NHA Certified Billing and Coding Specialist (CBCS) Vocabulary

Key vocabulary terms and definitions covering all four content domains of the NHA Certified Billing and Coding Specialist (CBCS) exam.

CBCS Exam

A closed-book exam administered by the NHA measuring end-to-end claim mastery over 125 multiple-choice questions (100 scored, 25 unscored pretest) in 3 hours with a passing scaled score of 390 out of 500.

HIPAA Privacy Rule

Federal regulation protecting individually identifiable Protected Health Information (PHI), permitting disclosures without authorization only for Treatment, Payment, and Healthcare Operations (TPO).

HIPAA Security Rule

Federal regulation governing electronic PHI (ePHI) through administrative, physical, and technical safeguards.

Notice of Privacy Practices (NPP)

A mandatory document informing patients of their privacy rights and how PHI is utilized, presented at the first encounter.

Minimum Necessary Standard

A HIPAA principle requiring staff to access or disclose only the minimum amount of PHI required to perform an intended job task.

HITECH Act

A 2009 law expanding HIPAA requirements, increasing noncompliance penalties, and mandating breach notifications (notifying HHS and local media within 60 days for breaches affecting 500 or more individuals).

False Claims Act (FCA)

Federal statute prohibiting knowingly submitting false or fraudulent claims to federal healthcare programs, including qui tam (whistleblower) provisions.

Anti-Kickback Statute (AKS)

A criminal statute prohibiting the exchange of anything of value (remuneration) to induce or reward patient referrals for services payable by federal programs.

Stark Law

A civil law barring physicians from referring Medicare or Medicaid patients for designated health services (DHS) to entities in which the physician or an immediate family member has a financial interest.

Fair Debt Collection Practices Act (FDCPA)

Federal law restricting third-party debt collection practices, including prohibiting calls before 8:00 AM or after 9:00 PM, harassing calls, or contacting debtors at work once notified.

Fraud

Intentional deception or misrepresentation committed to secure unauthorized payment.

Abuse

Practices resulting in unnecessary costs to payers through improper, non-compliant, or careless actions falling short of intentional deceit.

Internal Compliance Audit

Periodic audit conducted by practice staff or compliance officers to identify billing patterns and areas of noncompliance.

External Compliance Audit

Audit conducted by government contractors (such as RAC, ZPIC/UPIC, or MAC) to identify overpayments and underpayments, requiring refunds within 60 days of identification.

Premium

The recurring payment (typically monthly) made to keep an insurance policy active.

Deductible

The out-of-pocket amount a patient must pay annually for covered services before insurance coverage begins paying.

Copayment (Copay)

A fixed, predetermined dollar amount paid by the patient at the time of service.

Coinsurance

The percentage split of covered medical expenses shared between the patient and payer after meeting the deductible.

Out-of-Pocket Maximum (OOPM)

The maximum cumulative amount a patient pays in cost-sharing during a policy period, after which the plan pays 100% of allowed charges.

Health Maintenance Organization (HMO)

A managed care plan requiring selection of a Primary Care Physician (PCP) and specialist referrals, offering no out-of-network coverage except in true emergencies.

Preferred Provider Organization (PPO)

A plan offering in-network and out-of-network coverage without requiring a PCP or specialist referrals.

Exclusive Provider Organization (EPO)

A hybrid plan requiring no specialist referrals but strictly offering no out-of-network coverage.

Point of Service (POS)

A hybrid plan combining HMO structure (PCP required) with out-of-network coverage options at higher cost.

Medicare Part A

Inpatient coverage encompassing hospital care, skilled nursing facility care, hospice, and home healthcare, premium-free for individuals with 40 or more work credits.

Medicare Part B

Outpatient coverage encompassing physician services, preventive care, diagnostic tests, outpatient surgery, and durable medical equipment, requiring a monthly premium.

Medicare Part C (Medicare Advantage)

Private managed care plans contracted with Medicare to deliver Part A and Part B benefits (and usually Part D).

Medicare Part D

Prescription drug coverage under Medicare.

Medicaid

State- and federally funded healthcare program for low-income individuals and families, serving as the payer of last resort.

TRICARE

Healthcare program serving active-duty military personnel, retirees, and their eligible dependents.

CHAMPVA

Civilian Health and Medical Program of the Department of Veterans Affairs, covering dependents and survivors of permanently disabled or deceased service-connected veterans.

Birthday Rule

Rule establishing primary insurance for a dependent child under both parents' plans based on whose month and day of birth falls earlier in the calendar year, disregarding the birth year.

Medicare Secondary Payer (MSP)

Regulations specifying when Medicare pays secondary to another primary coverage, such as Employer Group Health Plans, Workers' Compensation, or no-fault insurance.

Excludes1

An ICD-10-CM instructional convention meaning 'NOT CODED HERE!', indicating mutually exclusive conditions that cannot exist together in the same patient at the same time.

Excludes2

An ICD-10-CM instructional convention meaning 'Not included here', indicating an excluded condition is not part of the code, but both conditions may be reported together if documented.

