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Healthcare Glossary
Term |
Definition |
Details |
ABN |
Advanced Beneficiary Notice |
A notice presented to fee-for-service Medicare patients advising that Medicare is likely not to pay for a particular service that has been ordered by the patient's physician. The notice lists the item(s) or service(s), an estimate of the cost for the item(s) or service(s), and the reason why Medicare may not pay, giving the patient information needed to make an informed choice about whether or not to accept financial responsibility for the item(s) or service(s). |
AHA |
American Hospital Association
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AHRQ |
Agency for Healthcare Research and Quality |
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AMA |
American Medical Association |
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APC |
Ambulatory Payment Classification |
A specific payment methodology used by various healthcare payers to pay for selected outpatient services as defined by the payer; the APC payment methodology was adopted by Medicare in CY2000 as the payment system of choice to pay for facility services provided to Medicare outpatients; see also Outpatient Prospective Payment System (OPPS). |
APG |
Ambulatory Patient Group |
A specific payment methodology used by various healthcare payers to pay for selected outpatient services as defined by the payer. |
APR- DRG |
All-Patient Refined Diagnosis Related Group |
Expansion of the basic DRG structure by adding subclasses to reflect severity of illness and risk of mortality. |
ASC |
Ambulatory Surgery Center |
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ASP |
Average Sale(s) Price |
Drug pricing information submitted by drug manufacturers to CMS on a quarterly basis. |
AWP |
Average Wholesale Price |
Used relative to drug pricing. |
CAH |
Critical Access Hospital |
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CC |
Complication or Co- Morbidity |
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CCI |
Correct Coding Initiative |
Officially known as the Medicare National Correct Coding Initiative (NCCI), CCI code-pair edits are automated prepayment edits that prevent improper payment when certain codes are submitted together for Part B-covered services. |
CCR |
Cost to Charge Ratio |
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CDI |
Clinical Documentation Improvement |
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CDT |
Code on Dental Procedures and Terminology |
Clinical code-set owned, maintained and published annually by the American Dental Association; used to describe dental services and procedures provided by dental health professionals. |
CMI |
Case Mix Index |
Case mix index (CMI) is the average relative weight for a target population of patients whose inpatient services have been coded and grouped using the Medicare MS-DRG system. In general, the CMI reflects the relative severity of illness and complexity of care provided for the target group of patients. Example: A hospital with a CMI >1.000 is presumed to be caring for a patient population that is sicker and likely to require more resource consumption than a hospital with a CMI <1.000. CMI is calculated by summing the relative weights of the assigned DRGs for the target population and dividing by the total number of patients in the target population. |
CMS |
Centers for Medicare and Medicaid Services |
Proprietary clinical code-set owned, maintained and published annually by the American Medical Association. |
CPT |
Current Procedural Terminology |
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DNFB |
Discharges Not Final Billed |
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DNFC |
Discharges Not Final Coded |
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DRG |
Diagnosis Related Group |
A statistical system used to classify inpatient hospital stays into clinically similar groups of cases requiring similar care and treatment and consuming a similar level of healthcare resources. The DRG system was originally developed for Medicare as a prospective payment mechanism for inpatient services. |
FFS |
Fee For Service |
Healthcare payment models where services are typically not bundles and are paid for using a cost or negotiated rate for each service provided. |
HCPCS |
Healthcare Common Procedure Coding System |
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HIM |
Health Information Management |
Most commonly used to describe hospital operations related to management and maintenance of patient-specific healthcare information maintained in hard-copy or electronic "medical records." |
HL7 |
Health Level Seven International |
A framework and set of standards used for the exchange, integration, sharing and retrieval of electronic health information. |
ICD-10 |
International Classification of Diseases - 10th Revision |
