Balance Billing - The practice of billing a patient for the fee amount remaining after insurer payment and co-payment have been made. Under Medicare, the excess amount cannot be more than 15 percent above the approved charge.
CAP – College of American Pathologists
Case/Accession – For tracking and identification purposes, each specimen (tissue, fluid, etc.) is assigned an accession number upon receipt at a lab. Accession series vary among groups. Common series are S for surgicals, C for non-gyn cytologies, BM for bone marrows, P for pap smear, etc.
Claim – A request by an insured person for the medical insurance benefits provided by the person’s contract.
CLIA – Clinical Laboratory Improvement Act, which sets standards for laboratory certification.
COB – Coordination of Benefits; a process for determining payment obligations when two or more health plans have financial responsibility for a medical claim.
CSR – Client Service Representative; Practice marketing representative who is primarily responsible for maintaining business from referring physician. If the practice doesn’t employ a BDR the CSR will also focus on increasing business from referring physicians.
Cytologist – A person trained in cytology
Cytology - The branch of biology that deals with the formation, structure, and function of cells.
Date of Service – The date the service or procedure was performed. This is usually the collection date on the pathology report.
Demo – Patient demographic
Dermatology - The branch of medicine that is concerned with the physiology and pathology of the skin (e.g., Skin Biopsies).
DHHS – Department of Health Human Services, the federal agency that administers the Medicare program through the center for Medicare and Medicaid Services, a division of DHHS.
EOB – Explanation of Benefits
FISH – (Florescent In-Situ Hybridization) Type of genetic testing which will determine what type of treatment the patient should receive, and the patient’s ability to recover from the treatment.
Flow Cytometry - A method of measuring fluorescence from stained cells that are in suspension and flowing through a narrow orifice, usually in combination with one or two lasers to activate the dyes; used to measure cell size, number, viability, and nucleic acid content with the aid of acridine orange, Kasten fluorescent Feulgen stain, ethidium bromide, trypan blue, and other selected staining reagents. As referred to by codes 88184, 88185, 88187, 88188 and 88189.
Gastroenterology - The branch of medicine dealing with the study of disorders affecting the stomach, intestines, and associated organs (e.g., Tissue Biopsies).
Global – This service includes both the professional and technical components.
Gynecology - The branch of medicine dealing with health care for women, especially the diagnosis and treatment of disorders affecting the female reproductive organs (e.g., Pap Smears, Tissue Biopsies).
Hematology - The science encompassing the medical study of the blood and blood-producing organs.
HER2Neu – A type of FISH or Immunohistochemistry test run on Breast Cancers to determine what type of treatment would work best (e.g., breast biopsies).
HIPAA - Health Insurance Portability and Accountability Act - was established in 1996 as a set of rules to be followed by health plans, doctors, hospitals and other healthcare providers. The rules state that patients must have access to their medical records and that the records are kept confidential.
Histology - The anatomical study of the microscopic structure of tissues.
Histology/Surgical/Tissue – Study of microscopic tissue; specimens are often obtained during surgical procedures/biopsies.
HMO - Health Maintenance Organization – a healthcare system that assumes or shares both the financial risks and the delivery risks associated with providing comprehensive medical services to a voluntarily enrolled population in a particular geographic area, usually in return for a fixed, prepaid fee.
HPV - Human Papilloma Virus - has many strains that cause warts, especially of the hands, feet or genitals with some strains believed to be a causative factor in cancer of the cervix, vagina and vulva.
Internal Medicine - The branch of medicine that deals with the diagnosis and nonsurgical treatment of diseases affecting the internal organs of the body, especially in adults (e.g. Pap Smears, Tissue Biopsies).
MCO - Managed Care Organization – an entity that utilizes certain concepts or techniques to manage the accessibility, cost and quality of healthcare.
Medicaid – State programs of public assistance to persons whose income and resources are insufficient to pay for health care.
Medicare – The federal government’s hospital and medical insurance program for the aged, totally disabled, and those with end-stage renal disease. It is in two parts: Part A – hospital insurance and Part B – supplemental medical insurance.
Modifier – A two-digit code added to a CPT code to further explain the nature of the medical services provided.
Molecular Pathology – The study of DNA and its relationship to disease or inheritance patterns.
