Medical Billing and Coding Acronyms and Terms

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Medical billing and coding terms and medical terminology can be confusing!

What's a CPT Code? And other confusing terms

When you're just starting out learning about medical billing and coding, maybe before you've even taken your first certification course, you're bound to have tons of questions, like:

  • What's a CPT code?
  • What's HIPAA stand for?
  • What are the AAPC and AHIMA associations I keep hearing about?

Consider this page your 1-stop shop for finding out what these acronyms and terms mean.

How to use this page

This page is just a long list of medical coding and medical billing terms and terminology, so just search for the term you're looking for!

(We like to use Ctrl+F on our browsers to pull up the search.)

Medical Billing and Coding Glossary

What is a CPT code?

A CPT code, or Current Procedural Terminology code, is a five-digit numerical code used by healthcare providers to classify medical, surgical, and diagnostic services.

It is used to identify specific services and procedures performed by healthcare providers, such as a doctor’s office visit, a lab test, or a surgery.

What is the AAPC?

The AAPC (American Academy of Professional Coders) is a professional organization that specializes in medical coding and billing. They offer certification and training programs, as well as resources and networking opportunities for medical coders and billers. They are the providers of the popular CPC and CPCS exams.

What is AHIMA?

AHIMA (American Health Information Management Association) is a professional association for health information management (HIM) professionals. AHIMA provides professional education, certification, advocacy and standards development for health information management and health care delivery.

Members of AHIMA include health information professionals, coders, clinical documentation improvement specialists, and medical records administrators. AHIMA is a leading provider of medical coding and billing training, certification and professional development for those in the medical coding and billing field.

Notably, AHIMA provides the popular CCA and CCS medical coding certifications.

What is ICD-10 and ICD-11?

ICD-10 (International Classification of Diseases, 10th Revision) is a medical coding system developed and maintained by the World Health Organization (WHO). It is used in many countries to classify and code diagnoses, procedures, and other health information. ICD-10 is used in medical billing and coding to assign codes to medical diagnoses and procedures for billing and reimbursement purposes.

ICD-11 (International Classification of Diseases, 11th Revision) is the latest version of the World Health Organization’s ICD, the international standard for diagnostic coding. It is used to classify diseases and other health problems recorded on many types of health and vital records, including death certificates, in order to allow for consistent comparison of health statistics worldwide.

ICD-10 and ICD-11 are important because they allow medical codes made in one country to match up with medical codes written in another country. If you write an ICD-11 code for cirrhosis of the liver in the USA, and another coder writes one for cirrhosis in India, you'll both use the same code (DB94.3).

This makes it standardized, and extra easy for doctor's offices, hospitals, and insurance companies to get on the same page about the procedure that was conducted.

ICD-11 Code: DB94.3 (Alcoholic cirrhosis of liver without hepatitis).
ICD-10 Code: K70.3 (Alcoholic cirrhosis of liver).

In ICD-11, the code definitions changed slightly (for example, to be specific that the cirrhosis is without hepatitis), and so the code alphanumeric letters and numbers also changed.

What is HCPCS Level II?

HCPCS Level II (Healthcare Common Procedure Coding System, Level II) is a standardized coding system used for billing Medicare and other health insurance providers. It includes numerical codes for medical procedures and supplies, such as drugs, medical equipment, and services.

You often hear about HCPCS in the context of Medicare, because it covers many topics that aren't included in the CPT codes that Medicare providers want to know about. For example, HCPCS Level II includes codes for ambulance services and durable medical equipment, prosthetics, orthotics, and supplies when used outside a doctor's office.

HCPCS codes contain additional detail that CPT codes do not.

HCPCS Level II codes are also called alphanumeric codes, because they start with a single letter followed by 4 digits, while CPT codes are made up of 5 numeric digits, without letters.

CPT Code: 99201 (office visit for an established patient).
HCPCS Level II Code: G0377 (screening Pap test with moderate complexity, guided by abnormal laboratory results).

What is a DRG?

A DRG (Diagnosis-Related Group) is a system used by Medicare and other health insurance programs to classify hospital inpatient stays into categories that are clinically meaningful and financially relevant.

DRGs are used to identify the type of care the patient received, the cost of treatment, and the length of the hospital stay.

What is an EOB?

EOB stands for Explanation of Benefits. It is a document that provides details about medical services provided and the associated costs.

he EOB outlines the cost of services, including any insurance payments and out-of-pocket costs. It also provides a breakdown of what was billed and what was paid by insurance.

What is an ENC?

ENC stands for “encounter” and is a term used to describe a visit to a healthcare provider.

It is used to refer to the services provided to a patient during that visit, as well as the associated medical billing codes that are used to describe the services rendered.

What is a UB Form or UB-04 Form?

UB forms, or UB-04 forms, are a type of claim form used by healthcare providers in the United States to bill for medical services.

