Healthcare RCM & Medical Billing Glossary
Plain-English definitions for 405 revenue cycle, medical-billing, coding, denial, payer, and compliance terms. Every entry leads with a 40–60 word answer block, followed by a formula (where one exists), an industry benchmark, and a worked example — reviewer-authored, cited inline.
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Showing 81 terms in Coding. Clear filters.
A
- Add-On CodeCodingaka Add-On CPT, Secondary Procedure Code, CPT Add-On
An add-on code is a CPT code identified by a plus (+) symbol designating that the service is always performed in conjunction with a primary…
- Ambulatory Payment Classification (APC)Codingaka APC, OPPS APC, Outpatient APC
An Ambulatory Payment Classification (APC) is the outpatient-payment equivalent of a DRG, used by Medicare's Outpatient Prospective Payment…
- Autonomous CodingCodingaka Automated Coding, AI Medical Coding, Zero-Touch Coding
Autonomous coding is the application of AI systems — typically large language models, NLP, and computer vision — to generate final medical…
C
- Certified Risk Adjustment Coder (CRC)Codingaka CRC, CRC Credential, Certified Risk Adjustment Coder
A Certified Risk Adjustment Coder (CRC) is an AAPC credential validating expertise in risk-adjusted coding for Medicare Advantage, ACA comm…
- CMS-HCC V24 Risk Adjustment ModelCodingaka V24, 2020 HCC Model, CMS-HCC Model V24
CMS-HCC V24 is the Medicare Advantage risk-adjustment model used for payment years 2020 through 2023 and blended with V28 during the 2024–2…
- CMS-HCC V28 Risk Adjustment ModelCodingaka V28, 2024 HCC Model, CMS-HCC Model V28
CMS-HCC V28 is the updated Medicare Advantage risk-adjustment model phased in starting payment year 2024. It restructured the HCC taxonomy,…
- Coding Gap AnalysisCodingaka Risk Gap Analysis, HCC Gap Report, Coding Accuracy Assessment
Coding gap analysis systematically compares documented conditions against coded diagnoses across a population to identify HCCs present in c…
- Computer-Assisted Coding (CAC)Codingaka CAC, Coding Assistance Software, AI-Assisted Coding
Computer-Assisted Coding (CAC) is software that analyzes clinical documentation and suggests ICD-10-CM, CPT, and HCPCS codes to human coder…
- Concurrent Risk AdjustmentCodingaka Point-of-Care HCC Review, Real-Time Risk Review, Concurrent Coding
Concurrent risk adjustment is real-time HCC validation during or immediately after a patient encounter. A coder or NLP engine reviews the n…
- Condition CategoryCodingaka HCC Category, Risk Category, CC Grouping
A condition category (CC) is the taxonomic grouping of clinically related ICD-10-CM diagnoses used in the CMS-HCC and HHS-HCC models. Categ…
- CPT Code (Current Procedural Terminology)Codingaka CPT, Current Procedural Terminology
A CPT code is a five-character alphanumeric code from the American Medical Association's Current Procedural Terminology code set, used to r…
E
- E/M LevelingCodingaka Evaluation and Management Leveling, E/M Code Level, Visit Leveling
E/M Leveling is the process of selecting the appropriate Evaluation and Management code level based on the encounter's medical decision-mak…
- Evaluation and Management (E&M) CodingCodingaka E/M Coding, E&M, Evaluation and Management Coding
Evaluation and Management (E&M) coding is the process of selecting the correct CPT code for professional evaluation and management services…
G
- Generative AI Medical CodingCodingaka LLM-Powered Coding, Generative Medical Coding, AI Coding Generation
Generative AI medical coding uses large language models to generate ICD-10-CM, CPT, and HCPCS codes from clinical documentation. It is the…
- Global Surgical PackageCodingaka Global Period, Global Surgery Rule, Surgical Global
The Global Surgical Package is the CMS payment rule under which a single surgical payment covers the pre-operative, intra-operative, and po…
- Global Surgical PeriodCodingaka Global Period, Surgical Global Period, Postoperative Period
The global surgical period is the defined time frame after a surgical procedure during which related services are bundled into the surgery'…
H
- HCC Capture RateCodingaka HCC Coding Accuracy Rate, Risk Adjustment Capture Rate
HCC Capture Rate is the percentage of qualifying Hierarchical Condition Category diagnoses documented in a payment year relative to conditi…
- HCC Coding AccuracyCodingaka HCC Accuracy Rate, Risk Adjustment Coding Accuracy
HCC Coding Accuracy measures the percentage of claim-submitted HCCs that are supported by appropriate clinical documentation per MEAT crite…
- HCC Gap ClosureCodingaka HCC Recapture, Risk Adjustment Gap Closure, HCC Documentation Gap
