Medical Billing & Coding Glossary

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1 term

72-Hour Rule: Medicare requires outpatient tests done within 72 hours before an admission to be billed with the hospital stay, not separately.

A

15 terms

Accountable Care Organization (ACO): A group of providers jointly responsible for the cost and quality of a patient population's care.
Accounts Receivable (A/R): Money owed to the provider for care already delivered but not yet paid.
Acuity: How sick and complex a patient is. Risk adjustment exists to match payment to it.
Administrative Law Judge (ALJ) Hearing: The third level of Medicare appeal, heard by an independent judge. Requires a minimum claim value.
Aging Bucket: Grouping unpaid claims by how long they've been outstanding, usually in 30-day blocks. Older means harder to collect.
Aging Distribution: How outstanding A/R is spread across time buckets. Weighted toward older buckets signals trouble.
Ambiguous Documentation: Notes that are unclear or contradictory, so a coder can't confidently assign a code.
Ambulatory Surgery Center (ASC): A facility for same-day surgeries with no overnight stay. Generates clinical, consent, and billing records that must be stored.
Annual Recapture: Chronic conditions must be re-documented every calendar year. Last year's coding doesn't carry over.
Appeal: A formal challenge to a denied claim, backed by documentation. Each insurer sets its own deadline.
Audit Exposure: How much risk an organization faces if its billing comes under outside review.
Audit Finding: A problem identified in an audit, such as a code with no supporting documentation. Often means paying money back.
Audit Readiness: Having documentation organized and defensible in advance, so an audit means verifying rather than scrambling.
Audit-Ready Documentation: Records detailed enough that every submitted diagnosis can be traced to proof.
Auditing Solutions: Reviews of coding, billing, and documentation for accuracy and rule compliance. Depends on fast access to source documents.

B

5 terms

Back-End Revenue Cycle: Everything after care is delivered: charge capture, billing, payment posting, denials, and collections.
Bad Debt: Patient balances written off as uncollectible.
Benefits Verification: Checking what a patient's plan actually covers for a service, including their costs and any limits.
Billing Solutions: Services that prepare, submit, and follow up on claims to insurers and patients.
Business Associate Agreement (BAA): A HIPAA-required contract with any vendor handling patient data, setting rules for its use and protection.

