AAHAM CRCS-P Study

CRCS
Certified Revenue Cycle Specialist
AAHAM
The American Association of Healthcare Administrative Management
1-Day Rule
a requirement that all diagnostic or outpatient services
furnished in connection with the principle admitting diagnosis within one day prior to the hospital admission are bundled with the inpatient services for Medicare billing.
3-Day Rule
a requirement that all diagnostic or outpatient services
furnished in connection with the principle admitting diagnosis within three days prior to the hospital admission are bundled with the inpatient services for Medicare billing.
5010A1
the American National Standards Institute transaction for a
professional claim (the electronic equivalent of the CMS 15000),
formerly the 837P
837I
the American National Standards Institute transaction for an
institutional claim; as a result of HIPAA, it is replacing the electronic
UB-04.
837P
a former American National Standards Institute transaction for a
professional claim (the electronic equivalent of the CMS 15000), sincereplaced by the 5010A1.
ABN
the Advance Beneficiary Notice of Noncoverage; a form given to a Medicare beneficiary before services are furnished when a service does not meet or is not expected to meet medical necessity.
abuse
the misuse of a person, substance, service, or financial matter such that harm is caused; some forms of healthcare abuse include excessive or unwarranted use of technology, pharmaceuticals, and services; abuse of authority; and abuse of privacy, confidentiality, or duty to care; it also includes improper billing practices (like billing Medicare instead of primary insurer), increasing charges to Medicare beneficiaries but not to other patients, unbundling of services, and unnecessary transfers of
patients.
Accounts Receivable (AR) Days Outstanding
an estimate, using average current revenues, of the days required to turn over the accounts receivable under normal operating conditions; in simple terms, this is an estimate of the time needed to collect the accounts receivable.
ACF
Administration for Children and Families; one of the DHHS
Operating Divisions.
ACL
Administration for Community Living; one of the DHHS Operating
Divisions.
actual or expressed consent
written or oral agreement by the patient to
the treatment outlined.
acute inpatient
a level of healthcare delivered to patients experiencing
acute illness or trauma; it generally occurs in a hospital or emergency room and is generally short-term care rather than long-term or chronic care.
ADC
average daily census; the average number of inpatients maintained in the hospital each day for a specific period of time.
ADRR
Average Days of Revenue in Accounts Receivable; also known as Accounts Receivable (AR) Days Outstanding; an estimate, using average current revenues, of the days required to turn over the accounts receivable under normal operating conditions; in simple terms, this is an estimate of the time needed to collect the accounts receivable.
Advance Beneficiary Notice
the Advance Beneficiary Notice of Noncoverage; a form given to a Medicare beneficiary before services are furnished when a service does not meet or is not expected to meet medical necessity.
AFDC
Aid to Families with Dependent Children; a financial assistance
program provided by DHHS.
agents
individuals who help consumers and small businesses complete
the application process and enroll in healthcare coverage through the Marketplace; they are able to make recommendations about coverage and may only sell plans from specific health insurance companies.
AHA
the American Hospital Association.
AHRQ
Agency for Healthcare Research and Quality; one of the DHHS
Operating Divisions.
ALOS
average length of stay; a metric calculated by dividing the total
number of patient days by the number of discharges.
ancillary services
services other than routine room and board charges
that are incidental to the hospital stay; they include operating room; anesthesia; blood administration; pharmacy; radiology; laboratory; medical, surgical, and central supplies; physical, occupational, speech pathology, and inhalation therapies; and other diagnostic services.
ANSI
the American National Standards Institute.
APC
ambulatory payment classification; a payment methodology in
which services paid under the prospective payment system are
classified into groups that are similar clinically and in terms of the
resources they require; a payment rate is established for each APC.
APR
annual percentage rate; one of the elements of disclosure required by the Truth in Lending Act.
assignment of benefits
a written authorization, signed by the policyholder (or the patient, in the absence of the policyholder) to an insurance company, to pay benefits directly to the provider; when assignment is not accepted, the payment will be sent to the patient and the provider will have to collect it.
ATB
aged trial balance; a resource for internal collection efforts.
ATSDR
Agency for Toxic Substances and Disease Registry; one of the
DHHS Operating Divisions.
average daily census
the average number of inpatients maintained in the
hospital each day for a specific period of time.
average daily revenue
the average amount of revenue or charges
generated each day over a specified period of time.
Average Days of Revenue in Accounts Receivable
also known as
Accounts Receivable (AR) Days Outstanding; an estimate, using average
current revenues, of the days required to turn over the accounts
receivable under normal operating conditions; in simple terms, this is an
estimate of the time needed to collect the accounts receivable.
bad debt
an uncollectible account resulting from the extension of credit.
beneficiary
a person who has healthcare insurance through Medicare
birthday rule
a rule to determine coordination for benefits for a child
covered by both parents; it dictates that the parent with the first
birthday in the calendar year will provide the primary coverage; if both parents happen to have the same birthday, the plan that has covered a parent longer pays first.
