A tool for the Medical Coder
Student
A
·
Account
- Your charges for a
medical visit.
·
Account
Number - Number you’re given
by your doctor or hospital for a medical visit.
·
Actual
Charge - The amount of money
a doctor or supplier charges for a certain medical service or supply. This
amount is often more than the amount an insurance plan approves.
·
Adjustment - The portion of your bill that your doctor
or hospital has agreed not to charge you.
·
Admission
Date (Admit Date) - Date you were
admitted for treatment.
·
Admission
Hour - Hour when you were
admitted for inpatient or outpatient care.
·
Admitting
Diagnosis - Words that your
doctor uses to describe your condition
·
Advance
Beneficiary Notice (ABN)
- A notice the hospital or doctor gives you before you’re treated, telling you
that Medicare will not pay for some treatment or services. The notice is given
to you so that you may decide whether to have the treatment and how to pay for
it.
·
Advance
Directive (Healthcare) -
Written ahead of time, a health care advance directive is a written document
that says how you want medical decisions to be made if you lose the ability to
make decisions for yourself. A health care advance directive may include a
Living Will and a Durable Power of Attorney for health care.
·
All-inclusive
Rate - Payment covering
all services during your hospital stay.
·
Ambulatory
Payment Classifications (APC) - A Medicare payment system that classifies outpatient services
so Medicare can pay all hospitals the same amount.
·
Ambulatory
Care - All types of health
services that do not require an overnight hospital stay.
·
Ambulatory
Surgery - Outpatient surgery
or surgery that does not require an overnight hospital stay.
·
Amount
Charged - how much your doctor
or hospital bills you.
·
Amount
Paid -The dollar amount
that you paid for your doctor or hospital visit.
·
Amount
Not Covered - What your insurance
company does not pay. It includes deductibles, co -insurances, and charges for
non -covered services.
·
Amount
Payable by Plan - How much your
insurer pays for your treatment, minus any deductibles, coinsurance, or charges
for non -covered services.
·
Ancillary
Service - Services you need
beyond room and board charges, such as laboratory tests, therapy, surgery and
the like.
·
Anesthesia - Drugs given to you during surgery to
eliminate or reduce surgical procedure pain.
·
Appeal - A process by which you, your doctor, or
your hospital can object to your health plan when you disagree with the health
plan’s decision to not pay for your care.
·
Applied
to Deductible - Portion of your
bill, as defined by your insurance company, that you owe your doctor or
hospital.
·
Assignment
- An agreement you
sign that allows your insurance to pay the doctor or hospital directly.
·
Assignment
of Benefits - When insurance
payments are sent directly to your doctor or hospital.
·
Attending
Physician Name - The doctor who
certifies that you need treatment and is responsible for your care.
·
Authorization
Number - A number stating
that your treatment has been approved by your insurance plan. Also called a
Certification Number or Prior-Authorization Number.
·
Balance
Bill - How much doctors and
hospitals charge you after your health plan, insurance company, or Medicare
have paid its approved amount.
·
Beneficiary
- Person covered by
health insurance.
·
Beneficiary
Eligibility Verification -
A way for doctors and hospitals to get information about whether you have
insurance coverage.
·
Beneficiary
Liability - A statement that
you are responsible for some treatments or charges.
·
Benefit - The amount your insurance company pays for
medical services.
·
Bill/Invoice/Statement - Printed summary of your medical bill.
·
Cardiology
Charges - Charges for heart
procedures. Examples are heart catheterization and stress testing.
·
Case
Management - A way to help you
get the care you need, especially when you need pre -authorized care from
several services. Usually a nurse helps arrange for your care.
·
Centers
for Medicare and Medicaid (CMS) - The federal agency that runs the Medicare program. In
addition, CMS works with the States to run the Medicaid program. CMS works to
make sure that the beneficiaries in these programs are able to get high quality
health care.
·
CHAMPUS - Insurance linked to military service, also
known as TriCare.
·
Charity
Care - Free or reduced -fee
care for patients who have financial hardship.
·
Claim
- Your medical bill
that is sent to an insurance company for processing.
·
Claim
Number - A number given to a
medical service.
·
Clean
Claim - A claim that does
not have to be investigated by insurance companies before they process it.
·
Clinic - An area in a hospital or separate building
that treats regularly scheduled or walk -in patients for non -emergency care.
