| 72-hour rule | Hospital coding rule for Medicare beneficiaries that allows outpatient services performed within 72 hours of an inpatient admission to be reported on the claim as part of the inpatient stay so long as the services are related to the inpatient stay; also known as the three-day window rule.
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| 837I | HIPAA-mandated electronic transaction for hospital claims.
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| 837P | HIPAA-mandated electronic transaction for professional claims.
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| abuse | Improper billing practices, such as billing for a noncovered service or misusing codes on a claim.
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| access | The ability to obtain needed health care services.
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| accommodation revenue code | A revenue code that reports a particular bed/accommodation/board charge of a facility on a UB-04 claim.
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| accounts receivable (AR) | Amount of money owed to a facility by patients and payers.
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| accredited | Health care organization or facility that has met quality standards set by private national groups.
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| acute care facility | A health care facility that provides continuous professional medical care to patients with acute conditions or illnesses.
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| adjustment | An amount (positive or negative) entered in a billing program to change an account balance.
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| Administrative Simplification | A part of HIPAA that requires the health care industry to use certain standards for the electronic exchange of health care data to protect confidentiality of patient's records. It is in Title II.
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| admission | The registration process in which patients enter the facility for care.
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| admission date | The date a patient was admitted for inpatient care, outpatient service, or start of care.
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| admitting diagnosis (ADX) | The disease or condition that is the reason for the patient's admission for care.
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| Advance Beneficiary Notice of Noncoverage (ABN) | A notice that a facility should give a Medicare beneficiary to sign if Medicare will probably not pay for the services that the patient will receive; used to establish the patient's responsibility for payment.
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| aging | The classification of accounts receivable by the amount of time they are past due.
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| all-inclusive rate | A fixed amount charged on a daily basis during a patient's hospitalization or a total rate charged for an entire stay.
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| ambulatory payment classification (APC) | A Medicare payment classification for outpatient services.
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| ambulatory surgical center (ASC) | A health care facility providing surgical services only on an outpatient basis.
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| American Academy of Professional Coders (AAPC) | National association that fosters the establishment and maintenance of professional, ethical, and educational standards for all parties concerned with procedural coding.
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| American Association for Medical Transcription (AAMT) | National association fostering the profession of medical transcription.
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| American Health Information Management Association (AHIMA) | A National association of health information management professionals; promotes valid, accessible, yet confidential health information and advocates quality health care.
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| American Medical Association (AMA) | Member organization for physicians; goals are to promote the art and science of medicine, improve public health, and promote ethical, educational, and clinical standards for the medical profession.
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| American National Standards Institute (ANSI) | Organization that sets standards for electronic date interchange on a national level.
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| ancillary charge | Fee for services other than room and board provided during a patient's hospitalization, such as anesthesia, pharmacy, supplies, and therapies.
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| ancillary service revenue code | A revenue code used on a UB-04 claim to report services, other than routine room and board charges, that are incidental to the hospital stay.
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| appeal | A request sent to a payer for reconsideration of a claim denial or partial payment.
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| assignment of benefits | Authorization by a policyholder that allows a payer to pay benefits directly to a health care provider. Under Medicare, when the payment is made directly to a provider who is accepting assignment, the assignment is also an agreement to accept Medicare's payment as payment in full and not to bill the patient for any amount that exceeds the DRG or allowance amount, except for a deductible and/or coinsurance amount or for noncovered services.
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| attending physician | The clinician primarily responsible for the care of the patient from the hospital admission through discharge or transfer.
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| base rate | Under the Medicare Inpatient Prospective Payment System, a number which is calculated based on a hospital's costs, wage index, and location, and is used in determining what a hospital will be paid for a particular DRG.
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| basic medical care plan | An insurance plan that provides limited hospital, surgical, and medical benefits.
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| benchmark | To compare something against a standard, such as an activity looked at in an audit that is compared against a HIPAA standard.
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| beneficiary | A person eligible to receive benefits under a health plan.
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| benefit period | The method used by Medicare to measure a beneficiary's use of hospital and skilled nursing facility services; see also spell of illness .
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| capitation | A fixed amount per person, per time period paid by a purchaser, such as a health plan, to a health care provider to supply covered health services to beneficiaries during the period.
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| carrier | (1) An insurance company; (2) a private company that has a contract with Medicare to process Medicare Part B bills.
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| carrier code | The code assigned to an insurance carrier for UB-04 claim processing.
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| case mix | The mix of patients treated in a facility based on a patient classification system such as DRGs.