C

34 terms

Centers for Medicare & Medicaid Services (CMS): The federal agency running Medicare and Medicaid and setting most coding and billing rules.
Certified Coder Credentials (CPC, CCS, CIC, COC): Coding certifications. CPC covers physician coding; CCS covers hospital coding; CIC is inpatient-only; COC is outpatient-only.
Charge Capture: Recording every billable service delivered. Anything missed here is revenue lost for good.
Charge Reconciliation: Checking recorded charges against schedules and notes to find services delivered but never billed.
Chart: The medical record for a patient visit, from which all coding is derived.
Chronic Condition: A long-term illness like diabetes or kidney disease, needing ongoing management.
Claim Adjustment Reason Code (CARC): A standard code on the insurer's response explaining why a claim was denied or reduced.
Claim Edit: An automatic rule that flags a claim before payment, usually for invalid code combinations or quantities.
Claim Scrubbing: Checking a claim against payer and coding rules before sending it, so errors are caught early.
Claims Prevention: Stopping errors before they reach the claim, instead of fixing them after a denial.
Claims Submission: Sending completed claims to insurers in their required format and tracking acceptance.
Clean Claim: A claim with complete, correct information that the insurer can pay without questions.
Clean Claim Rate: The share of claims paid on the first try with no corrections. A core accuracy measure.
Clinical Documentation: The doctor's written record of a visit. Every code must be backed by what's written there.
Clinical Documentation Improvement (CDI): Specialists reviewing records so documentation fully reflects the patient's condition and can be coded correctly.
Clinical Documentation Integrity (CDI): Making sure patient records fully and accurately reflect the care given.
Clinical Intent: What the doctor meant to convey. Gaps appear when notes don't say it in codable terms.
CMS-HCC Model: The formula CMS uses to set Medicare Advantage payments based on patients' documented conditions.
Co-Pay: A fixed amount a patient pays for a covered service at the time of care.
Coder-Level Feedback: Giving individual coders their own accuracy results, so mistakes get corrected at the source.
Coding Backlog: Charts waiting to be coded. Backlogs delay billing and payment.
Coding Quality Audit: Regular accuracy checks across coders, specialties, and claim types.
Coding Validation: Checking that submitted risk adjustment codes are accurate and supported before they go to CMS.
Comorbidity: An extra condition alongside the main diagnosis. Missing them lowers payment and quality scores.
Compliance Posture: How well-protected or exposed an organization currently is against regulatory risk.
Compliance Program: An organization's formal system for preventing and correcting rule violations, built on seven standard elements.
Compliance Review: Checking coding practices against CMS, OIG, and insurer rules to find gaps early.
Complication: A problem that arises during or after care. If undocumented, the claim understates the work involved.
Concurrent and Retrospective Review: Reviewing documentation during the patient's stay (concurrent) or after it ends (retrospective).
Concurrent Review: Reviewing documentation while the patient is still being treated, so gaps can be fixed immediately.
Contract Variance Analysis: Comparing payments line by line against the agreed contract rate to find shortfalls.
Contracted Rate: The amount an insurer agreed to pay for a service. Payments below it are underpayments.
Coordination of Benefits (COB): Rules deciding which insurer pays first when a patient has more than one plan.
Current Procedural Terminology (CPT): The code set describing procedures and services performed.

D

18 terms

Days in A/R: The average days between delivering care and getting paid.
Deductible: What a patient must pay out of pocket each year before insurance starts paying.
Denial: An insurer's refusal to pay a claim. Common causes: registration errors, duplicates, non-covered services, missing authorization, coding mistakes.
Denial Categorization: Sorting denials by type so each goes to the right fix, rather than being handled generically.
Denial Management: Finding denied claims, fixing the cause, appealing them, and preventing repeats.
Denial Rate: The share of claims an insurer denies.
Denial Trend Analysis: Studying denial patterns over time. A few root causes usually drive most of the losses.
Denial Trend Reporting: Tracking denial volume and reasons over time to separate systemic problems from one-offs.
Diagnosis Specificity: How detailed a diagnosis code is. Vague codes may carry no risk adjustment value at all.
Diagnosis-Related Group (DRG): A grouping of similar hospital stays that sets a fixed payment amount.
Digital Document Capture: Turning paper records and loose digital files into organized electronic documents.
Discharged Not Final Billed / Coded (DNFB / DNFC): Discharged patients whose claims aren't yet billed or coded. Money earned but stuck.
Disease Burden: The total weight of a patient's conditions across a full year.
Document Lifecycle Management: Managing a document from creation through storage to eventual deletion, under consistent rules.
Document Repository: A single secure location where all electronic documents are stored, replacing scattered filing.
Document Retrieval: Finding and opening a specific record on demand. Speed here is a key measure of system effectiveness.
Documentation Compliance: Confirming the medical record is complete and detailed enough to support what was billed.
Downcoding: Assigning a lower-paying code than the care warranted, usually because documentation lacked detail.

E

9 terms

Electronic Document Management (EDM): Capturing, organizing, storing, and retrieving documents electronically instead of on paper.
Electronic Health Record (EHR): The digital system holding patient clinical and demographic information.
Electronic Remittance Advice (ERA): The insurer's electronic explanation of what was paid, adjusted, or denied, and why.
Eligibility Denial: A denial because the patient's coverage wasn't active on the date of service.
Eligibility Verification: Confirming coverage is active for the date of service. Errors here cause denials later.
Enrollee: A member covered by a health plan. RADV audits sample their records.
Error Trending: Tracking mistakes over time to tell repeated, systemic problems apart from one-offs.
Evaluation and Management (E/M) Coding: Coding for office visits and consultations, based on complexity or time. One of the most audited areas.
External Audit: A review by an outsider - insurer, RAC, or government - with real financial consequences.