·
COBRA
Insurance - Health insurance
that you can buy when you lose your job. It is generally more expensive than
insurance provided through your job but less expensive than insurance purchased
on your own when you are unemployed.
·
Coding
of Claims - Translating
diagnoses and procedures in your medical record into numbers that computers can
understand.
·
Coinsurance - The cost sharing part of your bill that you
have to pay.
·
Coinsurance
Days (Medicare) - Hospital Inpatient
Medicare coverage from day 61 to day 90 of continuous hospitalization. You are
responsible for paying for part of those days. After the 90th day, you enter
your "Lifetime Reserve Days."
·
Collection
Agency - A business that
collects money for unpaid bills.
·
Consent
(for treatment) - An agreement you
sign that gives your permission to receive medical services or treatment from
doctors or hospitals.
·
Contractual
Adjustment - A part of your bill
that your doctor or hospital must write off (not charge you) because of billing
agreements with your insurance company.
·
Coordination
of Benefits (COB) - A way to decide
which insurance company is responsible for payment if you have more than one
insurance plan.
·
Co-payment
- A cost sharing part of
your bill that is your responsibility to pay. Also known as co -pay.
·
Coronary
Care - Routine charges for
care you receive in a heart center because you need more care than you can get
in a regular medical unit.
·
Covered
Benefit - A health service or
item that is included in your health plan, and that is paid for either
partially or fully.
·
Covered
Days - Days that your
insurance company pays for in full or in part.
·
CPT
Codes - A coding system
used to describe what treatment or services were given to you by your doctor.
·
CT
Scan - A type of X -ray of
the head or body; usually done in a hospital’s x -ray department.
·
Date
of Bill - The date the bill
for your services is prepared. It is not the same as the date of service.
·
Date
of Service (DOS) - The date(s) when
you were treated.
·
Days - The total number of days that you are being
charged for the hospital’s services.
·
Deductible - How much cost sharing that you must pay for
medical services often before your insurance company starts to pay.
·
Description
of Services - Tells what your
doctor or hospital did for you.
·
Diagnosis
Code - A code used for
billing that describes your illness.
·
Diagnosis-Related
Groups (DRGs) - A payment system
for hospital bills. This system categorizes illnesses and medical procedures
into groups for which hospitals are paid a fixed amount for each admission.
·
Discharge
Hour - Hour when you were
discharged.
·
Discount
- Dollar amount taken
off your bill, usually because of a contract with your hospital or doctor and
your insurance company.
·
Drugs/Self
Administered - Drugs that do not
require doctors or nurses to help you when you take them. You may be charged
for these. You will need to check with your doctor or hospital their policy on
this.
·
Due
from Insurance - How much money is
due from your insurance company.
·
Due
from Patient - How much you owe
your doctor or hospital.
·
Durable
Medical Equipment (DME)
- Medical equipment that can be used many times, or special equipment ordered
by your doctor, usually for use at home.
·
EEG - Equipment or medical procedure that
measures electricity in the brain.
·
EKG/ECG
- Equipment or medical
procedure that measures how your heart works, and your doctor’s reading of the
results.
·
Eligible
Payment Amount - Those medical
services that an insurance company pays for.
·
Emergency
Care - Care given for a
medical emergency when you believe that your health is in serious danger when
every second counts.
·
Emergency
Room - A special part of a
hospital that treats patients with emergency or urgent medical problems.
·
Estimated
Insurance - Estimated cost paid
by your insurance company.
·
Enrollee - A person who is covered by health
insurance.
·
Estimated
Amount Due - How much the doctor
or hospital estimates you or your insurance company owes.
·
Explanation
of Benefits (EOB/EOMB) - The notice you
receive from your insurance company after getting medical services from a
doctor or hospital. It tells you what was billed, the payment amount approved
by your insurance, the amount paid, and what you have to pay.
·
External
Cause of Injury Code - A code describing a
place or item that may have caused injuries, poisoning, or health problems.
·
Federal
Tax ID Number - A number assigned
by the federal government to doctors and hospitals for tax purposes.
·
Financial
Responsibility - How much of your
bill you have to pay.
·
Fiscal
Intermediary (FI) - A Medicare agent
that processes Medicare claims.
·
Fraud
and Abuse - Fraud: To
purposely bill for services that were never given or to bill for a service that
has a higher reimbursement than the service produced. Abuse: Payment for
items or services that are billed by mistake by providers, but should not be
paid for by the insurance plan. This is not the same as fraud.
