Glossary of Common Terminology
in e-MDs Software
A
Abx: Abbreviation for antibiotics
Allopathic Medicine: The thinking that chemistry is the root of most problems and that the use of drugs to restore normal chemistry levels will help cure illnesses. Most M.D.s are more allopathic than osteopathic (taking note of some specialties), but the two disciplines are definitely not mutually exclusive.
Alternative Therapy: Therapies that are not accepted by "traditional" medicine. This would include acupuncture, herbal remedies, meditation, etc. Most physicians recognize at least some alternative therapies as being valid.
Applications: Refers to each separate component of e-MDs Solution Series (Chart, Bill, Schedule, DocMan, Tracking Board).
Assessment Section: Section in
B
Balance Forward: An accounting reference for the amount outstanding on an account transferred from another billing system. Used mainly in reference to during data transfers from existing (legacy) billing systems to
BMI (Body Mass Index): Calculation based on height and weight. This is similar to percent body fat and demonstrates how much effect a person's weight is on their health.
C
Capitated Insurance Plans (Capitation): Some insurance plans do not pay providers based on the specific services rendered (with some exceptions). These plans pay the providers a set amount per month per patient (called the per member per month). This is called capitation. These patients will only owe a nominal copay at the time of service. Capitation creates risk for a practice because it is then up to the provider to make sure they manage their patients problems within the amount they are receiving. They can be penalized for referring patients out to more expensive specialists, so the emphasis is very much on preventive care. Capitation is usually associated with HMO plans, and the physician writes off the charges after the copay, although "carve-outs" can be negotiated for procedures that a provider can perform, but are more expensive and may be less commonly seen.
Chief Complaint (CC:): In the patient's own words, why they are being seen for the visit today.
Chronic Medical Problems: A list of a patient's ongoing long term medical problems (i.e. diabetes).
CLIA (Clinical Laboratory Improvement Act): "CLIA" is the common term for the laws governing laboratory tests and the facilities in which they are conducted. The laws are very strict and CLIA certification is usually required for a lab to be reimbursed. The CLIA number assigned to a lab will need to be
included for billing of certain lab tests and is entered in the setup for
Copay: A set amount that an insurance sets that is the patient's portion of the office visit (due at the time of service). The copay can change depending on the type of visit. E.g. a standard office visit will require payment of the usual amount, a blood draw or nurse visit may not require a copay, and a surgical procedure may have a higher copay.
Conversion Factor: A dollar value to 4 decimal places used as a multiplier by HCFA when calculating reimbursement rates. The CF is updated annually to allow for inflation. Many payors will base their reimbursement rates on a CF slightly different from Medicare's but maintain the other multipliers.
CPT® (Current Procedural Terminology): Procedure codes (i.e. EKG).
Current Medications: All medications a patient takes regularly.
D
Deductible: The amount a patient must meet in a covered (insured) year before insurance starts to pay claims. Most group plans only have a deductible or copay for normal office visits. Deductibles are almost always due for hospital and other visits.
Dx: Abbreviation for diagnosis
Differential Diagnosis (ddx): List of possible diagnoses. For example, if a patient was given a general diagnosis of chest pain, but the provider had ordered additional tests to rule out other more specific diagnoses, they would list the differential diagnosis as a way of notating that they are considering several possibilities. Differentials for chest pain may include pneumonia, pleurisy, GERD or cardiac problems. Documenting differential diagnoses helps substantiate higher coding for medical decision-making.
DME (Durable Medical Equipment): Medical equipment that can withstand repeated use and is used primarily to serve a medical purpose. For example, wheelchairs, crutches or nebulizers. These are specific billed using specific HCPCS codes called E codes.
D.O. (Doctor of Osteopathy): Similar training to M.D., but focus on the body structure (bones, nerves and muscles) in the belief that problems with these are often the causes of illness and manipulation can be a cure. They attend specific osteopathic schools that cover much the same information as traditional medical schools, in addition to manipulative therapy, and are qualified to treat the same illnesses. Most D.O.s specialize in primary care disciplines and practice exactly like M.D.s while others concentrate on herbal and alternative remedies.
E
E Codes: Specific HCPCS codes used for DME.
e-MDs: Electronic Medical Data Systems. Pronounced "ee-em-dees".
E&M (Evaluation and Management) Codes: Visit codes (i.e. level 3 office visit, newborn initial evaluation, etc.). E&M codes are a subset of CPT® codes.
EPSDT (Early and Periodic Screening, Diagnosis and Testing): Medicaid term referring to well visits, immunizations and other standard childhood wellness standards.
F
Family History: A list of the patient's family medical history including the chronic medical problems of parents, siblings, grandparents, etc.
Fee Schedules: A list of all CPT® and HCPCS codes and their corresponding charges. Can be variable based on insurance. Fee schedules are usually associated with a particular payor and reflect the reimbursement rates negotiated under the contract.
