plan.

Answer 92

N/C

Question 93

Not Elsewhere Classifiable. Medical billing terminology used in ICD when information needed to code the term in a more specific category is not available.

Answer 93

NEC

Question 94

Health care provider who is contracted with an insurance provider to provide care at a negotiated cost.

Answer 94

Network Provider

Question 95

When a healthcare provider chooses not to accept Medicare-approved payment amounts as payment in full.

Answer 95

Nonparticipation

Question 96

Not Otherwise Specified. Used in ICD for unspecified diagnosis.

Answer 96

NOS

Question 97

National Provider Identifier. A unique 10 digit identification number required by HIPAA and assigned through the National Plan and Provider Enumeration System (NPPES).

Answer 97

NPI Number

Question 98

Office of Inspector General – Part of department of Health and Human Services. Establish compliance requirements to combat healthcare fraud and abuse. Has guidelines for billing services and individual and small group physician practices.

Answer 98

OIG

Question 99

A provider that does not have a contract with the insurance carrier. Patients usually responsible for a greater portion of the charges or may have to pay all the charges for using an out-of network provider.

Answer 99

Out-of Network (or Non-Participating)

Question 100

The maximum amount the patient has to pay under their insurance policy. Anything above this limit is the insurers obligation. These Out-of-pocket maximums can apply to all coverage or to a specific benefit category such as prescriptions.

Answer 100

Out-Of-Pocket Maximum

Question 101

Typically treatment in a physicians office, clinic, or day surgery facility lasting less than one day.

Answer 101

Outpatient

Question 102

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

Answer 102

Patient Responsibility

Question 103

Primary Care Physician – Usually the physician who provides initial care and coordinates additional care if necessary.

Answer 103

PCP

Question 104

Point-of-Service plan. Medical billing terminology for a flexible type of HMO (Health Maintenance Organization) plan where patients have the freedom to use (or self-refer to) non-HMO network providers. When a non-HMO specialist is seen without referral from the Primary Care Physician (self-referral), they have to pay a higher deductible and a percentage of the coinsurance.

Answer 104

POS

Question 105

Place of Service. Medical billing terminology used on medical insurance claims – such as the CMS 1500 block 24B. A two digit code which defines where the procedure was performed. For example 11 is for the doctors office, 12 is for home, 21 is for inpatient hospital, etc.

Answer 105

POS (Used on Claims)

Question 106

Preferred Provider Organization. Commercial insurance plan where the patient can use any doctor or hospital within the network. Similar to an HMO.

Answer 106

PPO

Question 107

software used for the daily operations of a providers office. Typically used for appointment scheduling and billing.

Answer 107

Practice Management Software

Question 108

Requirement of insurance plan for primary care doctor to notify the patient insurance carrier of certain medical procedures (such as outpatient surgery) for those procedures to be considered a covered expense.

Answer 108

Preauthorization

Question 109

Sometimes required by the patients insurance company to determine medical necessity for the services proposed or rendered. This doesn’t guarantee the benefits will be paid.

Answer 109

Pre-Certification

Question 110

Maximum payment insurance will pay towards surgery, consultation, or other medical care – determined before treatment.

Answer 110

Predetermination

Question 111

A medical condition that has been diagnosed or treated within a certain specified period of time just before the patients effective date of coverage. A Pre-existing condition may not be covered for a determined amount of time as defined in the insurance terms of coverage (typically 6 to 12 months).

Answer 111

Pre-existing Condition (PEC)

Question 112

When insurance coverage is denied for the insured when a pre-existing medical condition existed when the health plan coverage became effective.

Answer 112

Pre-existing Condition Exclusion

Question 113

The amount the insured or their employer pays (usually monthly) to the health insurance company for coverage.

Answer 113

Premium

Question 114

The HIPAA privacy standard establishes requirements for disclosing what the HIPAA privacy law calls Protected Health Information (PHI). PHI is any information on a patient about the status of their health, treatment, or payments.

Answer 114

Privacy Rule

Question 115

An individuals identifying information such as name, address, birth date, Social Security Number, telephone numbers, insurance ID numbers, or information pertaining to healthcare diagnosis or treatment.

Answer 115

Protected Health Information (PHI)

Question 116

Physician or medical care facility (hospital) who provides health care services.

Answer 116

Provider

Question 117

Provider Transaction Access Number. Also known as the legacy Medicare number.

Answer 117

PTAN

Question 118

When one provider (usually a family doctor) refers a patient to another provider (typically a specialist).

Answer 118

Referral

Question 119

A document supplied by the insurance payer with information on claims submitted for payment. Contains explanations for rejected or denied claims. Also referred to as an EOB (Explanation of Benefits).

Answer 119

Remittance Advice (R/A)

Question 120

The person responsible for paying a patients medical bill. Also referred to as the guarantor.

Answer 120

Responsible Party

Question 121

Medical billing terminology for a 3-digit number used on hospital bills to tell the insurer where the patient was when they received treatment, or what type of item a patient received.

Answer 121

Revenue Code

Question 122

Relative Value Amount. This is the average amount Medicare will pay a provider or hospital for a procedure (CPT-4). This amount varies depending on geographic location.

