MC209 TERMINOLOGY.csv

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teloff
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193395
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MC209 TERMINOLOGY.csv
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2013-01-17 10:43:59
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healthcare reimbursement terminology
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healthcare reimbursement terminology
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  1. "Allowable charge- Allowable fee
    average or maximum amount the third-party payer will reimburse providers for the service"
  2. "Block grant
    fixed amount of money given or allocated for a specific purpose- such as a transfer of governmental funds to cover health services"
  3. "capitated payment method- capitation
    method of payment for health services in which an individual or institutional provider is paid a fixed- per capita amount for each person enrolled without regard to the actual number or nature of services provided or number of persons served"
  4. "case
    patient- resident or client with a given condition or disease"
  5. "case-based payment
    type of prospective payment method in which the third party payer reimburses the provider a fixed- pre-established payment for each case."
  6. "charge
    price assigned to a unit of medical or health service- such as a visit to a physician or a day in a hospital. The charge for a service may be unrelated to the actual cost of providing the service -see fee-."
  7. "claim
    request for payment or itemized statement of healthcare services and their costs- provided by a hospital- physician's office or other healthcare provider. Claims are submitted for reimbursement to the healthcare insurance plan by either the policy or certificate holder or the provider. Also called bills for Medicare Part A and Part B- services billed through fiscal intermediaries- and for Part B-- physician or supplier services billed through carriers."
  8. "clinical risk group -CRG-
    capitated- prospective payment system that predicts future healthcare expenditures for populations"
  9. "connector
    an independent state agency that regulates the policies -contracts- for healthcare insurance coverage offered by the small group and individual healthcare insurance companies"
  10. "copayment
    cost-sharing measure in which the policy or certificate holder pays a fixed dollar amount -flat fee- per service- supply or procedure that is owed to the healthcare facility by the patient. The fixed amount that the policyholder pays may vary by type of service- such as $20 per prescription or $15 per physician office visit."
  11. "Customary
    prevailing and reasonable -CPR-
  12. "Deductible
    annual amount of money that the policyholder must incur -and pay- before the health insurance will assume liability for the remaining charges or covered expenses."
  13. "Dependent -family- coverage
    healthcare insurance benefits for spouses- children- or both of the member -enrollee- subscriber- certificate holder-- coverage is dependent upon relationship with members"
  14. "Episode-of-care
    one or more healthcare services given by a provider during a specific period of relatively continuous care in relation to a particular health or medical problem or situation. In home health- the episode of care is all home care services and non-routine medical supplies delivered to a patient during a 60 day period. in the home health prospective payment system -HHPPS-- the episode of care is the unit of payment."
  15. "Episode-of-care reimbursement
    healthcare payment method in which providers receive one lump sum for all the care they provide related to a condition or disease. See episode of care"
  16. "Fee
    price assigned to a unit of medical or health service- such as a visit to a physician or a day in a hospital. The fee for a service may be unrelated to the actual cost of providing the service -see charge-."
  17. "Fee Schedule
    third-party payer's predetermined list of maximum allowable fees for each healthcare service."
  18. "Fee-for-service -FFS- reimbursement
    healthcare payment method in which providers retrospectively receive payment for each service rendered."
  19. "Fundamental healthcare reform
    implementation of policies that change key existing structures of the healthcare delivery system- such as unlinking employment and healthcare insurance or mandating universal coverage"
  20. "Global payment method
    method of payment in which the third-party payer makes on consolidated payment to cover the services of multiple providers who are treating a single episode of care."
  21. "Guarantor
    person who is responsible for paying the bill or guarantees payment for healthcare services. Patients who are adults are often their own guarantor. Parents guarantee payments for the healthcare costs of their children's."
  22. "Incremental healthcare reform
    implementation of policies that make changes to existing structures- such as changing fee structures."
  23. "Individual -single- coverage
    healthcare insurance benefits that only cover one individual- the member -enrollee- subscriber- certificate holder-."
  24. "insurance
    reduction of a person's -insured's- exposure to risk of lass by having another party -insurer- assume the risk"
  25. "Minimal creditable coverage
    minimum level of healthcare insurance that includes coverage for preventive and primary care- hospitalization- mental health benefits- and prescription drugs."