G
GPCI (Geographic Practice Cost Index): A regional weight assigned to a Medicare locality that takes into account the cost of delivering services in that area. It stands to reason that GPCI weights are higher for urban and east coast areas than for rural areas (higher office rents, etc.). Each RVU component (Work, PE, MP) is given a weight, with 1.00 being the mean (therefore .9 would reflect a lower cost base, and 1.1 would be higher). GPCIs are a multiplier in the equation used to calculate Medicare allowable reimbursement rate.
Guarantor: The final responsible party on a bill after insurance (if applicable). It is essentially the person responsible for paying the balance due.
H
HCFA (Health Care Financing Administration): Referred to as "hicfa", it is the government body that controls and directs legislation for government sponsored health coverage (Medicare, Medicaid). They are responsible for much of the direction in reimbursement including forms such as the HCFA-1500, as well as reimbursement rates upon which other payors will base theirs.
HCFA (1500) Form: The standard insurance claim form used by most insurances to submit paper claims. However, some have their own forms such as Medicaid in Illinois and Massachusetts.
HCFA-1450: More commonly known as the UB-92 (Universal Bill). This is also an insurance claim form, but is used for hospital visits and rural health claims. It is characterized by including more procedure level reporting lines, as well as place for information such as hospital days.
HCPCS (HCFA Common Procedural Coding System): Codes for supplies, materials and injections (i.e. bandages, rubber gloves, penicillin). These are reported in the same parts of insurance forms as CPT® codes (HCPCS as Level II CPT® codes). There are specialized HCPCS codes such as E, J and L codes used for specific procedures or services.
Health Summary: Summary of a patient's medical history including chronic medical problems, current medications, drug allergies and past medical, family and social history.
HPI (History of Present Illness): The patient's account of related symptoms for today's visit. The HPI is generated with the use of templates in
HTN: Abbreviation for hypertension (high blood pressure)
Hx: Abbreviation for history or history of
I
ICD-9 (International Classification of Diseases) Codes: Diagnosis codes. For example, 401.1 represents benign hypertension. These codes have been color coded in
IDDM: Abbreviation for Insulin Dependent Diabetes Mellitus
J
J Codes: Specific HCPCS codes used for drugs administered other than oral method. For example, J0530 is and injection of penicillin.
L
LMP: Abbreviation for Last Menstrual Period
M
M.A. (Medical Assistant): If certified, is referred to as CMA. Some clinics have similar positions known as Clinical Assistants. Used in most offices as a part of the nursing staff with responsibilities including working up patients, triaging and returning patient calls and assisting the provider in general.
MD: Medical Doctor
Medicare Locality: A region within the US defined by HCFA as having a particular cost structure. This affects reimbursement of fees because each is assigned a different GPCI weight. Localities are often major metropolitan areas and other, and are classified by state.
Mid-level Practitioner: Refers to the group of providers considered to be one-level below M.D.s and D.O.s. Physician assistants (P.A.s) and Nurse Practitioners (N.P.s) are examples.
Modifier: A two-character code added to a CPT® or HCPCS code that is used to help in the reimbursement process. For example, a modifier can be used to explain that a procedure not normally covered when billed on the same day as another is actually a separate and significant process, or that it is a rural health procedure that gets higher reimbursement. Up to 4 modifiers can be attached to each CPT®, although in most cases only 1 or 2 are used.
N
NIDDM: Abbreviation for Non Insulin Dependent Diabetes Mellitus
NKDA (NDA): Abbreviation for No Known Drug Allergies
Notice Processor: Feature in
N.P. (Nurse Practitioner): A mid-level provider. They are required to have a Bachelor's degree and then attend a rigorous 3-year training program mainly instructed by advanced nurses. Must be supervised by a physician. NPs can specialize much like physicians can, but are somewhat limited (i.e. pediatrics, family medicine, etc.).
NPI (National Provider Identifier): Fairly new 8 digit alphanumeric identifier given to all medical facilities. Most M.D.s and DOS do not have NPIs at this time (they still use UPIN numbers). However, mid-level practitioners usually do.
NSF (National Standard Format): Standard format for electronic filing.
O
Objective: Section in
Office Visit Levels: Otherwise know as E&M codes, the code varies from Level I to V depending on complexity with V being the most complex.
P
P.A. (Physician Assistant): A mid-level provider. They are required to have a Bachelor's degree and then attend a rigorous 3-year training program mainly instructed by physicians. They are not physicians, but in most states have similar rights and privileges. However, they must be supervised by a physician.
Past Medical History: A list of a patient's past health problems, surgeries and specialists.
Patient Demographics: All the patient's pertinent information such as first and last name, SSN, DOB, insurance, etc.
Payor: Any party responsible for payment of services rendered, usually an insurance company.
PCN: Abbreviation for penicillin
PCP (Primary Care Physician): Term used by insurance companies to describe the provider that will manage a patient's health. In most cases this is a family practitioner, internist, general practitioner or pediatrician. The PCP is responsible for obtaining referrals to specialists as needed.
PEFR: Abbreviation for Peak Expiratory Flow Rate. Usually known as Peak Flow
Plan: Section in a progress note used to document the treatment the provider will prescribe including medications, recommendations and any testing. Consists of patient education, prescription writer, CPT®, HCPCS and E&M coding; and the Plan template in
Posting: The process by which charges are generated and payments are noted.