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| case mix index (CMI) | A measure of the clinical severity or resource requirements of the patients in a particular hospital or treated by a particular clinician during a specific time period.
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| cash deductible | The amount of a patient's payment that is applied to a patient's deductible for a particular health plan.
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| CC and MCC lists | Medicare lists containing the ICD-9-CM codes for the secondary diagnoses that are considered significant acute diseases, acute exacerbations of significant chronic diseases, or other chronic conditions that have an effect on the use of hospital resources and can therefore be assigned as CCs or MCCs under the MS-DRG system.
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| CCI column 1/column 2 code pair edits | Medicare code edit under which CPT codes in column 2 will not be paid if reported for the same patient on the same day of service by the same provider as the column 1 code.
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| CCI mutually exclusive edits | CCI edits for codes for services that could not have reasonably been done during a single patient encounter, so both will not be paid by Medicare. Only the lower-paid code is reimbursed.
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| Centers for Medicare and Medicaid Services (CMS) | Federal agency within the Department of Health and Human Services that runs Medicare, Medicaid, Clinical Laboratories, and other governmental health programs. Formerly known as the Health Care Financing Administration (HCFA).
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| charge description master (CDM) | A hospital's list of the codes and charges for its services.
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| charge explode | A billing system feature that stores all charges for particular services; when a service is provided, the system automatically bills all of its component charges.
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| charge slip | A form that lists the typical major services a facility department provides.
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| Civilian Health and Medical Program of the Veterans Administration (CHAMPVA) | The Civilian Health and Medical Program of the Veterans Administration (now known as the Department of Veterans Affairs) that shares health care costs for families of veterans with 100 percent service-connected disability and the surviving spouses and children of veterans who die from service-connected disabilities.
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| claim denial | A payer's determination that a claim will not be paid; a denial can be appealed.
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| claim rejection | A payer's determination that a claim is not ready for processing; the claim is returned to the sender for revision.
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| clean claim | A claim that meets all of a payer's specifications and edits.
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| clearinghouse | A company that offers providers, for a fee, the service of receiving electronic/paper claims, checking and preparing them for processing, and transmitting them in proper data format to the correct carriers.
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| clinic | An outpatient facility that provides scheduled medical services for patients.
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| CMS-1450 | The Medicare-required Part A (hospital) claim form; also known as the UB-04 and formerly called the HCFA-1450.
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| CMS-1500 | The Medicare-required Part B (physician) claim form; also known as the Universal Health Insurance Claim form and formerly called the HCFA-1500.
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| code set | Alphabetic and/or numeric representations for data. Medical code sets are systems of medical terms that are required for HIPAA transactions. Administrative (nonmedical) code sets, such as taxonomy codes and ZIP codes, are also used in HIPAA transactions.
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| coinsurance | The portion of charges that an insured person must pay for health care services after payment of the deductible amount; usually stated as a percentage.
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| coinsurance days | Under Medicare Part A, for the 61 st through 90 th day of hospitalization in a benefit period, a daily amount (equal to 25% of the inpatient hospital deductible) for which the beneficiary is responsible.
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| comorbidity | Admitted patient's coexisting condition that affects the length of the hospital stay or the course of treatment.
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| complete procedure | Under the CPT procedural coding system, most surgical codes represent groups of procedures that include all routine elements, such as the operation, local anesthesia, and routine follow-up care. Facilities report these codes to charge for their service associated with the procedure.
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| compliance | Actions that satisfy official guidelines and requirements.
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| compliance plan | A medical practice's written plan for the following: the appointment of a compliance officer and committee; a code of conduct for physicians' business arrangements and employees' compliance; training plans; properly prepared and updated coding tools such as job reference aids, encounter forms, and documentation templates; rules for prompt identification and refunding of overpayments; and ongoing monitoring and auditing of claim preparation.
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| compliance program guidance | Guidance issued by the Office of the Inspector General (OIG) for a specific covered entity with descriptions of what that entity should include in their compliance plan in order to uncover and correct compliance problems connected with HIPAA violations, fraud, and abuse.
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| complication | Condition an admitted patient develops after surgery or treatment that affects the length of hospital stay or the course of further treatment.
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| comprehensive outpatient rehabilitation facility (CORF) | A facility that provides physician-supervised rehabilitation services, such as physical, occupational, and speech therapies, to patients who do not require an overnight stay.
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| condition code | A two-digit numeric or alphanumeric code used to report a special condition or unique circumstance about a claim.
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| conditional payment | A payment from Medicare requested in advance of a primary payer's payment when Medicare is the secondary payer and the provider believes the primary payer will not pay promptly (within 100 days) due to liability issues.