  26. "Payer
    a payer is an entity that pays for health services- such as an insurance company- workers' compensation- Medicare or an individual"
  27. "Per diem -per day- payment
    type of prospective payment method in which the third- party payer reimburses the provider a fixed rate for each day a covered member is hospitalized."
  28. "policy
    binding contract issued by a healthcare insurance company to an individual or group in which the company promises to pay for healthcare to treat illness or injury -aka health plan agreement and evidence of coverage-"
  29. "premium
    amount of money that policyholder or certificate holder must periodically pay a healthcare insurance plan in return for healthcare coverage."
  30. "prospective payment method
    type of episode-of-care reimbursement in which the third-party payer establishes the payment rates for healthcare services in advance for a specific time period."
  31. "provider
    physician- clinic- hospital- nursing home- or other healthcare entity -second party- rendering the care."
  32. "reimbursement
    compensation or repayment for healthcare services already rendered"
  33. "resource-based relative value scale -RBRVS-
    type of retrospective fee-for-service payment method that classifies- health services based on the cost of providing physician services in terms of effort- practice expense -overhead-- and malpractice insurance."
  34. "Retrospective payment method
    type of fee-for-service reimbursement in which providers receive recompense after health services have been rendered."
  35. "Risk pool
    group of people who will be covered by a healthcare insurance plan"
  36. "Self-insured plan
    method of insurance in which the employer or other association itself administers the health insurance benefits for its employees or their dependents- thereby assuming the risks for the cost of healthcare for the group."
  37. "sliding scale
    a method of billing in which the cost of healthcare services is based on the patient's income and ability to pay."
  38. "third-party payer
    insurance company or health agency that pays the physician- clinic- or other healthcare provider -second party- for the care or services to the patient -first party-. An insurance company or healthcare benefits program that reimburses healthcare providers and/or patients for covered medical services."
  39. "third-party payment
    payments for healthcare services made by an insurance c company or health agency on behalf of the insured."
  40. "universal healthcare coverage
    minimum level of healthcare insurance that includes coverage for preventive and primary care- hospitalization- mental health benefits- and prescription drugs."
  41. "usual
    customary and reasonable -UCR-
  42. "Abuse
    unknowing or unintentional submission of an inaccurate claim for payment."
  43. "AHA Coding Clinic for ICD-9-CM
    a publication issued quarterly by the American Hospital Association and approved by the Centers for Medicare and Medicaid Services to give coding advise and direction for ICD-9-CM."
  44. "AHA Coding Clinic for HCPCS
    official coding guidance for HCPCS Level II procedure- services- and supply codes"
  45. "AHIMA Standards of Ethical Coding
    standards developed by the Council on Coding and Classification of the American Health Information Management Association to give health information coding professionals ethical guidelines for performing their coding and grouping tasks."
  46. "Ambulatory payment classification -APC-
    Hospital outpatient prospective payment system -HOPPS-. The classification is a resource-based reimbursement system. The payment unit is the ambulatory payment classification group -APC group-"
  47. "Average length of stay -ALOS-
    Average number of days patients are hospitalized. Statistic is calculated by dividing the total number of hospital bed days in a certain period by the admissions or discharges during the same period."
  48. "Balanced Budget Act of 1997 -BBA-
    Legislation that affected several aspects of the healthcare industry- including the hospital outpatient prospective payment system -HOPPS-- fraud and abuse- and programs of all-inclusive care for elderly -PACE-"
  49. "Benchmarking
    the process of comparing performance to a pre-established standard or performance of another facility of group"
  50. "Case mix index -CMI-
    Single number that compares the overall complexity of the healthcare organization's patients to the complexity of the average of all hospitals. Typically- the CMI is for a specific period and is derived from the sum of all diagnosis-related group -DRG- weights- divided by the number of Medicare cases."
