vocabulary Flashcards
coding and billing specialist
is a healthcare professional that organizes, manages, and codes health information data
Medical coding specialist
assign numeric or alphanumeric codes to the information obtained from a patient’s visit to a medical facility
medical billing specialist
uses codes to complete insurance forms
scope of practice
competency standards, code of ethics, as well as conduct that the practice and public need, demand, and expect
*working outside your scope of practice is grounds for disciplinary action by the facility you work for or by your licensing agency
standard of care
level at which is an ordinary, prudent professional having the same training would practice under the same or similar circumstances
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 patients admitted for a variety of medical conditions
outpatient setting
may be a provider’s office, urgent care center, emergency department or an outpatient surgical facility
physician
a person qualified to practice medicine
Registered Nurse (RN)
has completed an associate degree in nursing (ADN) or a bachelor of science in nursing (BSN) and has taken a test that is required to earn RN credentials.
Licensed Practical Nurse (LPN)
Must pass a licensure exam from the National Council of State Boards of Nursing in order to work as an LPN in the United States.
Certified Nursing Assistant (CNA)
works under the supervision of RN’s or LPN’s. CNAs do not generally need any additional licensure to pursue employment, but they can obtain additional credentials if desired.
Advanced practice provider (APP)
refers to nurse practitioners and physician assistants, as well as other licensed nonphysician providers, including certified nursing midwives, clinical nurse specialist and certified registered nurse anesthetist.
Nurse Practitioner (NP)
Specialized healthcare providers who have training and expertise to care for patients; they provide direct care and coordinate care.
Physician Assistants (PAs)
Medical professionals who diagnose illnesses, develop and manage treatment plans, prescribe medications and often serve as a patient’s principal healthcare provider
Case Manager
oversees the collaborative process of assessment, planning, facilitation, care coordination, evaluation and advocacy for options and services to meet an individual’s and family’s comprehensive health and needs through communication and available resources to promote safety, quality of care and cost effective outcomes. The case manager develops the plan of care for the client with the assistance of other healthcare professionals and the caregiver follows this plan when working with the client.
Case Manager
oversees the collaborative process of assessment, planning, facilitation, care coordination, evaluation and advocacy for options and services to meet an individual’s and family’s comprehensive health and needs through communication and available resources to promote safety, quality of care and cost effective outcomes. The case manager develops the plan of care for the client with the assistance of other healthcare professionals and the caregiver follows this plan when working with the client.
Physical Therapist
specialist who aids in a patients rehabilitation. also known as physiatrists
Physical Therapy
type of patient therapy that focuses on helping patients recover physical strength, movement and function after an injury or illness.
speech-language pathologists (SLP’s)
assists patients of all ages with swallowing and communication difficulties. They work with patients who have a variety of diagnoses, including traumatic brain injury and stroke
Emergency Personnel
group of professionals with the sole responsibility of providing immediate medical assistance and transporting the patient to the hospital for treatment
Occupational therapy (OT)
seeks to restore a patient’s ability to live independently and to preform activities of daily living.
EMT’s
take classes that enable them to stabilize patients who have a wide variety of emergency conditions. They are often members of ambulance crews and volunteer fire-fighting organizations.
Paramedics
not only stabilize the patients, but they can also begin treatments to cure patients, such as administering medication.
Medical Assistant (MA)
Preforms administrative and clinical duties
Health Services Manager
oversees the services a healthcare facility provides, and might work for a group of physicians who have offices in several locations
Patient Care Technicians (PCT’s)
assist patients with eating, dressing, bathing, skin care, and walking. They also turn, reposition, and transfer patients between beds and wheelchairs.
Home care aides
are PCT’S who visit clients’ homes to assist them with activities they can no longer perform alone.
Pharmacy
the science of preparing and dispensing medications and information about the medications.
Pharmacist
professionals who perform these services, ensuring that people receive the proper medications for their health problems, and providing information about these medications.
Pharmacologists
research drugs and the ways drugs act in the human body. They also develop new drugs and demonstrate that these drugs are safe and effective for patients.
Pharmacy Technician
performs pharmacy-related functions, working under the direct supervision of a licensed pharmacist
medical transcriptionist
listens to the doctor’s dictation and types what she hears and then adds it to the patient’s medical record.
medical editors
listen to the doctor’s spoken notes while editing rough reports that a speech recognition program produced based on the doctors’ dictation
electronic medical records (EMR) specialist
trained to organize and manage patient health data in digital and hard-copy formats, ensuring the quality, accuracy, accessibility, and security of this critical documentation.
Professionalism
conduct, aim, or qualities that characterize a profession or professional person.
Presentation
is the act of bringing or introducing something into the presence of someone else.
adaptability
the ability to be modified or changed.