HCC gap closure is the Medicare Advantage workflow to document and code previously-identified Hierarchical Condition Category (HCC) diagnos…
- HCC RecaptureCodingaka Diagnosis Recapture, Chronic Condition Recapture, Persistent HCC Capture
HCC recapture is the annual re-documentation of chronic conditions from prior years so they continue to contribute to a member's risk score…
- HCPCS CodeCodingaka HCPCS, Healthcare Common Procedure Coding System, HCPCS Level II
A HCPCS code is a code from the Healthcare Common Procedure Coding System, a two-level code set used to identify medical services, procedur…
- HHS-HCC Commercial Risk Adjustment ModelCodingaka HHS-HCC, ACA Risk Adjustment, Commercial Risk Adjustment
HHS-HCC is the risk-adjustment model used by the ACA commercial marketplace and small-group market to transfer funds between issuers based…
I
- ICD-10 CodeCodingaka ICD-10, ICD-10-CM, International Classification of Diseases 10th Revision
An ICD-10 code is a diagnosis code from the International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM), use…
- ICD-10-PCSCodingaka ICD-10 Procedure Coding System, ICD-10-PCS Code Set
ICD-10-PCS is the standardized inpatient procedure classification used in US hospital billing, maintained by CMS with annual updates. Unlik…
- Incident To BillingCodingaka Incident To, Incident-to Services, Incident To Billing
Incident to billing allows a physician to bill for services personally performed by an NPP or auxiliary personnel in the office setting, at…
M
- MEAT CriteriaCodingaka MEAT Documentation, Monitor Evaluate Assess Treat, MEAT Standard
MEAT (Monitor, Evaluate, Assess, Treat) is the documentation framework used to demonstrate that a chronic condition was actively addressed…
- Medical Decision Making (MDM)Codingaka MDM, Medical Decision-Making, E/M MDM
Medical Decision Making (MDM) is one of two alternative E/M code leveling methods in CPT 2021 and 2023. MDM is determined by three elements…
- Medically Unlikely Edits (MUE)Codingaka MUE, Medicare MUE, Unit Limit Edits
Medically Unlikely Edits (MUE) are CMS-published unit caps on procedure codes that define the maximum number of units of a specific CPT/HCP…
- Modifier 22 (Increased Procedural Services)Codingaka Modifier 22, -22, Increased Complexity Modifier
Modifier 22 indicates substantially greater procedural effort or complexity than typical for a given CPT code — for example, morbid obesity…
- Modifier 24 (Unrelated E/M in Postoperative Period)Codingaka Modifier 24, -24, Unrelated E/M Modifier
Modifier 24 identifies an Evaluation and Management (E/M) service performed by the same physician during the postoperative period of a prio…
- Modifier 25Codingaka Mod 25, Significant Separately Identifiable E&M Modifier
Modifier 25 indicates that a significant, separately identifiable evaluation and management (E&M) service was performed by the same physici…
- Modifier 26 — Professional ComponentCodingaka Mod 26, PC Modifier, Professional Component Modifier
Modifier 26 identifies the professional component of a service that has both a professional and technical component — typically a physician…
- Modifier 33 (Preventive Services)Codingaka Mod 33, Modifier 33 Preventive, PPACA Modifier
Modifier 33 identifies a service as a preventive service covered under the Affordable Care Act without patient cost-sharing when medically…
- Modifier 50 (Bilateral Procedure)Codingaka Modifier 50, Bilateral Procedure Modifier, -50
Modifier 50 identifies that a procedure was performed bilaterally — on both sides of the body during the same operative session. Medicare a…
- Modifier 51 — Multiple ProceduresCodingaka Mod 51, Multiple Procedure Modifier
Modifier 51 identifies the second and subsequent procedures performed by the same provider on the same date when multiple distinct surgical…
- Modifier 52 (Reduced Services)Codingaka Mod 52, Reduced Services Modifier, Modifier 52 Reduced
Modifier 52 indicates that a service or procedure was partially reduced or eliminated at the provider's discretion. It is used when the ser…
- Modifier 53 (Discontinued Procedure)Codingaka Mod 53, Discontinued Procedure Modifier
Modifier 53 identifies a procedure that was discontinued after anesthesia induction or after the procedure was started, due to extenuating…
- Modifier 57 — Decision for SurgeryCodingaka Mod 57, Decision for Surgery Modifier
Modifier 57 is appended to an evaluation and management service when the E/M visit resulted in the initial decision to perform a major surg…
- Modifier 58 (Staged or Related Procedure)Codingaka Mod 58, Staged Procedure Modifier