  51. "Centers for Medicare and Medicaid Services -CMS-
    a division of the Department of Health and Human Services -DHHS- that is responsible for administering the Medicare program and the federal portion of the Medicaid program- responsible for maintaining the procedure portion of the International Classification of Diseases- 9th revision- Clinical Modification -ICD-9-CM-. Prior to 2001- MCS was named the Health Care Financing Administration -HCFA-"
  52. "Classification system
    1. a system for grouping similar diseases and procedures and organizing related information for easy retrieval. 2. a system for assigning numeric or alphanumeric code numbers to represent specific diseases and/or procedures"
  53. "Coding compliance plan
    a component of an HIM compliance plan or a corporate compliance plan that focuses on the unique regulations and guidelines with which coding professionals must comply."
  54. "Comorbidity
    preexisting condition that- because of its presence with a specific diagnosis- causes an increase in length of stay by at least one day in approx. 75% of the cases -as in complication and comorbidity -CC--"
  55. "compliance
    managing a coding or billing department according to the laws- regulations and guidelines that govern it."
  56. "compliance officer
    designated individual who monitors the compliance process at a healthcare facility"
  57. "compliance program guidance
    information provided by the Office of Inspector General -OIG- of the Department of Health and Human Services -DHHS- to assist healthcare organizations with the development of compliance plans and programs"
  58. "complication
    1. A medical condition that arises during an inpatient hospitalization -for example- a postoperative wound infection-- 2. a condition that arises during the ho hospital stay that prolongs the length of stay at least one day in approx. 75% of the cases -as in complication and comorbidity [CC]-."
  59. "CPT Assistant
    Official coding guidance for CPT codes"
  60. "Current Procedural Terminology -CPT-
    coding system created and maintained by the American Medical Association that is used to report diagnostic and surgical services and procedures."
  61. "Current Procedural Terminology Category I Code
    A CPT code that represents a procedure or service that is consistent with contemporary medical practice and is performed by many physicians in clinical practice in multiple locations."
  62. "Current Procedural Terminology Category II Code
    A CPT code that represents services and/or test results that contribute to positive health outcomes and quality patient care."
  63. "Current Procedural Terminology Category III Code
    a CPT code that represents emerging technologies for which a Category I code has yet to be established."
  64. "False Claims Act
    legislation passed during the Civil War that prohibits contractors from making a false claim to a governmental program- used to reinforce healthcare fraud and abuse."
  65. "Fraud
    intentionally making a claim for payment that one know to be false"
  66. "Health Care Procedure Coding System -HCPCS-
    Coding system created and maintained by the Centers for Medicare and Medicaid Services -CMS- that provides codes for procedures- services and supplies not represented by a Current Procedural Terminology -CPT- code."
  67. "Health Insurance Portability and Accountability Act of 1996 -HIPPA-
    significant piece of legislation aimed at improving healthcare data transmission among providers and insurers- designated code sets to be used for electronic transmission of claims"
  68. "Health information technology -HIT-
    the use of electronic devices and media to collect- store and retrieve healthcare information"
  69. "Hospital Outpatient Prospective Payment System -HOPPS-
    the reimbursement system created by the Balanced Budget Act of 1997 for hospital outpatient services rendered to Medicare beneficiaries- maintained by the Centers for Medicare and Medicaid Services -CMS-"
  70. "Hospital Payment Monitoring Program -HPMP-
    coding compliance monitoring program created by the 7th Scope of Work- which ensures that proper payment is made for Medicare beneficiary admissions- administered by regional Quality Improvement Organizations -QIOs-"
  71. "ICD-9-CM Coordination and Maintenance Committee
    committee composed of representatives from the National center for Health Statistics -NCHS- and the Centers for Medicare and Medicaid Services -CMS- that is responsible for maintaining the US clinical modification version of the International Classification of Diseases- 9th revision -ICD-9-CM- code sets."
  72. "International Classification of Diseases
    9th revision
  73. "Length of Stay -LOS-
    number of days a patient remains in a healthcare organization. The statistic is the number of calendar days from admission to discharge- including the day of admission but not the day of discharge. This statistic may have an impact on prospective reimbursement."
  74. "Local Coverage Determination -LCD-
    reimbursement and medical-necessity policies established by regional fiscal intermediaries. New format for Local Medical Review policies -LMRPs-. LCDs and LMRPs vary from state to state."