The UB-04 is the standard claim form for submitting institutional health care claims to both Medicare and Medicaid. It is also used by private insurers and other third-party payers.

What is a COB?

COB stands for Coordination of Benefits. It is a process used by health insurance companies to determine which insurance company is responsible for paying a claim when an individual is covered by two or more health insurance policies.

What is a PCP?

PCP stands for primary care provider. It is a healthcare provider who coordinates a patient's care and is typically the first point of contact for medical care.

PCPs are often doctors who deal with common ailments, like flu, sprains, or muscle aches, and will refer patients to a specialist to deal with more complex or complicated medical issues.

What is an HMO?

An HMO is a Health Maintenance Organization. Patients with HMO insurance receive health care from a network of providers that contract with the HMO.

In an HMO, members usually have to choose a primary care physician and usally have to obtain referrals from the primary physician in order to receive care from specialists.

Patients with HMOs usually have to make sure their providers are in the HMO network, or else their procedure will likely not be covered by the HMO insurance.

What is a PPO?

A Preferred Provider Organization (PPO) is a type of health insurance plan that contracts with medical providers, such as doctors, hospitals, and other health care providers, to create a network of participating providers.

PPOs give their members the freedom to receive care from any provider within the network, but members may receive additional cost savings for using providers that are in-network.

What is E&M?

E&M stands for Evaluation and Management.

It is a type of medical billing code used to describe a healthcare provider's services, such as an office visit, hospital stay, or medical consultation.

E&M codes are used to bill for procedures done in doctor's offices that are not necessarily surgeries or prescriptions, such as a check-in with your doctor, your annual physical, or an overnight stay in a hospital bed after routine surgery.

What is an HPSA?

HPSA stands for Health Professional Shortage Area. It is an area designated by the US Department of Health and Human Services (HHS) as having a shortage of primary care, dental, and mental health providers.

These areas are eligible for special funding and grants to help increase the number of healthcare providers in the area.

What is an SNF?

SNF stands for Skilled Nursing Facility.

It is a type of rehabilitation center or nursing home that provides specialized care and services, typically for long-term care or recovery from an illness or injury.

What is a PAS?

PAS stands for Patient Account Summary.

It is a detailed explanation of a patient's hospital bill and can include information such as the charges for each item, the amount due, and any adjustments made.

What is NOS?

NOS stands for Not Otherwise Specified. It is a code used in medical billing and coding to indicate that a diagnosis or procedure does not fit into a specific category or is not captured by the current code set.

What is NPI?

NPI stands for National Provider Identifier.

It is an identification number that healthcare providers in the United States are required to have in order to submit claims to Medicare and other insurance companies. It is also used to identify healthcare providers in the US for HIPAA transactions.

What is PHI?

PHI stands for “Protected Health Information” and is any information that relates to the past, present, or future physical or mental health or condition of an individual.

This includes medical records, laboratory results, diagnosis, and treatment information.

PHI is kept confidential and protected by federal laws such as the Health Insurance Portability and Accountability Act (HIPAA).

What is POS?

POS stands for Place of Service. It is a two-digit code that is used to identify the location where a medical service was provided.

This code is used to determine the correct reimbursement rate for the service provided.

What are RVUs?

RVU stands for Relative Value Unit. It is a unit of measure used by the Centers for Medicare & Medicaid Services (CMS) to determine Medicare payments for medical services and procedures.

RVUs are based on the amount of time, skill, and resources required to perform a service, and are used to calculate the reimbursement amount for each service.

What is SOF?

SOF stands for Signature on File. A signature is kept on file by a medical provider or practice in order to document that a patient has given consent or authorization for a particular procedure or treatment. The signature on file is typically kept on paper as hard copy documentation.

What is the HEDIS?

HEDIS (Healthcare Effectiveness Data and Information Set) is a set of performance measures used by more than 90% of health plans in the United States to measure the quality of their care and services.

Insurance providers use HEDIS to compare their plans on important dimensions of care and service, including preventive care, access to care, customer service, and more.

What is HIPAA?

HIPAA stands for the Health Insurance Portability and Accountability Act.

It is a federal law enacted in 1996 that sets guidelines for protecting the privacy, security, and integrity of protected health information (PHI). It also sets standards for electronic healthcare transactions.

You will usually hear about HIPAA in the context of patient health data. Because patient health data is protected under the law with HIPAA, it is important that billers and coders take steps to keep patient information private and safe.

What are the CMS?

CMS stands for the Centers for Medicare and Medicaid Services. It is a federal agency within the U.S. Department of Health and Human Services that administers the Medicare and Medicaid programs.

The CMS is responsible for setting standards for medical billing and coding and establishing guidelines for the proper use of codes.

What is the WHO?

The WHO (World Health Organization) is an international organization that is responsible for setting global health standards, promoting research, and providing evidence-based policies.

It is also responsible for the International Classification of Diseases (ICD) codes, which are used in medical billing and coding to identify the diagnosis and treatment for a given patient.

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