Medical Practices, Clinics, Therapy Centres Industry Terminology

Accountable Care Organization (ACO)

A Medicare-defined network of providers that share financial risk and rewards for cost and quality outcomes, often using population health strategies.

We joined an ACO to improve our Medicare shared savings; The ACO’s quality scores affected our distribution; Our ACO care coordinators track high-risk patients.

Advance Beneficiary Notice (ABN)

A written notice informing Medicare patients that a service may be noncovered and they may be responsible for payment if they choose to receive it.

Have the patient sign an ABN before the non-covered test; We issued an ABN for the out-of-guideline therapy; Missing an ABN led to a write-off.

Advanced Practice Provider (APP)

Non-physician clinicians such as nurse practitioners (NPs) and physician assistants (PAs) who diagnose, treat, and prescribe within scope.

Our APPs expand same-day access; The APP leads our chronic care clinic; APP productivity is tracked in wRVUs.

Admission, Discharge, Transfer (ADT)

A standard set of messages that signal patient status changes across systems for care coordination.

We receive ADT alerts when our patients are discharged; ADT feeds trigger post-discharge calls; The HIE delivers ADT events to our EHR.

Balance Billing

Charging patients the difference between a provider’s charge and the payer’s allowed amount; often restricted by contract or law.

In-network contracts prohibit balance billing; Surprise balance billing is limited by the No Surprises Act; We wrote a policy to avoid inadvertent balance billing.

Bundled Payment

A single payment covering multiple services within an episode of care, encouraging coordination and cost control.

Our joint replacement bundle includes rehab; The therapy center participates in a bundled payment pilot; We track bundle gainsharing metrics.

Capitation

Fixed per-member-per-month (PMPM) payment to manage a population’s care; the provider assumes financial risk.

Our primary care clinic is on partial capitation; We monitor utilization to manage capitated risk; Capitation requires strong care management.

Care Coordination

Organizing patient care activities across providers and settings to improve outcomes and efficiency.

Our RN navigator coordinates post-op therapy; We use ADT alerts to enhance care coordination; Care plans are shared via the HIE.

Charge Capture

The process of accurately recording and submitting all billable services and supplies.

Missed charge capture caused revenue leakage; We implemented mobile charge capture for PT visits; Daily audits improved charge capture accuracy.

Clearinghouse

A third-party that scrubs, formats, and transmits electronic claims to payers and returns remittance files.

Claims reject at the clearinghouse if data are missing; We switched clearinghouses to improve first-pass rates; ERAs flow from the payer via the clearinghouse.

CPT (Current Procedural Terminology)

The AMA’s procedural coding system used to describe medical, surgical, E/M, and therapy services.

We billed CPT 97110 for therapeutic exercises; 99213 is an established patient E/M; Ensure CPT-ICD medical necessity alignment.

Credentialing

Verification of a clinician’s qualifications and enrollment with payers and facilities.

New hires start credentialing 120 days prior; Payer credentialing delays postponed start dates; Maintain CAQH profiles to streamline credentialing.

Days in Accounts Receivable (A/R Days)

A key revenue cycle metric showing how long, on average, it takes to collect payment.

Our A/R days dropped from 52 to 38; High A/R days signal claim denials; We set a target of ≤35 A/R days.

Deductible

The amount a patient must pay before insurance starts covering services, subject to plan rules.

Verify deductibles during VOB; The patient is still meeting their deductible; High-deductible plans increase patient collections work.

Denial Management

Processes to prevent, identify, appeal, and resolve claim denials to accelerate cash.

We built a denial workqueue by reason code; Prior auth denials dropped after training; Our overturn rate improved with better documentation.

Direct Access (Therapy)

State laws allowing patients to see physical therapists without a physician referral, with limits by jurisdiction.

We market direct access for back pain; Check state rules for direct access duration; Payer policy may still require a referral.

