Friday, 26 May 2017

Medical billing Terms

Incremental Nursing Charge​ - Charges for hospital nursing services in addition to basic room and board. 

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. 

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-9 codes (soon to be ICD-10) and corresponding CPT treatment codes and any related CPT modifiers. 

Medical Billing Specialist​ - 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.

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​ - 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 physicians) 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. There are 2 parts: 
● 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."

Medicare Donut Hole​ - The gap or difference between the initial 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. 

Monday, 22 May 2017

Medical billing basic terms

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. 

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. 

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 medical billing codes. 

Financial Responsibility​ - The portion of the charges that are the responsibility of the patient or insured. 

Fiscal Intermediary (FI)​ - A Medicare representative who processes Medicare claims. 

Formulary​ - A list of prescription drug costs which an insurance company will provide reimbursement for. 

Fraud​ - When a provider receives payment or a patient obtains services by deliberate, dishonest, or misleading means. 

GPH​ - Group Health Plan. A means for one or more employer who provide health benefits or medical care for their employees (or former employees). 

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.

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. 

Health Care Reform Act​ - Health care legislation championed by President Obama in 2010 to provide improved individual health care insurance or national health care insurance for Americans. Also referred to as the Health Care Reform Bill or the Obama Health Care Plan. 

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

ICD-9 Code​ - Also known as ICD-9-CM. International Classification of Diseases classification system used to assign codes to patient diagnosis. This is a 3 to 5 digit number. 

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 set an implementation deadline of October, 2013 for ICD-10.

Thursday, 18 May 2017


CMS 1500​ - Medical claim form established by CMS to submit paper claims to Medicare and Medicaid. Most commercial insurance carriers also require paper claims be submitted on CMS-1500's. The form is distinguished by it's red ink.

Coding​ - Medical Billing Coding involves taking the doctor's notes from a patient visit and translating them into the proper ICD-9 code for diagnosis and CPT codes for treatment. 

COBRA Insurance​ - This is health insurance coverage 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 extend up to 36 months.

Coinsurance​ - Percentage or amount defined in the insurance plan for which the patient 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 patient pays 20%. 

Collection Ratio​ - This is in reference to the providers accounts receivable. It's the ratio of the payments received to the total amount of money owed on the provider's accounts.

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

Coordination of Benefits​ - When a patient is covered by more than one insurance plan. One insurance carrier is designated as the primary carrier and the other as secondary. 

Co-Pay​ - Amount paid by patient at each visit as defined by the insured plan. 

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-9 diagnosis code. Established by the American Medical Association. This is one of the medical billing terms we use a lot. 

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 company 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 (for example $50-). It may also be shown in parenthesis; ($50). The provider may owe the patient a refund. 

Crossover claim​ - When claim information is automatically sent from Medicare the secondary insurance such as Medicaid. 

Date of Service (DOS)​ - Date that health care services were provided. 

Day Sheet - Summary of daily patient treatments, charges, and payments received.

Deductible​ - amount patient must pay before insurance coverage begins. For 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 corresponding amount) 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. 

Duplicate Coverage Inquiry (DCI)​ - Request by an insurance company or group medical plan by another insurance company or medical plan to determine if other coverage exists. 

Dx​ - Abbreviation for diagnosis code (ICD-9 or ICD-10 code). 

Electronic Claim​ - 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 as defined by the receiver.

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

EMR​ - 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

Sunday, 14 May 2017

Medical billing Terms

AMA​ - American Medical Association. The AMA is the largest association of doctors 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. 

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 - such as surgery, tests, counseling, therapy, etc.

Appeal​ - When an insurance plan does not pay for treatment, an appeal (either by the provider or patient) is the process of objecting this decision. The insurer 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​ - You typically see these medical billing terms on the patient statement. 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.

ASP​ - Application Service Provider. This is a computer based services over a network for a particular application. Sometimes referred to as SaaS (Software as a Service). There application service providers that offer Medical Billing. The appeal of an ASP is it frees a business of the the need to purchase, maintain, and backup software and servers. 

Beneficiary​ - Person or persons covered by the health insurance plan. 

Blue Cross Blue Shield (BCBS)​ - 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

Capitation​ - 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​ - 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 reduced cost to a patient that cannot afford to pay. 

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

Clearinghouse​ - This 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. Federal agency which administers Medicare, Medicaid, HIPAA, and other health programs. Formerly known as the HCFA (Health Care Financing Administration). You'll notice that CMS it the source of a lot of medical billing terms. 

Wednesday, 10 May 2017

AMBA certification

The American Medical Billing Association (AMBA) confers the title of Certified Medical Reimbursement Specialist to qualified individuals who pass its certification exam. AMBA also offers a certificate program that teaches medical terminology and ICD-9, ICD-10, CPT, and HCPCS standards for coding medical procedures. You’ll also learn about state and federal regulations, as well as insurance company policies and practices.
AMBA doesn’t recommend taking the exam unless you have on-the-job medical experience, or some other education in medical billing and coding. Continuing education and membership to the organization are also requirements of this certification.

AHIMA certification

The American Health Information Management Association (AHIMA) offers several general medical coding certifications, which demonstrate the proficiency and accuracy required to work in hospitals, clinics, nursing homes, care centers, and private coding businesses.
Certified Coding Assistant (CCA): This is the general-purpose certification for professional coders. The exam requires a high school diploma, but the association encourages medical coding experience or training. AHIMA also requires 20 continuing education units biannually, as well as a fee to remain certified.
Certified Coding Specialist (CCS): This certification is for coders who use their coding skills in a clinical environment, like large hospitals and research institutions. This designation requires specialized training and/or experience, and you’ll need to brush up on your accuracy and proficiency with code systems in order to pass the exam. You’ll also need 20 units of continuing education and a fee to remain certified.
Certified Coding Specialist – Physician-Based (CCS-P): This certification program emphasizes the coding used in physicians’ offices and private practice work environments. AHIMA recommends that you’ve had some combination of work experience or education in coding or managing health records and health information. Like the other AHIMA certifications, this also requires 20 continuing education units every other year (which can be earned from a variety of sources, so check the website for details.)