  75. "Local Medical Review Policy -LMRP-
    see Local Coverage Determination -LCD-"
  76. "Major diagnostic category -MDC-
    highest level in hierarchical structure of the federal inpatient prospective payment system -IPPS-. The 25 MDCs are primarily based on body system involvement- such as MDC No. 06- Diseases and Disorders of the Digestive System. However- a few categories are based on disease etiology- for example- Human Immunodeficiency Virus Infections."
  77. "Medicare administrative contractor -MAC-
    newly established contracting authority to administer Medicare Part A and Part B as required by section 911 of the MMA of 2003. Fifteen Medicare Administrative Contractors will replace Medicare Carriers and Fiscal Intermediaries by 2011. Each MAC will process and manage both Part A and Part B claims."
  78. "Medicare-severity diagnosis-related group -MS-DRG-
    Medicare refinement to the diagnosis-related group -DRG- classification system- which allows for payment to be more closely aligned with resource intensity."
  79. "Modifier
    two-digit alpha/alphanumeric/numeric code that provides the means by which a physician or facility can indicate that a service provided to the patient has been altered by some special circumstance-s-- but for which the basic code description itself has not changed."
  80. "Mortality
    the incidence of death."
  81. "National Center for Health Statistics -NCHS-
    Organization that developed the clinical modification to the ICD-9- responsible for maintaining and updating the diagnosis portion of the ICD-9-CM."
  82. "National Correct Coding Initiative -NCCI-
    a set of coding regulations to prevent fraud and abuse in physician and hospital outpatient coding- specifically addresses unbundling and mutually exclusive procedures."
  83. "National Coverage Determination -NCD-
    National medical necessity and reimbursement regulations"
  84. "Office of Inspector General -OIG-
    a division of the Department of Health and Human Services -DHHS- that investigates issues of noncompliance in the Medicare and Medicaid programs such as fraud and abuse."
  85. "Office of Inspector General Work plan
    yearly plan released by the OIG that outlines the focus for reviews and investigates in various healthcare settings."
  86. "Operation Restore Trust
    a 1995 joint effort of the Department of Health and Human Services -DHHS-- Office of Inspector General -OIG-- the Centers for Medicare and Medicaid Services -CMS-- and the Administration of Aging -AOA- to target fraud and abuse among healthcare providers."
  87. "Outpatient Services Mix Index -SMI-
    the sum of the weights of ambulatory payment classification groups for patients treated during a given period- divided by the total volume of patients treated."
  88. "Payment Error Prevention Program -PEPP-
    payment compliance program established under the 6th Scope of Work to help healthcare facilities identify simple mistakes that are causing payment errors- monitored by Quality Improvement Organizations -QIOs-"
  89. "Program for Evaluation Payment Patterns Electronic Report -PEPPER-
    a benchmarking database maintained by the Texas Medical Foundation that supplies individual QIOs with hospital data to determine state benchmarks and monitor hospital compliance."
  90. "Quality Improvement Organization -QIO-
    Medicare contractor that is responsible for carrying out a specified scope of work during a three-year period- monitors and assists healthcare facilities with quality- payment- treatment denial- and health information technology issues."
  91. "Recovery Audit Contractor -RAC-
    the result of a successful a demonstration project required by the Medicare Modernization Act of 2003. RACs ensure correct payments are made to providers and facilities by Medicare for Part A and Part B claims."
  92. "Scope of Work/ Statement of Work
    the contract specifications for quality improvement organizations -QIOs- to complete during their three-year contract period."
  93. "Third-party payer
    insurance company of health agency that pays the physician- clinic or other healthcare provider -second party- for the care or services to the patient -first party-. An insurance company or healthcare benefits program that reimburses healthcare providers and/or patients for covered medical services."
  94. "Utilization Review Committee
    consists of representatives from HIM- Quality- Utilization and Medical Staff- and responsible for determining whether a patient's medical care is necessary according to established guidelines and regulations."
  95. "World Health Organization -WHO-
    Organization that created and maintains the International Classification of Diseases -ICD- used throughout the world to collect morbidity and mortality information."

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