Common Medical Billing Terms - MD Billing Facts

Common Medical Billing Terms and Descriptions for Medical Billers and Coders

AMA

American Medical Association. The AMA is the largest association of medical physicians in the United States. They publish the Journal of American Medical Association which is one of the most widely circulated medical journals in the world.

AMA (Against Medical Advice)

Against medical advice (AMA), sometimes known as discharge against medical advice (DAMA), is a term used in health care institutions when a patient leaves a hospital against the advice of their doctor.

Aging

One of the medical billing terms referring to the unpaid insurance claims or patient balances that are due past 30 days. Most medical billing software’s have the ability to generate a separate report for insurance aging and patient aging. These reports typically list balances by 30, 60, 90, and 120 day increments.

Ancillary Services

These are typically services a patient requires in a hospital setting that are in addition to room and board accommodations – i.e. surgery, tests, therapy, etc.

Appeal

When an insurance plan does not pay for the services or treatment, an appeal (either by the provider or patient) is the process of objecting this decision. The insurance may require documentation when processing an appeal and typically has a formal policy or process established for submitting an appeal. Many times the process and associated forms can be found on the insurance providers web site.

Applied to Deductible

This is the amount of the charges, determined by the patients insurance plan, the patient 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 doctor or hospital for a patient’s treatment.

Adjuster

An adjuster is an insurance claims agent. A claims adjuster is charged with evaluating an insurance claim to determine the insurance company’s liability under the terms of an owner’s policy.

Admitting Diagnosis

The admitting diagnosis is defined as the initial working diagnosis documented by the patient’s admitting or attending physician who determined that inpatient care was necessary.

Allowed or Approved Amount

The allowable amount (also referred to as allowable charge, approved charge, eligible expense) is the dollar amount that is typically considered payment-in-full by an insurance company and an associated network of healthcare providers.

Appointment Scheduling or Scheduler

A Scheduler, or Appointment Scheduler, coordinates appointments for employees, customers or patients. Their main duties include planning weekly employee schedules, determining appointment lengths and making phone calls to patients or customers regarding their appointment or meeting times.

AR (Accounts Receivable)

A medical account receivable refers to the outstanding reimbursement owed to providers for issued treatments and services, whether the financial responsibility falls to the patient or their insurance company. Healthcare providers must stay on top of efforts to collect reimbursement for accounts receivable.

ABN

The ABN is a notice given to beneficiaries in Original Medicare to convey that Medicare is not likely to provide coverage in a specific case.

Learn More:

CPT Category Codes by Specialty 2021

Updated List of CPT and HCPCS Modifiers 2021 & 2022

Complete List of Place Of Service Codes (POS) for Professional Claims

Revenue Codes for Hospitals, Emergency Rooms and Facilities with UB04 Billing 2021

Beneficiary

Person or persons covered by the health insurance plan.

Blue Cross Blue Shield (BCBS)

BCBS is an organization of affiliated insurance companies (approximately 450), independent of the association (and each other), that offer insurance plans within local regions under one or both of the association’s brands (Blue Cross or Blue Shield). Many local BCBS associations are nonprofit BCBS sometimes acts as administrators of Medicare in many states or regions.

Billing Executive

Processes insurance claims for payment of services performed by a physician or other health care provider. Ensures patient medical billing codes, diagnosis, and insurance information are entered correctly and submitted to insurance payer. The specialist enters insurance payment information and processes patient statements and payments. Performs tasks vital to the financial operation of a practice. Knowledgeable in medical billing
terminology.

Capitation

It is a fixed payment paid per patient enrolled over a defined period of time, paid to a health plan or provider. This covers the costs associated with the patient’s health care services. This payment is not affected by the type or number of services provided.

CHAMPUS

CHAMPUS is a Civilian Health and Medical Program of the Uniformed Services. Recently renamed TRICARE. This is federal health insurance for active duty military, National Guard and Reserve, retirees, their families, and survivors.

Charity Care

When medical care is provided at no cost or at a reduced cost to a patient that cannot afford to pay for the care.

Clean Claim

Medical billing term for a complete submitted insurance claim that has all the necessary correct information without any mistakes or error that allows it to be processed and paid promptly.

