- CBCS (Certified Billing and Coding Specialist)
- An entry-level certification from the National Healthcareer Association (NHA) that validates a candidate's competency in medical billing and coding tasks. The exam has 100 scored questions and must be completed within 180 minutes.
- CPT (Current Procedural Terminology)
- A standardized code set maintained by the American Medical Association used to report medical, surgical, and diagnostic procedures and services. Coders assign CPT codes to describe what services a provider performed.
- ICD-10-CM
- The diagnosis code set used in the United States to classify patient conditions, diseases, and reasons for a healthcare encounter. It answers the 'why' of a visit, whereas procedure codes answer the 'what.'
- HCPCS Level II
- A code set that identifies products, supplies, and services not included in CPT, such as durable medical equipment, ambulance services, and certain drugs. It is commonly used for Medicare and Medicaid billing.
- CMS-1500
- The standard paper claim form used by non-institutional providers and suppliers (such as physicians) to bill Medicare, Medicaid, and most commercial payers for professional services.
- EOB (Explanation of Benefits)
- A statement sent by an insurance payer to the patient explaining what charges were billed, what the plan paid, and what the patient may owe. It is not a bill but a summary of how a claim was processed.
- HIPAA (Health Insurance Portability and Accountability Act)
- Federal legislation that establishes national standards for protecting the privacy and security of patient health information (PHI). Billing and coding staff must safeguard PHI and follow its rules when handling records.
- Medical Necessity
- The principle that a service or procedure must be reasonable, appropriate, and consistent with accepted standards of care for a patient's diagnosis in order to be covered by a payer. Claims lacking documented medical necessity are commonly denied.
- Modifier
- A two-character code appended to a CPT or HCPCS code to give additional detail about a service without changing its core definition, such as indicating a bilateral procedure or a distinct service. Correct modifier use is essential to accurate reimbursement.
- Remittance Advice (RA)
- A document sent from a payer to a provider detailing the adjudication of one or more claims, including amounts paid, adjustments, denials, and the reason codes for each. It is the provider-facing counterpart to the patient's EOB.
- Adjudication
- The process by which an insurance payer reviews a submitted claim and decides whether to pay it in full, pay it in part, or deny it based on coverage, coding, and medical necessity. The outcome is communicated through remittance advice and an EOB.