Medical billing terminology refers to the specialized language used in the healthcare industry to describe services, procedures, diagnoses, and the process of submitting claims for payment to insurance companies or patients. It plays a crucial role in ensuring accurate communication between healthcare providers, insurers, and patients. Understanding these terms is essential for professionals in medical billing and coding, as it affects reimbursement, compliance, and the overall financial management of healthcare facilities.
Key components include:
- ICD-10 Codes (International Classification of Diseases): These codes represent diagnoses and conditions.
- CPT Codes (Current Procedural Terminology): Codes used to describe medical, surgical, and diagnostic procedures.
- HCPCS Codes (Healthcare Common Procedure Coding System): A broader set of codes that include CPT but also cover other services like durable medical equipment.
- EOB (Explanation of Benefits): A document from the insurance company explaining what was covered, denied, or unpaid in a claim.
- Claim: A request for payment submitted to an insurance company for services provided by a healthcare provider.
- Deductible, Co-pay, and Coinsurance: Terms that describe the patient’s financial responsibility.
- Authorization: Approval required from the insurance company for certain services or procedures.
- Modifier: Codes added to CPT codes to give more specific details about the service provided.
Grasping these concepts is crucial for professionals to ensure accurate billing and reduce errors that can lead to denied claims or legal issues.
Payor/Provider Terminologies:
- Payor: Insurance
- Provider: Hospital or Physician
- PCP: Primary Care Physician
- PCL: Professional Courtesy Letter
Insurance Types:
- HMO: Health Maintenance Organization
- PPO: Preferred Provider Organization
- POS: Point of Service
- EPO: Exclusive Provider Organization
- COBRA: Consolidated Omnibus Budget Reconciliation Act
- MEDIGAP: Medicare Supplement Insurance
- SHMO: Social Health Maintenance Organization
Medicare and Medicaid:
- CMS: Center for Medicare and Medicaid Services
- EOMB: Explanation of Medicare Benefits
- MSN: Medicare Summary Notice
- MSP: Medicare Secondary Payer
- GEP: General Enrollment Period
- IEP: Initial Enrollment Period
- QMB: Qualified Medicare Beneficiary
- LTR: Lifetime Reserve Days
Billing Codes and Systems:
- CPT: Current Procedural Terminology
- CCI: Correct Coding Initiatives
- Piggyback: Automatic cross over of claims from Medicare to the secondary carrier
Agencies and Acts:
- OIG: Office of Inspector General
- HIPAA: Health Insurance Portability and Accountability Act
- HCFA: Health Care Financing Administration
Equipment and Services:
- DME: Durable Medical Equipment
- SNF: Skilled Nursing Facility
- HHA: Home Health Agency
Patient Care:
- IP: Inpatient
- OP: Outpatient
- NP: Nurse Practitioner
- PA: Physician Assistant
Other:
- SSN: Social Security Number
- ESRD: End Stage Renal Disease
- LGHP: Large Group Health Plan
- EGHP: Employer Group Health Plan
- EOB: Explanation of Benefits
- Capitation: A fixed pre-determined payment to a provider by the carrier
- VA: Veterans Administration
- CHAMPUS: Civilian Health and Medical Program of the Uniformed Services
- WC: Workers Compensation