CPPM Practice Management key terms

A weighted number assigned to a medical service reflecting the physician work, practice expense, and malpractice cost involved. Payers multiply RVUs by a conversion factor and a geographic adjuster to set the payment amount.

A list of set payment amounts for specific services identified by CPT or HCPCS code, established by Medicare, a state Medicaid program, or a commercial payer contract.

The process of recording every service, supply, and diagnosis provided during an encounter and converting that information into billable claims so that no legitimate revenue is lost.

A paper or electronic form listing the diagnoses and services a clinician commonly provides, checked off during or after a visit to document what occurred and trigger charge entry.

The difference between the practice's submitted charge and the amount the payer contract allows. The practice writes it off and generally may not bill the patient for it.

Payments received divided by charges allowed after contractual adjustments, expressed as a percentage. It measures how much of the money the practice is actually owed it succeeds in collecting.

Total accounts receivable divided by average daily charges or payments. The result estimates how long, on average, the practice waits to be paid for its work.

A report that groups unpaid balances by how long they have been outstanding, such as 0-30, 31-60, 61-90, and over 120 days, showing where collection follow-up is most needed.

The share of a practice's visits or revenue coming from each payer category, such as Medicare, Medicaid, commercial insurance, and self-pay. It shapes contracting and budget decisions.

A payment arrangement in which a payer pays a fixed amount per enrolled patient per period, regardless of how many services that patient actually uses.

A federal statute that bars physicians from referring Medicare patients for designated health services to entities in which the physician or an immediate family member has a financial relationship, unless a specific exception applies.

A federal criminal law prohibiting knowingly offering, paying, soliciting, or receiving anything of value to induce referrals for items or services paid by federal health care programs.

A federal law imposing civil liability on anyone who knowingly submits, or causes to be submitted, false claims to government payers; private whistleblowers may sue and share in the recovery.

A federal database of individuals and organizations barred from participating in federal health care programs. Practices screen new hires, employees, and contractors because billing for excluded persons can create liability.

The HIPAA rule requiring that uses, disclosures, and requests for protected health information be limited to the smallest amount reasonably needed to accomplish the intended purpose.

A written notice a covered entity must give patients explaining how their health information may be used and disclosed, what rights patients have, and what the practice's legal duties are.

The HIPAA duty to inform affected individuals, the federal government, and sometimes the media when unsecured protected health information is acquired or disclosed without authorization.

An organized set of written policies, an assigned compliance officer, training, auditing, a reporting hotline, and enforcement that together prevent, detect, and correct violations of law; the OIG describes seven core elements.

A standardized form a Medicare patient signs before receiving a service the practice expects may be denied as not medically necessary, acknowledging financial responsibility if payment is refused.

Billing a service furnished by auxiliary personnel under a supervising physician's provider number when the service is part of the physician's established plan of care and supervision requirements are met.

The federal test deciding whether an employee is exempt from overtime (salaried and meeting duties tests) or nonexempt and therefore owed overtime pay for hours beyond forty in a workweek.

A federal law entitling eligible employees to up to twelve weeks of unpaid, job-protected leave each year for specified family or medical reasons, with continued group health coverage.

A stepwise response to performance or conduct problems, such as verbal warning, written warning, suspension, then termination, giving the employee notice of the problem and a chance to correct it.

A document summarizing practice policies, workplace expectations, benefits, and the at-will employment statement; it should be reviewed by legal counsel and acknowledged in writing by each employee.

A scheduled, documented review of an employee's work compared with job expectations, used to give feedback, set goals, and support decisions about pay, promotion, or discipline.

An OSHA rule requiring employers to keep an exposure control plan, offer hepatitis B vaccination, supply protective equipment, and train employees whose duties may expose them to blood or body fluids.

A written summary of a position's duties, reporting relationships, and required qualifications. It supports recruiting, sets performance expectations, and helps defend employment decisions.

A digital record of a patient's history, orders, results, medications, and notes that the care team shares and that supports clinical decision-making, reporting, and quality measurement.

An intermediary that receives electronic claims from the practice, checks them for errors, transmits them to the correct payer, and returns acceptance reports and remittance advice to the practice.

Standard electronic transaction formats used in health care: the 837 transmits claims, and the 835 returns remittance advice showing payments, adjustments, and denials.

A security method that grants system permissions according to job duties, so staff see only the patient information and functions they need, supporting minimum necessary and audit requirements.

Documented procedures, including regular off-site or cloud copies of records and a tested restoration plan, that let the practice resume operations after an outage, theft, fire, or ransomware attack.

The policy defining how long clinical and financial records must be kept to satisfy state law, payer contracts, and federal rules before authorized destruction.

A standardized questionnaire, such as Clinician and Group CAHPS, that asks patients about access, communication, courtesy, and coordination; results guide improvement work and may be publicly reported.

A rapid improvement method in which a small change is planned, tried, measured, and then adopted, adapted, or abandoned based on what the data show.

A structured team review after a serious error or adverse event that traces contributing factors and system failures back to their sources and produces corrective actions.

The percentage of scheduled appointments that patients miss without canceling in advance; it is tracked to judge access, reminder effectiveness, and lost revenue.

The total minutes from a patient's arrival to departure, used to locate bottlenecks and reduce waiting during a visit.

A formal complaint about care or service that the practice must log, investigate, answer within a defined timeframe, and analyze for improvement opportunities.