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| consumer-driven health plan (CDHP) | Type of medical insurance that combines a high-deductible health plan with a medical savings plan which covers some out-of-pocket expenses.
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| continuing claim | A claim that is submitted after an initial or subsequent bill has been sent for the same confinement or course of treatment; it is anticipated that subsequent bills will be submitted.
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| conventions | Typographic techniques or standard practices that provide visual guidelines for understanding printed material.
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| coordination of benefits (COB) | A clause in an insurance policy that explains how the policy will pay if more than one insurance policy applies to the claim.
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| copayment (copay) | An amount that an insured person must pay for each health care service encounter.
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| Correct Coding Initiative (CCI) | Medicare's national coding policy, under which mutually exclusive services and comprehensive/component edits are set up as the basis for computerized claim review.
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| cost outlier | Payment made by Medicare in addition to a regular DRG payment when a patient in a particular DRG has an exceptionally high cost compared to other similar patients.
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| cost-based reimbursement | The method Medicare initially used to pay health care facilities for services furnished to beneficiaries. Payment was based on providers' costs as reported annually.
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| covered days | The number of days of inpatient care that are covered by primary insurance benefits.
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| covered entity | A health plan, a health care clearinghouse, or a health care provider who transmits any health information in electronic form in connection with a HIPAA transaction.
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| covered services | The patient services that are covered by primary insurance benefits.
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| critical access hospital (CAH) | A freestanding hospital emergency department.
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| crosswalk | A comparison or map of the codes for the same or similar classifications under two coding systems; it serves as a guide for selecting the closest match.
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| Current Procedural Terminology , Fourth Edition (CPT) | Publication of the American Medical Association containing a standardized classification system for reporting medical procedures and services.
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| deductible | An amount that an insured person must pay, usually on an annual basis, for health care services before a payer's insurance payment begins.
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| de-identified health information | Medical data from which individual identifiers have been removed; also known as a redacted or blinded record.
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| delimiter | A character or symbol used in printed material to visually separate one group of words or values from another.
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| demographics | Information about a patient, such as name, address, Social Security number, employment, and insurance carrier data.
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| detail-level code | The fourth digit of a revenue code defines the detail description of the code; the general classification is indicated by a zero (such as 0430, the general classification for Occupational Therapy) and the detail-level codes—the numbers 1 through 9—represent different details for that particular revenue code (such as 0443 to report a group rate for Occupational Therapy).
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| development | The process of determining the primary payer for an insurance claim; often used with the Medicare Secondary Payer program to describe the series of questions asked of patients to find out whether they are beneficiaries of insurance other than Medicare.
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| diagnosis | A physician's opinion of the nature of a patient's illness or injury.
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| diagnosis code | The number assigned to a diagnosis in the International Classification of Diseases.
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| diagnosis-related groups (DRGs) | A system of analyzing conditions and treatments for similar groups of patients used to establish Medicare fees for hospital inpatient services; patients are classified by their principal diagnosis, surgical procedure, age, and other factors.
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| discharge | Release of a patient from a facility, including those who have died and those who are transferred to another facility.
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| discharge date | Date a patient is released from a facility.
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| DNFB (discharged/not final bill) list | A hospital list containing the accounts of patients who have been discharged but whose claims have not yet been transmitted to payers, used by hospitals to measure the timeliness of their billing process.
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| DRG weight | Under the Medicare Inpatient Prospective Payment System, a national relative amount assigned to each DRG that represents the average resources required to care for cases in that particular DRG relative to the average resources used to treat cases in all DRGs.
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| durable medical equipment (DME) | Medicare term for reusable physical supplies such as wheelchairs and hospital beds.
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| Durable Medical Equipment Regional Carriers (DMERCs) | Medicare contractors that process claims for durable medical equipment, prosthetics, orthotics, and supplies.
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| E code | An alphanumeric code in the ICD that identifies an external cause of injury or poisoning.
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| edits | Computer programs that third-party payers use to find coding problems and inconsistencies on insurance claims.
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| elective admission | Hospital admission of a patient whose health is not at risk; often scheduled in advance.
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| electronic data interchange (EDI) | The system-to-system exchange of data in a standardized format.
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| electronic health record (EHR) system | A running collection of health information that provides immediate electronic access by authorized users.
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| electronic media claim (EMC) | A computerized insurance claim form transmitted electronically from a provider to a payer's computer system.
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| emergency | A situation in which a delay in the treatment of the patient would lead to a significant increase in the threat to life or body part.