F

5 terms

Facility Coding: Coding the hospital's side of the claim - its rooms, staff, and resources.
First Pass: The initial claim submission. Claims paid on first pass needed no fixes or appeals.
First-Pass Acceptance: The share of claims accepted on first submission. Acceptance isn't payment - a claim can still be denied afterward.
First-Pass Rework: Fixing claims that failed on first submission. High volume signals upstream problems.
Front-End Revenue Cycle: Everything that happens before and during the visit: scheduling, registration, verification, authorization, and upfront payment.

G

1 term

Government Audit: A review by a federal or state agency. Usually broader and more serious than an insurer audit.

H

8 terms

HCC Capture: Identifying and coding every qualifying condition for a patient that year. Missed ones can't be recovered later.
HCC Capture Rate: The share of expected conditions actually coded. A low rate usually means conditions are being missed.
Health Information Management (HIM): The department responsible for keeping patient records accurate, private, and accessible.
Health System: A network of hospitals and clinics under shared ownership, needing document standards that work across all sites.
Healthcare Common Procedure Coding System (HCPCS): Codes for supplies, drugs, and equipment not covered by CPT.
Healthcare Compliance: Following the laws and rules governing healthcare, including protecting patient data and keeping records for set periods.
Hierarchical Condition Category (HCC): Groups of related diagnoses used to predict a patient's expected cost of care.
HIPAA: The federal law setting rules for protecting patient health information.

I

5 terms

ICD-10-CM: The code set for diagnoses - what's wrong with the patient.
ICD-10-PCS: The code set for inpatient hospital procedures only.
Inpatient Coding: Coding for admitted hospital patients, which produces a DRG.
Intelligent Document Organization: Filing and labeling documents by set rules, so everything lands in a predictable place.
Internal Audit: A self-review, letting the organization find and fix errors on its own terms.

K

1 term

Key Performance Indicator (KPI): A tracked metric showing revenue cycle health, like days in A/R or denial rate.

M

9 terms

Medical Coding: Turning clinical notes into standard codes that insurers use to process claims.
Medical Decision-Making (MDM): How complex a visit was, used to set the right E/M level.
Medical Necessity Denial: A denial claiming the service wasn't clinically justified. Overturning it takes clinical documentation.
Medically Unlikely Edit (MUE): A CMS limit on how many units of a service can be billed for one patient in one day.
Medicare Advantage: Medicare delivered through private plans that get paid based on patient health status.
Medicare Appeals Process: Five formal levels: redetermination, reconsideration, ALJ hearing, Appeals Council, federal court. Each has its own deadline.
Mid-Cycle: The middle stage of the revenue cycle, where notes become codes.
Modifier: A two-character add-on to a code that explains special circumstances. Missing modifiers cause denials.
Multispecialty Group: A practice with doctors across several specialties, producing many different document types.

N

2 terms

National Correct Coding Initiative (NCCI): CMS rules on which codes can and cannot be billed together.
Net Collection Rate: The share of collectible revenue actually collected, after contractual adjustments.

O

5 terms

Office of Inspector General (OIG): The federal watchdog for fraud and abuse in healthcare programs.
Out-of-Pocket Costs: The share of care a patient pays themselves, including co-pays and deductibles.
Outpatient / Ambulatory Coding: Coding for same-day visits and procedures, using CPT and HCPCS.
Outpatient Facility: A care setting where patients are treated and go home the same day.
Overcoding: Billing a higher level of service than documentation supports. Creates audit and compliance risk.

