Medical Coding and Billing
Expert-defined terms from the Certified Professional in Healthcare Virtual Assistants course at Greenwich School of Business and Finance. Free to read, free to share, paired with a globally recognised certification pathway.
Medical Coding and Billing #
Medical Coding and Billing
Medical coding and billing are crucial components of the healthcare industry tha… #
Certified Professional in Healthcare Virtual Assistants must have a strong understanding of medical coding and billing to effectively support healthcare providers and facilities.
Medical Coding #
Medical Coding
Medical coding involves translating medical services, procedures, diagnosis, and… #
These codes are used for billing purposes, insurance claims, data analysis, and research. Medical coders assign specific codes based on documentation provided by healthcare providers. The two main code sets used in medical coding are:
- International Classification of Diseases, Tenth Revision, Clinical Modifica… #
- International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM): Used to report diagnoses and inpatient procedures.
- Current Procedural Terminology (CPT) : Used to report procedures and ser… #
- Current Procedural Terminology (CPT): Used to report procedures and services provided by healthcare professionals.
Medical Billing #
Medical Billing
Medical billing refers to the process of submitting and following up on claims w… #
It involves:
- Verifying patient insurance coverage #
- Verifying patient insurance coverage.
- Creating and submitting claims #
- Creating and submitting claims.
- Resolving claim denials or rejections #
- Resolving claim denials or rejections.
- Posting payments and adjustments #
- Posting payments and adjustments.
- Following up on unpaid claims #
- Following up on unpaid claims.
Revenue Cycle Management (RCM) #
Revenue Cycle Management (RCM)
Revenue cycle management is the financial process that healthcare organizations… #
RCM encompasses the entire patient experience, including pre-authorization, charge capture, claims submission, payment posting, denial management, and accounts receivable follow-up.
Health Insurance Portability and Accountability Act (HIPAA) #
Health Insurance Portability and Accountability Act (HIPAA)
HIPAA is a federal law that establishes privacy and security standards to protec… #
Healthcare providers and their business associates must comply with HIPAA regulations to safeguard patient data and ensure confidentiality.
Electronic Health Record (EHR) #
Electronic Health Record (EHR)
An EHR is a digital version of a patient's paper chart that contains the patient… #
EHRs allow healthcare providers to access and share patient information securely.
Centers for Medicare and Medicaid Services (CMS) #
Centers for Medicare and Medicaid Services (CMS)
CMS is a federal agency within the United States Department of Health and Human… #
CMS sets reimbursement rates, quality standards, and regulations for healthcare providers and facilities.
Superbill #
Superbill
A superbill is a form used by healthcare providers to document the services rend… #
It includes codes for diagnoses, procedures, and supplies provided to the patient. The superbill is used to generate claims for reimbursement from insurance companies.
Explanation of Benefits (EOB) #
Explanation of Benefits (EOB)
An EOB is a statement sent by a health insurance company to policyholders explai… #
It details the services provided, the amount billed, the amount covered by insurance, and any patient responsibility, such as copayments or deductibles. EOBs help patients understand their healthcare expenses.
Clean Claim #
Clean Claim
A clean claim is a claim that is submitted accurately and completely to an insur… #
Clean claims contain all necessary information for processing, reducing the likelihood of denial or rejection. Clean claims are processed more quickly and result in faster reimbursement.
National Provider Identifier (NPI) #
National Provider Identifier (NPI)
An NPI is a unique 10 #
digit identification number assigned to healthcare providers by the Centers for Medicare and Medicaid Services (CMS). The NPI is used for billing purposes and is required on all claims submitted to insurance payers. Each healthcare provider, including individuals and organizations, must have an NPI.
Health Information Management (HIM) #
Health Information Management (HIM)
Health Information Management is the practice of acquiring, analyzing, and prote… #
HIM professionals are responsible for managing patient health information, ensuring its accuracy, accessibility, confidentiality, and security in both paper and electronic systems.
Compliance #
Compliance
Compliance refers to the adherence of healthcare organizations and providers to… #
Compliance ensures ethical practices, patient safety, data security, and quality care delivery.
Audit #
Audit
An audit is a systematic review and evaluation of healthcare provider documentat… #
Audits are conducted internally by healthcare organizations or externally by third-party entities to ensure accuracy, completeness, and adherence to regulatory requirements.