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| emergency department | Hospital department providing health care for patients who would have a significant increase in the threat to life or body part if treatment were delayed.
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| employer group health plan (EGHP) | A health plan offered by an employer of more than 20 people that provides medical benefits to employees, former employees, and their families.
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| encounter form | A listing of the services, procedures, and revenue departments for collecting charges for a patient's visit; also called a charge ticket or superbill.
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| end-stage renal disease (ESRD) | Permanent kidney failure that requires a regular course of dialysis or kidney transplantation to maintain life.
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| excluded (noncovered) services | Medical care that is not covered by a health plan; in Medicare, most preventive care and services that are not medically necessary are excluded.
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| explanation of benefits (EOB) | A document from a payer to a patient or a provider that shows how the amount of a benefit was determined.
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| external audit | A formal examination in which an agency, such as the OIG, selects certain records for review.
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| Federal Employees Health Benefits Program (FEHBP) | The health insurance program that covers employees of the federal government.
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| Federal Employees Retirement System (FERS) | Disability program for employees of the federal government.
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| Federal Employees' Compensation Act (FECA) | A federal law that provides workers' compensation insurance for civilian employees of the federal government.
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| Federal Insurance Contribution Act (FICA) | The federal law that authorizes payroll deductions for the Social Security Disability Program.
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| Federal Medicaid Assistance Percentage (FMAP) | Basis for federal government Medicaid allocations to individual states.
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| Federal Register | A publication of the Office of the Federal Register (OFR), which is responsible for publishing federal laws, presidential documents, administrative regulations and notices, and descriptions of federal organizations, programs, and activities.
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| fee schedule | List of charges for services performed.
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| fiscal intermediary (FI) | A government contractor that processes claims for Medicare Part A claims.
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| focused medical review (FMR) | The CMS process of closely examining Medicare claims considered to be associated with the greatest probability of inappropriate payments.
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| form locator (FL) | A numeric indicator that directs the reader to a specific box or space on a data collection form; there are 81 form locators on the UB-04 claim form.
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| fraud | Under Medicare, fraud is an intentional misrepresentation that is known to be false and could result in unauthorized benefit, such as claiming costs for noncovered items and intentionally double billing for the same services.
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| guarantee of payment provision | Policy that Medicare will pay for hospital inpatient services—even if the patient's benefits were exhausted before the admission—if the hospital acted in good faith in admitting the patient.
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| guarantor | The person who is responsible for the payment of a patient's bill for medical services.
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| guardian | An adult responsible for care and custody of a minor.
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| Health Care Common Procedure Coding System (HCPCS) | Procedure codes for Medicare claims, made up of CPT-4 codes (Level I) and national codes (Level II).
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| health insurance claim number (HICN) | A number issued by the Social Security Administration to individuals or beneficiaries who are entitled to Medicare benefits. The HIC number, as recorded on the beneficiary's Medicare card, is the source of beneficiary information that is required for processing Medicare claims.
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| Health Insurance Portability and Accountability Act (HIPAA) of 1996 | Federal government act that set forth guidelines for standardizing the electronic data interchange of administrative and financial transactions, exposing fraud and abuse in government programs, and protecting the security and privacy of health information.
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| Health Insurance Prospective Payment System (HIPPS) | Procedural coding system used in association with the skilled nursing facilities (SNF) and home health prospective payment systems.
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| Health Insurance Prospective Payment System (HIPPS) rate code | A five-digit alphanumeric payment code used under the Prospective Payment Systems associated with skilled nursing facilities, home health providers, and inpatient rehabilitation facilities.
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| health maintenance organization (HMO) | A managed health care system in which providers agree to offer health care to the organization's members for fixed periodic payments from the plan; usually members must receive medical services only from the plan's providers.
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| health plan | Under HIPAA, an individual or group plan that either provides or pays for the cost of medical care; includes group health plans, health insurance issuers, HMOs, Medicare Part A or B, Medicaid, TRICARE, and other government and nongovernment plans.
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| HIPAA claim | Generic term for the HIPAA X12N 837 institutional or professional health care claim transaction.
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| HIPAA Electronic Health Care Transactions and Code Sets (TCS) | HIPAA standards governing the electronic exchange of health information using standard formats and standard code sets.
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| HIPAA Privacy Rule | Law that regulates the use and disclosure of patients' protected health information (PHI).
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| HIPAA Security Rule | Security standards that require appropriate administrative, physical, and technical safeguards to protect the privacy of protected health information against unintended disclosure through breach of security.
