Module 11- Key Terms

after visit summary (AVS)

Information that includes follow-up appointments, provider orders, instructions, educational resources, and financial account information.

aging report

A report that lists outstanding balances that have not been paid by either the patient or the insurance payer.

Center for Medicare and Medicaid Services (CMS)

A federal agency that oversees the Medicare program and assists states with Medicaid programs.

clearinghouse

An organization that accepts the claims data from a health care provider, performs edits comparable to payer edits, and submits clean claims to the third-party payer.

clustering

Scheduling patients in groups with common medical needs.

coinsurance

The percentage of the allowed amount the patient will pay once the deductible is met.

copayment

A set amount determined by the plan/payer that the patient pays for specified services, usually office visits and emergency department visits.

CPT codes

Current Procedural Terminology codes that identify medical services and procedures performed by a provider.

deductible

The amount that must be paid before benefits are paid by the insurance company.

diagnosis codes

International Classification of Diseases, 10th revision, Clinical Modification (ICD-10-CM) codes based on the provider’s diagnosis (why the patient is in need of medical services).

double-booking

A type of scheduling in which two or more patients are scheduled within the same time slot.

eligibility

Meeting the stipulated requirements to participate in the health care plan.

encounter form

A record of the diagnosis and procedures covered during the current visit; also known as superbill.

established patient

Patient who received same-provider services within the last 3 years.

HCPCS codes

Healthcare Common Procedure Coding System codes that identify supplies and procedures not described by CPT codes.

inventory supply log

Form that tracks the amount of inventory the office has and can be used to predict anticipated amounts needed based on the history.

matrix

The designed time frame for appointments based on the method of appointment

medical necessity

Reasonable and appropriate services based on clinical standards per CMS and the OIG.

new patient

The initial patient appointment or the first encounter after a 3-year absence from the organization.

no-show

When a patient has a scheduled appointment and does not show up or contact the medical office.

notice of privacy practices (NPP)

Document that identifies how the provider will distribute and disclose a patient’s protected health information.

par level/threshold

Minimum amount of inventory an office will have on the shelf before placing another order.

practice management system (PMS)

Software used to electronically manage administrative functions, such as scheduling appointments, integrating patient documentation from electronic health records, coding, billing, and revenue cycle tasks such as running aging reports and managing the accounts receivable.

preauthorization

Approval of insurance coverage and necessity of services prior to the patient receiving them.

precertification

A request to determine if a service is covered by the patient’s policy and what the reimbursement would be.

real-time adjunction (RTA)

A tool that allows for a submission of the coded visit to the insurance company by participating providers for reimbursement decisions by third-party payers while the patient is present.

referral

An order from a provider for a patient to see a specialist or to obtain specific medical services.

revenue cycle

A series of administrative functions that are required to capture and collect payment for services provided by a health care organization.

wave scheduling

Scheduling two or three patients during a designated hourly time period (last 30 min of the hour, patients seen in order of arrival).