Health Insurance Claim Number (HICN) #
Health Insurance Claim Number (HICN)
The HICN is a unique identification number assigned to Medicare beneficiaries fo… #
The HICN is being replaced by the Medicare Beneficiary Identifier (MBI) to enhance security and protect patient privacy.
Healthcare Common Procedure Coding System (HCPCS) #
Healthcare Common Procedure Coding System (HCPCS)
HCPCS is a coding system used to describe healthcare procedures, supplies, produ… #
HCPCS Level II codes are alphanumeric and include durable medical equipment, prosthetics, orthotics, supplies, and other services.
Clearinghouse #
Clearinghouse
A clearinghouse is a third #
party entity that processes and submits electronic claims to multiple insurance payers on behalf of healthcare providers. Clearinghouses perform claim validation, formatting, transmission, and reconciliation to ensure accurate and timely claim submission.
Remittance Advice (RA) #
Remittance Advice (RA)
A remittance advice is a document sent by a health insurance payer to a healthca… #
The RA includes the claim number, payment amount, adjustment codes, denial reasons, and patient responsibility information. RAs assist providers in reconciling payments and managing accounts receivable.
Coordination of Benefits (COB) #
Coordination of Benefits (COB)
COB refers to the process of determining the primary and secondary insurance cov… #
COB rules establish the order in which insurance payers are responsible for processing and reimbursing claims to avoid duplicate payments.
ICD #
10-CM
ICD #
10-CM is the International Classification of Diseases, Tenth Revision, Clinical Modification, used by healthcare providers to report diagnoses for patient encounters in all healthcare settings. ICD-10-CM codes provide a standardized language for describing diseases, injuries, symptoms, and conditions.
CPT #
CPT
CPT is the Current Procedural Terminology, a medical code set published by the A… #
CPT codes describe medical, surgical, and diagnostic services and are essential for billing and reimbursement.
Modifiers #
Modifiers
Modifiers are two #
digit codes appended to CPT and HCPCS codes to provide additional information about the service or procedure performed. Modifiers indicate that a service was altered in some way but does not change the code's definition. Modifiers affect reimbursement and help describe complex scenarios.
Medical Necessity #
Medical Necessity
Medical necessity refers to the justification for services or procedures provide… #
Healthcare services must be reasonable, necessary, and appropriate for the patient's condition to be considered medically necessary for billing and reimbursement.
Compliance Plan #
Compliance Plan
A compliance plan outlines the policies, procedures, and protocols that healthca… #
Compliance plans include risk assessments, training programs, auditing processes, and corrective action plans to maintain compliance.
Retrospective Review #
Retrospective Review
A retrospective review is a process of examining medical records, documentation,… #
Retrospective reviews identify discrepancies, errors, and areas for improvement in healthcare operations.
Denial Management #
Denial Management
Denial management is the process of identifying, appealing, and resolving claim… #
Healthcare providers and billers must investigate denials, correct errors, provide additional information, and resubmit claims to receive reimbursement for services rendered.
Accounts Receivable (AR) #
Accounts Receivable (AR)
Accounts receivable is the amount of money owed to a healthcare provider for ser… #
AR management involves tracking outstanding balances, following up on unpaid claims, and resolving billing issues to improve cash flow and revenue.
Claim Scrubbing #
Claim Scrubbing
Claim scrubbing is the automated process of checking medical claims for errors,… #
Claim scrubbers identify missing information, incorrect codes, and potential billing issues to ensure clean claims and prevent rejections or denials.
Charge Description Master (CDM) #
Charge Description Master (CDM)
The Charge Description Master is a comprehensive list of all billable services,… #
The CDM contains standard charges, descriptions, and codes for each item to facilitate accurate billing, pricing transparency, and revenue capture.
Fee Schedule #
Fee Schedule
A fee schedule is a predetermined list of charges, prices, and reimbursement rat… #
Fee schedules may be set by insurance payers, government programs, or negotiated between providers and payers to establish payment amounts.
Compliance Training #
Compliance Training
Compliance training is educational programs and resources provided to healthcare… #
Compliance training helps prevent fraud, abuse, errors, and noncompliance in healthcare operations.