Clearinghouse

Clearinghouse is a service that transmits claims to insurance carriers. Prior to submitting claims the clearinghouse scrubs claims and checks for errors. This minimizes the amount of rejected claims as most errors can be easily corrected. Clearinghouses electronically transmit claim information that is compliant with the strict HIPAA standards (this is one of the medical billing terms we see a lot more of lately).

CMS

Centers for Medicaid and Medicare Services. A GOVT. agency which administers Medicare, Medicaid, HIPAA, and other health programs. Formerly known as the HCFA (Health Care Financing Administration).

CMS 1500 or HCFA

Medical claim form established by CMS to submit paper claims to Medicare and Medicaid for Professional Services. Most commercial insurance carriers also require paper claims be submitted on CMS-1500 or HCFA form.

Coding

Medical Coding involves taking the doctor’s notes from a patient visit and translating them into the proper ICD-10 codes for diagnosis and CPT & HCPCS codes for treatment.

COBRA Insurance

COBRA Insurance coverage is available to an individual and their dependents after becoming unemployed – either voluntary or involuntary termination of employment for reasons other than gross misconduct. Because it does not typically receive company matching, It’s typically more expensive than insurance the cost when employed but does benefit from the savings of being part of a group plan. Employers must extend COBRA coverage to employees dismissed for a. COBRA stands for Consolidated Omnibus Budget Reconciliation Act which was passed by Congress in 1986.

COBRA coverage typically lasts up to 18 months after becoming unemployed and under certain conditions can be extended up to 36 months.

Coinsurance

Percentage or amount defined in the insurance plan for which the patient is considered responsible. Most of the plans have a ratio of 90/10 or 80/20, 70/30, etc.

Example: The insurance carrier pays 80% and the patient pays 20%.

Collection Ratio

It’s the ratio of the payments received to the total amount of charges owed on the provider’s accounts.

Collection Agency

A collection agency is a company used by Providers or Medical Billing Companies to recover balance on Medical Bills that are past due, or from accounts that are in default.

Contractual Adjustment

The amount of charges a provider or hospital agrees to write off and not charge the patient per the contract terms signed with the insurance company.

Coordination of Benefits

When a patient is covered by more than one insurance plans. One insurance carrier is designated as the primary carrier and the other carrier as secondary.

Co-Pay or Co-Payment

Amount paid by patient at each visit as defined by the Insurance plan.

Condition Codes

Condition codes are extra bits kept by a processor that summarize the results of an operation and that affect the execution of later instructions.

CPT Code

Current Procedural Terminology. This is a 5 digit code assigned for reporting a procedure performed by the physician. The CPT has a corresponding ICD-10 diagnosis code.

Credentialing

This is an application process for a provider to participate with an insurance carrier. Many carriers now request credentialing through CAQH. CAQH credentialing process is a universal system now accepted by insurance companies and networks.

Credit Balance

The balance that’s shown in the “Balance” or “Amount Due” column of your account statement with a minus sign after the amount (i.e. -$50). The provider may owe the patient a refund.

Crossover claim

When claim information is automatically sent from Medicare the secondary insurance i.e. Medicaid and AARP.

Claim Status

A claim status transaction is used for: An inquiry from a provider or on behalf of provider to a health plan about the status of a claim. A response from the health plan to a provider about the status of a claim.

Learn More:

CPT Category Codes by Specialty 2021

Updated List of CPT and HCPCS Modifiers 2021 & 2022

Complete List of Place Of Service Codes (POS) for Professional Claims

Revenue Codes for Hospitals, Emergency Rooms and Facilities with UB04 Billing 2021

Date of Service (DOS)

It is the date when health care services were provided.

Day Sheet

Summary of daily patient treatments, charges, and upfront payments received.

Deductible

It is an amount that patient must pay before insurance coverage will begins.

Example: A patient could have a $1000 deductible per year before their health insurance will begin paying. This could take several doctor’s visits or prescriptions to reach the deductible.

Demographics

Physical characteristics of a patient such as age, sex, address, etc. necessary for filing a claim.

DME – Durable Medical Equipment

Medical supplies such as wheelchairs, oxygen, catheter, glucose monitors, crutches, walkers, etc.

