RCM: 15 Day Terminology to Know

Question 1

Accounts Receivable Reports

Answer 1

Shows payments billed but not paid by month or quarter and by payer and/or service delivery site.

Question 2

Allowances and Adjustments

Answer 2

Allowances are an adjustment made to gross charges based on the contractual amount a practice is paid by each insurance company for the service or supply charged on a bill. Also called a “contractual allowance”, the practice of applying allowances to the accounts receivable (see definition) adjusts the amount projected for collection by the service provider so that staff can accurately monitor revenue received compared to adjusted charges.

Question 3

Capitation Payments

Answer 3

Traditionally used by HMOs and other managed care organizations, capitation payments are monthly payments made by insurers to primary care providers for patients assigned to/enrolled in their care.

Question 4

Chargemaster or Charge Description Master (CDM)

Answer 4

A table consisting of all visit types and procedures and items a practice offers/uses. It includes a description of the activity or item, a CPT or HCPCS code and a dollar amount that is considered the “charge” for performing that service or providing that supply.

Question 5

Charges

Answer 5

Once set in a chargemaster, charges are used in the management of the accounts receivable for the service provider. Charges are referred to as Full or Gross charges if they have not been adjusted in any way, and are the top rate billed to any patient or insurer when a fee scale or contract is not in place.

Question 6

Chief Complaint

Answer 6

Concise statement describing the symptom, problem, condition, diagnosis, or other factor that is the reason for the patient encounter, usually stated in the patient’s own words.

Question 7

Claim

Answer 7

A request for payment under the terms of an insurance policy.

Question 8

CMS 1500

Answer 8

The official standard form used by physicians and other providers when submitting bills/claims for reimbursement to Medicare or Medicaid for health services. It is also used by private insurers and managed care plans. CMS 1500 contains patient demographics, diagnostic codes, CPT/HCPCS codes, diagnosis codes, units, etc.

Question 9

Coinsurance

Answer 9

The percentage that you must pay to share responsibility for your medical claims after you meet your annual deductible.

Question 10

Co-payment

Answer 10

A flat fee that you must pay toward the cost of medical visits, your insurance provider pays the remaining balance.

Question 11

Current Procedural Terminology (CPT)

Answer 11

A system developed by the American Medical Association for standardizing the terminology and coding used to describe medical services and procedures.

Question 12

Deductible

Answer 12

The annual amount of money you must pay out of pocket for medical expenses before your insurance kicks in and starts to make payments.

Question 13

Denial

Answer 13

Claim that is not paid by an insurance carrier. Denials can be made for many reasons: non-credentialed provider, client not insured on date of service, service not covered, prior authorization needed but not on claim, etc.

Question 14

Dependent

Answer 14

A person for whom the insured has some legal obligation to. For most plans, it is the insured’s spouse and/or children.

Question 15

Diagnosis Code (ICD-10)

Answer 15

Alphanumeric codes used to identify diagnoses for the purposes of computer storage. In combination with CPT codes, these are used to determine payment by Medicare, Medicaid Managed Care plans, commercial insurance plans and some Medicaid programs. (See also ICD and CPT).

Question 16

Effective Date

Answer 16

Electronic billing occurs when claims are sent from a provider to an insurer electronically from their practice management system or a billing module within their Electronic Health Record system.

Question 17

Evaluation and Management

Answer 17

Describes the medical visit a patient has with clinician; E/M, Medical Visit, Evaluation and Management are terms used interchangeably.

Question 18

Excluded Services

Answer 18

Health care services that your health insurance or plan does not pay for or cover.

Question 19

Explanation of Benefits (EOB)

Answer 19

A letter that goes to an insured person when a claim is filed with the insurance company for services. Primarily created for fraud prevention, EOBs are used consistently by some plans in some states; in other states or companies, the usage varies from random to occasional.

Question 20

Health Maintenance Organization (HMO)

Answer 20

A health care financing and delivery system that provides comprehensive health care for subscribing members in a particular geographic area using managed care techniques.

Question 21

Health Savings Account (HSA)

Answer 21

Plan that allows you to contribute pre-tax money to be used for qualified medical expenses.

Question 22

International Statistical Classification of Diseases (ICD-10)

Answer 22

A coding of diseases and signs, symptoms, abnormal findings, complaints, social circumstances and external causes of injury or diseases, as classified by the World Health Organization (WHO).

Question 23

Modifier

Answer 23

A two-digit code that can be put on a claim next to a CPT code for the purpose of affecting the allowed payment (commonly results in an increased allowed payment).

Question 24

Network

Answer 24

A group of doctors, hospitals and other health-care providers contracting with a health plan, usually to provide care at special rates and to handle paperwork with the health plan.

Question 25

Out-of-Network

Answer 25

Health care services received outside the HMO, POS or PPO network.

Question 26

Out-of-Pocket Expense

Answer 26

Any medical care costs not covered by insurance, which must be paid by the insured.

Question 27

Patient Type

Answer 27

Definition of patients based on frequency of service. New patient - an individual who has NOT received any professional services from the physician/non-physician practitioner (NPP) or another physician of the same specialty who belongs to the same group practice within the previous three years; Existing Patient – an individual who has received a service within the last 3 years.

Question 28

Premiums

Answer 28

The monthly or annual amount that you must pay in order to have the insurance coverage.

Question 29

Prescription Drug Coverage (Rx)

Answer 29

A type of specified expense coverage that provides benefits for the purchase of drugs and medicines prescribed by a physician and not available over-the-counter.

Question 30

Primary Care Physician (PCP)

Answer 30

A general or family practitioner who serves as the insured’s personal physician and first contact with a managed care system.

Question 31

Primary Diagnosis

Answer 31

Code assigned to the diagnosis, condition, problem, or other reason shown in the documentation to be chiefly responsible for services provided.

Question 32

Remittance (Paper or Electronic)

Answer 32

Information included with the payment from an insurer that describes what services and payments are included in the payment sent to the provider.

Question 33

Renewal Date

Answer 33

The specified date of when the health insurance coverage will renew for another period, typically one year.

Question 34

Revenue Cycle Management (RCM)

Answer 34

A process of reviewing and monitoring every step of the coding, billing, collection, posting and denial management processes for collecting revenue.