Black Lung Benefits Act
legislation which provides for medical
treatment for coal miners totally disabled from black lung disease.
Bressers
a cross-reference directory used in skip tracing.
brokers
individuals who help consumers and small businesses complete
the application process and enroll in healthcare coverage through the Marketplace; they are able to make recommendations about coverage and may only sell plans from specific health insurance companies.
CAH
Critical Access Hospital
Call centers
an option for consumers to ask questions about health
coverage options and obtain assistance with the Marketplace application
process.
capitation
a method of payment in which a provider is paid a set dollar
amount for each patient for a specific time period, and that payment covers all care the group of patients receives for that period, no matter the actual charges.
Case Management
also known as Utilization Review (UR); an area that
performs critical tasks during registration and a patient’s stay, such as reducing unnecessary admissions; managing the approved length of stay; ensuring an appropriate level of care for the patient’s condition; serving as liaison with the primary and specialty physicians; serving as liaison with the insurance carrier; obtaining approvals, when clinically necessary, for pre-certification/re-certification; advising the patient of discharge; and assisting with appeals for denials, when applicable.
CDC
Centers for Disease Control and Prevention; one of the DHHS
Operating Divisions.
CDM
charge description master; the chargemaster or master pricing list that includes services, supplies, devices, and medication charges for inpatient or outpatient services by a healthcare facility.
CERT
Comprehensive Error Rate Testing.
Certified application counselors
individuals (staff members or volunteers) who fulfill some of the same roles as Navigators and non-Navigators; they are not responsible for outreach and education but they do provide free information to consumers about insurance programs, they assist them in applying for coverage, and they help to facilitate the enrollment in health coverage.
CHAMPUS
Civilian Health and Medical Programs of the Uniformed
Services; the programs replaced by Tricare to cover healthcare for active duty and retired members of the uniformed services, their families, and survivors.
Chapter 7
a type of bankruptcy applying to individuals and businesses
that cannot pay their debts based on their income; except for exempt property as defined by state laws, the debtor’s assets are auctioned to satisfy creditor claims; about 70% of all bankruptcy claims are filed under Chapter 7.
Chapter 11
a type of bankruptcy frequently referred to as a “reorganization”; it gives a distressed business a reprieve from creditor claims while it continues to function and works out a repayment plan.
Chapter 12
a type of bankruptcy for a family farmer with “regular annual
income.”
Chapter 13
a type of bankruptcy designed for individuals with regular
income who desire to pay their debts, but currently are unable to do so; the debtor, under court supervision and protection, may propose and carry out a repayment plan under which creditors are paid over an extended period of time.
chargemaster
also known as charge description master (CDM); the
master pricing list that includes services, supplies, devices, and
medication charges for inpatient or outpatient services by a healthcare
facility.
charity care
service provided that is never expected to result in cash
SCHIP
the Children’s Health Insurance Program; a program for children
whose parents have too much money to be eligible for Medicaid, but not enough to buy private insurance; it is jointly financed by the federal and state governments, and administered by the states.
CLIA
the Clinical Laboratory Improvement Amendment of 1988;
legislation requiring all clinical laboratory services furnished to
Medicare beneficiaries to be performed by a provider who has a CLIA certificate.
Clinical Laboratory Improvement Amendment (CLIA) of 1988
legislation requiring all clinical laboratory services furnished to
Medicare beneficiaries to be performed by a provider who has a CLIA
certificate.
CMP
civil monetary penalty.
CMS
Centers for Medicare and Medicaid Services; one of the DHHS
Operating Divisions.
CMS 1450
another name for the UB-04 uniform bill form.
CMS 1500
the billing form used to submit physician and professional
service claims to Medicare.
CO
compliance officer.
COB
coordination of benefits; the determination of which plan or
insurance policy will pay first if two health plans or insurance policies cover the same benefits.
Common Working File
a CMS file that contains Medicare patient
eligibility and utilization data.
conditional payment
a payment made when another payer is
responsible, but the claim is not expected to be paid promptly (usually within 120 days from receipt of the claim); it prevents the beneficiary from having to pay out of pocket; Medicare then has the right to recover any payments that should have been made by another payer.
Consumer assistance programs
a resource to help to address consumers’
problems or questions about health coverage.
Consumer Credit Protection Act
the first general federal consumer protection legislation; its provisions include the Truth in Lending Act, the Fair Credit Billing Act, the Fair Credit Reporting Act, and the Fair Debt Collection Practices Act.
coordination of benefits contractor
a contracted entity that assists with the collection, management, and reporting of other health coverage; COB contractors do not process claims for the provider; they gather and disseminate coordination of benefits information to ensure that Medicare is not making primary payment for a service in error.
courtesy discharge
a type of discharge in which a patient’s financial considerations have been met so he or she is allowed to leave the hospital without going through the usual formalities; the patient is
billed at a later date.