P

21 terms

Patient Access: The team and process handling scheduling, registration, and financial clearance - the entry point to care.
Patient Acuity: How sick and complex a patient is.
Patient Throughput: How quickly patients move through check-in and care. Pending authorizations slow it down.
Payer: The insurance company or government program that pays the provider.
Payer Audit: An insurance company reviewing whether claims were coded and documented properly.
Payer Escalation: Contacting insurer representatives directly to unstick claims that normal follow-up hasn't moved.
Payer Mix: The breakdown of revenue by insurer type - commercial, Medicare, Medicaid, self-pay.
Payment Posting: Recording payments, adjustments, and denials against the right claims so balances stay accurate.
Plan Limitations and Exclusions: Specific restrictions in a plan, such as visit caps or services it won't cover at all.
Point-of-Service (POS) Collections: Payments collected from the patient at or before the visit.
Post-Bill Review: Auditing claims after they've been submitted, to spot patterns and correct going forward.
Pre-Bill and Post-Bill Review: Auditing claims before they're sent (pre-bill) or after (post-bill).
Pre-Bill Review: Auditing claims before submission, while errors can still be fixed for free.
Pre-Encounter Services: All revenue cycle work completed before the patient arrives.
Pre-Registration: Collecting patient and insurance details before arrival. The cheapest point to catch errors.
Predictive Analytics: Using past patterns to flag claims likely to be denied or accounts likely to age, before it happens.
Prior Authorization: Advance approval an insurer requires for certain services. Without it, care is delayed and claims are denied.
Professional Coding: Coding the doctor's side of the claim - their own services.
Provider Education: Training that shows doctors how their documentation affects billing and quality data.
Provider Panel: The group of patients assigned to a specific doctor or practice.
Provider Query: A formal question asking a doctor to clarify unclear documentation. Must not suggest an answer.

Q

3 terms

Quality Assurance (QA): Ongoing verification that coding meets accuracy standards, feeding back into training.
Quality Metrics: Standard measures of clinical performance, calculated from coded data.
Quality Reporting: Sending outcome data to CMS and insurers, often tied to payment.

R

27 terms

RCM Platform: The technology connecting patient access, coding, billing, and collections into one system with live reporting.
Reconciliation: Confirming that billed, paid, and outstanding amounts match across systems.
Reconsideration: The second Medicare appeal level, reviewed by an independent contractor.
Record Retention: How long a document must be kept before it can be archived or destroyed.
Recoupment: Taking back money already paid. RADV findings are often extrapolated, multiplying the cost.
Recovery Audit Contractor (RAC): A CMS contractor that reviews paid claims and recovers overpayments, sometimes years back.
Redetermination: The first Medicare appeal level, reviewed by the same contractor that processed the claim. Usually due within 120 days.
Registration: Collecting and checking patient and insurance details at intake. Errors here break the claim later.
Reimbursement: Payment received for services delivered, based on the codes submitted.
Reimbursement Benchmarking: Comparing actual payments against expected and contracted rates.
Remittance: The insurer's itemized explanation of what was paid, adjusted, or denied, and why.
Remittance Advice Remark Code (RARC): An extra code adding detail beyond the CARC, often naming exactly what was missing.
Remittance Review: Checking each insurer payment against billed charges and contract rates to spot underpayments early.
Retrospective Review: Reviewing documentation after the visit ends, to correct records and spot patterns.
Revenue Cycle Analytics: Measuring financial and operational performance to find bottlenecks and improvement opportunities.
Revenue Cycle Management (RCM): The full financial process from patient registration through coding, billing, and collections.
Revenue Cycle Process: The full sequence from booking an appointment to final payment or write-off.
Revenue Integrity: Making sure the organization bills correctly and collects everything it has legitimately earned.
Revenue Integrity Analysis: An ongoing review of billing accuracy and reimbursement, looking at the whole cycle rather than one part.
Revenue Leakage: Earned money lost through gaps: missed charges, unworked denials, unrecovered underpayments, write-offs.
Risk Adjustment: Paying more for sicker patients, so organizations aren't penalized for treating complex populations.
Risk Adjustment Coding: Coding a patient's full year of chronic conditions, not just one visit.
Risk Adjustment Data Validation (RADV): A CMS audit checking that submitted diagnoses are backed by medical records.
Risk Score: A number showing a patient's expected cost of care. Missing diagnoses make it too low.
Role-Based Access Control: Limiting system access by job role, so staff see only the data their work requires.
Root Cause: The underlying process failure behind a recurring problem. A registration error can surface weeks later as a coding denial.
Root-Cause Analysis: Tracing a denial back to where it started - registration, authorization, coding, or billing.

