NCICS key terms

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

A two-level coding system used for Medicare and other payers. Level I consists of CPT codes, while Level II covers products, supplies, and services not represented in CPT, such as drugs and durable medical equipment.

The diagnosis code set used in United States outpatient and physician settings. It documents patient conditions and establishes medical necessity for the services billed on a claim.

A procedure code set used only for inpatient hospital reporting in the United States. Codes are built from seven characters describing the body system, root operation, body part, approach, device, and qualifier.

A category of CPT codes for patient encounters such as office visits, hospital visits, and consultations. Selection depends on documented medical decision making or time, depending on the code family and current guidelines.

A two-character code appended to a procedure code to report a specific circumstance, such as a distinct service, laterality, or a reduced service. Modifiers affect how payers process and pay the claim.

A modifier added to an evaluation and management code when a significant, separately identifiable service is performed on the same day as another procedure. It signals that the visit was not merely part of the procedure.

A modifier used to indicate that a procedure or service was distinct and independent from other services reported on the same day. Payers scrutinize it closely because overuse can suggest unbundling.

A two-digit code on a claim identifying where a service was furnished, such as an office, hospital outpatient department, or patient home. The setting influences payment rates and coverage rules.

Payer edit tables that flag code pairs generally not reportable together on the same claim. They promote correct coding and prevent improper payment for overlapping or bundled services.

Billing components of a procedure or service separately when a single comprehensive code should be reported. It can result in overpayment and is a common target of payer audits.

Combining related services into one payment when they are considered part of a single procedure. Payers bundle to avoid paying twice for components included in a comprehensive code.

The requirement that a service be reasonable and necessary for diagnosing or treating a patient's condition. Documentation must support the diagnosis linked to the billed procedure.

A written notice given to a Medicare beneficiary before a service that may not be covered, explaining that the patient may have to pay. It shifts financial liability when requirements are met.

A statement from a payer to the patient summarizing processed claims, including allowed amounts, payments, and patient responsibility. It is not a bill, though providers often send a separate statement.

An electronic or paper document from a payer explaining how a claim was adjudicated, including paid, denied, or adjusted amounts and remark codes. It supports posting payments and managing denials.

An electronic version of a remittance advice transmitted in a standard format. Billing systems use it to auto-post payments and adjustments, reducing manual data entry errors.

The computer-to-computer exchange of healthcare transactions such as claims, remittances, and eligibility inquiries in standardized formats. It is required for most electronic claims under federal rules.

An intermediary that receives claims from providers, checks them for errors and formatting, and forwards them to the correct payer. It can also route remittances and eligibility responses back to the provider.

Software that reviews claims for missing data, invalid code combinations, and payer-specific rules before submission. Catching errors early reduces rejections and denials.

A claim returned before adjudication because it fails basic data or formatting requirements, such as a missing identifier. Corrected and resubmitted claims are usually needed; rejections are not payer denials.

A payer's decision not to pay a claim, in whole or in part, often due to coverage, medical necessity, or coding issues. Denials typically require review, appeal, or correction before payment.

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

The share of covered healthcare costs a patient pays after meeting the deductible, usually a percentage. The payer covers the remainder according to the plan's benefit design.

A fixed dollar amount a patient pays for a covered service at the time of care, such as a set fee for an office visit. It differs from coinsurance, which is a percentage.

The amount a patient must pay out of pocket for covered services before the health plan begins to pay its share. Deductibles reset on a schedule defined by the plan.

Rules determining which health plan pays first when a patient is covered by more than one plan. The primary plan pays first and the secondary plan considers the remaining balance.

The health plan that processes a claim first when a patient has multiple coverages. Its payment and adjustments are reported to the secondary payer for further consideration.

A health plan that pays after the primary plan has processed a claim, often covering some or all of the remaining patient responsibility. It relies on the primary plan's remittance information.

The end-to-end process of managing patient care revenue, from scheduling and registration through coding, claim submission, payment posting, and collections. Effective RCM reduces denials and improves cash flow.

The process of recording services and supplies provided to a patient so they can be billed. Missed or inaccurate capture leads to lost revenue or compliance risk.

A form or electronic record used by clinicians to document diagnoses and services performed during an encounter. Coders use it as a source for claim data.

Money owed to a practice for services already rendered but not yet paid. Aging reports track how long balances remain outstanding and help target collection efforts.

Programs that help clinicians document diagnoses and care more completely and accurately. Better documentation supports correct coding, medical necessity, and appropriate reimbursement.

Delivery of healthcare services remotely using video, phone, or other technology. Billing rules vary by payer and often require specific place of service codes and modifiers.

A unique identifier for human drugs, including the labeler, product, and package size. Claims for physician-administered drugs often require the NDC along with the HCPCS code.

Reusable medical equipment prescribed for home use, such as wheelchairs or oxygen equipment. Claims require specific HCPCS codes and often supporting documentation of medical necessity.

The condition established after study to be chiefly responsible for the patient's admission or encounter. It is sequenced first and drives grouping and payment in many settings.