CPT
Current Procedural Terminology; a system of descriptive terms and five-digit numeric codes that are used primarily to identify medical services and procedures furnished by physicians and other healthcare professionals.
CPU
central processing unit.
CRA
credit reporting agency
Criminal Health Care Fraud Statute
a statute that prohibits willfully or knowingly executing a scheme to obtain any money or property owned by or in control of any healthcare benefit program or defrauding any healthcare benefit program.
Critical Access Hospital (CAH)
a non-profit hospital located in a state that has established a Medicare Rural Hospital Flexibility Program; it must have 25 or fewer beds and an ALOS of 96 hours or less, be located a certain minimum distance from other hospitals, and furnish 24-hour emergency care services; Medicare pays CAHs for most inpatient and outpatient services on the basis of reasonable cost.
custodial care
care that is primarily for the purpose of meeting personal
needs; persons without professional training may provide custodial care; it is not covered by Medicare.
CWF
Common Working File; a CMS file that contains Medicare patient
eligibility and utilization data.
data mailer
a system-generated, free-form statement that is used to
communicate the status of a patient’s account and/or to bill the patient for an unpaid amount remaining on the account.
definitive LCD/NCD
a policy that discusses and lists specific diagnosis codes, ICD procedure codes, and possibly signs and symptoms to support the need for the item or service being given.
DHHS
Department of Health and Human Services; the United States
government’s principal agency for protecting the health of all
Americans and providing essential human services; it is also the federal government’s largest grant-making agency.
discharge of debtor
a potential outcome of bankruptcy that releases the
guarantor/patient from financial responsibility of any and all account balances listed on the bankruptcy petition; the account balance is to be written off to the appropriate transaction code.
dismissal
a court ruling whereby a bankruptcy is rejected by the court;
the most common reason for dismissal is the failure of the debtor to follow through on the filing process and on payment to the attorney, and failure to provide requested documentation; upon dismissal of a bankruptcy, a creditor can bill the debtor directly, refer the account to a collection agency, or pursue litigation.
DME
durable medical equipment, such as wheelchairs, hospital beds,
oxygen, and walkers.
DMEPOS
durable medical equipment, prosthetics, orthotics, and
supplies.
DOJ
Department of Justice; one of the entities, along with the Office of
Inspector General (OIG), that coordinates fraud and abuse control.
DSMT
Diabetes Self-Management Training.
dual eligible
an individual who is entitled to Medicare Part A and/or
Part B, and also eligible for some form of Medicaid benefit.
Durable Power of Attorney for Healthcare
also known as Healthcare
Power of Attorney; a document that designates someone else (known as
a healthcare surrogate, agent, or proxy) to make decisions on the
patient’s behalf if he or she is unable to do so.
ECOA
Equal Credit Opportunity Act
Equal Credit Opportunity Act
a law that prohibits credit discrimination on the basis of race, color, religion, national origin, sex, marital status, age, or because someone receives public assistance.
E&M
evaluation and management; both the process of and the charge for examining a patient and formulating a treatment plan.
EGHP
Employer Group Health Plan.
emancipation
a process by which a minor is freed from parental control
based on specific criteria (the minor no longer requires parental
guidance or financial support, fathered or gave birth to a child, or has reached the age of majority).
Emergency Medical Treatment and Active Labor Act
also known as the Federal Anti-Dumping Statute; legislation enacted in 1986 in response to concerns that hospitals were refusing to treat patients without insurance and even transferring them to other facilities and leaving them there,
sometimes without notifying the receiving facility.
EMTALA
Emergency Medical Treatment and Active Labor Act
EOB
Explanation of Benefits; the former name for the Medicare
Summary Notice, which is a remittance advice.
evaluation and management (E&M)
both the process of and the charge for examining a patient and formulating a treatment plan.
Fair Credit Billing Act
an amendment to the Truth in Lending Act; it protects consumers from inaccurate or unfair practices by issuers of
open-ended credit, requires creditors to inform debtors of their rights and of the responsibilities of the creditor, and has as its principle thrust to provide for prompt settlement of billing disputes.
Fair Credit Reporting Act
defines what information from “consumer reports” can be used, by whom, and when; it provides the maximum protection of a consumer’s right to privacy and confidentiality of credit
reports.
Fair Debt Collection Practices Act
legislation enacted as the result of evidence that debt collectors were using abusive, deceptive, and unfair collection practices; it imposes strict limitations and prohibitions on debt collection practices.
false
a type of skip generally caused by clerical error at the time of
registration, such as transposed numbers in the street address, an incorrect zip code, or incomplete information.
