Claim Management Systems - curative Billing Terms and curative Coding Terminology
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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 guarnatee claims or outpatient balances that are due past 30 days. Most curative billing software's have the ability to generate a detach narrative for guarnatee aging and outpatient aging. These reports typically list balances by 30, 60, 90, and 120 day increments.
Appeal - When an guarnatee plan does not pay for treatment, an motion (either by the victualer or patient) is the process of formally objecting this judgment. The insurer may require added documentation.
Applied to Deductible - Typically seen on the outpatient statement. This is the number of the charges, considered by the patients guarnatee plan, the outpatient owes the provider. Many plans have a maximum annual deductible that once met is then covered by the guarnatee provider.
Assignment of Benefits - guarnatee payments that are paid to the physician or hospital for a patients treatment.
Beneficiary - someone or persons covered by the condition guarnatee plan.
Clearinghouse - This is a aid that transmits claims to guarnatee 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 of course corrected. Clearinghouses electronically forward claim facts that is compliant with the accurate 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 department which administers Medicare, Medicaid, Hippa, and other condition programs. At one time 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 guarnatee carriers also require paper claims be submitted on Cms-1500's. The form is noteworthy by it's red ink.
Coding -Medical Billing Coding involves taking the doctors notes from a outpatient visit and translating them into the proper Icd-9 code for pathology and Cpt codes for treatment.
Co-Insurance - ration or number defined in the guarnatee plan for which the outpatient is responsible. Most plans have a ratio of 90/10 or 80/20, 70/30, etc. For example the guarnatee carrier pays 80% and the outpatient pays 20%.
Co-Pay - number paid by outpatient 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 condition care services were provided.
Day Sheet - overview of daily outpatient treatments, charges, and payments received.
Deductible - number outpatient must pay before guarnatee coverage begins. For example, a outpatient could have a 00 deductible per year before their condition guarnatee will begin paying. This could take several doctor's visits or prescriptions to reach the deductible.
Demographics - physical characteristics of a outpatient such as age, sex, address, etc. Necessary 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 facts is sent electronically from the billing software to the clearinghouse or directly to the guarnatee carrier. The claim file must be in a suitable electronic format as defined by the receiver.
E/M - estimation and management section of the Cpt codes. These are the Cpt codes 99201 thru 99499 most used by physicians to way (or evaluate) a patients rehabilitation needs.
Emr - Electronic curative Records. curative records in digital format of a patients hospital or victualer treatment.
Eob - Explanation of Benefits. One of the curative billing terms for the statement that comes with the guarnatee business cost to the victualer explaining cost details, covered charges, write offs, and outpatient responsibilities and deductibles.
Era - Electronic Remittance Advice. This is an electronic version of an guarnatee Eob that provides details of guarnatee claim payments. These are formatted in agreeing to the Hipaa X12N 835 standard.
Fee agenda - Cost connected with each rehabilitation Cpt curative billing codes.
Fraud - When a victualer receives cost or a outpatient obtains services by deliberate, dishonest, or misleading means.
Guarantor - A responsible party and/or insured party who is not a patient.
Hcpcs - condition Care Financing management common course Coding System. (pronounced "hick-picks"). This is a three level law of codes. Cpt is Level I. A standardized curative coding law used to tell definite items or services provided when delivering condition 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 comprise 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 inexpressive insurers for definite areas or programs.
Hipaa - condition guarnatee Portability and responsibility Act. several federal regulations intended to enhance the efficiency and effectiveness of condition care. Hipaa has introduced a lot of new curative billing terms into our vocabulary lately.
Hmo - condition Maintenance Organization. A type of condition care plan that places restrictions on treatments.
Icd-9 Code - Also know as Icd-9-Cm. International Classification of Diseases classification law used to assign codes to outpatient diagnosis. This is a 3 to 5 digit number.
Icd 10 Code - 10th revising of the International Classification of Diseases. Uses 3 to 7 digit. Includes added digits to allow more ready codes. The U.S. department of condition 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 condition plan expenses. When this maximum limit is reached, the guarnatee typically then pays 100% of eligible expenses.
Medical Assistant - Performs administrative and clinical duties to preserve a condition care victualer such as a physician, physicians assistant, nurse, or nurse practitioner.
Medical Coder - Analyzes outpatient charts and assigns the accurate Icd-9 pathology codes (soon to be Icd-10) and corresponding Cpt rehabilitation codes and any connected Cpt modifiers.