·
Guarantor - Someone who has agreed to pay the bill.
·
HCPC
Codes - A coding system used
to describe what treatment or services were given to you by your doctor.
·
Health
Care Financing Administration (HCFA) - Former name of the government agency now called the Centers
for Medicare & Medicaid Services.
·
Healthcare
Provider - Someone who provides
medical services, such as doctors, hospitals, or laboratories. This term should
not be confused with insurance companies that "provide" insurance.
·
Health
Insurance - Coverage that pays
benefits for sickness or injury. It includes insurance for accidents, medical
expenses, disabilities, or accidental death and dismemberment.
·
Health
Maintenance Organization (HMO) - An insurance plan that pays for preventive and other medical
services provided by a specific group of participating providers.
·
HIPAA - Health Insurance Portability and
Accountability Act. This federal act sets standards for protecting the privacy
of your health information.
·
Home
Health Agency - An agency that
treats patients in their homes.
·
Hospice - Group that offers inpatient, outpatient,
and home healthcare for terminally ill patients.
·
Hospital
Inpatient Prospective Payment System (PPS) - A federal system that pays a fixed fee for inpatient care.
·
Incremental
Nursing Charge - Charges for nursing
services added to basic room and board charges.
·
Inpatient
(IP) - Patients who stay
overnight in the hospital.
·
Insurance
Company Name - Name of the company
that your claim will be sent to.
·
Insured
Group Name - Name of the group
or insurance plan that insures you, usually an employer.
·
Insured
Group Number - A number that your
insurance company uses to identify the group under which you are insured.
·
Insured's
Name (Beneficiary) - The name of the
insured person.
·
Intensive
Care - Medical or surgical
care unit in a hospital that provides care for patients who need more care than
a general medical or surgical unit can give.
·
Internal
Control Number (ICN) - A number assigned
to your bill by your insurance company or their agent.
·
International
Classification of Diseases, 9th Edition (ICD -9 -CM) - A coding system used to describe what
treatment or services your doctor gave to you.
·
IV
Therapy - Treatment provided
by giving intravenous solutions or drugs.
·
Labor
and Delivery Room - A unit of a
hospital where babies are born.
·
Laboratory - Charges for blood tests and tests on body
tissue samples, such as biopsies.
·
Lifetime
Reserve Days (Medicare)
- Under Medicare, you have a lifetime reserve of 60 more days of inpatient
services after you use the first 90 benefit days. You must pay a fixed amount
for each day of service.
·
Long-Term
Care - Care received in a
nursing home. Medicare does not pay for long -term care unless you need skilled
nursing or special rehabilitation.
·
Mailer/Summary
of Account - A monthly summary of
services (and charges?) mailed to the person who pays the bill.
·
Managed
Care - An insurance plan
that requires patients to see doctors and hospitals that have a contract with
the managed care company, except in the case of medical emergencies or urgently
needed care if you are out of the plan’s service area.
·
Medicaid
- A state
administered, federal and state funded insurance plan for low -income people
who have limited or no insurance.
·
Medical
Record Number - The number assigned
by your doctor or hospital that identifies your individual medical record.
·
Medical/Surgical
Supplies - Special supplies,
such as materials used to repair a wound or instruments used for your care.
·
Medicare - A health insurance program for people age
65 and older. Medicare covers some people under age 65 who have disabilities or
end -stage renal disease (ESRD).
·
Medicare
+ Choice - A Medicare HMO
insurance plan that pays for preventive and other healthcare from designated
doctors and hospitals.
·
Medicare
Approved - Medical services
for which Medicare normally pays.
·
Medicare
Assignment - Doctors and
hospitals who have accepted Medicare patients and agreed not to charge them
more than Medicare has approved.
·
Medicare
Number - Every person
covered under Medicare is assigned a number and issued a card for
identification to providers.
·
Medicare
Paid - The amount of your
bill that Medicare paid.
·
Medicare
Paid Provider - The amount of your
bill that Medicare paid to your doctor or hospital.
·
Medicare
Part A - Usually referred to
as Hospital Insurance, it helps pay for inpatient care in hospitals and hospices,
as well as some skilled nursing costs.
·
Medicare
Part B - Helps pay for
doctor services, outpatient care, and other medical services not paid for by
Medicare Part A.
