CPB Certified Professional Biller Certification

Abuse
Actions inconsistent with accepted, sound medical business or fiscal practice

Accept Assignment
Provider accepts as payment in full whatever is paid on the cliam by the payer (except for any copayment and or coinsurance amounts.)

Accounts Receivable
The amount owed to a business for services or goods provided.

Accounts Receivable Aging Report
Shows the status (by date) of outstanding claims from each payer, as well as payments due from patients.

Accounts Receivable Management
Assists Providers in the collection of appropriate reimbursement for services rendered; include functions such as insurance verification/eligibility and preauthorization of services.

Accreditation
Voluntary Process that a healthcare facility or organization (e.g. hospital or manged care plan) undergoes to demonstarte that it has met standards beyond those required by law.

Adjudication
Judicial dispuite resolution process in which an appeals board makes a final determination.

Adjusted Claim
payment correction resulting in additional payment(s) to the provider.

Advance Beneficiary Notice (ABN)
Document that acknowledges patient responsiblity for payment if Medicare denies the cliam.

Adverse Effect
Also called adverse reaction; the appearance of a pathologic condition due to ingestion r exposure to a chemical substance properly administered or taken.

Adverse Reaction
Also called adverse effect; the appearance of a pathologic condition due to ingestion r exposure to a chemical substance properly administered or taken.

Adverse Selection
Covering members who are sicker then the general population.

Allowable Charge
see limiting charge; maximum fee a physician may charge.

Allowed Charge
The Maximum amount the payer will reimburse for each procedure or service, according to the patients policy.

All Patient Diagnosis-Related Group (AP-DRG)
DRG system adapted for use by third-party payers to reimburse hospitals for inpatient care provided to non-Medicare beneficiaries (e.g. Blue Cross Blue Shield, commercial health plans, TRICARE); DRG assignment is based on intensity of resources.

All Patient Refined Diagnosis-Related Group (ARP-DRG)
Adopted by Medicare in 2008 to reimburse hospitals for inpatient care provided to Medicare beneficiaries; expanded originial DRG system (based on intensity of resources) to add two subclasses to each DRG that adjusts Medicare inpatient hospital reimbursement rates for severity of illness (SOI) (extent of physiological decompensation or organ system loss of function) and risk of mortality (ROM) (likelihood of dying); each subclass, in turn, is subdivided into four areas: (1) minor, (2) moderate, (3) major, (4) extreme.

Ambulance Fee Schedule
Payment system for ambulance services provided to Medicare Beneficiaries.

Ambulatory Payment Classification (APC)
Prospective payment system used to calculate reimbursement for outpatient care according to similar clinical characteristics and in terms of resources required.

Ambulatory Surgical Center (ASC)
State Licensed Medicare-certified supplier (not provider) of surgical healthcare services that must accept assignment on Medicare Claims.

Ambulatory Surgical Center Payment Rate
Predetermined amount for which ASC services are reimbursed, at 80 percent after adjument for regional wage variations.

Amendment to the HMO Act of 1973
Legislation that allowed federally qualified HMOs to permit members to occasionally use non HMO physicians and be partially reimbursed.

American Academy of Processional Coders (AAPC)
Professional association established to provide a national certification and credentialing process, to support the national and local membership by providing educational products and opportunities to network, and to increase and promote national recognition and awareness of professional coding.

American Association of Medical Assistants (AAMA)
Enables medical assisting professionals to enhance and demonstrate the knowledge, skills, and professionalism required by employers and patients; as well as protect medical assistants’ right to practice.

837
Claims validation table (as in ANSI ASC X12 837)

AAMA
American Association of Medical Assistants

ABN
Advance Beneficiary Notice

ADA
Americans with Disabilties Act

AHA
American Hospital Association

AHFS
American Hospital Formulary Service

AHIMA
American Health Information Management Association

AMA
American Medical Association

ANSI
American National Standards Institute

APC
Ambulatory Payment Classification

AP-DRG
All Patient Diagnosis-Related Group

ARP-DRG
All Patient Refined Diagnosis-Related Group

ASC
Accredited Standards Committee

ASC
Ambulatory Surgical Center

BC
Blue Cross

BCAC
Beneficary Counseling and Assistance Coordinator

BCBS
Blue Cross Blue Shield

BCBSA
Blue Cross Blue Shield Association

BS
Blue Shield

BSR
Beneficiary Services Representative

CA
Cancer or Carcinoma

CAC
Common Access Card

CAC
Computer Assisted Coding

CAT
Computerized Axial Tomography

CCS
Certified Coding Specialist

CDAC
Clinical Data Abstracting Center

CDHP
Consumer Directed Health Plan

CDHS
California Department of Health Services

CDT
Current Dental Terminology

CERT
Comprehensive Error Rate Testing

CF
Conversion Factor

CHAMPUS
Civilian Health and Medical Program of Veterans Affairs

CLIA
Clinical Laboratory Improvement Act

CMP
Competitive Medical Plan

CMS
Centers of Medicare and Medicaid Services

CMS-1450
UB-04 Claim used by institutional and other selected providers to bill payers

