The Significance of Medical Billing and Coding Terminology
On a daily basis medical billers and coders review medical reports and documents to maintain accurate records, assign codes and identify any data needed to process claims and submit them. Medical terminology in general involves the terms used to describe conditions, diagnosis, symptoms, medications and medical services given. Medical insurance terminology includes language and terms that pertain to policies, coverage’s, deductibles and reimbursement procedures (just to name a few).
Below is part 2 of Medical Billing and Coding Terminology:
Fraud is when a doctor or other provider has received payment or when a patient obtains their service through means that are either dishonest or misleading means.
The guarantor is not a term used to describe the patient but the one who is insured and is responsible for the actual patient.
Health Maintenance Organization (HMO)
HMO is a health care plan that has a variety of restrictions on what treatments can be received by the patient.
Health Care Financing Administration Common Procedure Coding System (HCPCS)
Health Care Financing Administration Common Procedure Coding System is a 3 level coding system. When a provider delivers health related services the HCPCS is a standard medical coding system that describes them. Below is a brief overview of the 3 levels within the Health Care Financing Administration Common Procedure Coding System.
Level One- CPT
CPT (American Medical Associations Current Procedural Terminology codes)
Level Two- Alphanumeric Codes
This is the level that uses alphanumeric codes, that do not describe medical services and procedures but they mainly describe supplies used in the medical offices, prostheses, etc. These services and the items are not covered under level one procedure.
Level Three- Local Codes
Local codes are the codes used by medical organizations such as Medicaid and Medicare organizations and contractors as well as specific areas or programs covered through private insurers
This term is used to describe patients that stay in the hospital for long than 24 hours or one day.
Max. Out of Pocket Expenses
The insured patient may incur some out of pocket expenses that they will be responsible for. When the maximum amount of expenses has been reached the insurance company will then typically pay for the remaining balance.
Medical Assistant and Administrative Medical Assistant
These are medical professionals that perform clinical and administrative duties that support the smooth running of the healthcare facility in which they are currently employed.
Medical necessity describes a procedure or a service performed for the treatment of the patient’s injury or illness that cannot be classified as cosmetic, experimental or investigational purposes.
This is the method used to convert voice recorded dictations to hand written information. The dictation generally comes from a health care professional. These transcribed records can be either digital or on paper.
Medicare is insurance offered to individuals 65 years of age or older. Individuals under the age of 65 may also be eligible dependent of certain restrictions. Medicare comes in two parts: Medicare Part A and Part B. Part A mainly handle coverage for patients in the hospital (inpatient care) and Part B is for medical office visits (outpatient care).
Medicare Donut Hole
The donut hole in Medicare is a term used to describe a difference or gap in the initial insurance limits. An example of this can be found in the Medicare Part D limited coverage for prescription medication.
Even though Medicaid is often described as insurance coverage for low-income families and individuals, there are a number of other eligibility requirements. Medicaid is funded by state and federal governments and then administered by the state(s).
Healthcare providers that are contracted through an insurance company that provide care to patients at a previously discussed cost are known as a network provider.
National Provider Identifier (NPI) Number
National Provider Identifier number is an ID number comprised of 10 numbers assigned by the NPPES (National Plan and Provider Enumeration System). The number is also required to be used to identify patients in compliance with the Health Insurance Portability and Privacy Act (HIPPA).