Maintained by the World Health Organization (WHO), the International Classification of Diseases (ICD) is the standard diagnostic tool for epidemiology, health management and clinical purposes. This includes the analysis of the general health situation of population groups. It is used to monitor the incidence and prevalence of diseases and other health problems. The 10th revision was endorsed by WHO in 1990 and many WHO member states began using it in 1994. |
ICD-10 CM |
International Classification of Disease - version 10 - Clinical Modification |
United States' adaptation of ICD-10 for the purpose of assigning and reporting clinical codes for documented diagnoses. |
ICD-10 PCS |
International Classification of Disease - version 10 - Procedure Coding System |
Procedure coding system specifically developed to replace Volume 3 of the ICD-9-CM system for the purpose of coding and reporting inpatient services and procedures. |
ICD-9 CM |
International Classification of Disease - version 9 - Clinical Modification |
United States' adaptation of ICD-9 for the purpose of assigning and reporting clinical codes for diagnoses and healthcare related services and procedures. ICD-9-CM Volumes 1 and 2 are used for reporting diagnoses (DX) and ICD-9-CM Volume 3 is specific for reporting services and procedures (PX). |
IPPS |
Inpatient Prospective Payment System |
|
LCD |
Local Coverage Decisions |
Medicare payment policy documents developed and maintained at the local level by local or regional Medicare Contractors. LCDs were previously known as Local Medical Review Policies (LMRP). |
MCC |
Major Complication or Co-Morbidity |
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MS- DRG |
Medicare Severity Diagnosis Related Group |
Severity-adjusted DRG payment methodology implemented by Medicare on October 1, 2007 for inpatient, acute care services. See: DRG |
MUE |
Medically Unlikely Edits |
The CMS developed Medically Unlikely Edits (MUEs) to reduce the paid claims error rate for Part B claims. An MUE for a HCPCS/CPT code is the maximum units of service that a provider would report under most circumstances for a single beneficiary on a single date of service. Not all CPT/HCPCS codes have an MUE. MUE was implemented January 1, 2007 and is utilized to adjudicate claims at Carriers, Fiscal Intermediaries, and DME MACs. |
NCD |
National Coverage Determination |
Medicare coverage is limited to items and services that are reasonable and necessary for the diagnosis or treatment of an illness or injury (and within the scope of a Medicare benefit category). National coverage determinations (NCDs) are made through an evidence-based process, with opportunities for public participation. In some cases, CMS' own research is supplemented by an outside technology assessment and/or consultation with the Medicare Evidence Development & Coverage Advisory Committee (MEDCAC). In the absence of a national coverage policy, an item or service may be covered at the discretion of the Medicare contractors based on a local coverage determination (LCD). |
NDC |
National Drug Codes |
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NOS |
Not otherwise specified |
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OPPS |
Outpatient Prospective Payment System |
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PDX |
Principal Diagnosis |
That condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care." |
PFS |
Patient Financial Services |
|
POA |
Present on Admission |
For each diagnosis code reported on an inpatient claim, a POA code is appended to indicate whether or not the condition represented by the diagnosis code was present at the time of admission. POS indicators carry specific payment implications under Medicare IPPS. |
PPX |
Principal Procedure |
The principal procedure (PPX) is one that was performed for definitive treatment rather than one performed for diagnostic or exploratory purposes, or was necessary to take care of a complication. When two procedures are performed that meet this definition, then the one most related to the principal diagnosis should be assigned as the principal procedure. |
SAF |
Standard Analytical File |
|
SDX |
Secondary Diagnosis |
Also called "other diagnoses;" UHDDS Definition for Other Diagnoses: "All conditions that coexist at the time of admission, that develop subsequently, or that affect the treatment received and/or the length of stay. Diagnoses that relate to an earlier episode [and] which have no bearing on the current hospital stay are to be excluded." |
SI |
Status Indicator |
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SPX |
Secondary Procedure |
Per UHDDS guidelines, all significant procedures are to be reported. Significant procedures include those that are surgical in nature; carry a procedural risk; carry an anesthetic risk; or require specialized training. Procedures that meet these guidelines and are listed in addition to the principal procedure (see PPX) are commonly referred to as secondary procedures (SDX). |
TOB |
Type of Bill |
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UHDDS |
Uniform Hospital Discharge Data Set |
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