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| home health agency (HHA) | Health care provider, licensed under state or local law, that provides skilled nursing and other therapeutic services, such as visiting nurse associations and hospital-based home care programs.
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| hospice | Care for the terminally ill that emphasizes emotional support and coping with pain and death.
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| hospital-acquired condition | A secondary condition developed during a hospital stay; for certain of these conditions, CMS will not assign a higher paying DRG for treatment unless it is documented as present on admission.
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| Hospital-Issued Notice of Noncoverage (HINN) | A hospital notice to a beneficiary that is provided to inform the patient that the inpatient care the beneficiary is receiving or about to receive is not covered.
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| ICD-9-CM Official Guidelines for Coding and Reporting | Written by NCHS (National Center for Health Statistics) and CMS and approved by the cooperating parties, it provides rules for selecting and sequencing diagnosis codes in both the inpatient and the outpatient environments.
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| indemnity plan | An insurance company's agreement to reimburse a policyholder for covered losses if required payments have been made.
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| inpatient | A person admitted to a health care facility for services that require an overnight stay.
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| Inpatient Prospective Payment System (IPPS) | Medicare payment system for hospital services; based on diagnosis-related groups (DRGs).
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| inpatient-only procedures | Surgical procedures which, due to their invasive nature and the need for a twenty-four-hour recovery time, Medicare has designated will only be paid for if performed on an inpatient basis.
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| interim bill | A bill that does not cover a complete hospital or SNF stay; used after a minimum stay of 30 days when it is expected that additional claims will be submitted for the same confinement.
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| intermediate care facility (ICF) | A health care facility providing care to patients who do not require professional medical or skilled nursing services.
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| internal audit | Self-audit conducted by a staff member or consultant as a routine check of compliance with reporting regulations.
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| International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) | A publication that classifies diseases and injuries according to a system developed by the World Health Organization and modified for use in the United States.
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| Joint Commission | Organization that reviews accreditation of hospitals and other organizations/programs; previously know as the Joint Commission on Accreditation of Healthcare Organizations (JCAHO).
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| large group health plan (LGHP) | A group health plan that covers employees of either an employer or employee organization that has more than 100 employees.
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| leave of absence (LOA) days | Days on which a patient is temporarily released from the hospital.
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| lifetime reserve days (LRD) | The 60 days of reduced-cost hospitalization coverage that Medicare benefits allow a patient for use after a benefit period is used up; for each lifetime reserve day, Medicare pays all covered costs except for a daily coinsurance.
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| lifetime reserve days coinsurance rate | An amount set annually that is always equal to 25 percent of the Medicare Part A annual inpatient deductible.
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| lifetime reserve days rate | An amount set annually that is always equal to 50 percent of the Medicare Part A annual inpatient deductible.
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| local coverage determination (LCD) | Notice sent to providers with detailed and updated information about the coding and medical necessity of a specific Medicare service.
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| local medical review policy (LMRP) | See local coverage determination .
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| major CC (MCC) | Secondary diagnosis classified by the Inpatient Prospective Payment System as severe when assigning the DRG.
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| major diagnostic category (MDC) | Under the Inpatient Prospective Payment System, a classification of principal diagnoses based on groups of patients who are similar clinically and who require similar hospital resources.
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| major medical benefit plan | An insurance plan that provides comprehensive hospital, surgical, and medical benefits.
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| managed care organization (MCO) | Organization offering some type of managed health care plan.
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| manifestation | Characteristic sign or symptom of a disease.
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| Medicaid | A federal/state assistance program that pays for health care services for people who cannot afford them.
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| medical necessity | Payment criterion of payers that requires medical treatments to be appropriate and provided in accordance with generally accepted standards of medical practice.
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| medical/health record number | A number assigned by a facility to a patient's medical record.
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| Medicare administrative contractors (MACs) | New entities assigned by CMS to replace the numerous FIs and carriers that currently administer the Medicare Part A and Part B programs; fifteen of them will process and pay Medicare Part A and Part B claims within specified multistate jurisdictions.
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| Medicare Advantage | Medicare plans other than the Original Medicare Plan.
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| Medicare blood deductible | Under Medicare, a patient must either replace or pay for the first 3 pints of blood used each calendar year.
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| Medicare Code Editor (MCE) | A computer program used by Medicare to find billing problems and inconsistencies on inpatient claims, and to verify compliance with Medicare coverage rules.
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| Medicare Common Working File (CWF) | CMS databases containing the histories of Medicare beneficiaries used by FIs and carriers to check eligibility, use of benefits, and other insurance coverage.