Insurance
refers to the contract between an insurance company also called the carrier or insurer, and an individual or a group which is also called the insured.
medical insurance
also called health insurance or healthcare coverage, is a contract between an insurance company and the insured for medical benefits.
policy
a contract that in the case of certain injuries or illnesses, the insurance carrier will pay some or all of the medical bills of the insured.
premiums
in exchange for coverage, the insurance carrier collects payments from the insured. Premiums are paid in advance, either monthly, quarterly, semi-annually, depending on the contract between the carrier and the insured.
Benefits
when an insurance carrier pays for medical treatment based on a policy
Reimbursement
in healthcare refers to the compensation or repayment for healthcare services
first-party
patient, or person responsible for the patient’s health bill
guarantor
someone who is responsible for an account
second-party
physician, clinic, or hospital. This group is often known as the provider because it provides the health care.
third-party payer
an organization other than the patient or healthcare provider involved in the financing of personal health services.
participating providers
when physicians enter into contracts with specific companies.
allowable charge
maximum amount an insurance carrier will pay for specific service.
Deductible
the amount of money an individual must pay before insurance benefits begin.
co-payment
flat amount of money paid by the paitent
explanation of benefits (EOB)
is a document that explains how much the insurance company paid and how much is disallowed. it may include payment from one patient or several patients. always check each patient’s name, dates of service, procedures billed for, the amounts billed, the amounts allowed, deductibles, co-payment amounts and the amount paid on each individual claim.
Preauthorization
the process of notifying an insurance company before hospitalization, surgery, or tests
visitation limits
set number of visits to a specialist that a patient may make or the number of special treatments a patient may have
claim form
is the document that is completed and submitted to an insurance carrier to request reimbursement for services rendered.
CMS-1500
standard claim form used to request payment for services rendered by the healthcare provider.
UB-04
Also known as CMS-1450 is the uniform claim form used in hospitals and other inpatient settings.
diagnosis
physician’s opinion about what’s wrong with a patient
Procedure
anything a physician does to determine a diagnosis and treat a patient.
medical coding
is the translation of medical record documentation of illnesses, diseases, injuries, treatments and procedures into numeric and alphanumeric characters.
CPT
The current procedural terminology manual, developed and maintained by the American Medical Association, contains codes that describe the procedures and services performed by the provider for outpatient services. CPT codes are then used by insurers to determine the amount of reimbursement for the provider. Within the CPT manual, there are category I,II,III codes
Category I codes
include all of the “regular” CPT codes in the six main sections of the manual. These are all five-digit codes
Category II codes
special collection of CPT codes that providers use to track and measure performance internally. Insurance companies do not use these codes to determine reimbursement. Instead, physicians use them to see just how much work they do in certain situations. These codes are optional.
Category III codes
temporary codes. these codes unlike category I codes are listed in numeric order, not by anatomic location. After five years, if an emerging technology code is not accepted for placement in the category I section of the CPT manual, it may be renewed for another five years by the actions of the CPT editorial panel. otherwise it will be removed.
HCPCS Level II
the center for medicare and medicaid services (CMS) developed the Healthcare Common Procedure Coding System, Level II to carry out the operational needs of the medicare reimbursement system. the codes consist of five-digit alphanumeric codes for physician and nonphysician services that the CPT manual does not cover. These codes include drugs, durable medical equipment, ambulance services and prosthetic procedures.
ICD-10-CM
The International Classification of Diseases, 10th Revision, Clinical Modification manual is the system to determine diagnostic codes for both inpatient and outpatient services. It is an alphanumeric classification system. A valid code may be between three and seven characters, with a decimal after the third character.
ICD-10-PCS
The International Classification of Diseases, 10th Revision, Procedural Coding System manual is the system for inpatient procedures. It is a seven-character, alphanumeric code system using digits 0 through 9 and letters A through H, J through N and P through Z, with no decimal.
Encounter Form
also known as a super bill, is a template of commonly used codes that may be used in a specific practice that serves as a communication device between the physician and medical billing specialist
CMS
Centers for Medicare and Medicaid Services is a branch of the U.S Department of Health and Human Services and is the administrator for Medicaid and Medicare. It mainly acts as a purchaser of healthcare services for the Medicaid and Medicare programs. The agency also assures that contractors and state agencies properly administer Medicaid and Medicare, assesses the quality of healthcare services and establishes polices for reimbursement to healthcare providers.
Medicare
federally administered, federally funded health insurance program for people age 65 or older, people under age 65 with certain disabilities and people of all ages with end-stage renal disease.
Medicare Part A
generally pays for medically necessary inpatient care in a general hospital, skilled nursing facility care, home health care and nursing home care. Medicare Part A is financed by the Social Security payroll withholding tax paid by workers and their employers. They don’t have to pay premium.
