Common Terminology

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  1. 2. A reference number or letter that links specific diagnoses to particular procedures or services provided, ensuring accurate billing and reimbursement. The diagnosis pointer can be link from box 21 A through L to the line number from box 24E service(s) line items. You can only enter up to 4 diagnosis pointers per line item. (HCFA Box 24D[A-D])
  2. 6. Durable Medical Equipment refers to reusable medical devices and supplies, such as wheelchairs, oxygen tanks, and hospital beds, used to support patients' healthcare needs at home or in clinical settings.
  3. 9. A healthcare provider who directs a patient to another specialist or healthcare service for further diagnosis, treatment, or care.
  4. 12. Electronic Remittance Advice: is a digital document sent by an insurance company to healthcare providers, detailing the payment or denial of claims, along with explanations for adjustments.
  5. 13. Alphanumeric codes used to identify specific medical conditions and diseases for billing, reporting, and treatment purposes. We’re currently using ICD10 codes. (HCFA Box 21)
  6. 14. Electronic Health Record: is a digital version of a patient's medical history, including diagnoses, treatments, medications, and test results, that can be accessed and shared across healthcare providers.
  7. 16. The American National Standards Institute's X12 standards, which define the formatting rules, loops, and segments for consistent data exchange between businesses.
  8. 17. Protected Health Information any individually identifiable health information, such as medical records or personal details, that is protected under HIPAA to ensure confidentiality and privacy.
  9. 20. Healthcare Common Procedure Coding System codes are a set of standardized codes used to identify medical procedures, services, and supplies for billing and reimbursement purposes. (UB04 claims Box 44)
  10. 22. A standardized code used by insurance companies to explain the justification for claim adjustments, denials, or rejections on medical claims.
  11. 27. The primary healthcare provider responsible for overseeing and managing a patient's care during a specific episode of treatment or hospitalization. (UB04)
  12. 28. The date when an insurance company processes a claim to determine its approval, denial, or adjustment.
  13. 30. Current Procedural Terminology codes are standardized numeric codes used to describe medical, surgical, and diagnostic procedures and services for billing and documentation purposes. (HCFA Box 24D)
  14. 31. Provider Transaction Access Number) is a unique identification number assigned to healthcare providers by Medicare to access and manage their billing information and transactions.
  15. 33. A standardized form used by healthcare providers to submit claims for medical services to insurance companies for reimbursement. The form is most commonly used by individual healthcare providers, such as physicians, chiropractors, and other outpatient specialists, to submit claims for services rendered to insurance companies, including Medicare and Medicaid.
  16. 34. Extensible Markup Language: is a flexible, text-based format used to structure, store, and transport data in a way that is both human-readable and machine-readable.
  17. 35. Electronic Medical Record: is a digital version of a patient's medical chart used by healthcare providers to document and manage patient care within a single practice or facility.
  18. 36. National Drug Code is a unique 10-digit identifier assigned to each medication approved by the FDA, used to track and identify drugs in the healthcare system for billing and inventory purposes.
  19. 37. The healthcare provider or organization that submits claims and is responsible for receiving payment for medical services rendered to a patient.
  20. 38. A unique identifier assigned by an insurance company to approve a specific medical service, treatment, or prescription before it is provided, ensuring it meets the insurer’s coverage requirements.
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  1. 1. Employer Identification Number (EIN) is a unique nine-digit number assigned by the IRS to businesses and organizations for tax reporting and identification purposes.*Also See TIN
  2. 3. A healthcare professional responsible for overseeing the clinical activities and ensuring the quality of care provided by other practitioners, such as residents, nurse practitioners, or physician assistants.
  3. 4. A healthcare professional or facility that directly provides medical services or treatment to a patient.
  4. 5. Health Insurance Portability and Accountability Act is a U.S. law designed to protect patient privacy, secure health information, and ensure the confidentiality and integrity of healthcare data.
  5. 7. Place of Service: Refers to the code used on medical claims to indicate the location where a healthcare service was provided, such as a hospital, physician's office, outpatient facility, etc.,.
  6. 8. Electronic Data Interchange is the digital exchange of business documents between organizations in a standardized electronic format, enabling faster, more accurate, and efficient transactions.
  7. 10. National Provider Identifier (NPI) is a unique 10-digit identification number assigned to healthcare providers in the U.S. for the purpose of simplifying administrative processes and ensuring accurate billing and claims processing.
  8. 11. Taxpayer Identification Number is a unique identification number assigned by the IRS to individuals or entities for tax reporting purposes. *See EIN
  9. 15. Centers for Disease Control and Prevention is a U.S. federal agency responsible for protecting public health by preventing and controlling disease outbreaks, injuries, and health risks.
  10. 16. American Medical Association is a professional organization that represents physicians in the United States, advocating for medical standards, ethics, and healthcare policy.
  11. 18. Explanation of Benefits: Is a PRINTED statement from an insurance company detailing the services provided, the amount covered, the patient's financial responsibility, and the reasons for any claim adjustments. An Explanation of Benefits (EOB) can be sent to both the patient and the provider.
  12. 19. American Dental Association) claim is a standardized form used by dental providers to submit billing information for dental services to insurance companies for reimbursement.
  13. 21. An intermediary organization that receives, processes, and transmits healthcare claims between providers and insurance companies, ensuring that the claims are correctly formatted and compliant with industry standards before submission.
  14. 23. Clinical Laboratory Improvement Amendments U.S. federal standards that regulate laboratory testing to ensure the accuracy, reliability, and quality of patient test results. (HCFA Box 31 Additional Fields)
  15. 24. A healthcare professional who authorizes or requests a specific service, test, or procedure for a patient, such as lab work or imaging.
  16. 25. A program established under the Health Information Technology for Economic and Clinical Health (HITECH) Act that incentivizes healthcare providers to adopt and demonstrate the effective use of Electronic Health Records (EHRs) to improve patient care, enhance coordination, ensure patient safety, and reduce healthcare costs, with specific goals and measures for data exchange, clinical decision support, and quality reporting.
  17. 26. Subjective Objective Assessment and Plan: A method of documentation employed by health care providers to write out notes in a patient's chart - Found in EHR.
  18. 29. Electronic Funds Transfer is the digital transfer of money between banks or financial institutions, commonly used for payments and transactions in healthcare, business, and personal finance.
  19. 32. A standardized set of codes used to classify healthcare providers based on their specialty, type, or area of expertise for billing, credentialing, and identification purposes.