Definitions Flashcards
Terminology/Abvs
Practice
Services provided for the business
(eg. PT/OT/ABA)
Clinic
Location of the business
(eg. Good Shepherd)
Business
The term for the operation encompasses the financial/management aspects
(Can include multiple practices and/or clinics.)
Outpatient
Patients receiving care outside of the hospital setting
(Therapy/Rehab post hospital/ppc treatment)
Inpatient
Patients receiving care inside the hospital setting
(Not a good fit for RT - Care-homes, Skilled Nursing Facilities [SNF} etc.)
Home Health
Broad term for delivery of care outside of a traditional clinic or office
(dig deeper in convo)
Medicare (A)
Med Services delivered by [MD,RN, BSN, CNP]. Inpatient hospital stays, care in SNF, hospice, HH.
(Not a good fit for RT)
Medicare (B)
Med Services NOT delivered by [MD, RN, BSN, CNP]. Covers services, outpatient care, and other services not provided in (A), but necessary.
(eg. Therapy, nutrition, well checks, counseling, etc… Good fit for RT)
Medicare
Medical coverage provided by the Federal Gov for people 65< ; some younger w/ disabilities.
(eg. Social security)
Medicaid
Coverage provided by the state gov and partially financed by the fed gov. Nations public health insurance for people w/ lower income.
(covers 1/5 Americans)
Electronic Medical Record (EMR)
Term used for medical/clinical record for a specific specialty/practice.
Electronic Health Record (EHR)
Historical medical record for all EMR records.
(eg. interchangeably with EMR)
Practice Management (PM)
Part of the software that runs the practice/business
Scheduler
Manages clinic practice schedule
Clinical Notes
Medical notes on the patient EMR
(from PCP - outpatient practice)
Reporting
Aspect of the PM that creates reports on data within the EMR/PM
(eg patients progress throughout the treatment)
Billing & Collections
Managing AR process (Accounts Receivables). Sends claims to a payor via a clearinghouse
Clearinghouse
Term for a data exchange between payor and billing system
Revenue Cycle Management (RCM)
General term for the entire Billing & Collection process
In-house Billing
Business/Practice has its own internal staff managing the RCM process
Outsourced Billing
Business/practice outsources some or all of the RCM to a third party.
(usually for a fee ranging from 2-7%)
Health Language 7 (HL7)
A data connection between two systems using a defined language. Critical part of the interoperability requirements in the healthcare industry
defined by:
HHS - Health & Human services
CMS - Centers for Medicare & Medicaid Services
Interoperability
Ability of two systems to exchange data
Drummond Certification (ONC-ACB)
Third party certification company that reviews software for specific functionality, interoperability, security etc.
ONC - Office of the National Coordinator for Health Info Tech
ABC - Authorized Certification Body
(raintree is ONC-ACB certified)
Claim
Bill sent to a payor for medical service
CMS/HCFA 1500
(“hic-fa)
It’s the work of the (CMS), which is devised to facilitate Medicare & Medicaid reimbursements. Standard health insurance claim form used for submitting physician & professional claims to bill Medicare providers.
(CMS-1500 is used for individual provider claims and is used to submit charges under Medicare Part-B. )
837,271,835,270,275
Electronic file types that contains patient claim information. Different file types are used in certain situations or for a specific purpose
(eg. 837 file is called a Transaction Set. This file is submitted to an insurance company or to a clearinghouse instead of printing and mailing a paper claim)
UB04 (CMS-1450)
All institutional providers may use the UB-04 form to bill claims, such as hospitals, specialists, mental health centers, hospices, rehabs, organ procurement organizations and therapy services. This is the standard health insurance claim form used for submitting physician and professional claims to bill Medicare providers.
American National Standards Institute Claim File (ANSI)
Specific claim file format used universally by all billing systems, clearinghouses and payors. ANSI is the main organization supporting the development of technology standards in the United States.
