AMCA BCSC key terms

A standardized code set maintained by the American Medical Association that describes medical, surgical, and diagnostic services. Payers use these codes to process claims and determine reimbursement amounts.

A two-level code set used for billing Medicare and other payers. Level I consists of CPT codes, while Level II covers products, supplies, and services not represented in CPT.

The standardized system for reporting diagnoses and inpatient procedures. ICD-10-CM codes describe patient conditions and justify the medical necessity of services billed.

A category of CPT codes used to report patient encounters such as office visits and hospital consultations. Selection depends on documented history, examination, and medical decision-making or time.

A two-character code appended to a procedure code to clarify or alter how a service is reported. Modifiers explain circumstances such as a bilateral procedure, multiple providers, or a discontinued service.

A two-digit code on a claim identifying where a service was furnished, such as an office, hospital, or patient home. The setting often changes the reimbursement rate for the same procedure.

The determination that a service is reasonable and required to diagnose or treat a patient's condition. Payers deny claims when documentation does not support that the care was medically necessary.

A statement from an insurer summarizing how a claim was processed, including allowed amounts, payments, and patient responsibility. It is sent to the patient and often to the provider as a remittance.

An electronic or paper document from a payer that accompanies payment and explains each claim's adjudication. It lists paid, denied, and adjusted amounts and supports posting payments to patient accounts.

The standard paper claim form used by non-institutional providers to bill Medicare and other insurers. It captures patient, provider, diagnosis, and procedure information in numbered fields.

A claim submitted with all required information complete and accurate so that a payer can adjudicate it without requesting additional data. Clean claims are typically paid within prompt-pay timeframes.

A payer's refusal to pay a claim, often due to missing information, ineligibility, or lack of medical necessity. Denials must be tracked, corrected, and appealed within payer deadlines.

A formal request asking a payer to reconsider a denied or underpaid claim. Appeals usually require supporting documentation and must be filed within the payer's stated timeframe.

A fixed dollar amount a patient pays at the time of service, such as a set fee for an office visit. The insurer pays the remaining allowed amount according to the plan.

The percentage of allowed charges a patient is responsible for after meeting the deductible. For example, a 20 percent coinsurance means the patient pays that share of the cost.

The amount a patient must pay out of pocket for covered services before the insurance plan begins to pay. Deductibles typically reset each plan year.

The maximum amount a payer will recognize for a covered service under its contract or fee schedule. Patient cost-sharing and insurer payment are calculated from this figure.

A list of predetermined payment amounts a payer assigns to specific procedure codes. Providers use it to estimate expected reimbursement and to negotiate contracts.

The payment a provider receives for services rendered, usually from an insurer or patient. It is generally based on contracted rates rather than the provider's full charge.

Money owed to a practice for services already delivered but not yet paid. Managing A/R involves tracking aging claims and following up on outstanding balances.

The payer practice of combining component services into a single payment rather than paying each separately. Bundling rules affect how procedures should be coded and modified.

Reporting components of a procedure as separate codes when they should be billed together. This can be considered improper billing and may trigger claim denials or compliance review.

Assigning a higher-paying code than the documentation supports. It is a form of fraudulent billing and can result in audits, penalties, and exclusion from federal programs.

A federal law that protects the privacy and security of patient health information and sets standards for electronic transactions. Covered entities must safeguard protected health information and follow breach notification rules.

Individually identifiable health information held or transmitted by a covered entity. It includes data such as names, dates, diagnoses, and account numbers linked to a patient.

A HIPAA principle requiring that only the least amount of protected health information needed for a purpose be used or disclosed. It applies to most routine uses and disclosures.

A written notice a provider gives a Medicare patient before a service that may not be covered. Signing it shifts financial responsibility to the patient if Medicare denies payment.

A federal statute that imposes liability on individuals or entities that knowingly submit false or fraudulent claims to government programs. Penalties include fines and treble damages.

A unique ten-digit identification number assigned to healthcare providers for use in standard electronic transactions. It replaces legacy identifiers and is required on most claims.

A ten-character alphanumeric code that identifies a provider's specialty and classification. It is registered with the NPI and helps payers route claims correctly.

A unique identifier assigned to medications and reported on claims when drugs are administered. It identifies the labeler, product, and package size of the drug.

The condition chiefly responsible for the patient encounter and listed first on a claim. It supports the medical necessity of the services reported.

The standard reference posture in which a person stands upright facing forward with arms at the sides and palms facing forward. Body directions and locations are described relative to this position.

A directional term meaning closer to the point of attachment or to the trunk of the body. For example, the shoulder is proximal to the elbow.

A directional term meaning farther from the point of attachment or from the trunk of the body. For example, the fingers are distal to the wrist.

A word part attached to the end of a medical term that alters its meaning, often indicating a condition, procedure, or process. For example, -itis means inflammation.

A word part attached to the beginning of a medical term that modifies its meaning, often indicating location, number, or time. For example, hyper- means above or excessive.

The core part of a medical term that carries its fundamental meaning, often referring to a body part or system. Combining vowels are frequently added to connect roots to suffixes.