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EZ MedBill Medical Billing Glossary
Even experts in the field may become overwhelmed by the medical billing process’s many acronyms, specialized terminology, and compliance requirements. We made this extensive, user-friendly glossary for that reason. Billers, coders, medical office employees, and healthcare providers can all benefit from it. Whether you’re training new team members or need a quick refresher, this glossary simplifies the complex language of medical billing with clear and practical definitions.
Terminology for Coding
Accurate billing and reimbursement are predicated on medical coding. Diagnoses, treatments, and services are represented by these codes.
CPT (Current Procedural Terminology):
Medical, surgical, and diagnostic services that are discussed by codes.
ICD-10 (International Classification of Diseases, 10th Revision):
Diagnostic codes that are utilized for categorizing illnesses and ailments.
Healthcare Common Procedure Coding System (HCPCS):
HCPCS are codes used billing Medicare and Medicaid for non-physician services and supplies.
Modifiers:
are a two-digit code that provides more information regarding the service rendered.
DX Code:
An abbreviation for diagnosis code, usually used to refer to the ICD-10 code.
Compliance and Regulatory Terms
Being aware of healthcare regulations is crucial to ensure compliance and avoid costly penalties.
MIPS (Merit-based Incentive Payment System)
A Medicare program that manages payments based on performance.
MACRA (Medicare Access and CHIP Reauthorization Act)
Legislation that incorporates MIPS and other quality-based payment models.
HIPAA (Health Insurance Portability & Accountability Act)
Federal law that secures sensitive data of patient information.
PHI (Protected Health Information)
Any or all patient health information that HIPAA requires to be kept private.
NPI (National Provider Identifier)
A unique 10-digit number assigned to healthcare providers.
OIG (Office of Inspector General)
A federal organization that looks into healthcare program fraud and abuse.
Revenue Cycle Management (RCM) Terms
RCM is all about the full procedure of mitigating claims, payments, and revenue generation.
- Accounts Receivable (AR):Money that is owed to the practitioner by patients or insurance companies.
- Charge Entry:The procedure of integrating the coded services into billing software.
- Superbill:A listing of the documents of the solutions provided, used for billing purposes.
- Denial: A rejected claim due to errors, missing information, or non-compliance.
- Clean Claim:A claim that is accurate, complete, and accepted on first submission.
- Claim Scrubbing:Verifying the accuracy of claims prior to submission to the payer
Insurance and Payment Terms
Every medical billing team should be familiar with these most frequently used insurance-related terms.
- Co-pay: A set sum that the patient must pay at the time of service.
- Deductible:The sum of money a patient must pay out of pocket before their insurance starts to pay.
- Explanation of benefits, or EOB:Is a document that the insurer provides outlining what was paid and covered.
- Participating Provider (PAR): A provider with a contract with the insurance company.
- Non-participating provider (Non-PAR):A provider who is not under contract with the insurance company, which typically results in higher expenses for the patient.
- Pre-authorization: Some insurers require approval before certain services can be rendered.
- Not in the Pocket Maximum: The highest amount a patient must pay before their insurance pays for all other expenses during a benefit period.
Additional Key Terms
These terms often come up in daily operations and should be familiar to billing staff.
- A clearinghouse:is a third-party service that verifies and sends electronic claims to insurance providers.
- Fee Schedule:A list of fees established by an insurance company or provider for services rendered.
- Electronic Remittance Advice (ERA): A benefit explanation in digital form.
- Patient Responsibility:The amount of the bill that the patient is responsible for paying, including deductibles and copays.
- Write-off: The sum that a provider consents not to collect from the patient.
- Payer: An organization, such as an insurance company, that reimburses providers for services rendered. Please update this.
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