·
Medicare
Summary Notice (MSN) - The notice you
receive from Medicare after getting services from your doctor or hospital. It
tells you what was billed to Medicare, Medicare's approved payment, the amount
Medicare paid, and what you have to pay. Also called an Explanation of Medicare
Benefits (EOMB).
·
Medigap - Medicare Supplement Insurance that pays for
some services not covered by Medicare A or B, including deductible and
coinsurance amounts. Co-pay - Agreed amount of the charges for medical services
that patients or guarantors must pay.
·
MRI
- A type of X -ray;
magnetic resonance brain or body images, usually done in a hospital’s x -ray
department.
·
Network - A group of doctors, hospitals, pharmacies,
and other health care experts hired by a health plan to take care of its
members.
·
Non-Covered
Charges - Charges for medical
services denied or excluded by your insurance. You may be billed for these
charges.
·
Non-Participating
Provider - A doctor, hospital,
or other healthcare provider that is not part of an insurance plan’s doctor or
hospital network.
·
Nursery - Nursing care charges for newborn babies.
·
Observation - Type of service used by doctors and
hospitals to decide whether you need inpatient hospital care or whether you can
recover at home or in an outpatient area. Usually charged by the hour.
·
Oncology - Charges for treating cancer and related
diseases.
·
Operating
Room - A hospital or clinic
area where surgeries are done.
·
Other
Room and Board - Any extra charges
that cannot be included in routine room and board charges.
·
Out-of-Network
Provider - A doctor or other healthcare
provider who is not part of an insurance plan's doctor or hospital network.
Same as non-participating provider.
·
Out-of-Pocket
Costs - Costs you must pay
because Medicare or other insurance does not cover them.
·
Outpatient
(OP) - Patient who does
not need to stay overnight in a hospital. Outpatient services include lab
tests, x -rays, and some surgeries.
·
Outpatient
Service - A service you
receive in one day at a hospital or clinic without staying overnight.
·
Over-the-Counter
Drug - Drugs not needing a
prescription that you buy at a pharmacy or drug store.
·
Paid
to Provider - Amount the
insurance company pays your medical provider.
·
Paid
to You - Amount the
insurance company pays you or your guarantor.
·
Participating
Provider - A doctor or hospital
that agrees to accept your insurance payment for covered services as payment in
full, minus your deductibles, co-pays and coinsurance amounts.
·
Patient
Amount Due - The amount charged
by your doctor or hospital that you have to pay.
·
Patient
Type - A way to classify
patients - -outpatient, inpatient, etc.
·
Pay
This Amount -How much of your
bill you have to pay.
·
Per
Diem - Charged or paid by
the day.
·
Pharmacy
Charges - Cost of drugs given
under a pharmacist’s direction.
·
Physical
Therapy - Treatment of
diseases or injuries by exercise, heat, light, and/or massage.
·
Physician - Person licensed to practice medicine.
·
Physician
Extenders - Also called mid
-level service providers. Physician extenders include licensed nurse
practitioners and/or licensed physician assistants. They coordinate patient
care under a doctor’s supervision.
·
Physician
Office - Your doctor’s
office.
·
Physician
Practice - A group of doctors,
nurses, and physician assistants who work together.
·
Physician
Practice Management - Non -physician
staff hired to manage the business aspects of a physician practice. These staff
include billing staff, medical records staff, receptionists, lab and X -ray
technicians, human resources staff, and accounting staff.
·
Point-of-Service
Plan (POS) - An insurance plan
that allows you to choose doctors and hospitals without having to first get a
referral from your primary care doctor.
·
Policy
Number - A number that your
insurance company gives you to identify your contract.
·
Pre-Admission
Approval or Certification
- An agreement by your insurance company to pay for your medical treatment.
Doctors and hospitals ask your insurance company for this approval before
providing your medical treatment.
·
Pre
-Existing Condition - A health condition
or medical problem that you already have before you sign up to receive
insurance. Some health insurers may not pay for health conditions you already
have.
·
Prepayments - Money you pay before getting medical care;
also referred to as preadmission deposits.
·
Prevailing
Charge - A billing charge
that is commonly made by doctors in a specific region or community. Your
insurance company determines this charge.
·
Primary
Care Network (PCN) - A group of doctors
serving as primary care doctors.
·
Primary
Care Physician (PCP) - A doctor whose
practice is devoted to internal medicine, family/general practice, or
pediatrics. Some insurance companies consider Obstetrician/gynecologists
primary care physicians.