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| Medicare Conditional Payment request | See conditional payment.
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| Medicare distinct part unit | A distinct unit or a unique level of care in a hospital, such as a psychiatric or rehabilitation unit, that operates under its own payment system and therefore requires a separate claim to the payer.
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| Medicare Part A | The part of the Medicare program that pays for hospitalization, care in a skilled nursing facility, home health care, and hospice care.
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| Medicare Part B | The part of the Medicare program that pays for physician services, outpatient hospital services, durable medical equipment, and other services and supplies.
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| Medicare Secondary Payer (MSP) | Under MSP, Medicare does not pay for services if payment has been made or can reasonably be expected to be made by another payer. For example, Medicare is secondary to workers compensation, automobile, medical no-fault, and liability insurance. Medicare is also secondary to GHPs and certain group health plans covering aged and disabled beneficiaries. MSP cases are identified by CMS through the development process, which includes beneficiary questionnaires, provider identification of third-party coverage during the admissions process, data transfers with other state and federal agencies, and Common Working File edits.
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| Medicare Summary Notice (MSN) | The explanation of Part A and Part B benefits supplied by Medicare to beneficiaries in the Original Medicare Plan.
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| Medicare-Severity DRGs (MS-DRGs) | Medicare Inpatient Prospective Payment System revision that takes into account whether certain conditions were present on admission.
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| Medigap | Medicare supplemental insurance sold by private companies to Original Medicare Plan beneficiaries to fill the "gaps" of coverage.
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| minimum necessary standard | Principle that individually identifiable health information should be disclosed only to the extent needed to support the purpose of the disclosure.
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| modifier | A two-digit number in the CPT-4 coding system used to report special circumstances involved with a procedure or service.
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| MS Grouper | A software program used by Medicare and hospitals to assign DRGs and determine payments for inpatient claims.
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| MSP value code | One of nine value codes and its corresponding amount that indicates the amount paid on behalf of the beneficiary that is the portion of payment from the primary payer; Medicare is being billed as secondary for the Medicare-covered services on the claim.
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| national coverage determination (NCD) | Medicare policy stating whether and under what circumstances a service is covered by the Medicare program.
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| National Provider Identifier (NPI) | Under HIPAA, unique 10-digit identifier assigned to each provider by the National Provider System; replaces both the UPIN and Medicare PIN.
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| National Provider Identifier (NPI) Registry | The query-only portion of the NPPES (National Plan and Provider Enumeration System) database which is maintained as part of the CMS website and which contains a complete list of NPIs and other provider data that can be made available to the public.
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| non-CCs | Under the MS-DRG system, a category of secondary conditions with the lowest of three levels of severity, representing chronic conditions that do not require additional hospital resources.
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| noncovered days | Days of inpatient care that are not covered by a patient's primary insurance.
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| observation services | Physician-ordered care provided to a patient admitted to evaluate a condition or determine a course of treatment.
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| occurrence codes | Two-digit numeric or alphanumeric codes that define a significant event in connection with a claim which has an effect on its processing and payment; an associated date must also be reported.
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| occurrence span codes | Two-digit numeric or alphanumeric codes that identify significant events which occur over a span of time and which affect the processing and payment of the claim; associated "from" and "through" dates must also be reported.
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| Office of the Inspector General (OIG) | Federal agency that investigates and prosecutes fraud against government health care programs such as Medicare.
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| Original Medicare Plan (OMP) | A pay-per-visit health plan with two parts, Medicare Part A and Part B, requiring the beneficiary to pay a premium (Part B), a deductible, and coinsurance.
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| outlier | A hospital case that incurs unusually high costs for its DRG classification and therefore may qualify for an outlier payment.
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| outlier payment | A supplemental payment made to a hospital, in addition to the base payment for the DRG, if its costs for treating a particular case exceed the usual Medicare payment for that case by a set threshold.
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| outpatient | A person who receives health care in a medical setting without an overnight admission; the length of stay is generally less than 23 hours.
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| Outpatient Code Editor (OCE) | The computer program used by Medicare to review claims for hospital-based outpatient services.
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| Outpatient Prospective Payment System (OPPS) | The Medicare payment system for outpatients, which sets payment amounts in advance for services and procedures based on ambulatory payment classifications (APCs).
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| paper claim | Insurance claim submitted to a payer as a printed or typed form; it an be an optical character recognition (OCR) claim that is designed to be read by a scanner or a claim that is converted to electronic format by the payer.
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| patient control number | A unique alphanumeric identifier assigned by the provider to each patient and generally displayed on payment checks and vouchers.