NCCI – National Correct Coding Initiative, a series of edits used by Medicare which prevent inappropriate billing of similar services.
Neurologist - Physician who specializes in the medical science that deals with the nervous system and disorders affecting it (e.g., Brain Biopsies).
Non-gyn Cytologies – Tests involving cells obtained from bodily fluids or tissues, excluding gynecological fluids/tissues. In other words, non-Pap smears.
Obstetrician - A physician who specializes in the care of women during pregnancy, childbirth, and the recuperative period following delivery (e.g., Pap Smears, Tissue biopsies).
Oncology - The branch of medicine that deals with tumors, including study of their development, diagnosis, treatment, and prevention (e.g., Bone Marrow).
Ophthalmology - The branch of medicine that deals with the anatomy, functions, pathology, and treatment of the eye (e.g., Eyelid Biopsies).
Otolaryngology - The branch of medicine that deals with diagnosis and treatment of diseases of the ear, nose, and throat (e.g., Tissue Biopsies and Non-Gyn Cytology smears).
Outpatient – Patient who is not admitted to the hospital, but is registered on hospital records and receives services.
Part A Compensation – Hospital insurance that pays for inpatient hospital stays, care in a skilled nursing facility, hospice care and some home health care.
Part B Compensation – Insurance that pays for physicians services.
Pathology - The scientific study of the nature of disease and its causes, processes, development, and consequences.
- Anatomic pathology - The subspecialty of pathology that pertains to the gross and microscopic study of organs and tissues removed for biopsy.
- Clinical pathology - The subspecialty of pathology that pertains to the technical aspects of chemistry, immunology, hematology (e.g., blood) and other fields as they pertain to the diagnosis and prevention of disease.
- Cytopathology - The study of disease changes within individual cells or cell types (e.g., fluid based specimens).
Pathology Report – Written summary of specimen collection, preparation, review and diagnosis.
PHI – Protected Health Information; Information about patients which healthcare entities are obligated not to release except in certain circumstances defined by HIPAA.
Place of Service – The place where the specimen originated (doctor’s office, hospital inpatient, hospital outpatient).
Plastic Surgery - Surgery to remodel, repair, or restore body parts, especially by the transfer of tissue (e.g., Skin Biopsies).
Podiatry - The branch of medicine that deals with the diagnosis, treatment, and prevention of diseases of the human foot (e.g., Tissue Biopsies).
PPO - Preferred Provider Organization – a healthcare benefit arrangement designed to provide services at a discounted cost by providing incentives for members to use designated healthcare providers (who contract with the PPO at a discount), but which also provides services rendered by healthcare providers who are not part of the PPO network.
Professional (26) – A CPT code modifier which refers to the interpretation of the specimen for diagnosis by the pathologist.
Professional Component of Clinical Lab Services – These services (commonly referred to as “Part A services”) are medically necessary services that are separate and distinct from the technical component of clinical laboratory services. They encompass many different elements including the pathologist’s direction of laboratory technical personnel, the direction, performance and evaluation of quality assurance and quality control procedures, etc.
Provider – An individual or institution which renders medical care.
PSA - Pathology Service Associates, LLC – the business solution for pathology.
Reasonable and Customary Charge – Refers to the maximum amount an insurer will reimburse for medical care expenses covered under group health insurance plans.
Reference Lab – Any lab that receives a specimen from another lab for testing, usually involving highly specialized tests not routinely performed in standard laboratory.
Referring Physician – A physician who refers specimens to a laboratory.
Requisition – Written or printed request for testing and/or consultation.
Review of Major Third Party Payors Report:
- Personal – Self pay
- Sec – Secondary insurance
- Tert – Tertiary insurance
- The column labled “Personal/Sec/Tert” shows the total amount of Ending Receivables by payor not currently primary insurance’s responsibility.
- Net Ratio – Net Collection percentage. This is calculated by dividing Net Collections by Net Charges.
Technical (TC) – A CPT code modifier which indicates “technical component” of a service, specifically the preparation of the slide by the pathologist.
Urology - The branch of medicine that deals with the diagnosis and treatment of diseases of the urinary tract and urogenital system (e.g., Core Tissue Biopsies).
Complete terms of Health Insurance Terminology: http://www.agencyinfo.net/iv/medical/health-terms.htm