E/M (Evaluation and Management)

CPT codes for office, hospital, and other cognitive services, selected by history, exam, and medical decision making or time.

We billed 99214 based on MDM; New E/M rules emphasize MDM and time; Avoid upcoding E/M levels.

Electronic Health Record (EHR)

A digital system to document, order, e-prescribe, and exchange clinical data.

Structured EHR notes support quality measures; We integrated the EHR with our HIE; EHR alerts remind us of preventive gaps.

Electronic Remittance Advice (ERA)

An electronic payment and denial report from payers, often in X12 835 format, used to post and reconcile.

Auto-post ERAs to speed cash; The ERA shows bundling adjustments; Our clearinghouse aggregates ERAs.

Evidence-Based Practice (EBP)

Clinical decisions guided by the best available research, clinician expertise, and patient preferences.

Our PT protocols follow EBP; We use EBP guidelines for low back pain; EBP underpins our formulary choices.

Explanation of Benefits (EOB)

A payer document explaining how a claim was processed, including allowed amounts, patient responsibility, and denials.

The EOB shows the applied deductible; Review EOB remark codes for denial reasons; Patients often confuse EOBs with bills.

FHIR (Fast Healthcare Interoperability Resources)

A modern standard for exchanging healthcare data via APIs, enabling interoperability and patient access.

Our app pulls meds via FHIR; Payers expose FHIR APIs for patient access; We map assessments to FHIR resources.

Fee Schedule

A list of maximum allowed amounts for services by payer or practice.

Compare payer fee schedules before contracting; Our therapy fee schedule updates annually; Underpayment detected against the fee schedule.

Fee-for-Service (FFS)

Payment model where providers are paid per service provided, regardless of outcomes.

Most of our visits are reimbursed FFS; FFS incentivizes volume over value; We are transitioning from FFS to VBC.

Federally Qualified Health Center (FQHC)

Community-based clinics that receive federal funding and enhanced Medicare/Medicaid reimbursements.

Our FQHC qualifies for PPS rates; FQHC status affects sliding fee scales; We report UDS measures as an FQHC.

Good Faith Estimate (GFE)

A cost estimate for uninsured or self-pay patients under the No Surprises Act.

Provide a GFE before scheduling; Our portal auto-generates GFEs; Disputes reference the original GFE.

HCPCS (Healthcare Common Procedure Coding System)

Medicare’s code set (Levels I and II) for procedures, supplies, and services beyond CPT.

HCPCS Level II code for DME; G-codes used for certain reporting; Verify HCPCS modifiers for injections.

HCC (Hierarchical Condition Category)

A risk adjustment model that uses diagnosis codes to predict cost and set payments in MA and ACOs.

Annual wellness visits capture HCCs; Accurate HCC coding affects our MA revenue; Close HCC care gaps each year.

HEDIS (Healthcare Effectiveness Data and Information Set)

Standardized quality measures widely used by health plans, MA, and value contracts.

Our diabetes HEDIS rates improved; Payers tie bonuses to HEDIS; We use HEDIS specs for our registries.

HIE (Health Information Exchange)

Organizations and platforms that enable sharing patient data across entities.

We query the HIE for outside imaging; HIE ADT alerts support transitions; Joining the HIE reduced duplicate tests.

HIPAA (Health Insurance Portability and Accountability Act)

US law governing privacy, security, and portability of health information (PHI/ePHI).

Encrypt ePHI to meet HIPAA Security Rule; HIPAA requires a Notice of Privacy Practices; A BAA is needed with our billing vendor.

HITECH Act

US law that incentivized EHR adoption and strengthened HIPAA enforcement.

We achieved meaningful use under HITECH; HITECH increased breach penalties; HITECH drove EHR interoperability standards.

ICD-10-CM (International Classification of Diseases, 10th Revision, Clinical Modification)

Diagnosis coding system used for clinical documentation, billing, and risk adjustment.