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| patient discharge status | A patient's discharge status as of the "through" date of the billing period; the options are routine discharge, discharged to another facility, still a patient, or expired.
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| patient's reason for visit | For unscheduled outpatient encounters, such as an emergency department visit, the condition the patient states is responsible for the hospital visit.
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| payer | General term for an insurance carrier or government program that provides benefits for patients of a facility.
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| pay-for-performance programs | Quality initiative programs that align financial incentives with the delivery of high-quality care.
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| per diem | A payment method that reimburses a set rate for each inpatient day according to the case category.
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| point of origin for admission or visit | On the UB-04 form, a field (FL 15) for reporting the patient's point of origin for the emergency, elective, or other type of inpatient admission, as well as the point of origin for outpatient services, previously referred to as the source of admission.
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| precertification | Prior authorization from a payer that must be received before elective hospital-based or outpatient surgeries are covered; also preauthorization or authorization.
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| preferred provider organization (PPO) | A managed care network of health care providers who agree to perform services for plan members at discounted fees; usually, plan members can receive services from non-network providers for a higher cost.
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| premium | The periodic amount of money paid to an insurance company for an insurance plan.
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| present on admission (POA) | Indicator required by Medicare that identifies whether a coded condition was present at the time of hospital admission.
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| present on admission (POA) exempt list | List of conditions that do not require a POA (present on admission) indicator.
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| primary care physician (PCP) | In a health maintenance organization (HMO), the physician assigned to direct all aspects of a patient's care, including routine services, referrals to specialists within the system, and supervision of hospital admissions; also known as gatekeeper.
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| primary diagnosis | Diagnosis that represents the patient's major illness or condition for an encounter.
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| primary insurance | The insurance carrier that pays benefits first when a patient is covered by more than one medical plan.
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| principal diagnosis | The condition that after study is established as chiefly responsible for a patient's admission to a hospital.
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| principal procedure | The main service performed for the condition listed as the principal diagnosis for a hospital inpatient.
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| procedure code | A code that identifies medical or diagnostic services.
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| professional services | The work of physicians—such as surgeons, anesthesiologists, and patients' private doctors—that is billed to patients by the physician rather than by the facility.
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| prospective payment | A method of payment that sets a predetermined rate for each category of patient illness or for services provided for a standard type of case.
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| Prospective Payment System (PPS) | The Medicare payment system for inpatients, which sets payment amounts in advance for services based on diagnosis-related groups (DRGs).
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| protected health information (PHI) | Individually identifiable health information that is transmitted or maintained by electronic media.
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| provider | Person or entity that supplies medical or health services and bills for or is paid for the services in the normal course of business. A provider may be a professional member of the health care team, such as a physician, or a facility, such as a hospital or skilled nursing home.
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| provider number | A number assigned to a provider of health care services by a payer entered in FL57 on the UB-04 claim form; Medicare uses a six-digit provider number whose last four digits indicate the type of facility with which the provider is connected. When the NPI system is fully in place, it will replace the provider numbering system and provider numbers will no longer be required on the UB-04.
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| qualifier codes | Two-digit code for a type of provider identification number other than the National Provider Identifier (NPI).
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| Quality Improvement Organization (QIO) | An organization hired by CMS to determine the medical necessity, appropriateness, and quality of patients' treatments; formerly Peer Review Organization (PRO).
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| quality measures | A specified set of measures based on scientific evidence that are used to gauge how well an entity provides care to its patients.
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| referring physician | The physician who orders a patient's services.
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| remittance advice (RA) | The document sent by a payer to a provider that itemizes the patients, claims, and explanations for payment decisions included in the attached payment.
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| revenue code | A code that reports a particular accommodation or ancillary charge on a UB-04 claim.
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| revenue code series | The component subcategories of a four-digit revenue code that are described using the convention of an X in the last position (instead of a number from 0 to 9); for example, revenue code 013X stands for the revenue code series "Room & Board — Three and Four Beds."
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| routine charge | The total of the costs of all supplies that are customarily used to provide the service; items included in the routine charge should not be billed separately.
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| secondary identifiers | Provider identifiers that may be required by various plans in addition to the NPI, such as a plan identification number.
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| secondary insurance | The insurance plan that pays benefits after the primary payer when a patient is covered by more than one medical insurance plan.
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| self-referral | A patient who requests outpatient services without a physician referral.
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| skilled nursing facility (SNF) | A health care facility that provides skilled nursing care and related services for patients who need nursing care or rehabilitation services.
