Plain-English definitions for 50 of the most common terms in medical billing, coding, compliance, and revenue cycle management. Bookmark this page.
Advance Beneficiary Notice, Medicare notice given before a service CMS may deny as not covered.
EDI standard family defining HIPAA transaction formats like 837, 835, 270.
Ambulatory Payment Classification, Medicare OPPS outpatient payment grouping.
Business Associate Agreement, HIPAA contract between covered entities and PHI-handling vendors.
Council for Affordable Quality Healthcare, centralized credentialing data via CAQH ProView.
Claim Adjustment Reason Code, standardized code explaining why a claim was adjusted or denied.
Intermediary that translates, scrubs, and routes EDI transactions between providers and payers.
CMS designation for the UB-04 institutional claim form used by facilities.
Standard paper claim form used for professional (physician) services.
Coordination of Benefits, determines payer order when a patient has multiple coverages.
Current Procedural Terminology, 5-digit AMA code set for reporting medical services.
Diagnosis-Related Group, inpatient prospective payment classification.
Electronic Data Interchange, structured electronic exchange of claims and other transactions.
Electronic Funds Transfer, direct-deposit payment mechanism used by payers to settle claims.
Explanation of Benefits, document sent to patient explaining claim adjudication.
Explanation of Payment, provider-facing remittance summary, often paired with ERA.
Electronic Remittance Advice, HIPAA 835 transaction with claim payment detail.
Geographic Practice Cost Index, regional adjustment applied to RVUs.
Healthcare Common Procedure Coding System, CMS code set for supplies, DME, drugs.
Federal privacy and security standards for health data.
HIPPS codes, classification used in home health and SNF prospective payment.
Certifiable security framework commonly required in healthcare vendor contracts.
International Classification of Diseases, 10th Revision, diagnosis (CM) and inpatient procedure (PCS) code sets.
Inpatient Prospective Payment System, Medicare DRG-based hospital inpatient payments.
Local Coverage Determination, MAC-issued policy on Medicare coverage for a specific service.
Medicare Administrative Contractor, private contractor that processes Medicare Part A/B claims.
Minimum Data Set, standardized SNF resident assessment driving PDPM payment.
Medicare Physician Fee Schedule, annual CMS Part B physician services schedule.
Medicare Severity DRG, reflects patient severity and comorbidities.
Medicare Secondary Payer, rules determining when Medicare pays secondary to other coverage.
National Correct Coding Initiative, CMS edits preventing improper code-pair billing.
National Coverage Determination, CMS-issued national Medicare coverage policy.
Notice of Admission, home health notification required for PDGM 30-day billing periods.
National Provider Identifier, 10-digit unique identifier for US healthcare providers.
Outcome and Assessment Information Set, CMS-required home health assessment.
Outpatient Prospective Payment System, Medicare payment system for hospital outpatient.
Patient-Driven Groupings Model, Medicare home health payment model (2020+).
Patient-Driven Payment Model, Medicare SNF payment model replacing RUG-IV.
Protected Health Information, individually identifiable health information under HIPAA.
Place of Service, 2-digit claim field identifying where service was delivered.
Remittance Advice, general term for payer payment detail document (ERA or paper).
Remittance Advice Remark Code, supplementary detail on a CARC adjustment.
Relative Value Unit, Medicare physician fee schedule component.
Tax Identification Number, IRS-issued identifier used on claims for payment routing.
Third Party Liability, non-Medicaid payer responsible for payment ahead of Medicaid.
Uniform Bill 2004, institutional claim form used by hospitals, SNFs, and home health.
HIPAA eligibility inquiry (270) and response (271) transactions.
HIPAA claim status inquiry (276) and response (277) transactions.
HIPAA prior authorization request and response transaction.
HIPAA EDI transaction carrying ERA claim payment and adjudication detail.
HIPAA EDI transaction for electronic claim submission (837P professional, 837I institutional).
Detail pages for each term are being published on a rolling basis. In the meantime, each card shows the core definition above. TODO: individual term pages.