·
Primary
Insurance Company - The insurance
company responsible for paying your claim first. If you have another insurance
company, it is referred to as the Secondary Insurance Company.
·
Private
Room (Deluxe) - A more expensive
hospital room than those available to other patients. You may have to pay extra
for this type of room if it is not a medical necessity.
·
Procedure
Code (CPT Code) - A code given to
medical and surgical procedures and treatments.
·
Prospective
Payment System (PPS) - A Medicare system
that pays hospitals a set amount for covered diagnostic or treatment services.
·
Provider
Contract Discount - A part of your bill
that your doctor or hospital must write off (not charge you) because of billing
agreements with your insurance company.
·
Provider
Name, Address, and Phone #
- Name and address of the doctor or hospital submitting your bill.
·
Psychiatric/Psychological
Treatments - Nursing care and
other services for emotionally disturbed patients, including patients admitted
for inpatient care and those admitted for outpatient treatment.
·
Radiology - X -rays used to identify and diagnose
medical problems.
·
Reasonable
and Customary (R & C)
- Billing charges that insurers believe are appropriate for services throughout
a region or community.
·
Recovery
Room - A special room where
you are taken after surgery to recover before being sent home or to your
hospital room.
·
Referral - Approval needed for care beyond that
provided by your primary care doctor or hospital. For example, managed care
plans usually require referrals from your primary care doctor to see
specialists or for special procedures.
·
Release
of Information - A signed statement
from patients or guarantors that allows doctors and hospitals to release
medical information so that insurance companies can pay claims.
·
Renal
Dialysis - Removal of wastes
from the blood. Normally the kidneys would remove these wastes if they were
functioning properly.
·
Respiratory
Therapy - Giving oxygen and
drugs through breathing, as well as other therapies that measure inhaled and
exhaled gases and blood samples.
·
Responsible
Party - The person(s)
responsible for paying your hospital bill - -usually referred to as the
guarantor.
·
Revenue
Code - A billing code used
to name a specific room, service (X -ray, laboratory), or billing sum.
·
Room
and Board Private - Routine charges for
a room with one bed.
·
Room
and Board Semiprivate - Routine charges for
a room with two beds.
·
Same-Day
Surgery - Outpatient surgery.
·
Secondary
Insurance - Extra insurance
that may pay some charges not paid by your primary insurance company. Whether
payment is made depends on your insurance benefits, your coverage, and your
benefit coordination.
·
Service
Area - Geographic area
where your insurance plan enrolls members. In an HMO, it is also the area
served by your doctor network and hospitals.
·
Service
Begin Date - The date your
medical services or treatment began.
·
Service
Code - A code describing
medical services you received.
·
Service
End Date - The date your
medical services or treatment ended.
·
Skilled
Nursing Facility - An inpatient
facility in which patients who do not need acute care are given nursing care or
other therapy.
·
Source
of Admission - The source of your
admission—referral, transfer, emergency room, etc.
·
Specialist
- A doctor who
specializes in treating certain parts of the body or specific medical
conditions. For example, cardiologists only treat patients with heart problems.
·
Statement
Covers Period - The date your
services or treatment begin and end.
·
Submitter
ID - Identification
number (ID) that identifies doctors and hospitals who bill by computers.
Doctors and hospitals get an ID from each insurance company to whom they send
claims using the computer.
·
Supplemental
Insurance Company - An additional
insurance policy that handles claims for deductible and coinsurance
reimbursement.
·
Swing
Bed - Bed for a patient
who receives skilled nursing care in a non -skilled nursing facility.
·
Total
Charges - Total cost of your
medical services.
·
Type
of Admission - The reason for your
admission, such as emergency, urgent, elective, etc.
·
Type
of Bill - A bill that shows
what type of care is being billed, such as hospital inpatient, hospital
outpatient, skilled nursing care, etc.
·
UB
-92 - A form used by
hospitals to file insurance claims for medical services.
·
Units
of Service - Measures of medical
services, such as the number of hospital days, miles, pints of blood, kidney
dialysis treatments, etc.
·
Utilization
Review (UR) - Hospital staff who
work with doctors to determine whether you can get care at a lower cost or as
an outpatient.
·
You
May be Billed - A phrase used by
your insurance company informing you that your doctor or hospital may bill some
charges directly to you.