Private Pay: Refers to patients without insurance.
Progress Note: The documentation of a patient visit or encounter including all or part of the SOAP format.
Provider: General title for MD, D.O., NP, or P.A.. A provider of service. Most M.D.s and DOS don't like to be referred to as providers. Other providers are mental health professionals, chiropractic, etc.
Provider Login: Consists of a login and password for providers only. This allows providers to sign off in
R
RBRVS (Resource Based Relative Value Scale): This is a scale of "weights" assigned to particular CPT® codes that takes account of the relative amount of effort taken to perform a procedure based on the cost of supplies, the risk or difficulty and the time spent. For instance, brain surgery will have more RVUs than a wart removal. The RBRVS is controlled by HCFA.
Referral: Some insurance companies require that on specific plans a referral must be obtained for certain procedures or visits to specialists. The referral is acquired by the primary care physician (PCP) by contacting the insurance company by phone or mail. This
is a request for the service. The referral consists of an authorization code, a number of visits allowed (if applicable) and an expiration date. This information can be stored and referenced in
Referring Provider: The provider that referred the patient to a specialist or for a specific procedure.
Rendering/Performing Provider: The provider actually treating the patient.
Risk Pool: Sometimes a group of practices will come together for negotiating and contractual reasons (e.g. an IPA). A certain percentage of each amount reimbursed is withheld from the practice and put into a risk pool. This is used to cover unexpected expenses, but if it is not used, then it will be distributed back to the practices. The distribution structure is often based on productivity, profitability and other factors that make it a reward for more efficient operations.
ROS (Review of Systems): A series of questions related to the system(s) that the patient is having complaints about (i.e. respiratory for cold symptoms).
Rural Health Clinic (RHC): A clinic that is contracted by HCFA to provide services to underserved populations. RHCs are reimbursed at a slightly higher level than the normal Medicare allowable. As is obvious, these are usually clinics in outlying rural areas where the government needs to encourage practitioners to have clinics, although some "rural" clinics are located in poorer parts of cities. RHCs are given a special status and when they bill particular procedures with QB (rural) or QU (urban) modifiers, they will get the higher rate. RHCs usually have to submit claims on a UB-92.
RVU (Relative Value Unit): The weight within the RBRVS assigned to a particular CPT®. The Total RVU for a CPT® is made up of the Work RVU (the amount of time and effort it takes), the Practice Expense RVU (the overhead cost of that time), and the Malpractice RVU (the likelihood of complications),
S
SOAP Note: Progress note format utilized by
Social History: A description of a patient's social habits and history including marital status, alcohol and drug use and exercise habits.
Subjective: Section in a progress note where a patient's account of their current problem is documented. Consists of chief complaint, HPI and ROS.
Superbill: Also known as an encounter form, route slip or fee slip. This is a paper charge capture tool used to document coding for a specific patient visit. It is a printed form with patient information at the top, and a subset of the provider's/practice's most commonly used ICD and/or CPT® codes. The form travels with the patient through the clinic. Providers check off items when they see the patient, and the form then travels to the checkout desk or billing office where the codes are entered into the billing system.
Supervising Provider: The physician that is supervising patient care for a mid-level. In some practices, the supervising provider signs off on every chart after a mid-level sees a patient, while in others he is simply available to assist if necessary. Physicians in some rural areas do not have to be on-site and can supervise remotely.
Sx: Abbreviation for symptoms
System Administrator: The user group with the highest security level.
T
Till Reconciliation: A report used to balance what has been posted in the practice management software against the actual monies and other forms of payment in the till/cash register.
Time Grid: A provider's specific schedule for seeing patients (i.e. number of appointments in a day, duration of each appointment slot, or request for specific appointment types at certain times).
tops: Total Office Paperless Solution.
Trial Balance: A detailed report of invoices for a patient.
U
UPIN: A standard 6 digit alphanumeric identifier assigned to providers. Can be used for single provider or a group/facility.
URI: Abbreviation for Upper Respiratory Infection (Cold)
User Login: Consists of a login and password for non-provider staff.
UTI: Abbreviation for Urinary Tract Infection (Bladder infection)
W
Wave Scheduling: Scheduling patients in "waves", i.e. scheduling several patients at the top of the hour (in the same time slot), and several at the bottom of the hour. Patients rarely arrive on time, and offices often run behind. Having blocks of busy and catch-up time can even this out. Modified wave scheduling is a more recent trend where the schedule is based around the actual time spent with patients. Most patient visits do not require the provider to be in the room with the patient for 100% of the time. Wave scheduling allows more efficient scheduling by allowing for this. For example, a patient visiting an ophthalmologist may spend 15 minutes of a half hour visit waiting for their eyes to dilate. The doctor is only present for the last 15 minutes. Thus, another patient could be scheduled for the first 15 minutes. Thus, modified wave scheduling refers to creating a schedule that accounts only for the providers' time spent with patients. This is only efficient if there is enough nursing staff to prepare several patients simultaneously.