DOB

Abbreviation for Date of Birth

DownCoding

When the insurance company reduces the code and charges of a claim when there is no documentation to support the level of service submitted by the provider. The insurers computer processing system converts the code submitted down to the closest code in use which usually reduces the payment.

DX (Diagnosis)

Abbreviation for diagnosis code (ICD-10 codes).

DRG

A diagnosis-related group (DRG) is a patient classification system that standardizes prospective payment to hospitals and encourages cost containment initiatives. The DRG includes any services performed by an outside provider. Claims for the inpatient stay are submitted and processed for payment only upon discharge.

DAR

Days in Accounts Receivable (Days in AR of DAR). DAR measures the average number of days it takes a center to collect or fully adjudicate a claim.

Subtract all credits received from the total number of charges. Divide the total charges, less credits received, by the total number of days in the selected period (e.g., 30 days, 90 days, 120 days, etc.)

Learn More:

CPT Category Codes by Specialty 2021

Updated List of CPT and HCPCS Modifiers 2021 & 2022

Complete List of Place Of Service Codes (POS) for Professional Claims

Revenue Codes for Hospitals, Emergency Rooms and Facilities with UB04 Billing 2021

Electronic Claim / EDI

Claim information is sent electronically from the billing software to the clearinghouse or directly to the insurance carrier. The claim file must be in a standard electronic format (EDI – Electronic Date Interchange) as defined by the receiver.

837 EDI: EDI 837 document type is used to submit health care claim billing information, encounter information, or both, from health care service providers to payers.

835 EDI: EDI 835 is used primarily by Healthcare insurance plans to make payments to healthcare providers, to provide Explanations of Benefits (EOBs), or both.

Electronic Funds Transfer (EFT)

An electronic paperless means of transferring money. This allows funds to be transferred, credited, or debited to a bank account and eliminates the need for paper checks.

E/M Codes

Evaluation and Management section of the CPT codes. These are the CPT codes 99201 thru 99499 mostly used by physicians to access (or evaluate) a patient’s treatment needs.

EHR/EMR

Electronic Health Records or Electronic Medical Records. This is a medical record in digital format of a patient’s hospital or provider treatment.

Enrollee

Individual covered by health insurance.

EOB

Explanation of Benefits. One of the medical billing terms for the statement that comes with the insurance company payment to the provider explaining payment details, covered charges, write offs, and patient responsibilities and deductibles.

Enrollment

Payor enrollment – commonly referred to as provider enrollment – is the process of enrolling providers with health plans. … The reluctance to pay more to see non participating providers stems from the fact that the high costs of health insurance already burden most people.

ERA

Electronic Remittance Advice. This is an electronic version of an insurance EOB that provides details of insurance claim payments. These are formatted in according to the HIPAA X12N 835 standard.

ERISA

Employee Retirement Income Security Act of 1974. This law established the reporting, disclosure of grievances, and appeals requirements and financial standards for group life and health. Self-insured plans are regulated by this law.

EMTALA

In 1986, Congress enacted the Emergency Medical Treatment & Labor Act (EMTALA) to ensure public access to emergency services regardless of ability to pay.

Learn More:

CPT Category Codes by Specialty 2021

Updated List of CPT and HCPCS Modifiers 2021 & 2022

Complete List of Place Of Service Codes (POS) for Professional Claims

Revenue Codes for Hospitals, Emergency Rooms and Facilities with UB04 Billing 2021

Fee For Service

Insurance where the provider is paid for each service or procedure provided. Typically allows patient to choose provider and hospital. Some policies require the patient to pay provider directly for services and submit a claim to the carrier for reimbursement. The trade-off for this flexibility is usually higher deductibles and co-pays.

Fee Schedule

Cost associated with each treatment CPT codes for medical billing.

Financial Responsibility

The portion of the charges that are the responsibility of the patient or insured.

Follow-up

Follow-up is the process to assist in filing insurance claims, determining write-offs, and resolving coding issues. It also includes to analyze plans to determine which benefits are covered, submit patient claims, and follow-up on those submissions.

Fraud

When a provider charges and receives payment or a patient obtains services by deliberate, dishonest, or misleading means i.e. dishonesty in coding and billing.