False Claims Act
legislation that prohibits making a false record or
statement to get a false/fraudulent claim paid by the government,
submission of false/fraudulent claims, and conspiring to have
false/fraudulent claims paid by the government.
FDA
Food and Drug Administration; one of the DHHS Operating
Divisions.
FDCPA
Fair Debt Collection Practices Act; legislation enacted as the
result of evidence that debt collectors were using abusive, deceptive, and unfair collection practices; it imposes strict limitations and prohibitions on debt collection practices.
Federal Anti-Dumping Statute
another name for the Emergency Medical Treatment and Active Labor Act (EMTALA); legislation enacted in 1986 in response to concerns that hospitals were refusing to treat patients without insurance and even transferring them to other facilities and leaving them there, sometimes without notifying the receiving facility.
FOIA
Freedom of Information Act.
fraud
the intentional or illegal deception or misrepresentation made for
the purpose of personal gain, or to harm or manipulate another person or organization; fraud includes incorrect reporting of diagnosis and procedure codes to maximize payments, billing for services not furnished, altering claims to receive payment, accepting kickbacks, the routine waiver of deductible and coinsurance amounts, etc.
GAAP
generally accepted accounting principles.
HCFA
Health Care Financing Administration; the former name for the
Centers for Medicare and Medicaid Services.
HCPCS
Healthcare Common Procedure Coding System; the federal
government equivalent to the CPT system.
Health Care Fraud Prevention and Enforcement Action Team
HEAT, a team that uses government resources to help prevent fraud, waste, and abuse in both the Medicare and Medicaid programs.
Healthcare Power of Attorney
also known as Durable Power of Attorney for Healthcare; a document that designates someone else (known as a healthcare surrogate, agent, or proxy) to make decisions on the patient’s
behalf if he or she is unable to do so.
HICN
Medicare Health Insurance Claim Number
Hill-Burton Act
the Hospital Survey and Construction Act; legislation
designed to assist hospitals by providing loans for construction projects; once the hospitals were operational, the funds that were borrowed were to be paid back in the form of charity; also known as Title I.
HIPAA
Health Insurance Portability and Accountability Act of 1996
HIPAA is also know as?
the Kennedy-Kassenbaum Bill
Health Insurance Portability and Accountability Act of 1996
also known as the Kennedy-Kassenbaum Bill; it created federal standards for insurers, HMOs, and employer plans including those who are selfinsured.
HMO
Health Maintenance Organization; one of five types of Medicare
Advantage Plans in which members must generally get healthcare from providers in the plan’s network.
home health care
preventative, supportive, rehabilitative, or therapeutic
care provided to a patient at home; to be reimbursed by the Medicare program, a physician must certify that the patient is home bound, in need of skilled nursing care on an intermittent basis for physical, occupational, and/or speech therapy, with an established plan of care.
hospice care
coordinated, palliative care provided to terminally ill
patients and their families by nonprofit organizations.
HRSA
Health Resources and Services Administration; one of the DHHS
Operating Divisions.
HSA
Health Savings Account (formerly known as Medical Savings
Account, or MSA).
I-Bill
an itemized statement.
ICD
International Classification of Diseases; a standard transaction set used for 1) chief complaint or diagnosis for professional services and inpatient procedures, and 2) for diagnosis and procedure codes for professional and technical services for both inpatient and outpatient procedures.
ICD-10
the newest version of the International Classification of Diseases.
IEQ
Initial Enrollment Questionnaire; a questionnaire mailed about three months before patients become entitled to Medicare; it asks about any other healthcare coverage that may be primary to Medicare.
IHS
Indian Health Service; one of the DHHS Operating Divisions.
implied consent – by law
consent that occurs in a situation where the patient is unconscious and is taken to the emergency room; the law
allows treating the patient.
implied consent – in fact
consent by silence; the patient implies consent
to the treatment by not objecting.
imprest
petty cash.
indigent
an individual with no means of paying for services or
treatments, who is not eligible for Medicaid or another public assistance program.
informed consent
consent given when the risks and benefits of a
treatment are understood and the patient makes an informed decision whether to receive that treatment.
Initial Enrollment Questionnaire (IEQ)
a questionnaire mailed about three months before patients become entitled to Medicare; it asks about any other healthcare coverage that may be primary to Medicare.
IEQ
Initial Enrollment Questionnaire
initial preventive physical examination (IPPE)
the “Welcome to Medicare Physical Exam” that is offered to each beneficiary once in a lifetime.
IPPE
initial preventive physical examination
initiation
the beginning of the treatment for a new encounter or a new
plan of care; one of the times when a triggering event for an ABN can occur.
intentional
a type of skip in which someone avoids paying bills by
changing his or her residency and failing to leave a forwarding address, purposely changing his or her name, or intentionally giving false information.
involuntary bankruptcy
a type of bankruptcy in which a debtor can be placed under Chapter 7 or 11 if the debtor has 12 or more creditors, three of which have claims in excess of $5,000 each and are willing to force the issue, or one creditor owed at least $10,775.