S

2 terms

Self-Pay: The portion of a bill the patient owes themselves.
Specificity: How much clinical detail a code carries. Vague codes reimburse less and get denied more.

T

2 terms

Time-to-Submission: How long between delivering care and sending the claim.
Timely Filing: The deadline for getting a claim to the insurer. Miss it and the claim is dead regardless of merit.

U

6 terms

Unbundling: Billing parts of a procedure separately when one combined code applies. A compliance risk.
Undercoding: Billing below what documentation supports. This revenue is usually lost permanently.
Underpayment: A payment below the contracted rate. Easy to miss because the claim technically paid.
Unsupported Code: A code with no documentation to justify it. The most common audit finding.
Unsupported Diagnosis: A submitted diagnosis with no documentation behind it. The main RADV finding.
Unworked Denial: A denied claim nobody has touched. It expires against the deadline and becomes a write-off by default.

V

2 terms

Vague Diagnosis: A diagnosis written in general terms, forcing use of imprecise codes that pay less.
Value-Based Care: Payment tied to quality and cost outcomes rather than how many services are delivered.

W

3 terms

Wind-Down Services: Working through leftover old A/R after a system change, practice sale, or vendor switch.
Workflow Integration: Building document management into existing daily processes rather than running it as a separate system.
Write-Off: Removing an amount as uncollectible. A denial write-off is care already delivered that won't be paid for.

The RCM glossary.

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72-Hour Rule

A

Accountable Care Organization (ACO)

Accounts Receivable (A/R)

Acuity

Administrative Law Judge (ALJ) Hearing

Aging Bucket

Aging Distribution

Ambiguous Documentation

Ambulatory Surgery Center (ASC)

Annual Recapture

Appeal

Audit Exposure

Audit Finding

Audit Readiness

Audit-Ready Documentation

Auditing Solutions

B

Back-End Revenue Cycle

Bad Debt

Benefits Verification

Billing Solutions

Business Associate Agreement (BAA)

C

Centers for Medicare & Medicaid Services (CMS)

Certified Coder Credentials (CPC, CCS, CIC, COC)

Charge Capture

Charge Reconciliation

Chart

Chronic Condition

Claim Adjustment Reason Code (CARC)

Claim Edit

Claim Scrubbing

Claims Prevention

Claims Submission

Clean Claim

Clean Claim Rate

Clinical Documentation

Clinical Documentation Improvement (CDI)

Clinical Documentation Integrity (CDI)

Clinical Intent

CMS-HCC Model

Co-Pay

Coder-Level Feedback

Coding Backlog

Coding Quality Audit

Coding Validation

Comorbidity

Compliance Posture

Compliance Program

Compliance Review

Complication

Concurrent and Retrospective Review

Concurrent Review

Contract Variance Analysis

Contracted Rate

Coordination of Benefits (COB)

Current Procedural Terminology (CPT)

D

Days in A/R

Deductible

Denial

Denial Categorization

Denial Management

Denial Rate

Denial Trend Analysis

Denial Trend Reporting

Diagnosis Specificity

Diagnosis-Related Group (DRG)

Digital Document Capture

Discharged Not Final Billed / Coded (DNFB / DNFC)

Disease Burden

Document Lifecycle Management

Document Repository

Document Retrieval

Documentation Compliance

Downcoding

E