Medical Billing & Coding

Medical Billing and Coding Glossary Terms

If you're interested in medical insurance billing and coding as a profession, the following terms can help you learn more about this exciting industry. At the very least, they can help you understand the common practices and industry terms that a medical biller or coder should know.

  • AMA - The American Medical Association serves the largest association of doctors in the United States. This organization, widely known and respected, publishes The Journal of the American Medical Association.
  • Aging - A medical billing term that refers to unpaid insurance claims that become past due.
  • Assignment of Benefits - These are the insurances paid to a hospital or doctor for services rendered to a patient.
  • Beneficiary - The person covered by a health insurance plan is the beneficiary.
  • CMS 1500 - Created by the Centers for Medicaid and Medicare Services (CMS), this medical claim form (red ink) allows for the submission of paper claims to Medicare and Medicaid.
  • Coding - This is the process of taking a doctor's notes about a patient and transcribing them in the proper ICD-9 code (defined below).
  • Collection Ratio - Every health care provider has accounts receivable. This ratio is determined by the payments received compared to the total amount of money owed on the account.
  • Coordination of Benefits - Some patients are covered by more than one insurance plan. One of the plans is chosen as the primary plan and the other as the secondary.
  • Copay - The amount a patient is required to pay at each visit as determined by his or her insurance plan.
  • Deductible - This is the amount a patient must pay before insurance coverage begins.
  • Electronic Claim - Claim information is sent directly to the insurance carrier via electronic transfer.
  • Enrollee - A person enrolled in a health insurance plan.
  • EPO - An exclusive provider organization (EPO). Where employers agree not to contract with other plans, is a type of managed care plan that combines features of HMOs and PPOs.
  • EOB - Explanation of benefits. A statement sent by the insured's health care provider that explains the treatment and services they will pay.
  • Group Name - This is the name of the patient's insurance carrier.
  • Group Number - Insurance companies assign each insured patient a number that references a group plan.
  • Health Care Insurance - Coverage that helps to manage the cost of patient medical care.
  • Health Care Provider - Typically refers to a hospital, physician or health care facility that provides health care services.
  • HIPAA - The Health Insurance Portability and Accountability Act provides coverage for family members of workers who have lost or changed jobs.
  • HMO - A health maintenance organization (HMO) is an organization that provides or arranges managed care for health insurance, self-funded health care benefit plans, individuals and other entities on a prepaid basis.
  • ICD-9-CM and ICD-10-CM Code (International Classification of Diseases, 9th or 10th Revision, Clinical Modification coding system) - An international classification of diseases that are assigned codes to patient diagnosis.
  • Inpatient - A patient who is admitted to the hospital and stays overnight or for an indeterminate time.
  • Medical Coder - Professionals who analyze patient charts and who assign appropriate ICD-9-CM and ICD-10-CM codes.
  • Medical Billing Specialist - A person who processes claims for services provided by a physician or health care provider.
  • Medical Transcription - The conversion of handwritten or voice-recorded medical information. The records can be paper or electronic.
  • Medicaid - Considered the nation's primary health safety net for low-income people and families.
  • Medicare - Provides health coverage for younger people with certain disabilities and people over the age of 65.
  • Outpatient - A person who receives medical treatment without admittance to a hospital for 24 hours or more.
  • PPO - Preferred provider organization. Allows a patient to use any doctor or hospital within the network to provide health care at reduced rates to the insurer's or administrator's clients.
  • Premium - The amount that the insured or their employer pays for health insurance coverage.
  • WHO - The World Health Organization directs and coordinates health care initiatives within the United Nations. It helps set standards for global research norms, provides technical support to countries and assesses world health trends.

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