Other Health Care Industry Terminology

Accountable Care Organization (ACO)

A network of providers jointly accountable for quality, patient experience, and total cost of care for a defined population under shared-savings or risk contracts. Encourages care coordination and population health management to reduce avoidable utilization.

1) Our ACO achieved shared savings in MSSP by reducing readmissions. 2) The ACO’s risk score improved after better HCC capture.

Adverse Event (AE)

Any unintended harm associated with medical care, product use, or clinical operations. Includes medication errors, device malfunctions, and complications.

1) All AEs are logged and investigated within 24 hours. 2) Pharmacovigilance teams monitor AEs reported post-launch.

Bundled Payment

A single, predetermined payment covering all services for a defined episode of care across providers and settings. Aligns incentives for efficiency and outcomes.

1) We negotiated a bundled rate for joint replacements. 2) Care redesign reduced post-acute spend under the bundle.

Capitation

Per-member-per-month (PMPM) payment to cover a defined set of services for a population, shifting financial risk to the provider.

1) Our clinic moved to partial capitation for primary care. 2) Care management is funded from capitation margin.

Care Management

A coordinated set of interventions to help at-risk patients manage conditions, improve adherence, and navigate care. Often nurse-led with digital tools.

1) Care managers close gaps for diabetics with A1c > 9. 2) Outreach and home visits reduced ED utilization.

CDI (Clinical Documentation Integrity)

A discipline ensuring clinical documentation accurately reflects patient severity, services rendered, and quality metrics to support correct coding and reimbursement.

1) A CDI query clarified sepsis vs. SIRS. 2) CDI improvements increased RAF scores in MA.

CDS (Clinical Decision Support)

Workflow-integrated tools that provide knowledge, alerts, order sets, and recommendations to optimize decisions and reduce variation.

1) CDS warns of drug–drug interactions at order entry. 2) Sepsis CDS prompts lactate and fluids bundle.

Claims Data

Administrative data generated by billing (e.g., 837 claim, ICD/CPT/HCPCS codes, billed/allowed amounts, dates of service). Useful for longitudinal utilization and cost analytics.

1) Claims lag affects monthly cost-of-care reporting. 2) Identify high utilizers via 12-month claims runout.

CPT (Current Procedural Terminology)

AMA-maintained code set for procedures and physician services used for billing and analytics.

1) CPT 99214 for established patient visit with MDM of moderate complexity. 2) Use modifier 25 with E/M service plus minor procedure.

DRG (Diagnosis-Related Group)

Inpatient case-mix classification that groups stays by diagnoses/procedures to determine payment weight.

1) DRG 470 covers major joint replacement without MCC. 2) Secondary diagnoses can shift DRG by adding CC/MCC.

E/M Coding

Rules for coding evaluation and management visits based on medical decision making or time. Affects reimbursement and audit risk.

1) Follow 2021 E/M guidelines for office visits. 2) Education reduced E/M upcoding denials.

EDI X12 Transactions

HIPAA standard formats for electronic data interchange (e.g., 837 claim, 835 remittance, 270/271 eligibility, 276/277 claim status).

1) The clearinghouse rejected our 837 due to NPI mismatch. 2) Set up auto-posting from 835 ERA files.

EHR (Electronic Health Record)

A longitudinal, digital record of patient health information that supports clinical workflows, coding, and reporting.

1) Implementing FHIR APIs enables EHR app interoperability. 2) Downtime procedures ensure safe care during EHR outages.

EOB (Explanation of Benefits)

Payer document summarizing how a claim was adjudicated, including allowed amount, adjustments, and patient responsibility.

1) The EOB shows the deductible applied. 2) We reconcile 835 remits to patient EOBs.

Fee-for-Service (FFS)

Payment model in which providers are reimbursed per service performed. Often contrasted with value-based models.

1) FFS incentivizes volume over outcomes. 2) We’re migrating from FFS to shared-risk contracts.

FHIR (Fast Healthcare Interoperability Resources)

HL7 standard that structures health data as resources and uses modern web APIs (REST/JSON) for exchange.

