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Patient Portal
Allows patients to send and receive information with a provider electronically.
Shoppable Services
Services that can be scheduled in advance and are generally not emergency services, such as imaging, lab tests, or outpatient visits.
Price Transparency
Readily available information about the price of healthcare services.
Prior Authorization
A process in which the provider submits a request for approval before providing certain services to the patient.
Charge Description Master (CDM)
A comprehensive listing of items billable to a hospital or healthcare provider, including procedure/service charges and corresponding codes.
Computerized Provider Order Entry (CPOE)
Allows physicians/providers to order services for a patient via a computerized system.
Modifiers
Codes that provide additional information about services and procedures, though their inclusion in the CDM is rare.
Adjudication
The process of reimbursement amount determination based on the beneficiary's insurance plan benefits.
Allowable Charge
The amount the payer has agreed to reimburse for a provided service, accepted as payment in full by the provider.
Accrual Accounting
Accounting method that records accounts receivable at the time of service delivery instead of when funds are received.
Recovery Audit Program
Medicare contractors hired to review improper payments and paid on a contingency fee basis.
Upcoding
The fraudulent practice of submitting codes for higher-paying services than those actually received by the patient.
National Coverage Determination (NCD)
Regulations detailing the circumstances under which medical services are covered by Medicare.
Clinical Validation Denial
Type of denial indicating insufficient clinical indicators in the health record to support the assigned diagnosis.
Key Performance Indicators (KPIs) for Coding
Metrics used to measure coding performance, including Denial Rate, Clean Claim Rate, and DNFB.
False Claims Act
Law that penalizes federal contractors who knowingly file false claims to defraud the US government.
Systematic Random Sampling
A method used to select a sample from a larger population by using a random starting point and a consistent interval.
Patient Registration
The process of collecting data about a patient, including diagnosis, planned treatment, insurance coverage, and financial agreements.
Prior Authorization Request
A request made by the provider to obtain approval for specific healthcare services before they are provided to the patient.
Out of Pocket Cost of Care
The amount of money a patient is responsible for paying for healthcare services that are not covered by insurance.
Patient Financial Responsibility Agreement
An agreement that outlines the patient's responsibility for payment of healthcare services after insurance has been applied.
Advance Beneficiary Notification of Noncoverage (ABN)
A notice that a healthcare provider must issue to a Medicare beneficiary when a service is expected not to be covered by Medicare.
Coding Standardization
Certain CDM data elements are standardized across the US, including CPT/HCPCS codes and revenue codes.
ICD-10-CM
The coding system used for all diagnosis coding regardless of the healthcare setting.
ICD-10-PCS
The coding system specifically used for procedure coding in inpatient facilities.
HCPCS Level II
Coding used to report drugs, biologicals, and chemotherapy drugs in the outpatient setting.
Claims Reconciliation
The process of comparing expected reimbursement to actual payments received after the healthcare facility gets remittance advice.
Editing Software
Software used by facilities to identify errors in claims before submission.
Claim Payment Status - Paid
A claim that is paid without further review or processing.
Claim Payment Status - Suspend
Claims requiring manual review by a claims examiner or analyst.
Claim Payment Status - Reject
Claims that result in partial payment, error lines fixed, and then resubmitted.
Claim Payment Status - Denial
A claim that must be appealed by the facility if the payer's decision is contested.
Benefit Payment
The amount that the insurance company reimburses for a given service.
Coder Productivity Calculation
A measure involving total minutes worked divided by the average time to code one chart.
Coding Accuracy
Ensures correct assignment of diagnosis and procedure codes along with any applicable modifiers and discharge status codes.
Queries for Clinical Documentation
Queries should include clinical indicators, treatment & monitoring, and any related conditions such as comorbidities.
Key Performance Indicators (KPIs) for Coding - Denial Rate
Measures the ability to comply with documentation, coding, and billing requirements.
Key Performance Indicators (KPIs) for Coding - Clean Claim Rate
Measures the ability to comply with billing edits.
Key Performance Indicators (KPIs) for Coding - DNFB
Discharged, Not Final Billed; reflects the health of the claims generation process.
Medicare Claims Processing Manual
An online guide that provides billing regulations and requirements for all healthcare settings.
CMS Transmittals
Documents used by CMS to communicate policies and procedures regarding payment systems.
PERM
A program by CMS that measures improper payments for Medicaid and CHIP.
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