IPPS
Inpatient Prospective Payment System
Joint Commission, The (TJC)
the organization that accredits hospitals;
formerly called the Joint Commission on Accreditation of Healthcare Organizations (JCAHO); accreditation is extremely important for hospitals as it is a requirement of participation in the Medicare program.
judgment
a legally verified claim against a debtor; a legal right to collect
a debt that can be used to obtain a lien.
Kennedy-Kassenbaum Bill
another name for the Health Insurance Portability and Accountability Act of 1996 (HIPAA); it created federal standards for insurers, HMOs, and employer plans including those who are self-insured.
Local Coverage Determination (LCD)
policies developed by Medicare area contractors that specify criteria for services and show under what clinical circumstances an item or service is considered to be reasonable, necessary, and appropriate.
lien
a recorded claim against real or personal property; if the property is sold, the creditor must be paid out of the proceeds of that sale.
living will
a document that specifies what treatments a patient does and
does not wish to receive; it means that difficult decisions about future care are made while the person is alert; patients can choose the circumstances under which they will die; and patients’ desires regarding organ donation are made known.
long term care
care generally provided to the chronically ill or disabled
in a nursing facility or rest home; among the services provided by
nursing facilities are 24-hour nursing care; rehabilitative services such as physical, occupational, and speech therapy; and assistance with daily activities like eating, bathing, and dressing.
LTR
lifetime reserve.
MAAC
maximum allowable actual charge.
MCE
Medicare Code Editor; software that edits claims to detect incorrect billing data that is being submitted.
MDC
major diagnostic category; one of 25 groups of DRGs (diagnosisrelated groups).
MDS
Minimum Data Set; part of the federally required process for
clinical assessment of all residents in Medicare- or Medicaid-certified nursing homes; the MDS then determines the Resource Utilization Group (RUG) and hence the payment.
Medicaid
a health insurance program for certain low-income people; it is
funded and administered through a state-federal partnership.
Medicare
a health insurance program for the elderly (age 65 or older)
and those under age 65 who have permanent disabilities or end stage renal disease (ESRD).
Medicare Advantage Plans
another name for Medicare Part C; managed
care coverage provided by private insurance companies approved by Medicare.
Medicare Code Editor (MCE)
software that edits claims to detect incorrect billing data that is being submitted.
Medicare Participating Physician Program
a program that enables providers to accept assignment of benefits.
Medicare Secondary Payer (MSP)
laws that shifted costs from the Medicare program to other sources of payment; MSP information is gathered from each beneficiary to determine the proper coordination of benefits.
Medicare Summary Notice (MSN)
a remittance advice; formerly called
the Explanation of Benefits (EOB).
Medigap
also known as Medicare supplemental insurance; health
insurance sold by private insurance companies to fill in the “gaps” in coverage (like deductibles, coinsurance, and copayments) under the Original Medicare Plan; some Medigap policies also cover benefits that Medicare doesn’t cover, like emergency healthcare while traveling outside the United States.
MIC
Medicaid Integrity Contractors; review, audit, and educate
providers to combat fraud and abuse.
midnight census
the number of patients in the hospital at midnight
census; determined from the census count for the previous midnight, minus any discharges, plus any admissions, plus/minus any status changes.
MSN
Medicare Summary Notice; a remittance advice; formerly called
the Explanation of Benefits (EOB).
MSP
Medicare Secondary Payer
MSP Questionnaire
a questionnaire completed on an ongoing basis to
help determine if Medicare is primary or secondary; it asks about
employment, accidents, and several other relevant subjects.
MTF
Military Treatment Facility
MUE
Medically Unlikely Edit
Medically Unlikely Edit
an automated edit for HCPCS/CPT codes for services rendered by a provider to a single beneficiary on the same date of service; it helps to prevent inappropriate payments due to clerical entries and incorrect coding based on anatomic considerations.
MVPS
Medicare Volume Performance Standard; the element of the
Resource Based Relative Value Scale (RBRVS) for the rates of increase in Medicare expenditures for physician services.
NAS
Non-Availability Statement
National Correct Coding Initiative (NCCI)
a Medicare initiative to promote correct coding methodologies and strive to eliminate improper coding; it dentifies mutually exclusive CPT-4 and HCPCS codes or those that should not be billed together.
National Coverage Determination (NCD)
medical review policies issued by CMS which identify specific medical items, services, treatment procedures, or technologies that can be covered and paid for by the Medicare program.
Navigators
individuals who help consumers fill out applications for
health coverage through the Marketplace; they help determine if
consumers qualify for programs to help lower their costs.
NCCI
National Correct Coding Initiative
NIH
National Institutes of Health; one of the DHHS Operating Divisions.