CMS-1500
Insurance claim used by noninstitutional providers and supplier to bill payers

CNS
clinical nurse specialist

COB
Coordination of Benefits

COBRA
Consolidated Omnibus Budget Reconciliation Act of 1985

CPC
Ceterifed Professional Coder

CPT
Current Procedural Terminology

CRI
CHAMPUS Reform Initative

CSCP
Customized Sub-Capitation Plan

CT
Computed Tomography

DCAO
Debt Collection Assistance Officer

DEERS
Defense Enrollment Eligibility Reporting System

DME
Durable Medical Equipment

DMEPOS
Durable Medical Equipment, Prosthetic and Orthotic Supplies

DMERC
Durable Medical Equipment regional carriers

DOD
Department of Defense

DRG
Diagnosis related groups

DSH
Disproportionate share hospital (adjustment)

DSM
Diagnostic and statistical manual

EDD
(California) Employment Development Department

EDI
Electronic data interchange

EFT
Electronic funds transfer

EGHP
Employer group health plan

EHNAC
Electronic Healthcare Network Accreditation Commission

EHR
Electronic Health Record

E/M
Evaluation and Management

EMC
Electronic Media Claim

EMR
Electronic Medical Record

EOB
Explanation of Benefits

EPO
Exclusive provider organization

EPSDT
Early and Periodic screening, diagnostic, and treatment

EQRO
External Quality Review Organization

ERA
Electronic Remittance Advice

ERISA
Employee Retirements income security Act of 1974

FATHOM
First Look Analysis for Hospital Outlier Monitoring

FCA
False Claims Act

FDCPA
Fair Debt Collection Practices Act

FECA
Federal Employment Compensation Act

FEHBP
Federal Employee Health Benefit Program

FELA
Federal Employment Liability Act

FEP
Federal Employee Program

FMAP
Federal Medical Assistance Percentage

FPL
Federal Proverty Level

FR
Federal Register

FSA
Flexible Spending Account

GEM
General Equivalency Mapping

GEP
General Enrollment Period

GCPI
Geographic Cost Practice Index

GPWW
Group Practice Without Walls

HA
Health Affairs

HAVEN
Home Assessment Validation and Entry

HCF
Healthcare Finder

HCPCS
Healthcare Common Procedure Coding System

HCRA
Healthcare reimbursement Account

HEDIS
Health Plan Employer Data and Information Set

HHRG
Home Health Resource Group

HICN
Healh Insurance claim number

HIPAA
Health Insurance portability and accountability Act of 1996

HIPPS
Health insurance prospective payment system (code set)

HMO
Health Maintenance Organization

HPMP
Hospital Payment Monitoring Program

HPSA
Health personnel shortage area

HRA
Health reimbursement arrangement

HSA
Health Savings account

HSSA
Health savings security account

a- an-
no,not

ab-
away from

abdomin-
abdomen

acr-
extremities, top

ad-
toward

-ad
toward

adip-
fat

-al
pertaining to

angi-
vessel

ankyl-
crooked, bent

anti-
against

arthr-
joint

-asis
condition

iasis
condition

bi-
two

blephar-
eyelid

brachy-
short

brady-
slow

-esis
condition

-isis
condition

-sis
condition

bronch-
bronchial tube

cardi-
heart

cephal-
head

cervic-
neck, cervix

colp-, kolp-
vagina

contra-
against, opposite

crani-
skull

cry-
cold

cyan-
blue

dacry-
tear

dactyl-
fingers, toes

de-
lack of, down

demi-
half

derm-, dermat-
skin

dextr-
right

di-
two

dis-
separation

-dynia
pain

dys-
bad, painful

-ectomy
excision, removal

-emesis
vomiting

-emia
blood condition

en-
in, within

end-, endo-
in, within

epi-
above, upon

erythr-
red

-esthesia
nervous sensation

eti-
cause

ex-
out, away from

extra-
outside

fibr-
fiber

fore-
before

galact-, lact-
milk

gaster-, gastr
stomach

genit-
genitals

gloss-
tongue

gluc- glyc-
sugar, glucose

-gram
record

-graph
instrument for reading

-graphy
process of recording

gyn-, gyne-, gynec-
women, female

hem-
blood

hema-
blood

hemat-
blood

hemi-
half

hepat-
liver

hyp- hyph-
below, under

hyper-
above, excessive

hyster-
uterus, womb

-ia
condition

-iasis
condition

-ic
pertaining to

ileo-
ileum (small intestine)

ilio-
ilium (hip bone)

in-
in, into, not

infra-
within, into

inter-
between

intra- intro-
within, into

ipsi-
same

-itis
inflammation

juxta-
near

beneficiary counseling and assistance coordinator (BCAC)
individual available at military treatment facility (MTF) to answer questions, help solve healthcare related problems, and assist beneficiaries in obtaining medical care through TRICARE; was previously called health benefits advisor (HBA)

benefit period (Medicare)
begins with the first day of hospitalization and ends when the patient has been out of the hospital for 60 consecutive days.

benign
not cancerous

billing entity
the legal business name of the provider’s pratice.

birthday rule
determines coverage by primary and secondary policies when each parent subscribes to a different health insurance plan.

black box edits
nonpublished code edits, which were discontinued in 2000.