Claim Adjudication #
Claim Adjudication
Claim adjudication is the process of reviewing, evaluating, and deciding on the… #
Adjudication involves verifying coverage, applying contractual rates, coding accuracy, medical necessity, and compliance with policy terms.
ICD #
10-PCS
ICD #
10-PCS is the International Classification of Diseases, Tenth Revision, Procedure Coding System used by inpatient healthcare providers to report procedures performed during hospital stays. ICD-10-PCS codes are alphanumeric and provide detailed descriptions of surgical, diagnostic, and therapeutic interventions.
DRG Coding #
DRG Coding
Diagnosis #
Related Group (DRG) coding is a classification system used by Medicare and other payers to categorize inpatient hospital stays into groups based on similar clinical conditions and resource utilization. DRG coding determines reimbursement rates for hospital services and facilitates data analysis and quality reporting.
Claim Submission #
Claim Submission
Claim submission is the process of sending electronic or paper claims to health… #
Claim submissions include patient demographics, provider information, diagnosis codes, procedure codes, charges, and supporting documentation.
Accounts Payable (AP) #
Accounts Payable (AP)
Accounts payable is the amount of money owed by a healthcare provider to supplie… #
AP management involves tracking invoices, making payments, and maintaining financial records to ensure timely and accurate payment.
Charge Capture #
Charge Capture
Charge capture is the process of accurately recording and documenting healthcare… #
Charge capture ensures that all billable items are captured, coded, and submitted to insurance payers for reimbursement.
Appeal Process #
Appeal Process
The appeal process is a formal procedure used by healthcare providers to challen… #
Appeals involve submitting additional information, documentation, and arguments to support the reconsideration of denied claims.
Compliance Officer #
Compliance Officer
A compliance officer is a healthcare professional responsible for overseeing and… #
Compliance officers monitor operations, conduct audits, and investigate potential violations.
Audit Trail #
Audit Trail
An audit trail is a chronological record of electronic transactions, activities,… #
Audit trails provide a detailed history of data manipulation, usage, and security incidents to track user activities and ensure data integrity.
HIPAA Privacy Rule #
HIPAA Privacy Rule
The HIPAA Privacy Rule establishes national standards to protect individuals' me… #
The Privacy Rule limits the use and disclosure of protected health information (PHI) and gives patients control over their health data while ensuring its confidentiality and security.
ICD #
10-CM Guidelines
ICD #
10-CM guidelines provide instructions, conventions, and rules for assigning diagnosis codes to patient encounters based on the nature of the illness, injury, or condition. The guidelines cover code selection, sequencing, documentation requirements, and exceptions to ensure accurate and consistent coding.
Insured Party #
Insured Party
The insured party is an individual covered by a health insurance policy who is e… #
Insured parties may be the policyholder, a spouse, dependent children, or other designated individuals included in the insurance plan.
End #
to-End Testing
End #
to-end testing is a comprehensive evaluation of the entire healthcare revenue cycle process from patient registration to claims submission and payment posting. End-to-end testing ensures system integration, data flow accuracy, coding compliance, and revenue accuracy before full implementation.
ICD #
10-PCS Guidelines
ICD #
10-PCS guidelines provide instructions, definitions, and conventions for assigning procedure codes to inpatient hospital services based on the type of intervention, anatomical site, and approach used. The guidelines cover coding principles, definitions, and coding steps to ensure accurate and consistent reporting.
ICD #
10-CM Official Guidelines for Coding and Reporting
The ICD #
10-CM Official Guidelines for Coding and Reporting are published annually by the National Center for Health Statistics (NCHS) and the Centers for Medicare and Medicaid Services (CMS). The guidelines provide rules, conventions, and instructions for assigning diagnosis codes in various healthcare settings.
ICD #
10-PCS Official Guidelines for Coding and Reporting
The ICD #
10-PCS Official Guidelines for Coding and Reporting are published annually by the Centers for Medicare and Medicaid Services (CMS). The guidelines provide rules, conventions, and instructions for assigning procedure codes to inpatient hospital services in the United States.
ICD #
10-PCS Root Operation
ICD #
10-PCS root operation is the primary action performed during a surgical, diagnostic, or therapeutic procedure documented in the medical record. Root operations describe the objective of the procedure, such as excision, extraction, repair, creation, destruction, or revision, to assign the appropriate procedure code.