Non-Availability Statement (NAS)
a requirement before any nonemergent inpatient services may be provided to a Tricare Extra or Standard eligible beneficiary by a non-Military Treatment Facility (MTF).
non-definitive LCD/NCD
a policy that provides potential coverage circumstances, but most likely does not provide specific diagnoses, signs, symptoms, or ICD-9-CM codes that will be covered or noncovered; when the Medicare contractor considers or utilizes factors and information other than that in the LCD/NCD when making a coverage determination.
non-Navigators
individuals who perform the same functions as
Navigators but only in a state-based Marketplace or state partnership
Marketplace.
non-standard claim
a claim with extraneous attachments in lieu of data
entered correctly in the claim form.
notifier
CMS’ name for an entity that issues ABNs
NPI
National Provider Identification; a unique identifier for covered
healthcare providers.
NPP
non physician practitioner
NUBC
National Uniform Billing Committee
National Uniform Billing Committee (NUBC)
the entity that determined the data elements used in the UB-04 final format as a cooperative effort with the American Hospital Association (AHA).
Obamacare
one of the common names for the Patient Protection and
Affordable Care Act, PPACA.
OBRA
Omnibus Budget Reconciliation Act (OBRA) of 1989; it provided
for the Resource Based Relative Value Scale (RBRVS) as a payment
reform provision.
observation
services furnished on a hospital premises, including use of a
bed and periodic monitoring by a hospital’s nursing staff; services should be reasonable and necessary to evaluate an outpatient condition to assess the need for admission to the hospital; observation services usually do not exceed 24 hours; however, there is no hourly limit on the extent to which they may be used (CMS has indicated that instances would be rare that a patient would remain in observation for more than 48 hours).
office
care provided in a practitioner’s place of business; a practitioner
may be a medical doctor, podiatrist, chiropractor, dentist, advanced practice nurse, registered dietitian, physical therapist, psychologist, or one of many other professions.
OIG
Office of Inspector General
Office of Inspector General (OIG)
one of the entities, along with the
Department of Justice, that coordinates fraud and abuse control; it also
has identified seven elements of a compliance plan.
ordering physician
a physician who orders non physician services for a
patient, such as diagnostic x-rays.
outpatient
treatment received at a hospital, clinic, or dispensary by
someone who is not hospitalized; emergency room patients, ambulatory patients, clinic patients, and same-day surgery patients are all examples of the outpatient classification.
Part A
the hospital insurance component of Medicare that helps pay for
medically necessary inpatient hospitalization, care in a SNF following a three-day hospital stay, home health care, hospice care, and blood.
Part B
the medical insurance component of Medicare that helps pay for
doctor services, outpatient hospital care, and some other medical
services that Part A does not cover (such as the services of physical and occupational therapists, and some home health care).
Part C
also known as Medicare Advantage Plans; managed care coverage provided by private insurance companies approved by Medicare.
Part D
the component of Medicare that helps pay for prescription drugs.
PAT
pre-admission testing; the diagnostic medical screening of patients in advance of surgical or invasive procedures to determine hospitalization and/or surgical suitability.
Patient Bill of Rights
a development by the American Medical Association that guarantees a patient the right to receive courteous, considerate, respectful treatment in a clean/safe environment; appropriate healthcare; information about his/her health treatment plan
in a way that he or she understands; continuity of care; confidentiality; privacy; participation in planning care and treatment; refusal of care; use of grievance mechanisms; treatment without discrimination; an itemized bill and explanation of all charges; and review of the medical record and/or a copy at a reasonable fee.
PCP
primary care physician.
per diem
Latin for “for each day”; a payment methodology in which
providers are paid a predetermined amount for each day an inpatient is in the facility, regardless of actual charges or costs incurred.
percentage of occupancy
the ratio of actual patient days to the maximum
patient days as determined by bed capacity; a low percentage of
occupancy indicates inefficiency while a percentage that is too high will mean difficulty finding available beds, long hold times in ER, etc.
physician extender
physician assistant, nurse practitioner, etc.
PPO
Preferred Provider Organization
Preferred Provider Organization (PPO)
one of five types of Medicare Advantage Plans in which members can see any doctor or provider that accepts Medicare and they don’t need a referral to see a specialist.
PPS
prospective payment system.
pre-certification
the process of obtaining authorization from an
insurance company review organization approving the medical
necessity of a hospitalization.
Privacy Act of 1974
legislation that governs patient confidentiality and
provides safeguards against an invasion of privacy through the misuse of records by federal agencies.
PSA
Physician Scarcity Area.
PSDA
Patient Self Determination Act of 1990
Patient Self Determination Act of 1990
legislation that ensures that patients understood their right to participate in decisions about their own healthcare.