Answer 122

RVU

Question 123

Process of checking an insurance claim for errors in the health insurance claim software prior to submitting to the payer.

Answer 123

Scrubbing

Question 124

When a patient sees a specialist without a primary physician referral.

Answer 124

Self-Referral

Question 125

Payment made at the time of service by the patient.

Answer 125

Self Pay

Question 126

claim for insurance coverage paid after the primary insurance makes payment. Secondary insurance is typically used to cover gaps in insurance coverage.

Answer 126

Secondary Insurance Claim

Question 127

When a second CPT procedure is performed during the same physician visit as the primary procedure.

Answer 127

Secondary Procedure

Question 128

Provides guidance for developing and implementing policies and procedures to guard and mitigate compromises to security. The HIPAA security standard is kind of a sub-set or compliment to the HIPAA privacy standard. Where the HIPAA policy privacy requirements apply to all patient Protected Health Information (PHI), HIPAA policy security laws apply more specifically to electronic PHI.

Answer 128

Security Standard

Question 129

A nursing home or facility for convalescence. Provides a high level of specialized care for long-term or acutely ill patients. A Skilled Nursing Facility is an alternative to an extended hospital stay or home nursing care.

Answer 129

Skilled Nursing Facility

Question 130

Signature on File.

Answer 130

SOF

Question 131

Physician who specializes in a specific area of medicine, such as urology, cardiology, orthopedics, oncology, etc. Some healthcare plans require beneficiaries to obtain a referral from their primary care doctor before making an appointment to see a Specialist.

Answer 131

Specialist

Question 132

Medical billing term to describe the employee for group policies. For individual policies the subscriber describes the policyholder.

Answer 132

Subscriber

Question 133

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 used ICD-9 diagnosis and CPT procedural codes. One of the most frequently used medical billing terms.

Answer 133

Superbill

Question 134

Additional insurance policy that covers claims fro deductibles and coinsurance. Frequently used to cover these expenses not covered by Medicare.

Answer 134

Supplemental Insurance

Question 135

Treatment Authorization Request. An authorization number given by insurance companies prior to treatment in order to receive payment for services rendered.

Answer 135

TAR

Question 136

Specialty standard codes used to indicate a providers specialty sometimes required to process a claim.

Answer 136

Taxonomy Code

Question 137

Date the insurance contract expired or the date a subscriber or dependent ceases to be eligible.

Answer 137

Term Date

Question 138

Claim for insurance coverage paid in addition to primary and secondary insurance. Tertiary insurance covers gaps in coverage the primary and secondary insurance may not cover.

Answer 138

Tertiary Insurance Claim

Question 139

An independent corporate entity or person (third party) who administers group benefits, claims and administration for a self-insured company or group.

Answer 139

Third Party Administrator (TPA)

Question 140

Tax Identification Number. Also known as Employer Identification Number (EIN).

Answer 140

TIN

Question 141

Triple Option Plan. An insurance plan which offers the enrolled a choice of a more traditional plan, an HMO, or a PPO. This is also commonly referred to as a cafeteria plan.

Answer 141

TOP

Question 142

Type of Service. Description of the category of service performed.

Answer 142

TOS

Question 143

This is federal health insurance for active duty military, National Guard and Reserve, retirees, their families, and survivors. Formerly know as CHAMPUS.

Answer 143

TRICARE

Question 144

Claim form for hospitals, clinics, or any provider billing for facility fees similar to CMS 1500. Replaces the UB92 form.

Answer 144

UB04

Question 145

Submitting several CPT treatment codes when only one code is necessary.

Answer 145

Unbundling

Question 146

Medical claim submitted after the time frame allowed by the insurance payer. Claims submitted after this date are denied.

Answer 146

Untimely Submission

Question 147

An illegal practice of assigning an ICD-9 diagnosis code that does not agree with the patient records for the purpose of increasing the reimbursement from the insurance payor.

Answer 147

Upcoding

Question 148

Unique Physician Identification Number. 6 digit physician identification number created by CMS. Discontinued in 2007 and replaced by NPI number.

Answer 148

UPIN

Question 149

The allowable coverage limits (fee schedule) determined by the patients insurance company to limit the maximum amount they will pay for a given service or item as defined in the contract with the patient.

Answer 149

Usual Customary & Reasonable(UCR)

Question 150

The limits that Medicare sets on how many times certain services can be provided within a year. The patients claim can be denied if the services exceed this limit.

Answer 150

Utilization Limit

Question 151

Review or audit conducted to reduce unnecessary inpatient or outpatient medical services or procedures.

Answer 151

Utilization Review (UR)

Question 152

ICD-9-CM coding classification to identify health care for reasons other than injury or illness.

Answer 152

V-Codes

Question 153

Insurance claim that results from a work related injury or illness.

Answer 153

Workers Comp

Question 154

Typically reference to the difference between what the physician charges and what the insurance plan contractually allows and the patient is not responsible for. May also be referred to as “not covered” in some glossary of billing terms.

Answer 154

Write-off