BlueCard Program
program that allows BCBS subscribers to receive local Blue Plan healthcare benefits while traveling or living outside of their plan’s area.

Blue Cross (BC)
insurance plan created in 1929 when Baylor University Hospital, in Dallas, TX, approached teachers in Dallas school district with a plan that guaranteed up to 21 days of hospitalization per year for subscribers and each dependent for a $6 annual premium.

Blue Cross Blue Shield (BCBS)
joint venture between Blue Cross and Blue Shield where the corporation shared one building and computer

The coding system currently in use to report diagnoses and reasons for encounter is the:
International Classification of Diseases, 9th revision, clinical modification (ICD-9-CM)

The person who prepares and reviews claims for accuracy to ensure prompt payment is the :
Health Insurance Specialist

Medical Ethics are:
Principles of right or good conduct

A person who performs services for another under an expressed or implied agreement is called a(n):
Independent Contractor

Which is an authorization that must be received from a payer before treatment by a specialist wil be covered?
Preauthorization

Which coding systerm is used to report professional services to payers?
Current Procedural Terminology (CPT)

Which is a crucial skill that all health insurance specialists should learn in their training coursework?
Fluency in the language of medicine

Which is a professional member of the healthcare team who provides servies or supplies to the insured?
Healthcare provider

Which is the universal claim form used by physicians offices?
Centers of Medicare and Medicaid Services-150 (CMS-1500)

Which document is mailed by the payer to the patient to illustrate the reimbrsement amount of a covered benefit?
Explanation of Benefits

Which term means the patient is not responsible for paying for what the insurance plan denies?
Hold Harmless Clause

Which document communicates to the payer that the provider is requesting reimbursement?
Health Insurance Claim

Which professional association was founded to eleate the standards of medical coding by providing certification, ongoing education, networking, and recognition for coders?
American Academy of Professional Coders (AAPC)

Which professioinal association was founded to improve the quality of medical records and current advances toward an electronic and global environment including the implementation of ICD-10-CM
American Health Information Managment Association (AHIMA)

Which is a legal term that indicates that providers responsibility for their employees actions and omissions

Blue Cross Blue Shield (BCBS)
joint venture between Blue Cross and Blue shield where the corporations shared one building and computer services but maintained seperate corporate identities.

Blue Cross Blue Shield Association (BCBSA)
an association of independent Blue Cross Blue Shield plans

Blue Shield (BS)
began as a resolution passed by the house of Delegates at an american Medical Association meetings in 1938; incorporates a concept of voluntary health insurance that encpurages physicians to corporate with prepaid health plans.

Blue Worldwide Expat
provides global medical coverage for active employees and their dependents who spend more than six months outside the United States for six months or more is eligible for Blue World Expat.

bonding insurance
an insurance agreement that guarantees repayment for financial losses resulting form the act or failure to act of an employee. It protects the financial operations of the employer.

breach of confidentiality
unauthorized release of patient information to third party.

business liability insurance
protect business assets and covers the cost of lawsuits resulting from bodily injury, and false advertising.

cafeteria plan
also called triple option plan; provides different health benefits palns and extra coverage options through an insure or third-party administrator

capitation
provider accepts preestablished payments for providing healthcare services to enrollees over a period of time (usually one year).

carcinoma (Ca) in stiu
in stiu a malignant tumor that is localized, circumscribed, encapsulated, and noninvasive (has not spread to deeper or adjacent tissues or organs).

care plan oversight services
cover the physician’s time supervising a complex and multidisciplinary care treatment program for specific patient who is under the care of a home health agency, hospice, or nursing facility.

case law
also common law; based on a court decision that establishes a precedent.

case management
development of patient care plans to coordinate and provide care for complicated cases in a cost effective manner.

case mangement services process by which an attending physician coordinates and supervises care provided to patient by other providers.
process by which an attending physician coordinates and supervises care provided to patient by other providers.

case manager
submits written confirmation, authorizing treatment, to provider.

case mix
the types and categories of patients treated by a healthcare provider.

catastropic cap benefit
protects TRICARE beneficiaries form devastating financial loss due to serious illness or long-term treatment by establisihing limits over which payments is not required

catchment area
the region defined by code boundaries within a 40-mile radius of a military treatment facility.

Category I Codes
procedures/ services identified by a five- digit CPT code and descriptor nomnclature; these codes are traditionally associated with CPT and orginzed within six sections.

Category II codes
optional performance measurement tracking codes that are assigned an alphanumeric identifier with a letter in the last field (e,g.,1234A); these codes will be located after the medicine section; their use is optional.

Category III codes
temporary codes for data collection purposes that are assigned an alphanumeric identifier with a letter in the last field (e.g., 0001T) these codes are located after the Medicine section, and will be archived after five years unless accepted for placement within Category I sections of CPT.