QIO
Quality Improvement Organization
Quality Improvement Organization;
part of a CMS program to monitor and improve utilization and quality of care for Medicare beneficiaries.
RBRVS
Resource Based Relative Value Scale
Resource Based Relative Value Scale
a payment reform provision comprising three major elements: a fee schedule for payment of physician services, based on the relative value unit (RVU); the Medicare Volume Performance Standard (MVPS) for the rates of increase in Medicare expenditures for physician services; and limits on the amount non-participating physicians can charge beneficiaries, referred to as the limiting charge.
reduction
a decrease in the frequency or duration of care; one of the
times when a triggering event for an ABN can occur.
referring physician
a physician who requests an item or service for a
beneficiary for which payment may be made under Medicare.
Regulation Z
another name for Title I of the Consumer Credit Protection
Act, or the Truth in Lending Act; it requires disclosure of information before credit is extended.
remittance advice
another name for the Medicare Summary Notice;
formerly called the Medicare Explanation of Benefits (EOB).
Resource Utilization Group (RUG)
a system to determine the payment
rate for most skilled nursing care; the provider completes the Minimum
Data Set as part of the federally required process for clinical assessment
of all residents in Medicare- or Medicaid-certified nursing homes; the
MDS then determines the RUG and hence the payment; the patient is reevaluated
at intervals during his or her stay and the RUG rate may be
changed.
respite care
short-term, temporary custodial care that allows a family
member or other unpaid caregiver to get relief from caring for a
physically frail or dependant person at home.
RUG
Resource Utilization Group
RVU
relative value unit
relative value unit
the basis for the fee schedule for payment of
physician services that is one of the elements of the Resource Based Relative Value Scale (RBRVS).
SAMHSA
Substance Abuse and Mental Health Services Administration;
one of the DHHS Operating Divisions.
skip
a debtor who cannot be located by a creditor; there are three types:
intentional; unintentional, and false.
SNF
skilled nursing facility
skilled nursing facility
a separate wing of a hospital, a nursing home, or a freestanding facility; to qualify for SNF coverage, Medicare requires a person to have been a hospital inpatient for at least three consecutive days (not including the day of discharge).
spell of an illness
also known as the benefit period; the period of time that begins when a beneficiary enters the hospital and ends 60 days after discharge from the hospital or from a SNF.
statute of limitations
the amount of time in which a claim must be collected before it is deemed paid or satisfied.
superbill
an invoice used to document the services ordered or rendered
during a patient visit; it is often referred to as a face sheet and includes patient demographic data plus the CPT, ICD-9-CM, and HCPCS codes for the most common procedures performed in the practice or department; upon completion of treatment, the physician completes the superbill to document all services provided; thus a superbill essentially is a tool to eliminate the need for transcribing medical record notes from a patient chart and streamline the charge capture process.
termination
a discontinuation in the services being provided; one of the
times when a triggering event for an ABN can occur.
Title XVIII
Medicare
Title XIX
Medicaid
TJC
The Joint Commission; the organization that accredits hospitals;
accreditation is extremely important for hospitals as it is a requirement of participation in the Medicare program.
tort liability
a liability for an injury or wrongdoing by one person to
another resulting from a breach of legal duty.
TPA
third party administrator
Tricare
a regionally-managed healthcare program for active duty and
retired members of the uniformed services, their families, and survivors.
triggering event
an event that occurs during initiation, reduction, or
termination of a course of treatment that triggers the need for an ABN.
Truth in Lending Act
another name for Title I of the Consumer Credit
Protection Act; also known as Regulation Z; it requires disclosure of information before credit is extended.
Two Midnight Rule
CMS guideline stating that when a physician expects a Medicare patient to remain in the hospital for at least two midnights, the physician should write an inpatient admission order.
UB-04
the uniform bill required of hospital inpatient and outpatient
departments, skilled nursing facilities, home health practitioners,
comprehensive outpatient rehabilitation facilities, community mental health centers, and the like when billing Medicare.
UCR
usual, customary, and reasonable
usual, customary, and reasonable
a method to determine the value of services used by many third party payers; it relies on physiciancharge data accumulated over time; after ranking the charges for a given service from lowest to highest, the payer uses a specific point (for example, the 75th percentile) as the basis for UCR payments.
unintentional
a type of skip in which someone moves or changes
residence and fails to notify creditors; a forwarding address is normally
available.
unprocessable
a claim that is considered incomplete or invalid due to
missing claim form data elements.
UR
Utilization Review
Utilization Review
also known as Case Management; an area that performs critical tasks during registration and a patient’s stay, such as reducing unnecessary admissions; managing the approved length of
stay; ensuring an appropriate level of care for the patient’s condition; serving as liaison with the primary and specialty physicians; serving as liaison with the insurance carrier; obtaining approvals, when clinically necessary, for pre-certification/re-certification; advising the patient of discharge; and assisting with appeals for denials, when applicable.