Pass the AAPC Certified Professional Coder Examination

The AAPC offers twenty-one specialty examinations in medical specialties, such as cardiology and pediatrics, which you can take without earning a CPC or other certification. These exams are conducted in the same way as the CPC exams, but the content can vary slightly. Take a look at the AAPC’s list of specialty credentials to see what coding and other topics you will need to study.

Planning for the Exam

As noted above, the AAPC offers three main medical coding certifications and a number of specialized additional certifications, all of which are earned by examination. All of these examinations are multiple-choice based in medical coding, with some access to a medical coding manual allowed. In addition, the CPC-P exam includes questions on health insurance reimbursement.
All of AAPC’s exams are structured in a similar way: 150 multiple-choice questions, with the exam proctored at a specific location. The subjects of those questions vary; a CPC exam covers most topics in a general sense, while the other exams get increasingly focused on specific skills. All their exams provide you with five hours and forty minutes to finish, as well as providing you with an opportunity to retake the exam once at no additional cost.
AAPC charges a set fee for each of their examinations, which includes membership in the group – $300, or $260 if you have joined AAPC as a student. There is no formal educational requirement, although AAPC recommends that you earn an associate’s degree. You will also need to have two years of experience as a medical biller and coder to be fully certified. However, if you complete the exam without this work experience, you will still receive certification as a coding apprentice (CPC-A, CPC-P-A, etc.) and will earn your full credential as long as you work in the field and complete continuing education.
When you arrive at the exam site, you will be permitted to bring coding manuals with you. Here’s what you can bring:
  • A CPT book (AMA standard or professional edition); no other publisher’s work is allowed.
  • An ICD-9-CM codebook of your choice.
  • An HCPCS Level II codebook of your choice.
  • Officially published corrections to any errors in the above books.
  • For specialty exams only, relevant anatomical charts and sample worksheets for the specific field you are testing on; check the AAPC site for full details.
The questions in the exam are structured so that these books, as well as reasoning and understanding of medical terminology, anatomy and physiology, will permit you to succeed.
You will also need to continue studying in order to keep your certification, along with remaining a dues-paying member of AAPC. You will be expected to complete 36 Continuing Education Units (CEUs) every two years. This is less demanding than it may seem; you can earn a CEU each month by completing an small test in AAPC’s journal, and workshops, online webinars and conferences give you plenty of opportunities to make up the difference.

Preparing for the Exam

AAPC offers a range of exam preparation products, and there is a great deal of material on medical billing and coding available at bookstores. What’s more, you may already be studying medical billing and coding as well as related topics in formal courses at a school or other institution. Here are some tips that may help you prepare more effectively, as well as deal with other problems leading up to your certification exam.
  • If you’re stressed by the prospect of an expensive exam, remember that your payment comes with one free retest. AAPC will provide you with a full report of how you performed, including exact scores and notation of areas where you need to focus your studies. It may be helpful to think of your first try as practice.
  • Remember that you are permitted to bring in codebooks; you will not need to memorize the entire coding system you are being tested on, but instead you will need to know how to quickly and efficiently find out the codes you need. Focus your practice on learning to look up codes quickly and accurately, as well as on medical terminology.
  • A powerful way to study uses flash cards. Write down the information you are studying on a series of them, and go through the entire stack. If you get one right, place it in the “once weekly” stack; if you get it wrong, place it in the “once daily” stack. Review the “once daily” stack daily, moving correct answers into the “once weekly” stack, and do the same for the “once weekly” stack. This combines regular review with a focus on what you truly need to cover.

Study Guides

These resources can help you prepare yourself for medical billing and coding certification. Some of these are unofficial and others are produced by the AAPC or other professional groups.
  • Quizlet: Medical Billing and Coding – This resource provides you with free, student-made online “quizlets”. There is no cost for them, and you can be certain they were made to address genuine student needs.
  • – A free and searchable guide to ICD-9’s code standards, which are the primary topic of your certification exams.
  • Step-by-Step Medical Coding (2013 edition) – A guide to understanding medical coding by a veteran in the field. The latest update to a long series of yearly issues; earlier editions are still largely valid, although you should look up, and keep in mind, what changes have taken place in coding practice.
  • Official CPC Certification Study Guide – Published by the AAPC and written by the same panel that writes the CPC exam, you can be certain this guide will tell you what you need to know. It includes sample questions of all sorts, a specially prepared study guide, and a series of practical examples.

Sample Tests

Taking practice examinations can help you find your own weak spots for further study, as well as having benefits as a learning practice in its own right. These are some sources for sample medical coding and billing tests, which will let you test your learning without pressure and at little or no cost.
  • Medical Coding Consultants – These training specialists provide a wealth of resources on the AAPC certification exam and other medical coding topics. Look for the light blue entries to find the free resources.
  • Career Coders: Test your Knowledge – These sample questions, provided by a medical billing and coding instructional company, let you test your knowledge in specific fields, such as ICD-9, Medicare/Medicaid, and medical terminology.
  • AAPC – Online Practice Exams – AAPC offers a series of online practice exams in all of their certification, providing you with quick feedback, detailed explanations of the reasoning behind various questions’ answers, and as many retakes as you like. They are only available for a fee, although you will get a substantial discount with AAPC membership.

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