ANSI works with industry groups, and it is a U.S. member of the International Organization for Standardization (ISO) and the International Electrotechnical Commission (IEC). There is an ANSI format for all claim types
Adult Therapy
Therapy Services provided to Adults:
Physical Therapy (PT)
Occupation Therapy (OT)
Speech-Language Pathology (SLP)
Physical Therapy (PT)
The treatment of disease, injury, or deformity by physical methods such as massage, heat treatment, and exercise rather than by drugs or surgery.
Occupational Therapy (OT)
A form of therapy for those recuperating from physical or have developmental disability that encourages rehabilitation through the performance of activities required in daily life
Speech-Language Pathology / Speech Therapy (SLP)
Prevents, assesses, diagnoses, and treats speech, language, social communication, cognitive-communication, and swallowing disorders in children and adults.
Applied Behavior Analysis (ABA)
Therapy is based on the science of learning and behavior. ABA seeks to understand how behavior works, how behavior is affected by the environment, how learning takes place (they primarily work with Autistic kids)
Audiology
the branch of science and medicine concerned with the sense of hearing. Often used in conjunction with Speech Therapy
SOAP Note
The Subjective, Objective, Assessment and Plan (SOAP) note is an acronym representing a widely used method of documentation for healthcare providers. The SOAP note is a way for healthcare workers to document in a structured and organized way.
Clinical Note- RT
The clinical note is the primary tool used to document care, communicate plans and provide guidance for follow-up treatment and care. Gaps in the quality of clinical documentation could, therefore, adversely affect patient care and health care outcomes.
Claim Queue
The dashboard showing all claims and where they are in the RCM process. The claim que is essentially the work tasks for a biller that tells them what work needs to be done on a specific claim in order for it to be processed and eventually paid
Exceptions-Based RCM (Raintree)
An RCM process that simplifies the work for a Biller by showing claims that are outside of the “expected”. Usually, this is for claims that haven’t been paid within the expected time frame or under/overpaid based on the expected amount
Account-Based RCM
An RCM process that shows all claims for an account or patient regardless of where the claim is in the RCM process
Patient Engagement (Connect)
“Patient engagement” is a broader concept that combines patient activation with interventions designed to increase activation and promote positive patient behavior, such as obtaining preventive care or exercising regularly.
Lead
an unqualified contact
Prospect
qualified contact who has been moved into the sales process
Marketing Qualified Leads (MQL)
Leads that generally fit into the target market but haven’t been fully qualified yet
Sales Qualified Lead (SQL)
Marketing Qualified Leads that have been qualified and will become a prospect
Sales Accepted Lead (SAL)
Sales Qualified Leads that have been fully qualified and accepted by Sales and is now an Opportunity
Visits (VPM)
General term used for when a patient is seen by a provider. These are “billable” events for which the business can charge the patient or payor
Units
When submitting a claim, the payor receives the visit info and is converted to “units”. Each healthcare industry uses different medical billing services and codes. In this system, each unit represents the specific amount of time the therapist spent providing treatment.
CPT Codes
A billing unit describes the number of times you performed the service for a patient
A CPT code allows you to correctly describe and bill for the time you spent treating a patient.
Service-based time codes are for treatments that don’t require the continuous presence of the therapist, like an evaluation.
You can only bill these services once, no matter how much time you spend performing them.
Payor
Term for the organization or businesses that pay for services.
(eg. Medicare, Medicaid, private insurance, Blue Cross, Aetna, Kaiser, Tricare, etc)
Commercial Insurance
Private insurance (Blue Cross, Aetna, Kaiser, etc)
Cloud Based
AWS (Amazon) cloud services. No installed software except for the thin-client. EMR is browser-based
Browser-Based
EMR is accessed through a common browser (Chrome, Edge, Safari, etc)
MIPS
(Merit-Based Incentive Payment System)
MIPS is the program that will determine Medicare payment adjustments. Using a composite performance score, eligible clinicians (ECs) may receive a payment bonus, a payment penalty or no payment adjustment.
EVV
(Electronic Visit Verification)
Required in some instance to ensure that the location of service is correct. Required on a state by state basis
