Terms and Explanations Flashcards
What does “PA” stand for?
Physician Assistant
What does “EMT” stand for?
Emergency Medical Technician
What does “PCT” stand for?
Patient Care Technician
What does “EHRs” stand for?
Electronic Health Records
What’s another name for “Insurance?”
Carrier
What’s another name for “Medical Insurance?”
Health Insurance / Healthcare Provider
Define: First-Party
Patient / Guarantor
Define: Second-Party
Provider / Physician, Clinic or Hospital
Define: Third-Party
Insurance company for whom a claim has been submitted for repayment.
Define: Policy
A contract that states in the case of certain injuries or illnesses, the insurance carrier will pay some or all of the medical bills of the insured.
Define: Premiums
Payments made in advance, either monthly, quarterly, semi-annually or annually.
Define: Benefits
When an insurance company pays for medical treatment based on a policy.
Define: Reimbursement
The compensation or repayment for healthcare services.
Define: Participating Providers
“Contracted” physicians working with specific insurance companies.
Define: Allowable Charge
The maximum amount an insurance carrier will pay for a specific service; agreed to and accepted by participating providers.
Define: Usual, Customary and Reasonable
The maximum amount the insurer will consider eligible, for services rendered.
Define: Inpatient Setting
A facility, other than psychiatric, that provides diagnostic, therapeutic (both surgical and non-surgical) and rehabilitation services by or under the supervision of physicians to admitted patients.
Define: Outpatient Setting
A provider’s office, urgent care center, emergency department or an outpatient surgical facility.
Who composes the “Chief Complaint?”
A physician
What is a “Chief Complaint?”
A concise statement that describes why a patient is seeking treatment.
Define: Diagnosis
The physician’s opinion about what is wrong with the patient or what is causing the patient’s complaint.
Define: Procedure
Anything the physician does to determine a diagnosis and help the patient heal.
What do Nurses do?
Follow through with treatments physicians prescribe, give injections, check a patient’s vital signs, as well as assist in surgery.
What do Nurse’s Assistants do?
Help nurses with daily duties, such as paperwork, general organization and taking a patient’s temperature, weight and blood pressure.
What do EMTs do?
Stabilize patients who have a wide variety of emergency medical conditions.
What do Paramedics do?
Stabilize patients, and begin treatments to cure patients, such as administering medication.
What are the two duties of a Medical Assistant?
Administrative and Clinical.
What are the 5 basic responsibilities of a Health Document Specialist?
1) Transcribe/Edit Dictation. 2) Code Records. 3) Complete and Submit Insurance Claim Forms. 4) Follow-Up on Claims and Bills. 5) Secondary Insurance Claims and Patient Billing.
What is “The Customary Maximum?”
The fee charged by most providers in the community.
What is a “Fixed Fee Schedule?”
A predetermined dollar amount covered by the insurance company for a specific medical service or procedure.
Define: Deductible
The dollar amount an individual must pay before insurance benefits begin.
Define: Copayment
A flat amount of money paid by the patient, usually at the time of service.
What does “EOB” stand for?
Explanation of Benefits: A document that explains how much the insurance company paid and how much is disallowed.
What is Preauthorization?
The process of notifying an insurance company before hospitalization, surgery or tests.
What are Visitation Limits?
A set number of “visits” to a specialist that a person may make, or the number of special treatments a patient may have, such as physical therapy sessions. Insurance companies set them.
What is the CMS-1500?
The standard claim form used to request payment for services rendered by the healthcare provider. Usually, used by physician’s offices and government programs.
What is the UB-04?
The uniform claim form used in hospitals and other inpatient settings.
What is Medical Coding?
The translation of medical record documentation of illnesses, diseases, injuries, treatments and procedures into numeric and alphanumeric characters.
What is the IDC-9-CM stand for, and what is it?
International Classification of Diseases, 9th Revision, Clinical Modification: A manual used to determine diagnostic codes for both inpatient and outpatient services, as well as inpatient procedures.
What does “CPT” stand for, and what is it?
Current Procedural Terminology: A manual developed and maintained by the American Medical Association (AMA), containing codes that describe the procedures and services performed by the provider for outpatient services.
What are Category I Codes?
5-Digit codes that include all “regular” CPT codes in the six main sections of the manual.
What are Category II Codes?
A special collection of CPT codes that providers use to track and measure performance internally. Insurance companies do no use these codes to determine reimbursement. Instead, physicians use them to see just how much work they do in certain situations. (Category II Codes are optional.)
What are Category III Codes?
Temporary codes, unlike Category I Codes, listed in numeric order, not by anatomic location. (They are removed from the CPT Manual after a maximum of two 5-years terms if they are not adopted.)
What is CMS and who administers it?
Center for Medicare and Medicaid Services. Administered by the U.S. Department of Health and Human Services (HHS).
What is the HCPCS Level II?
Healthcare Common Procedure Coding System Level II: 5-digit, alphanumeric codes developed for physician and non-physician services that the CPT manual does not cover. These codes include drugs, durable medical equipment, ambulance services and prosthetic procedures.