Free Standing ER

A freestanding emergency department (FSED) is a licensed facility that is structurally separate and distinct from a hospital and provides emergency care.

Group Name

Name of the group or insurance plan that insures the patient.

Group Number

Number assigned by insurance company to identify the group under which a patient is insured.

Guarantor

A responsible party and/or insured party who is not a patient.

Learn More:

CPT Category Codes by Specialty 2021

Updated List of CPT and HCPCS Modifiers 2021 & 2022

Complete List of Place Of Service Codes (POS) for Professional Claims

Revenue Codes for Hospitals, Emergency Rooms and Facilities with UB04 Billing 2021

HCFA

Health Care Financing Administration. Now know as CMS (see above in Medical Billing Terms).

HCPCS

Health Care Financing Administration Common Procedure Coding System. (pronounced “hick-picks”). Three level system of codes. CPT is Level I. A standardized medical coding system used to describe specific items or services provided when delivering health services. May also be referred to as a procedure code in the medical billing glossary.

The three HCPCS levels are:

Level I – American Medical Association’s Current Procedural Terminology
(CPT) codes.
Level II – The alphanumeric codes which include mostly non-physician
items or services such as medical 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 private insurers for specific areas or programs.

Healthcare Insurance

Insurance coverage to cover the cost of medical care necessary as a result of illness or injury. May be an individual policy or family policy which covers the beneficiary’s family members. May include coverage for disability or accidental death or dismemberment.

Healthcare Provider

Typically a physician, hospital, nursing facility, or laboratory that provides medical care services. Not to be confused with insurance providers or the organization that provides insurance coverage.

HIC

Health Insurance Claim. This is a number assigned by the the Social Security Administration to a person to identify them as a Medicare beneficiary. This unique number is used when processing Medicare claims.

HIPAA

Health Insurance Portability and Accountability Act. Several federal regulations intended to improve the efficiency and effectiveness of health care. HIPAA has introduced a lot of new medical billing terms into our vocabulary lately.

HMO

Health Maintenance Organization. A type of health care plan that places restrictions on treatments.

Hospice

Inpatient, outpatient, or home health care for terminally ill patients.

Hospital Privileges

Hospital admitting privileges are the rights granted to a doctor by a hospital to admit patients to that particular hospital. The basic premise is that, if you need to go the hospital, your primary care physician can admit you at any hospital that has granted them privileges.

HHS

HHS works with federally qualified health clinics, medical associations, community partners and local governments to help clients find the health care they need. Aging and Disability Resource Centers can help Texans find personal care, nursing care, help at home and other long-term care services.

Learn More:

CPT Category Codes by Specialty 2021

Updated List of CPT and HCPCS Modifiers 2021 & 2022

Complete List of Place Of Service Codes (POS) for Professional Claims

Revenue Codes for Hospitals, Emergency Rooms and Facilities with UB04 Billing 2021

ICD 10 Code

10th revision of the International Classification of Diseases. Uses 3 to 7 digit. Includes additional digits to allow more available codes. The U.S. Department of Health and Human Services has implemented ICD 10 codes on October 1, 2015.

Indemnity

Also referred to as fee-for-service. This is a type of commercial insurance were the patient can use any provider or hospital.

In-Network or Participating Provider

An insurance plan in which a provider signs a contract to participate in. The provider agrees to accept a discounted rate for procedures.

Inpatient

Hospital stay of more than one day (24 hours).

IPA

Independent Practice Association. An organization of physicians that are contracted with a HMO plan.

Intensive Care

Hospital care unit providing care for patients who need more than the typical general medical or surgical area of the hospital can provide. May be extremely ill or seriously injured and require closer observation and/or frequent medical attention.

Insurance Eligibility Verification

Insurance eligibility verification and prior authorization is the first and vital step in the medical billing process. Eligibility verification is the process of checking a patient’s active coverage with the insurance company and verifying the authenticity of his or her claims.

IPPS

The system for payment, known as the Inpatient Prospective Payment System (IPPS), categorizes cases into diagnoses-related groups (DRGs) that are then weighted based on resources used to treat Medicare beneficiaries in those groups.

LWBS

Patients Who Leave the Emergency Department Without Being Seen.

