Coding Final

Front 1

Fee-for-service

Back 1

payment arrangements that outline, in a written fee schedule, exactly how much money the insurance carrier will pay the physician for each treatment and/or service provided

Front 2

Gatekeeper

Back 2

A physician, typically a practitioner or an internest, who serves as the primary care physician for an individual

Front 3

HMO

Back 3

type of health insurance that uses a PCP also known as a gatekeeper to manage health care services for an individual

Front 4

Managed Care

Back 4

type of health insurance coverage that controls the care of each subscriber by using a PCP as a central health care supervisor

Front 5

POS

Point of service

Back 5

a type of insurance plan that allows a HMO enrollee to choose his or her own non member physician at a lower benefit rate, costing the patient more money out of pocket

Front 6

PPO

Preferred Provider Organization

Back 6

a type of health insurance coverage in which physicians provide health care services to members of the plan at a discount

Front 7

Third party payer

Back 7

an individual or organization not directly involved in an encounter but connected to it through an obligation to pay for that encounter

Front 8

UCR

Usual Customary Reasonable

Back 8

a formula used by insurers to determine the fee to be paid for a particular treatment or service

Front 9

Copay

Back 9

a fixed amount of money that an individual pays for each visit to a health care provider

Front 10

Deductible

Back 10

the amount of money patients must pay, out of their own pockets, before insurance benefits begin

Front 11

Disclosure

Back 11

as defined by HIPAA, the sharing of information by health care professionals to anyone outside of their facility

Front 12

HIPAA

Back 12

-Health Insurance Portability and Accountability Act
-legislation that secures patients information so it is available to those who should see it, while protecting that information from those who should not

Front 13

PHI

Back 13

-Protected Health Information
-any identifiable patient health information, regardless of the form in which it is stored

Front 14

Use

Back 14

the sharing of information between people working in the same health care facility for purposes of caring for a patient

Front 15

Accept assignment

Back 15

the process whereby a policyholder gives permission to the insurer to pay benefits directly to the provider

Front 16

Birthday rule

Back 16

the rule used to establish the primary insurance policy for a child by determining which parent has a birthday closest to January 1

Front 17

Eligibility confirmation

Back 17

The process of contacting an insurance carrier to confirm that an individual is qualified for benefits to pay for services provided by a health care professional on a given day

Front 18

Encounter form/Superbill

Back 18

the form that documents what occurred during a meeting between a patient and a health care provider

Front 19

Policy holder

Back 19

also called the insured, the person who brings the insurance policy to the family

Front 20

Responsible party/guarantor

Back 20

the person who will pay any money due to a health care provider that is not paid by the insurance company

Front 21

Verification

Back 21

contacting an insurance carrier to confirm that an individual has current, valid health insurance coverage

Front 22

Abstracting

Back 22

Pulling out keywords

Front 23

Coding for coverage

Back 23

to change a code to fit what the insurance company will pay for

Front 24

CPT

Back 24

Current Procedural Terminology

Front 25

Diagnosis

Back 25

A physicians determination of a patient's condition, illness, or injury

Front 26

ICD-9-CM

Back 26

The International Classification of Diseases-9th Revision-Clinical Modification

Front 27

Mutually exclusive codes

Back 27

2 or more codes that are identified in the coding book which cannot be used on the same claim form

Front 28

Procedure

Back 28

A treatment or service provided by a health care professional

Front 29

Query

Back 29

to ask

Front 30

Unbundling

Back 30

Coding individual parts of a specific procedure, rather than one combo code that includes all of the components

Front 31

Upcoding

Back 31

using a code on a claim form indicating a higher level of service than that which was actually performed

Front 32

Adverse reaction

Back 32

harm or danger to an individual caused by interaction with a drug or chemical

Front 33

Condition

Back 33

The presenting situation, such as infection, fracture, or wound

Front 34

Eponym

Back 34

the name of a condition derived from the name of a person

Front 35

E code

Back 35

a code that explains how an injury or a poisoning happened, and/or where it happened

Front 36

V code

Back 36

a code to describe an encounter between a provider and an individual w/o a specific current health condition

Front 37

Manifestation

Back 37

a condition caused by or developed from the existence of another condition similar to a side effect

Front 38

Neoplasm

Back 38

abnormal tissue, also defined as a growth or tumor

Front 39

Underlying condition

Back 39

a disease that affects or encourages another condition

Front 40

Etiology

Back 40

The identification of the cause of a disease

Front 41

Morbidity

Back 41

the study of disease and the causes of disease in a given population or society

Front 42

Mortality

Back 42

the proportion of deaths to the population as a whole, also known as death rate

Front 43

Established patient

Back 43

a person who has received professional services from a particular provider within the past 3 years

Front 44

E/M
3 key components

Back 44

Evaluation and Management
1. Relationship
2. Location
3. Complexity/Time

Front 45

Modifier

Back 45

a code added to a CPT code to provide more detail or an explanation of an unusual circumstance affecting a service

Front 46

New patient

Back 46

A patient who has not received any professional services within the past 3 years from this provider

Front 47

Radiology

Back 47

x-rays, nuclear medicine, and diagnostic ultrasound

Front 48

Surgery

Back 48

Operative or surgical procedures

Front 49

Code linkage

Back 49

the process of directly connecting each procedure code to at least one diagnosis code on the insurance claim form

Front 50

Place of service

Back 50

a 2 digit code that categorizes the location where the procedure was performed

Front 51

Type of service

Back 51

A 1 or 2 digit code that categorizes the procedure performed

Front 52

tracer

Back 52

an official request for a third party payer to search its system for a missing health claim form

Front 53

EOB

Back 53

Explanation of Benefits

Front 54

allowed amount

Back 54

the maximum payment for service or treatment from an insurance carrier

Front 55

EFT

Back 55

Electronic Funds Transfer
money that is moved from one bank account to another bank account via computer

Front 56

Payee

Back 56

an individual or organization that receives payment from another individual or organization

Front 57

Payer (payor)

Back 57

an individual or organization that sends payment to another individual or organization

Front 58

Balance billing

Back 58

The invoicing of a patient for the difference between the allowed amount and the physician's charge

Front 59

Remittance

Back 59

Payment for services provided