Use ICD-10-CM to capture specificity; Z-codes document SDoH; Accurate ICD coding supports HCCs.

Incident-to Billing

Medicare billing that allows services by APPs under physician supervision to be billed under the physician’s NPI when criteria are met.

We used incident-to for follow-ups; Check incident-to supervision requirements; Not allowed by all payers.

Information Blocking (Cures Act)

Prohibited practices that unreasonably interfere with the access, use, or exchange of electronic health information.

We updated policies to avoid information blocking; Denying patient API access can be blocking; Document applicable exceptions.

Informed Consent

A process to disclose risks, benefits, alternatives, and obtain voluntary patient agreement for procedures or treatment.

Document informed consent in the EHR; Use teach-back to confirm understanding; Consent is required before initiating therapy plan.

KPI (Key Performance Indicator)

Quantifiable measures that track operational, financial, or clinical performance.

No-show rate is a core KPI; We review KPIs weekly in huddles; KPIs align with our value-based goals.

MACRA (Medicare Access and CHIP Reauthorization Act)

Law that created MIPS and Advanced APMs, tying Medicare payment to quality and value.

Our clinic reports under MACRA via MIPS; MACRA incentivizes risk-bearing APMs; MACRA compliance affects updates.

Medical Decision Making (MDM)

A key component in selecting E/M levels based on complexity of problems, data, and risk.

The MDM supported a 99214; Documented data review increased MDM; MDM tables guide coding.

Medical Necessity

Clinical justification that a service is reasonable and necessary per payer policy and standards of care.

Denial overturned with medical necessity notes; Policy requires medical necessity for therapy frequency; Link diagnosis to support necessity.

Medicare Advantage (MA)

Private plan alternatives to traditional Medicare, with capitated payments and network rules.

MA plans require prior authorization; HCC coding drives MA risk scores; We negotiated MA fee schedules.

MIPS (Merit-based Incentive Payment System)

Medicare payment program scoring clinicians on quality, cost, improvement activities, and Promoting Interoperability.

We selected high-impact MIPS measures; Our MIPS score affects payment adjustments; The EHR supports MIPS reporting.

NCCI Edits (National Correct Coding Initiative)

CMS edits that prevent improper coding combinations and unbundling.

NCCI edits bundled the therapy codes; We used a modifier per NCCI guidance; Always check NCCI tables when coding.

No-Show Rate

Percentage of scheduled appointments not attended by patients, impacting access and revenue.

Reminder texts lowered our no-show rate; We overbook based on historical no-shows; No-show fees are in our policies.

NPI (National Provider Identifier)

A unique 10-digit identifier for healthcare providers and organizations in the US.

Use the group NPI on claims; The APP’s NPI is on the rendering line; Update NPI info in NPPES.

Prior Authorization

Payer approval required before certain services, meds, or equipment are provided.

Submit prior auth for MRI and DME; Delays due to prior authorization impact access; Use checklists to reduce prior auth denials.

Relative Value Unit (RVU)

A measure of resource use for procedures and E/M, forming the basis of payment and productivity targets (work, practice expense, malpractice).

Provider goals set in wRVUs; RVU weights follow RBRVS updates; Compare payer rates per RVU.

Revenue Cycle Management (RCM)

End-to-end processes from scheduling and eligibility to charge capture, coding, billing, collections, and denials.

We centralized RCM to improve cash; KPIs include A/R days and clean claim rate; Automation reduced RCM costs.

Risk Adjustment

Method of adjusting payments and comparisons based on patient complexity, often using HCCs and ICD codes.

Annual coding reviews improve risk adjustment; MA contracts depend on accurate risk scores; Capture SDoH Z-codes for context.

Value-Based Care (VBC)

Payment and care models that reward outcomes, patient experience, and cost-efficiency rather than volume.

Our VBC contract ties bonuses to HEDIS; We invested in care managers for VBC success; VBC reduced avoidable ED visits.