Learn More:

CPT Category Codes by Specialty 2021

Updated List of CPT and HCPCS Modifiers 2021 & 2022

Complete List of Place Of Service Codes (POS) for Professional Claims

Revenue Codes for Hospitals, Emergency Rooms and Facilities with UB04 Billing 2021

MAC

Medicare Administrative Contractor. Contractors who process Medicare claims.

Managed Care Plan

Insurance plan requiring patient to see doctors and hospitals that are contracted with the managed care insurance company. Medical emergencies or urgent care are exceptions when out of the managed care plan service area.

Maximum Out of Pocket

The maximum amount 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

A health care worker who performs administrative and clinical duties in support of a licensed health care provider such as a physician, physician’s assistant, nurse, nurse practitioner, etc.

Medical Coder

Analyzes patient charts and assigns the appropriate code. These codes are derived from ICD-10 codes and corresponding CPT treatment codes and any related CPT modifiers.

Medical Biller / Medical Billing Specialist

Medical Necessity

Medical service or procedure that is performed on for treatment of an illness or injury that is not considered investigational, cosmetic, or experimental.

Medical Record Number

A unique number assigned by the provider or health care facility to identify the patient medical record.

MSP Type

Medicare Secondary Payer.

Medical Savings Account

Tax exempt account for paying medical expenses administered by a third party to reimburse a patient for eligible health care expenses. Typically provided by employer where the employee contributes regularly to the account before taxes and submits claims or receipts for reimbursement. Sometimes also referred to in medical billing terminology as a
Medical Spending Account.

Medical Transcription

The conversion of voice recorded or hand written medical information dictated by health care professionals (such as Healthcare Providers) into text format records. These records can be either electronic or paper.

Medicare

Insurance provided by federal government for people over 65 or people under 65 with certain restrictions.

Medicare Part A – Hospital coverage
Medicare Part B – Physicians visits and outpatient procedures
Medicare Part D – Medicare insurance for prescription drug costs for anyone enrolled in Medicare Part A or B.

Medicare Coinsurance Days

Medical billing terminology for inpatient hospital coverage from day 61 to day 90 of a continuous hospitalization. The patient is responsible for paying for part of the costs during those days. After the 90th day, the patient enters “Lifetime Reserve Days.”

Medicaid

Insurance coverage for low income patients. Funded by Federal and state government and administered by states.

Medigap

Medicare supplemental health insurance for Medicare beneficiaries which may include payment of Medicare deductibles, coinsurance and balance bills, or other services not covered by Medicare.

Modifier

Modifier to a CPT treatment code that provide additional information to insurance payers for procedures or services that have been altered or “modified” in some way. Modifiers are important to explain additional procedures and obtain reimbursement for them.

MVA or MVC

Insurance claim that results from a accident related injury or illness.

MPFS

The Centers for Medicare and Medicaid Services (CMS) uses the Medicare Physician Fee Schedule (MPFS) to reimburse physician services. The MPFS is funded by Part B and is composed of resource costs associated with physician work, practice expense and professional liability insurance.

MSE

A medical screening exam (MSE) is the initial exam performed when a patient presents to a dedicated emergency department and requests care. MSEs are to be performed by a qualified medical person, which should be determined in the hospital or health system’s by laws.

Learn More:

CPT Category Codes by Specialty 2021

Updated List of CPT and HCPCS Modifiers 2021 & 2022

Complete List of Place Of Service Codes (POS) for Professional Claims

Revenue Codes for Hospitals, Emergency Rooms and Facilities with UB04 Billing 2021

Network Provider

Health care provider who is contracted with an insurance provider to provide care at a negotiated cost.

Nonparticipation

When a healthcare provider chooses not to accept insurance approved payment amounts as payment in full.

NOS

Not Otherwise Specified. Used in ICD for unspecified diagnosis.

NPI Number

National Provider Identifier. A unique 10 digit identification number required by HIPAA and assigned through the National Plan and Provider Enumeration System (NPPES).

NP – Nurse Practitioner

Broadly speaking, NPs are trained to assess, diagnose, order, and interpret medical tests, prescribe medications, and collaborate in the care of patients. The scope of practice for a nurse practitioner varies from state to state, and sometimes even from hospital to hospital.