V code
a type of ICD-9-CM code used when services or visits relate to
circumstances other than disease or injury.
VA
the U.S. Department of Veterans Affairs
VCIS
voice case information system
voice case information system
a telephonic system used to perform an on-site check at the bankruptcy clerk’s office.
workers’ compensation
a plan that covers injuries sustained by a worker in the course of performing his or her job duties.
AHCA
Agency for Health Care Administration
AMA
Against Medical Advice or American Medical Association
ASC
Ambulatory Surgical Center
ATB
Aged Trial Balance
BBA
Balanced Budget Act
BNI
Beneficiary Notices Initiative
CCI
Correct Coding Initiative
CCS
Crippled Children’s Service
CDT
Current Dental Terminology
CEO
Chief Executive Officer
CFO
Chief Financial Officer
CHAMPUS
Civilian Health and Medical Program of the Uniformed Services
CHAMPVA
Civilian Health and Medical Program of the Veterans Administration
CHCBP
Continued Health Care Benefit Program
CMHC
Community Mental Health Clinic
COBRA
Consolidated Omnibus Budget Reconciliation Act
CORF
Comprehensive Outpatient Rehabilitation Facility
DEERS
Defense Enrollment Eligibility Reporting System
DEFRA
Deficit Equity and Reduction Act
DRA
Deficit Reduction Act
DRG
Diagnosis Related Groups
EDI
Electronic Data Interchange
EIN
Employer Identification Number
ESRD
End Stage Renal Disease
FCRA
Fair Credit Reporting Act
FECA
Federal Employees’ Compensation Act
FEP
Federal Employee Program
Federal Employee Program
FEP
FI
Fiscal Intermediary
GAO
General accounting office
GPO
Government printing office
HCPCS
Healthcare Common Procedure Coding System
Healthcare Common Procedure Coding System
HCPCS
HPSA
Health Provider Shortage Area
HSA
Healthcare Savings Accounts
ICD-9-CM
International Classification of Diseases, Volume 9, Clinical Modification
ICF
Intermediate Care Facility
ICR
Image Character Recognition
IDE
Investigational Device Exemption
IG
Implementation Guide
LMRP
Local Medical Review Policies
MAC
Medicare Administrative Contractor
MAAC
Maximum Allowable Actual Charge
MCO
Managed Care Organizations
MD
Doctorate of Medicine
MDC
Major Diagnostic Categories
MHI
Medicare Hospital Insurance
MIC
Medicaid Integrity Contractors
MIP
Medicaid Integrity Program
MMA
Medicare Modernization Act
NAIC
National Association of Insurance Commissioners
NCD
National Coverage Determinations
NDC
National Drug Code
NOC
Not Otherwise Classified
Not Otherwise Classified
Not Otherwise Classified
NPP
Non Physician Practitioner
ORT
Operation Restore Trust
OSHA
Occupational Safety and Health Act
PAT
Pre-admission testing
PIP
Periodic Interim Payment
PM
Program Memorandums
POE
Parallel Operating Environment
PPS
Prospective Payment System
PRO
Professional Review Organization
QA
Quality Assurance
RAC
Recovery Audit Contractors
RRB
Railroad Retirement Board
RTC
Residential Treatment Centers
SCHIP
State Children’s Health Insurance Program
SSA
Social Security Administration
SSI
Supplemental Security Income
SSN
Social Security Number
TAN
Treatment Authorization Number
TEFRA
Tax, Equity and Fiscal Responsibility Act
Title I
Hill Burton
Title V
Maternal Health and Child
Title XXI
State Children’s Health Insurance Program
TOB
Type of Bill
UPIN
Unique Physician Identification Number
US Public Health Service
USPHS
USTF
Uniformed Service Treatment Facility
WHO
World Health Organization
Benefit Period
A benefit period is a way of measuring a beneficiary’s use of
hospital and skilled nursing facility services covered by Medicare.
A benefit period begins the day the beneficiary is hospitalized. It
ends after the beneficiary has been out of the hospital or other
facility that primarily provides skilled nursing or rehabilitation
services for 60 days in a row.
Census
Refers to the number of patients in the hospital at a particular point
in time.
Clean Claim
A _______ ________ is one that does not require the fiscal intermediary to investigate or develop external to their Medicare operation on a prepayment basis. It is a claim that will pass all Common Working File edits, and are processed electronically, and the claim does not require any external development by the intermediary.
Collection Controls
Admission, pre-admission, in-house, at discharge and after
discharge.
Timely Filing
The shortest time period between providers discharge and claim
completion mailed or carried to the patient’s insurance company.
the goverment’s largest grant-making agency
DHHS
11 DHHS Operating Divisions
NIH, FDA, CDC, ATSDR, IHS, HRSA, SAMHSA, AHRQ, CMS, ACF, ACL