1) The app retrieves meds via FHIR R4 MedicationRequest. 2) SMART on FHIR enables single sign-on and launch.

Formulary

A payer- or PBM-managed list of covered medications, often tiered with utilization controls such as prior authorization and step therapy.

1) Omeprazole moved to Tier 2 on the formulary. 2) Formulary exclusions prompted therapy switches.

HEDIS (Healthcare Effectiveness Data and Information Set)

A widely used set of quality measures for health plans, used in accreditation and performance programs.

1) Closing HEDIS gaps improved MA Star Ratings. 2) Hybrid HEDIS measures require chart abstraction.

HIE (Health Information Exchange)

The electronic movement of health information across organizations to support patient care and public health.

1) Query the HIE for a CCD before the visit. 2) Onboarded ADT feeds to the regional HIE.

HIPAA (Health Insurance Portability and Accountability Act)

U.S. law and rules governing privacy and security of PHI and standard transactions.

1) A BAA is required for vendors handling PHI under HIPAA. 2) We followed HIPAA breach notification requirements.

ICD-10-CM/PCS

International classification systems for diagnoses (CM) and inpatient procedures (PCS) used for coding, reporting, and payment.

1) ICD-10-CM Z59.0 captures homelessness. 2) ICD-10-PCS codes affect MS-DRG assignment.

Interoperability

The ability of systems to exchange, interpret, and use data seamlessly across technical, semantic, and workflow levels.

1) TEFCA aims to scale nationwide interoperability. 2) Semantic interoperability requires mapping to LOINC and SNOMED.

J-Codes (HCPCS Level II)

Codes primarily for physician-administered drugs and biologics billed under the medical benefit.

1) Use J0171 for adrenalin injection. 2) Unclassified drug billed under J3490 with documentation.

KPI (Key Performance Indicator)

Quantifiable metric used to evaluate performance against targets.

1) Days in A/R is a core revenue cycle KPI. 2) Access KPIs include third-next-available appointment.

LOINC

A standard code system for laboratory tests and clinical observations used to enable data exchange and analytics.

1) Map HbA1c to LOINC 4548-4. 2) HIE requires LOINC-coded results for ingestion.

Managed Care Organization (MCO)

A health plan that manages cost, quality, and access through networks, utilization management, and value-based contracts, often in Medicaid and Medicare markets.

1) Our state moved Medicaid beneficiaries into MCOs. 2) MCO formularies require prior auth for GLP-1 drugs.

Medical Necessity

Clinical appropriateness standard used by payers to determine coverage; services must be reasonable and necessary.

1) MRI was denied for lack of medical necessity. 2) Document criteria met to establish medical necessity.

MIPS (Merit-based Incentive Payment System)

CMS program adjusting Part B payments based on performance in quality, cost, promoting interoperability, and improvement activities.

1) We submitted eCQMs for MIPS via a registry. 2) A low MIPS score leads to negative payment adjustment.

NCQA (National Committee for Quality Assurance)

Accredits health plans, sets quality standards, and recognizes patient-centered medical homes, often linked to HEDIS performance.

1) The plan maintained NCQA accreditation. 2) PCMH recognition required enhanced access and continuity.

Network Adequacy

Regulatory and contractual requirement that a plan’s network has sufficient providers by specialty, geography, and timeliness.

1) Geo-access reports validate network adequacy. 2) MA plans must meet time-and-distance standards.

NPI (National Provider Identifier)

Unique 10-digit identifier for covered health care providers and organizations used in transactions and credentialing.

1) Include Type 2 NPI for the billing entity. 2) The claim rejected due to missing NPI.

Patient-Reported Outcomes (PRO)

Measures of a patient’s health status or quality of life reported directly by the patient, without clinician interpretation.

1) Collect PROs using PROMIS surveys. 2) PROs supported an outcomes-based contracting deal.

PBM (Pharmacy Benefit Manager)

Intermediary administering drug benefits, negotiating rebates, and managing formularies and pharmacy networks.