No Show

A patient no-show refers to a missed patient appointment wherein the patient was scheduled, did not appear for the appointments, and made no prior contact with the clinic staff.

OIG

Office of Inspector General – Part of department of Health and Human Services. Establish compliance requirements to combat healthcare fraud and abuse. Has guidelines for billing services and individual and small group physician practices.

Out-of Network (or Non-Participating)

A provider that does not have a contract with the insurance carrier. Patients usually responsible for a greater portion of the charges or may have to pay all the charges for using an out-of network provider.

Out-of Network Negotiation

Negotiation on claim / charge amount with 3rd party Insurance companies for out-of network claims submitted by out-of network providers.

Out-Of-Pocket Expense

The amount the patient is responsible to pay to the provider under their insurance policy. Anything above this limit is the insurers obligation. These Out-of-pocket maximums can apply to all coverage or to a specific benefit category such as prescriptions.

Outpatient

Typically treatment in a physician’s office, clinic, or day surgery facility lasting less than one day.

Occurrence Span

These are codes that identifies a significant event relating to an institutional claim that may affect payer processing. These codes are claim-related occurrences that are related to a time period span of dates.

OPPS

The Outpatient Prospective Payment System (OPPS) is the system through which Medicare decides how much money a hospital or community mental health center will get for outpatient care to patients with Medicare.

Learn More:

CPT Category Codes by Specialty 2021

Updated List of CPT and HCPCS Modifiers 2021 & 2022

Complete List of Place Of Service Codes (POS) for Professional Claims

Revenue Codes for Hospitals, Emergency Rooms and Facilities with UB04 Billing 2021

Palmetto GBA

An administrator of Medicare health insurance for the Centers for Medicare & Medicaid Services (CMS) in the US and its territories. A wholly owned subsidiary of BlueCross BlueShield of South Carolina based in Columbia, South Carolina.

Patient Responsibility

The amount a patient is responsible for paying that is not covered by the insurance plan.

PCP

Primary Care Physician – Usually the physician who provides initial care and coordinates additional care if necessary.

POS (Point of Service)

Point-of-Service plan. Medical billing terminology for a flexible type of HMO (Health Maintenance Organization) plan where patients have the freedom to use (or self-refer to) non-HMO network providers. When a non-HMO specialist is seen without referral from the Primary Care Physician (self-referral), they have to pay a higher deductible and a percentage of the coinsurance.

POS (Place of Service)

Place of Service. Medical billing terminology used on medical insurance claims – such as the CMS 1500 block 24B. A two digit code which defines where the procedure was performed. For example 11 is for the doctors office, 12 is for home, 21 is for inpatient hospital, etc.

Complete List of Place Of Service Codes (POS) for Professional Claims

PPO

Preferred Provider Organization. Commercial insurance plan where the patient can use any doctor or hospital within the network. Similar to an HMO.

Practice Management Software

Billing software used for the daily operations of a provider’s office. Typically used for appointment scheduling and billing.

Preauthorization or Prior Authorization

Requirement of insurance plan for primary care doctor to notify the patient insurance carrier of certain medical procedures (such as outpatient surgery) for those procedures to be considered a covered expense.

Pre-Certification

Sometimes required by the patients insurance company to determine medical necessity for the services proposed or rendered. This doesn’t guarantee the benefits will be paid.

Predetermination

Maximum payment insurance will pay towards surgery, consultation, or other medical care – determined before treatment.

Pre-existing Condition

A medical condition that has been diagnosed or treated within a certain specified period of time just before the patients effective date of coverage. A Pre-existing condition may not be covered for a determined amount of time as defined in the insurance terms of coverage (typically 6 to 12 months).

Pre-existing Condition Exclusion

When insurance coverage is denied for the insured when a pre-existing medical condition existed when the health plan coverage became effective.

Premium

The amount the insured or their employer pays (usually monthly) to the health insurance company for coverage.

Primary Subscriber or Insured

The person under whom the insurance policy is obtained.

Privacy Rule

The HIPAA privacy standard establishes requirements for disclosing what the HIPAA privacy law calls Protected Health Information (PHI). PHI is any information on a patient about the status of their health, treatment, or payments.

Provider

Physician or medical care facility (hospital) who provides health care services.