ICD #
10-PCS Body System
ICD #
10-PCS body system is the anatomical region or body part associated with a surgical, diagnostic, or therapeutic procedure documented in the medical record. Body systems provide a classification structure for organizing procedure codes based on the affected body part or system.
ICD #
10-PCS Approach
ICD #
10-PCS approach is the method or technique used to access, examine, or treat a body part during a surgical procedure documented in the medical record. Approaches include open, percutaneous, percutaneous endoscopic, via natural or artificial opening, and via natural or artificial orifice to assign the appropriate procedure code.
ICD #
10-PCS Device
ICD #
10-PCS device is the medical instrument, implant, or appliance used during a surgical procedure documented in the medical record. Devices provide additional information about the tools, equipment, or materials utilized in the procedure to assign the appropriate procedure code.
ICD #
10-PCS Qualifier
ICD #
10-PCS qualifier is the additional detail or specification used to further describe a surgical, diagnostic, or therapeutic procedure documented in the medical record. Qualifiers provide specific information about the procedure, such as location, timing, or method, to assign the appropriate procedure code.
ICD #
10-PCS Root Operation Groups
ICD #
10-PCS root operation groups classify surgical, diagnostic, or therapeutic procedures based on their primary objective or action documented in the medical record. Root operation groups include body systems, approaches, devices, and qualifiers to facilitate procedure code assignment and reporting.
ICD #
10-CM Chapter Specific Guidelines
ICD #
10-CM Chapter Specific Guidelines provide additional instructions and rules for assigning diagnosis codes to specific diseases, conditions, or body systems. Chapter-specific guidelines address unique coding scenarios, exceptions, and conventions to ensure accurate and consistent code selection.
ICD #
10-CM Section Specific Guidelines
ICD #
10-CM Section Specific Guidelines offer guidance and recommendations for assigning diagnosis codes to specific healthcare encounters, symptoms, or factors influencing health status. Section-specific guidelines address coding challenges, sequencing rules, and documentation requirements for accurate code assignment.
ICD #
10-CM Conventions
ICD #
10-CM conventions are rules and principles used to assign diagnosis codes based on the format, structure, and organization of the code set. Conventions include instructional notes, symbols, abbreviations, punctuation, and sequencing guidance to facilitate accurate and consistent code selection.
ICD #
10-CM Alphabetic Index
The ICD #
10-CM Alphabetic Index is a reference tool that lists diagnosis terms in alphabetical order with corresponding code numbers. The Alphabetic Index assists coders in locating and selecting the appropriate diagnosis code based on the patient's condition, symptom, or reason for the encounter.
ICD #
10-CM Tabular List
The ICD #
10-CM Tabular List is the main classification structure that organizes diagnosis codes by disease, injury, condition, or external cause. The Tabular List provides a systematic arrangement of codes with categories, subcategories, and levels of specificity to facilitate accurate code assignment.
ICD #
10-CM Official Guidelines for Coding and Reporting Updates
ICD #
10-CM Official Guidelines for Coding and Reporting Updates are revisions, additions, or deletions made to the guidelines annually to reflect changes in coding conventions, rules, or best practices. Updates provide clarification, interpretation, and guidance on complex coding scenarios and coding principles.
ICD #
10-CM Documentation Requirements
ICD #
10-CM documentation requirements specify the necessary information, details, and data elements needed in the medical record to support accurate code assignment. Documentation requirements include diagnoses, conditions, symptoms, treatments, procedures, and other pertinent clinical information for coding purposes.
ICD #
10-CM Code Structure
ICD #
10-CM code structure consists of alphanumeric characters that represent diagnoses, symptoms, conditions, or factors influencing health status. The code structure includes up to seven characters to identify the category, etiology, anatomical site, severity, extension, and other characteristics of the patient's condition.
ICD #
10-CM Code Categories
ICD #
10-CM code categories group related diagnoses, conditions, or symptoms together based on similarities in clinical characteristics, etiology, or anatomical location. Code categories provide a systematic classification system to organize and differentiate diseases, injuries, and health problems for coding purposes.
ICD #
10-CM Code Blocks