Coding - healing Billing Terms and healing Coding Terminology
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healing Billing Terms and healing Coding Terminology
Those in curative billing and coding careers have a terminology of unique terms and abbreviations. Below are some of the more oftentimes used curative Billing terms and acronyms. Also included is some curative coding terminology.
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Aging - Refers to the unpaid insurance claims or inpatient balances that are due past 30 days. Most curative billing software's have the ability to create a isolate description for insurance aging and inpatient aging. These reports typically list balances by 30, 60, 90, and 120 day increments.
Appeal - When an insurance plan does not pay for treatment, an motion (either by the provider or patient) is the process of formally objecting this judgment. The insurer may want further documentation.
Applied to Deductible - Typically seen on the inpatient statement. This is the number of the charges, considered by the patients insurance plan, the inpatient owes the provider. Many plans have a maximum annual deductible that once met is then covered by the insurance provider.
Assignment of Benefits - insurance payments that are paid to the physician or hospital for a patients treatment.
Beneficiary - person or persons covered by the health insurance plan.
Clearinghouse - This is a aid that transmits claims to insurance carriers. Prior to submitting claims the clearinghouse scrubs claims and checks for errors. This minimizes the number of rejected claims as most errors can be verily corrected. Clearinghouses electronically send claim data that is compliant with the strict Hippa standards (this is one of the curative billing terms we see a lot more of lately).
Cms - Centers for Medicaid and Medicare Services. Federal branch which administers Medicare, Medicaid, Hippa, and other health programs. Once known as the Hcfa (Health Care Financing Administration). You'll notice that Cms it the source of a lot of curative billing terms.
Cms 1500 - curative claim form established by Cms to submit paper claims to Medicare and Medicaid. Most commercial insurance carriers also want paper claims be submitted on Cms-1500's. The form is distinguished by it's red ink.
Coding -Medical Billing Coding involves taking the doctors notes from a inpatient visit and translating them into the allowable Icd-9 code for pathology and Cpt codes for treatment.
Co-Insurance - percentage or number defined in the insurance plan for which the inpatient 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 inpatient pays 20%.
Co-Pay - number paid by inpatient at each visit as defined by the insured plan.
Cpt Code - Current Procedural Terminology. This is a 5 digit code assigned for reporting a course performed by the physician. The Cpt has a corresponding Icd-9 pathology code. Established by the American curative Association. This is one of the curative billing terms we use a lot.
Date of aid (Dos) - Date that health care services were provided.
Day Sheet - summary of daily inpatient treatments, charges, and payments received.
Deductible - number inpatient must pay before insurance coverage begins. For example, a inpatient could have a 00 deductible per year before their health insurance will begin paying. This could take several doctor's visits or prescriptions to reach the deductible.
Demographics - corporeal characteristics of a inpatient such as age, sex, address, etc. Important for filing a claim.
Dme - Durable curative equipment - curative supplies such as wheelchairs, oxygen, catheter, glucose monitors, crutches, walkers, etc.
Dob - Abbreviation for Date of Birth
Dx - Abbreviation for pathology code (Icd-9-Cm).
Electronic Claim - Claim data is sent electronically from the billing software to the clearinghouse or directly to the insurance carrier. The claim file must be in a thorough electronic format as defined by the receiver.
E/M - estimate and administration 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.
Emr - Electronic curative Records. curative records in digital format of a patients hospital or provider treatment.
Eob - Explanation of Benefits. One of the curative billing terms for the statement that comes with the insurance enterprise payment to the provider explaining payment details, covered charges, write offs, and inpatient responsibilities and deductibles.
Era - Electronic Remittance Advice. This is an electronic version of an insurance Eob that provides details of insurance claim payments. These are formatted in agreeing to the Hipaa X12N 835 standard.
Fee program - Cost associated with each treatment Cpt curative billing codes.
Fraud - When a provider receives payment or a inpatient obtains services by deliberate, dishonest, or misleading means.
Guarantor - A responsible party and/or insured party who is not a patient.
Hcpcs - health Care Financing administration base course Coding System. (pronounced "hick-picks"). This is a three level ideas of codes. Cpt is Level I. A standardized curative coding ideas used to report definite items or services in case,granted when delivering health services. May also be referred to as a course code in the curative billing glossary.
The three Hcpcs levels are:
Level I - American curative Associations Current Procedural Terminology (Cpt) codes.
Level Ii - The alphanumeric codes which contain mostly non-physician items or services such as curative supplies, ambulatory services, prosthesis, etc. These are items and services not covered by Cpt (Level I) procedures.
Level Iii - Local codes used by state Medicaid organizations, Medicare contractors, and hidden insurers for definite areas or programs.
Hipaa - health insurance Portability and accountability Act. several federal regulations intended to enhance the efficiency and effectiveness of health care. Hipaa has introduced a lot of new curative billing terms into our vocabulary lately.
Hmo - health Maintenance Organization. A type of health care plan that places restrictions on treatments.
Icd-9 Code - Also know as Icd-9-Cm. International Classification of Diseases classification ideas used to assign codes to inpatient diagnosis. This is a 3 to 5 digit number.