PTAN

Provider Transaction Access Number for Medicare Providers. Also known as the legacy Medicare number.

Principal Diagnosis

Principal diagnosis describes the underlying cause behind a patient’s initial hospital admission and is assigned only after a physician has completed necessary tests and examinations.

POA

Present on admission is defined as the conditions present at the time the order for inpatient admission occurs. The POA indicator is intended to differentiate conditions present at the time of admission from those conditions that develop during the inpatient admission.

Payer ID

The Payer ID or EDI is a unique ID assigned to each insurance company. It allows provider and payer systems to talk to one another to verify eligibility, benefits and submit claims. The payer ID is generally five (5) characters but it may be longer. It may also be alpha, numeric or a combination.

Pay to Address

Pay to address means the address that the provider has identified to the Insurance in its application for enrollment as the address at which it wishes to receive EOBs, Checks & Payments, and other correspondence.

PHI

PHI stands for Protected Health Information. The HIPAA Privacy Rule provides federal protections for personal health information held by covered entities and gives patients an array of rights with respect to that information.

Patient Statement

A printed bill that displays the details such as the amount that each patient has to pay, service dates, charges, and transaction descriptions along with the patient’s demographic details is called as patient statement. Patient statements enable cost reduction, save time, and enables swift and efficient billing.

Learn More:

CPT Category Codes by Specialty 2021

Updated List of CPT and HCPCS Modifiers 2021 & 2022

Complete List of Place Of Service Codes (POS) for Professional Claims

Revenue Codes for Hospitals, Emergency Rooms and Facilities with UB04 Billing 2021

Referral

When one provider (usually a family doctor) refers a patient to another provider (typically a specialist).

Remittance Advice (R/A)

A document supplied by the insurance payor with information on claims submitted for payment. Contains explanations for rejected or denied claims. Also referred to as an EOB (Explanation of Benefits) or ERA (Electronic Remittance Advice).

Responsible Party

The person responsible for paying a patient’s medical bill. Also referred to as the guarantor.

Revenue Code

Revenue codes are 4-digit numbers that are used on hospital bills to tell the insurance companies either where the patient was when they received treatment, or what type of item a patient might have received as a patient. A medical claim will not be paid if this is missing from a bill.

Reconsideration

A “Reconsideration” is defined as a request for review of a claim that a provider feels was incorrectly paid or denied because of processing errors.

Scrubbing

Process of checking an insurance claim for errors in the health insurance claim software prior to submitting to the payer.

Self Pay

Payment made at the time of service by the patient.

Secondary Insurance Claim

Claim for insurance coverage paid after the primary insurance makes payment. Secondary insurance is typically used to cover gaps in insurance coverage.

Secondary Procedure

When a second CPT procedure is performed during the same physician visit as the primary procedure.

Skilled Nursing Facility

A nursing home or facility for convalescence. Provides a high level of specialized care for long-term or acutely ill patients. A Skilled Nursing Facility is an alternative to an extended hospital stay or home nursing care.

SOF

Signature on File.

Software As A Service (SAAS)

One of the medical billing terms for a software application that is hosted on a server and accessible over the Internet. SAAS relieves the user of software maintenance and support and the need to install and run an application on an individual local PC or server. Many medical billing applications are available as SAAS.

Specialist

Physician who specializes in a specific area of medicine, such as urology, cardiology, orthopedics, oncology, etc. Some health care plans require beneficiaries to obtain a referral from their primary care doctor before making an appointment to see a Specialist.

Subscriber

Medical billing term to describe the employee for group policies. For individual policies the subscriber describes the policyholder.

Superbill

One of the medical billing terms for the form the provider uses to document the treatment and diagnosis for a patient visit. Typically includes several commonly used ICD-9 diagnosis and CPT procedural codes. One of the most frequently used medical billing terms.

Supplemental Insurance

Additional insurance policy that covers claims for deductibles and coinsurance. Frequently used to cover these expenses not covered by Medicare.

Specialty

Specialty Provider means a provider who provides specialized services. The term also can be used to describe a facility offering specialized services (e.g., cancer center).

