medical_billing_terms

CMS 1500​ - Medical claim form established by CMS to submit paper claims to Medicare and Medicaid. Most commercial insurance carriers also require paper claims be submitted on CMS-1500's. The form is distinguished by it's red ink.

Coding​ - Medical Billing Coding involves taking the doctor's notes from a patient visit and translating them into the proper ICD-9 code for diagnosis and CPT codes for treatment. 

COBRA Insurance​ - This is health insurance coverage available to an individual and their dependents after becoming unemployed - either voluntary or involuntary termination of employment for reasons other than gross misconduct. Because it does not typically receive company matching, It's typically more expensive than insurance the cost when employed but does benefit from the savings of being part of a group plan. Employers must extend COBRA coverage to employees dismissed for a. COBRA stands for Consolidated Omnibus Budget Reconciliation Act which was passed by Congress in 1986. 

COBRA coverage typically lasts up to 18 months after becoming unemployed and under certain conditions extend up to 36 months.

Coinsurance​ - Percentage or amount defined in the insurance plan for which the patient is responsible. Most plans have a ratio of 90/10 or 80/20, 70/30, etc. For example the insurance carrier pays 80% and the patient pays 20%. 

Collection Ratio​ - This is in reference to the providers accounts receivable. It's the ratio of the payments received to the total amount of money owed on the provider's accounts.

Contractual Adjustment​ - The amount of charges a provider or hospital agrees to write off and not charge the patient per the contract terms with the insurance company. 

Coordination of Benefits​ - When a patient is covered by more than one insurance plan. One insurance carrier is designated as the primary carrier and the other as secondary. 

Co-Pay​ - Amount paid by patient at each visit as defined by the insured plan. 

CPT Code​ - Current Procedural Terminology. This is a 5 digit code assigned for reporting a procedure performed by the physician. The CPT has a corresponding ICD-9 diagnosis code. Established by the American Medical Association. This is one of the medical billing terms we use a lot. 

Credentialing​ - This is an application process for a provider to participate with an insurance carrier. Many carriers now request credentialing through CAQH. CAQH credentialing process is a universal system now accepted by insurance company networks. 

Credit Balance​ - The balance that's shown in the "Balance" or "Amount Due" column of your account statement with a minus sign after the amount (for example $50-). It may also be shown in parenthesis; ($50). The provider may owe the patient a refund. 

Crossover claim​ - When claim information is automatically sent from Medicare the secondary insurance such as Medicaid. 

Date of Service (DOS)​ - Date that health care services were provided. 

Day Sheet - Summary of daily patient treatments, charges, and payments received.

Deductible​ - amount patient must pay before insurance coverage begins. For example, a patient could have a $1000 deductible per year before their health insurance will begin paying. This could take several doctor's visits or prescriptions to reach the deductible. 

Demographics​ - Physical characteristics of a patient such as age, sex, address, etc. necessary for filing a claim.

DME - Durable Medical Equipment​ - Medical supplies such as wheelchairs, oxygen, catheter, glucose monitors, crutches, walkers, etc. 

DOB​ - Abbreviation for Date of Birth

Downcoding​ - When the insurance company reduces the code (and corresponding amount) of a claim when there is no documentation to support the level of service submitted by the provider. The insurers computer processing system converts the code submitted down to the closest code in use which usually reduces the payment. 

Duplicate Coverage Inquiry (DCI)​ - Request by an insurance company or group medical plan by another insurance company or medical plan to determine if other coverage exists. 

Dx​ - Abbreviation for diagnosis code (ICD-9 or ICD-10 code). 

Electronic Claim​ - Claim information is sent electronically from the billing software to the clearinghouse or directly to the insurance carrier. The claim file must be in a standard electronic format as defined by the receiver.

Electronic Funds Transfer (EFT)​ - An electronic paperless means of transferring money. This allows funds to be transferred, credited, or debited to a bank account and eliminates the need for paper checks.

 E/M​ - Evaluation and Management section of the CPT codes. These are the CPT codes 99201 thru 99499 most used by physicians to access (or evaluate) a patient's treatment needs. 

EMR​ - Electronic Medical Records. This is a medical record in digital format of a patient's hospital or provider treatment. 

Enrollee​ - Individual covered by health insurance