Icd 10 Code - 10th correction of the International Classification of Diseases. Uses 3 to 7 digit. Includes further digits to allow more available codes. The U.S. branch of health and Human Services has set an implementation deadline of October, 2013 for Icd-10.
Inpatient - Hospital stay longer than one day (24 hours).
Maximum Out of Pocket - The maximum number 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.
Medical Assistant - Performs administrative and clinical duties to sustain a health care provider such as a physician, physicians assistant, nurse, or nurse practitioner.
Medical Coder - Analyzes inpatient charts and assigns the strict Icd-9 pathology codes (soon to be Icd-10) and corresponding Cpt treatment codes and any associated Cpt modifiers.
Medical Billing expert - The person who processes insurance claims and inpatient payments of services performed by a physician or other health care provider and vital to the financial execution of a practice. Makes sure curative billing codes and insurance data are entered correctly and submitted to insurance payer. Enters insurance payment data and processes inpatient statements and payments.
Medical Necessity - curative aid or course performed for treatment of an illness or injury not considered investigational, cosmetic, or experimental.
Medical Transcription - The conversion of voice recorded or hand written curative data dictated by health care professionals (such as physicians) into text format records. These records can be either electronic or paper.
Medicare - insurance in case,granted by federal government for citizen over 65 or citizen under 65 with unavoidable restrictions. Medicare has 2 parts; Medicare Part A for hospital coverage and Part B for doctors office or inpatient care.
Medicare Donut Hole - The gap or incompatibility between the introductory limits of insurance and the catastrophic Medicare Part D coverage limits for prescription drugs.
Medicaid - insurance coverage for low income patients. Funded by Federal and state government and administered by states.
Modifier - Modifier to a Cpt treatment code that furnish further data to insurance payers for procedures or services that have been altered or "modified" in some way. Modifiers are foremost to interpret further procedures and regain reimbursement for them.
Network provider - health care provider who is contracted with an insurance provider to furnish care at a negotiated cost.
Npi number - National provider Identifier. A unique 10 digit identification number required by Hipaa and assigned through the National Plan and provider Enumeration ideas (Nppes).
Out-of Network (or Non-Participating) - A provider that does not have a ageement with the insurance carrier. Patients regularly responsible for a greater quantum of the charges or may have to pay all the charges for using an out-of network provider.
Out-Of-Pocket Maximum - The maximum number the inpatient is responsible to pay under their insurance. Charges above this limit are the insurance companies obligation. These Out-of-pocket maximums can apply to all coverage or to a definite advantage category such as prescriptions.
Outpatient - Typically treatment in a physicians office, clinic, or day surgical operation premise persisting less than one day.
Patient accountability - The number a inpatient is responsible for paying that is not covered by the insurance plan.
Pcp - traditional Care physician - regularly the physician who provides introductory care and coordinates further care if necessary.
Ppo - favorite provider Organization. insurance plan that allows the inpatient to make your mind up a physician or hospital within the network. Similar to an Hmo.
Practice administration Software - software used for the daily operations of a providers office. Typically includes appointment scheduling and billing functions.
Preauthorization - Requirement of insurance plan for traditional care physician to inform the inpatient insurance carrier of unavoidable curative procedures (such as inpatient surgery) for those procedures to be considered a covered expense.
Premium - The number the insured or their manager pays (usually monthly) to the health insurance enterprise for coverage.
Provider - physician or curative care premise (hospital) that provides health care services.
Referral - When a provider (typically the traditional Care Physician) refers a inpatient to another provider (usually a specialist).
Self Pay - payment made at the time of aid by the patient.
Secondary insurance Claim - insurance claim for coverage paid after traditional insurance makes payment. Typically intended to cover gaps in insurance coverage.
Sof - Signature on File.
Superbill - One of the curative billing terms for the form the provider uses to document the treatment and pathology for a inpatient visit. Typically includes several commonly used Icd-9 pathology and Cpt procedural codes. One of the most oftentimes used curative billing terms.
Supplemental insurance - further insurance course that covers claims fro deductibles and coinsurance. oftentimes used to cover these expenses not covered by Medicare.
Taxonomy Code - Code for the provider specialty sometimes required to process a claim.
Tertiary insurance - insurance paid in increasing to traditional and secondary insurance. Tertiary insurance covers costs the traditional and secondary insurance may not cover.
Tin - Tax Identification Number. Also known as manager Identification number (Ein).
Tos - Type of Service. description of the category of aid performed.
Ub04 - Claim form for hospitals, clinics, or any provider billing for premise fees similar to Cms 1500. Replaces the Ub92 form.
Unbundling - Submitting more than one Cpt treatment code when only one is appropriate.
Upin - Unique physician Identification Number. 6 digit physician identification number created by Cms. Discontinued in 2007 and supplanted by Npi number.
Write-off (W/O) - The incompatibility between what the provider charges for a course or treatment and what the insurance plan allows. The inpatient is not responsible for the write off amount. May also be referred to as "not covered" in some glossary of billing terms.
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