Learn More:

CPT Category Codes by Specialty 2021

Updated List of CPT and HCPCS Modifiers 2021 & 2022

Complete List of Place Of Service Codes (POS) for Professional Claims

Revenue Codes for Hospitals, Emergency Rooms and Facilities with UB04 Billing 2021

Taxonomy Code

Specialty standard codes used to indicate a provider’s specialty sometimes required to process a claim.

Term Date

Date the insurance contract expired or the date a subscriber or dependent ceases to be eligible.

Tertiary Insurance Claim

Claim for insurance coverage paid in addition to primary and secondary insurance. Tertiary insurance covers gaps in coverage the primary and secondary insurance may not cover.

Third Party Administrator (TPA)

An independent corporate entity or person (third party) who administers group benefits, claims and administration for a self-insured company or group.

TIN

Tax Identification Number. Also known as Employer Identification Number (EIN).

TOP

Triple Option Plan. An insurance plan which offers the enrolled a choice of a more traditional plan, an HMO, or a PPO. This is also commonly referred to as a cafeteria plan.

TOS

Type of Service. Description of the category of service performed.

TRICARE

This is federal health insurance for active duty military, National Guard and Reserve, retirees, their families, and survivors. Formerly know as CHAMPUS.

Type of Bill

Type of bill codes are four-digit alphanumeric codes that specify different pieces of information on claim form UB-04 or form CMS-1450 and is reported in box 4 on line 1. Type of Bill (TOB) is not required when a Physicians office reports claim on a CMS-1500.

TDI

The Texas Department of Insurance regulates the state’s insurance industry, oversees the administration of the Texas workers’ compensation system, performs the duties of the State Fire Marshal’s Office, and provides administrative support to the Office of Injured Employee Counsel – a separate agency.

THCIC

THCIC’s charge is to collect data and report on health care activity in hospitals and health maintenance organizations operating in Texas. The goal is to provide information that will enable consumers to have an impact on the cost and quality of health care in Texas.

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CPT Category Codes by Specialty 2021

Updated List of CPT and HCPCS Modifiers 2021 & 2022

Complete List of Place Of Service Codes (POS) for Professional Claims

Revenue Codes for Hospitals, Emergency Rooms and Facilities with UB04 Billing 2021

UB04

Claim form for hospitals, clinics, or any provider billing for facility or Institutional fees similar to CMS 1500. Replaces the UB92 form.

Unbundling

Submitting several CPT treatment codes when only one code is necessary.

Untimely Submission

Medical claim submitted after the time frame allowed by the insurance payer. Claims submitted after this date are denied.

Upcoding

An illegal practice of assigning an ICD-9 diagnosis code that does not agree with the patient records for the purpose of increasing the reimbursement from the insurance payor.

UPIN

Unique Physician Identification Number. 6 digit physician identification number created by CMS. Discontinued in 2007 and replaced by NPI number.

Urgent Care

“Urgent care – the diagnosis and treatment of medical conditions which are serious or acute but pose no immediate threat to life and health but which requires medical attention within 24 hours.

Usual Customary & Reasonable(UCR)

The allowable coverage limits (fee schedule) determined by the patient’s insurance company to limit the maximum amount they will pay for a given service or item as defined in the contract with the patient.

Utilization Limit

The limits that Medicare sets on how many times certain services can be provided within a year. The patient’s claim can be denied if the services exceed this limit.

Utilization Review (UR)

Review or audit conducted to reduce unnecessary inpatient or outpatient medical services or procedures.

UHC

UnitedHealthcare is an operating division of UnitedHealth Group, the largest single health carrier in the United States.

Value Codes

The code indicating a monetary condition which was used by the intermediary to process an institutional claim.

Learn More:

CPT Category Codes by Specialty 2021

Updated List of CPT and HCPCS Modifiers 2021 & 2022

Complete List of Place Of Service Codes (POS) for Professional Claims

Revenue Codes for Hospitals, Emergency Rooms and Facilities with UB04 Billing 2021

Workers Comp

Insurance claim that results from a work related injury or illness.

Write-off

Typically reference to the difference between what the physician charges and what the insurance plan contractually allows and the patient is not responsible for. May also be referred to as “not covered” in some glossary of billing terms.

Acute Care Micro Hospitals
Freestanding Emergency Rooms
Urgent Care Centers
Physician Clinics
Solo Practioners & Physicians

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