Code First / Use Additional Code

An ICD-10-CM sequencing convention requiring the underlying etiology condition to be coded before the manifestation code.

Not Elsewhere Classifiable (NEC)

An ICD-10-CM convention used when clinical documentation provides specific details, but the code set lacks a more specific code.

Not Otherwise Specified (NOS)

An ICD-10-CM convention used when documentation is vague or insufficient to select a specific code.

Placeholder 'X'

A mandatory dummy character used in ICD-10-CM when a code requires a 7th character extension but has fewer than 6 characters.

CPT Category I Codes

5-digit numeric codes representing standard medical procedures, surgeries, diagnostic tests, and Evaluation and Management services.

CPT Category II Codes

Supplemental performance measurement tracking codes (4 digits followed by 'F') that are non-billable for direct reimbursement.

CPT Category III Codes

Temporary tracking codes (4 digits followed by 'T') used for emerging technology, procedures, and clinical trials.

Global Surgical Package

A single package encompassing preoperative care, the surgical procedure, and routine postoperative care over a specified period (0, 10, or 90 days).

HCPCS Level II

Alphanumeric codes consisting of one letter followed by four numbers that cover services and supplies outside CPT, such as ambulance, DMEPOS, and injectable drugs.

Modifier -25

Modifier indicating a significant, separately identifiable Evaluation and Management (E/M) service on the same day as a procedure.

Modifier -59

Modifier indicating a distinct procedural service performed on an entirely different site, separate lesion, or during a different encounter on the same day.

Modifier -26

Modifier indicating professional component only, such as physician interpretation of a test.

Modifier -TC

Modifier indicating technical component only, covering facility equipment, technician, and materials.

Modifier -50

Modifier indicating a bilateral procedure performed on paired right and left body structures during the same session.

Modifier -51

Modifier indicating multiple surgical procedures performed during the same session by the same provider.

Modifier -52

Modifier indicating reduced services where a procedure is partially reduced or eliminated at the physician's discretion.

Modifier -53

Modifier indicating a discontinued procedure terminated prematurely due to extenuating circumstances threatening patient well-being.

Modifier -GA

Modifier appended when an Advance Beneficiary Notice (ABN) is signed and on file for an expected Medicare denial.

Modifier -GZ

Modifier appended when an expected Medicare denial occurs but no signed Advance Beneficiary Notice (ABN) is on file.

NCCI Procedure-to-Procedure (PTP) Edits

Edits identifying code pairs that should not be billed together because one service is inherent in the other.

Medically Unlikely Edits (MUE)

Limits defining the maximum units of service a provider can report for a single beneficiary on a single date of service.

Upcoding

The illegal practice of reporting a higher-level code than supported by documentation to obtain higher reimbursement.

Unbundling

The improper practice of fragmenting a comprehensive code package into individual component codes to inflate reimbursement.

CMS-1500

The standard paper claim form used for professional and outpatient services, corresponding to the electronic 837P format.

Clean Claim

A claim submitted with complete and accurate information that passes all front-end edits without requiring external verification.

Clearinghouse

An entity that converts proprietary claims into standard HIPAA 837 formats, scrubs claims for technical errors, and routes them to payers.

Claim Rejection

An unadjudicated claim returned due to technical or formatting errors that must be corrected and resubmitted as an original claim.

Claim Denial

A claim that was processed through adjudication but refused payment based on coverage, clinical guidelines, or lack of medical necessity.

Explanation of Benefits (EOB)

A document sent to the patient detailing billed services, allowed amounts, payer payments, and patient financial responsibility.

Remittance Advice (RA)

A document sent to the provider explaining claim adjudication results, contractual adjustments, payments, and denials.

Claim Adjustment Reason Code (CARC)

A standardized code explaining why a claim line item was adjusted or paid differently than billed.

Remittance Advice Remark Code (RARC)

A supplemental code providing detailed explanations for a Claim Adjustment Reason Code (CARC).

Contractual Obligation (CO)

A group adjustment code representing mandatory provider write-offs that cannot be balance-billed to the patient.

Patient Responsibility (PR)

A group adjustment code representing cost-sharing amounts (deductible, copay, coinsurance) that can be collected directly from the patient.

Advance Beneficiary Notice of Noncoverage (ABN)

Form CMS-R-131 issued to traditional Medicare beneficiaries prior to service when Medicare is expected to deny payment as not medically reasonable or necessary.

A/R Aging Report

A report categorizing outstanding claims into age brackets (such as 0–30, 31–60, 61–90, 91–120, and 121+ days) to manage collections.

Redetermination

The first level of the Medicare denials appeal process, submitted in writing within 120 days from initial denial.

CMS-1500 Box 13

Field for Assignment of Benefits (AOB) signature authorizing direct payment from the payer to the provider.

CMS-1500 Box 21

Field used to list up to 12 ICD-10-CM diagnosis codes identified by letter pointers A through L without decimal points on paper forms.

CMS-1500 Box 24E

Field for Diagnosis Pointers referencing letters A–L from Box 21 to establish medical necessity for a service line.