Medical Billing scholar - The someone who processes guarnatee claims and outpatient payments of services performed by a physician or other condition care victualer and vital to the financial operation of a practice. Makes sure curative billing codes and guarnatee facts are entered correctly and submitted to guarnatee payer. Enters guarnatee cost facts and processes outpatient statements and payments.
Medical Necessity - curative aid or course performed for rehabilitation of an illness or injury not considered investigational, cosmetic, or experimental.
Medical Transcription - The conversion of voice recorded or hand written curative facts dictated by condition care professionals (such as physicians) into text format records. These records can be either electronic or paper.
Medicare - guarnatee provided by federal government for people over 65 or people under 65 with sure restrictions. Medicare has 2 parts; Medicare Part A for hospital coverage and Part B for doctors office or outpatient care.
Medicare Donut Hole - The gap or inequity in the middle of the initial limits of guarnatee and the catastrophic Medicare Part D coverage limits for prescription drugs.
Medicaid - guarnatee coverage for low wage patients. Funded by Federal and state government and administered by states.
Modifier - Modifier to a Cpt rehabilitation code that contribute added facts to guarnatee payers for procedures or services that have been altered or "modified" in some way. Modifiers are leading to elaborate added procedures and procure refund for them.
Network victualer - condition care victualer who is contracted with an guarnatee victualer to contribute care at a negotiated cost.
Npi number - National victualer Identifier. A unique 10 digit identification number required by Hipaa and assigned through the National Plan and victualer Enumeration law (Nppes).
Out-of Network (or Non-Participating) - A victualer that does not have a contract with the guarnatee 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 outpatient is responsible to pay under their insurance. Charges above this limit are the guarnatee companies obligation. These Out-of-pocket maximums can apply to all coverage or to a definite benefit kind such as prescriptions.
Outpatient - Typically rehabilitation in a physicians office, clinic, or day surgery facility persisting less than one day.
Patient responsibility - The number a outpatient is responsible for paying that is not covered by the guarnatee plan.
Pcp - former Care physician - regularly the physician who provides initial care and coordinates added care if necessary.
Ppo - beloved victualer Organization. guarnatee plan that allows the outpatient to take a physician or hospital within the network. Similar to an Hmo.
Practice management Software - software used for the daily operations of a providers office. Typically includes appointment scheduling and billing functions.
Preauthorization - Requirement of guarnatee plan for former care physician to fill in the outpatient guarnatee carrier of sure curative procedures (such as outpatient surgery) for those procedures to be considered a covered expense.
Premium - The number the insured or their employer pays (usually monthly) to the condition guarnatee business for coverage.
Provider - physician or curative care facility (hospital) that provides condition care services.
Referral - When a victualer (typically the former Care Physician) refers a outpatient to someone else victualer (usually a specialist).
Self Pay - cost made at the time of aid by the patient.
Secondary guarnatee Claim - guarnatee claim for coverage paid after former guarnatee makes payment. Typically intended to cover gaps in guarnatee coverage.
Sof - Signature on File.
Superbill - One of the curative billing terms for the form the victualer uses to document the rehabilitation and pathology for a outpatient visit. Typically includes several generally used Icd-9 pathology and Cpt procedural codes. One of the most oftentimes used curative billing terms.
Supplemental guarnatee - added guarnatee course that covers claims fro deductibles and coinsurance. oftentimes used to cover these expenses not covered by Medicare.
Taxonomy Code - Code for the victualer specialty sometimes required to process a claim.
Tertiary guarnatee - guarnatee paid in addition to former and secondary insurance. Tertiary guarnatee covers costs the former and secondary guarnatee may not cover.
Tin - Tax Identification Number. Also known as employer Identification number (Ein).
Tos - Type of Service. narrative of the kind of aid performed.
Ub04 - Claim form for hospitals, clinics, or any victualer billing for facility fees similar to Cms 1500. Replaces the Ub92 form.
Unbundling - Submitting more than one Cpt rehabilitation code when only one is appropriate.
Upin - Unique physician Identification Number. 6 digit physician identification number created by Cms. Discontinued in 2007 and substituted by Npi number.
Write-off (W/O) - The inequity in the middle of what the victualer charges for a course or rehabilitation and what the guarnatee plan allows. The outpatient 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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