Modifier 58 identifies a staged or related procedure performed by the same physician during the postoperative period of the original surger…
- Modifier 59Codingaka Mod 59, Distinct Procedural Service Modifier, XE/XS/XP/XU Modifiers (X-series)
Modifier 59 designates a distinct procedural service that would otherwise be bundled with another procedure on the same date. It permits se…
- Modifier 62 (Two Surgeons)Codingaka Mod 62, Co-Surgeon Modifier, Two Surgeons Modifier
Modifier 62 identifies a procedure requiring two surgeons as co-surgeons, each performing distinct parts of the procedure. Both surgeons bi…
- Modifier 66 (Surgical Team)Codingaka Mod 66, Surgical Team Modifier
Modifier 66 identifies a procedure requiring a surgical team of more than two surgeons working together, typically for highly complex proce…
- Modifier 76 — Repeat Procedure by Same PhysicianCodingaka Mod 76, Repeat Procedure Modifier
Modifier 76 indicates that the same physician or qualified health professional repeated a procedure or service on the same date of service.…
- Modifier 78 (Unplanned Return to OR During Global Period)Codingaka Modifier 78, -78, Unplanned Return to OR
Modifier 78 identifies an unplanned return to the operating room for a related procedure during the postoperative global period of an initi…
- Modifier 79 (Unrelated Procedure During Global Period)Codingaka Modifier 79, -79, Unrelated Procedure Modifier
Modifier 79 identifies an unrelated procedure performed by the same physician during the postoperative global period of a prior surgery. Be…
- Modifier 80 (Assistant Surgeon)Codingaka Mod 80, Assistant Surgeon Modifier
Modifier 80 identifies a physician serving as assistant surgeon during a surgical procedure. The assistant provides surgical support to the…
- Modifier 91 (Repeat Clinical Diagnostic Laboratory Test)Codingaka Modifier 91, -91, Repeat Laboratory Test Modifier
Modifier 91 identifies a repeat clinical diagnostic laboratory test performed on the same patient on the same day to obtain subsequent meas…
- Modifier AT (Active Treatment for Chiropractic)Codingaka Mod AT, Chiropractic Active Treatment Modifier
Modifier AT is required on chiropractic manipulation codes billed to Medicare when the service is active treatment rather than maintenance…
- Modifier CS (Cost-Sharing Waived for COVID-19 Testing)Codingaka Mod CS, COVID Cost-Sharing Waiver Modifier
Modifier CS identifies services for which cost-sharing is waived under the Families First Coronavirus Response Act and CARES Act for COVID-…
- Modifier GA (Waiver of Liability Statement on File)Codingaka Mod GA, ABN on File Modifier
Modifier GA indicates that a mandatory Advance Beneficiary Notice (ABN) has been issued to a Medicare beneficiary for a service that may be…
- Modifier GY (Statutorily Excluded)Codingaka Mod GY, Statutorily Excluded Modifier
Modifier GY indicates a service is statutorily excluded from Medicare coverage by law, not by medical-necessity determination. Examples inc…
- Modifier KX (Requirements Specified in Medical Policy Met)Codingaka Modifier KX, -KX, Medical Necessity Attestation
Modifier KX attests that specific medical policy or documentation requirements for a service have been met. Used most commonly in therapy s…
- Modifier TC (Technical Component)Codingaka Modifier TC, -TC, Technical Component Modifier
Modifier TC identifies the technical component of a diagnostic service — the equipment, supplies, non-physician personnel, and facility cos…
- Modifier XE (Separate Encounter)Codingaka Mod XE, Separate Encounter Modifier, X-Modifier
Modifier XE identifies a service that is distinct because it occurred during a separate patient encounter on the same date. It is one of fo…
- Modifier XS (Separate Structure)Codingaka Mod XS, Separate Structure Modifier, X-Modifier
Modifier XS identifies a service that is distinct because it was performed on a separate organ or anatomic structure. It is one of four X-m…
- Modifier XU (Unusual Non-Overlapping Service)Codingaka Mod XU, Unusual Non-Overlapping Service Modifier, X-Modifier
Modifier XU identifies a service as distinct because it does not overlap the usual components of another service, used as a catch-all X-mod…
- Modifiers LT and RT (Left/Right Side)Codingaka Modifier LT, Modifier RT, -LT
Modifiers LT (left side) and RT (right side) identify the laterality of a procedure or item performed on a paired body part. They communica…
- MS-DRG (Medicare Severity Diagnosis-Related Group)Codingaka MS-DRG, Medicare Severity DRG