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| source of admission | The source for a patient's admission, such as a referral, a transfer from another facility, or a newborn (such as a normal delivery).
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| spell of illness | A period of hospitalization as defined by a health plan. Medicare beneficiaries' spell of illness—a benefit period—begins with a hospital admission and ends when the patient has not received inpatient care for 60 consecutive days.
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| statement covers period | The "from" and "through" dates that represent the beginning and ending dates of service for the period covered by the bill.
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| status indicator (SI) | Letters assigned to each CPT/ HCPCS code identifying the payment rules established by CMS for that code.
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| subcategory code | See detail-level code.
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| supplemental insurance | An insurance plan, such as Medigap, that provides benefits for services which are not normally covered by a primary plan.
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| swing bed hospital | A hospital with a Medicare-approved swing bed agreement under which an acute care bed can be used to provide long-term care services similar to a skilled nursing facility.
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| taxonomy code | Administrative code set under HIPAA used to report a physician's specialty or an institutional provider's type of facility when it affects payment.
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| technical component (TC) | The technician's work and the equipment and supplies used in performing a procedure; billable by the facility rather than the physician.
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| three-day window rule | See 72-hour rule.
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| time of service | The patient's encounter with the provider; payments may be due and collected at the time of service, such as copayments, rather than billed after the service was provided.
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| transitional pass-through payment | Temporary additional reimbursement under APCs for new drugs or other treatments not included in the payment rate.
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| treatment, payment, and health care operations (TPO) | Under HIPAA, the rule that patients' protected health information may be shared without authorization for the purposes of treatment, payment, and operations.
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| TRICARE | The Civilian Health and Medical Program of the Uniformed Services that serves spouses and children of active-duty service members, military retirees and their families, some former spouses, and survivors of deceased military members; formerly CHAMPUS.
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| triggered reviews | An audit or review triggered by certain events or certain repeated actions indicating noncompliance.
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| type of bill (TOB) | A four-digit code; the first digit is a leading zero, the second digit identifies the type of facility where services were rendered, the third digit classifies the type of care being billed, and the fourth digit, a "frequency" code, indicates the sequence of the bill within a given episode of care.
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| UB-04 | The uniform bill introduced in 2004 by the National Uniform Billing Committee (NUBC) for submitting Medicare Part A inpatient and outpatient claims to Medicare fiscal intermediaries; used by most other payers as well because it meets the billing requirements of many types of provider facilities. The UB-04 officially replaced its predecessor, the UB-92, on March 1, 2007.
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| uncollectible account | A patient's balance that the billing department has determined cannot be collected from the debtor and is written off.
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| Uniform Hospital Discharge Data Set (UHDDS) | Classification system for inpatient health data.
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| unlisted procedure code | A service that is not listed in CPT-4; requires a special report when used.
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| UPIN (unique physician identification number) | In the past, a number assigned by CMS to identify physicians and suppliers who provided medical services or supplies to Medicare beneficiaries. Each physician had a unique six-character, alphanumeric identification number designed to track payment and utilization information for individual physicians. The UPIN has gradually been replaced by the NPI under HIPAA.
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| urgent | An admission category that indicates the patient is suffering from a physical or mental disorder that requires immediate attention and should be admitted as soon as a suitable bed is available, within 24 to 48 hours; prolonged delay will threaten the patient's life or well-being.
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| utilization review (UR) | A formal review to determine the appropriateness and usage of hospital-based health care services delivered to a member of a plan; may be conducted on a prospective, concurrent, or retrospective basis.
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| V code | An alphanumeric code in the ICD-9-CM that identifies factors that influence health status and encounters that are not due to illness or injury.
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| value code | A code reported along with an amount—a dollar figure or other unit of measure—to provide financial information on the UB-04 claim form such as the charge for a semiprivate room.
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| Volume 1 (Tabular List) | ICD-9-CM Tabular List of Disease and Injuries.
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| Volume 2 (Alphabetic Index) | ICD-9-CM Alphabetic Index to Disease and Injuries.
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| Volume 3 (Procedures) | ICD-9-CM Alphabetic Index and Tabular List of Procedures.
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| workers' compensation | A state or federal plan that covers medical care and other benefits for employees who suffer accidental injury or become ill as a result of employment.
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| working aged person | In Medicare, the term for a patient or his/her spouse who is over age 65 and who is eligible for group health insurance through employment or the employment of his/her spouse; Medicare is the secondary payer.
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| write off (noun write-off) | To deduct an amount from a patient's account because of a contractual agreement to accept a payer's allowed charge or other reason.
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