1) The PBM implemented step therapy for PCSK9s. 2) Spread pricing by PBMs is under scrutiny.

Payer Mix

The proportion of patient revenue by payer category (commercial, Medicare, Medicaid, self-pay) that influences pricing and strategy.

1) A shift toward Medicaid worsened payer mix. 2) Service line expansion targeted a favorable payer mix.

PHI (Protected Health Information)

Individually identifiable health information regulated by HIPAA when created or received by a covered entity or business associate.

1) Use the minimum necessary PHI in requests. 2) Apply Safe Harbor de-identification to remove 18 identifiers.

Population Health

Strategies and analytics to improve outcomes and reduce cost for a defined population, often through risk stratification and targeted interventions.

1) Care gaps were prioritized by risk score. 2) Community partnerships addressed food insecurity.

Prior Authorization

Payer requirement to obtain approval before delivering certain services or medications.

1) The CT scan requires prior authorization. 2) We automated PA submissions via an API.

Quality Measures

Standardized indicators of processes, outcomes, patient experience, or structure of care used in reporting and payment.

1) Blood pressure control is a key quality measure. 2) eCQMs are extracted from the EHR for MIPS.

Real-World Evidence (RWE)

Clinical evidence derived from real-world data (claims, EHRs, registries, devices) outside randomized trials.

1) RWE supported comparative effectiveness of GLP-1s. 2) We used RWE to design an outcomes-based contract.

Revenue Cycle Management (RCM)

Administrative and clinical processes that capture, manage, and collect patient service revenue from access to final payment.

1) Eligibility verification reduced denials in RCM. 2) We cut days in A/R by improving coding and collections.

Risk Adjustment

Methods to calibrate payments and comparisons for patient risk (e.g., HCC/RAF in Medicare Advantage), encouraging accurate diagnosis capture.

1) Annual wellness visits improved HCC capture. 2) RAF decreased due to under-documentation.

ROI (Return on Investment / Release of Information)

1) Financial metric comparing benefits to costs. 2) Health Information Management process for disclosing records under privacy rules.

1) The care management ROI was 2.8:1. 2) The ROI request was fulfilled within 30 days.

SDoH (Social Determinants of Health)

Nonmedical factors (housing, food, transportation, education, income, social support) that influence health outcomes.

1) Screen SDoH using PRAPARE and refer to resources. 2) Ride-share benefits address transportation barriers.

SNOMED CT

Comprehensive clinical terminology for coding problems, findings, procedures, and body structures to enable semantic interoperability.

1) Problem lists are coded in SNOMED CT. 2) Map SNOMED to ICD-10 for billing workflows.

Star Ratings

CMS quality ratings (1–5 stars) for Medicare Advantage and Part D plans that affect bonuses and enrollment.

1) Improving medication adherence boosted Star Ratings. 2) CAHPS scores materially impacted our stars.

Step Therapy

Utilization management policy requiring use of lower-cost, clinically appropriate options before higher-cost therapies.

1) The plan mandated step therapy from generic to brand. 2) The appeal documented failure of first-line therapy.

Telehealth

Remote delivery of clinical services via video, audio, or asynchronous tools, often with site-of-service and modality-specific billing rules.

1) Bill telehealth with modifier 95 and POS 10 when appropriate. 2) Telehealth expanded access for behavioral health.

Utilization Management (UM)

Processes to evaluate medical necessity and appropriateness, including prior authorization, concurrent review, and discharge planning.

1) UM nurses conducted concurrent review on day 2. 2) UM policies were updated to reflect new guidelines.

Value-Based Care (VBC)

Payment and delivery models that reward outcomes, patient experience, and cost efficiency rather than volume (e.g., ACOs, shared savings, bundles).

1) We entered a VBC contract with downside risk. 2) VBC incentives aligned providers around quality.

Z codes (SDoH Z codes)

ICD-10-CM Z55–Z65 codes that capture social needs like housing, food insecurity, and transportation, supporting care coordination and risk models.

1) Use Z59.01 for inadequate housing. 2) Z codes improved visibility of SDoH in analytics.