MS-DRG is the Medicare-specific severity-adjusted DRG classification used for inpatient prospective payment since 2008. It replaced the pri…
- Multiple Procedure Payment Reduction (MPPR)Codingaka MPPR, Multiple Procedure Reduction, Multiple Surgery Reduction
MPPR is Medicare's policy reducing payment for secondary and subsequent procedures performed on the same day to reflect pre- and post-servi…
N
- National Drug Code (NDC)Codingaka NDC, NDC Number, National Drug Code
The National Drug Code (NDC) is a unique 10- or 11-digit numeric identifier assigned by FDA to every drug product, identifying labeler, pro…
- NCCI EditsCodingaka National Correct Coding Initiative, NCCI, NCCI PTP Edits
NCCI Edits are the National Correct Coding Initiative edits published by CMS that identify code pairs that should not be billed together be…
- NLP in HealthcareCodingaka Clinical NLP, Medical NLP, Healthcare NLP
Natural Language Processing (NLP) in healthcare applies computational linguistics to clinical text — progress notes, discharge summaries, p…
P
- Present on Admission (POA Indicator)Codingaka POA, POA Indicator, Present On Admission
The Present on Admission (POA) indicator is a single-character code appended to diagnosis codes on inpatient institutional claims identifyi…
- Procedure-to-Procedure (PTP) EditCodingaka PTP Edit, NCCI PTP, Code Pair Edit
A Procedure-to-Procedure (PTP) Edit is a type of NCCI edit specifying that two procedure codes should not be reported together for the same…
- Professional Component (Modifier 26)Codingaka PC, Professional-Only Component, Interpretation Component
The professional component of a procedure represents the physician's interpretation and professional work, typically for diagnostic service…
- Prospective Risk AdjustmentCodingaka Prospective Chart Review, Pre-Visit Risk Review, Annual Wellness HCC Review
Prospective risk adjustment is the proactive identification of suspect chronic conditions before a patient's next visit so the provider can…
R
- Retrieval-Augmented Generation (RAG)Codingaka RAG, RAG Architecture, Grounded Generation
Retrieval-Augmented Generation (RAG) is an AI architecture that grounds LLM outputs in retrieved source data. A retrieval step fetches rele…
- Retrospective Risk AdjustmentCodingaka Retrospective Chart Review, Post-Visit HCC Capture, Chart Review Program
Retrospective risk adjustment is the review of completed clinical documentation to identify HCCs that should have been coded on submitted c…
- Revenue Code (UB-04 Form Locator 42)Codingaka Rev Code, UB-04 Revenue Code, Institutional Revenue Code
Revenue codes are four-digit codes on UB-04 institutional claims identifying the type of service or accommodation charged. They categorize…
- Risk AdjustmentCodingaka Risk Adjustment Coding, HCC Risk Adjustment, CMS-HCC Model
Risk adjustment is a statistical method that modifies payment or quality scores based on the health status and demographic attributes of en…
- Risk Adjustment Factor (RAF) ScoreCodingaka RAF, Risk Score, CMS-HCC Risk Score
The Risk Adjustment Factor (RAF) score is a numeric representation of an individual beneficiary's expected Medicare cost derived from docum…
- RxHCC (Prescription Drug Hierarchical Condition Category)Codingaka RxHCC Model, Part D Risk Adjustment, Prescription Drug HCC
RxHCC is the CMS risk-adjustment model that sets Medicare Part D prescription drug plan payments. It maps ICD-10-CM diagnoses to drug-cost…
S
- Split/Shared VisitCodingaka Split/Shared Visit, Split Shared Billing, Shared E/M
A split/shared visit is an E/M service in a facility setting where a physician and an NPP (nurse practitioner, physician assistant) both pe…
- Suspect ConditionCodingaka Suspect HCC, Suspected Diagnosis, Flagged Condition
A suspect condition is a likely-present but uncoded diagnosis flagged for provider evaluation during a risk-adjustment review. Suspects are…
T
- Teaching Physician RulesCodingaka TP Rules, Medicare Teaching Physician Requirements, Attending Physician Rules
Teaching Physician Rules are CMS requirements governing how teaching hospitals bill Medicare for services involving residents. The attendin…
- Telehealth BillingCodingaka Telemedicine Billing, Virtual Visit Billing, Telehealth Claims
Telehealth billing is the claims process for virtual patient encounters — video visits, audio-only calls, asynchronous messaging, and remot…
- Time-Based E/M CodingCodingaka E/M Time-Based Leveling, Total Time E/M, Time-Driven Coding
Time-Based E/M Coding uses total time spent on the patient's care on the encounter date — including pre-visit review, face-to-face encounte…
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