10 Must-Know Medical Billing and Coding Acronyms - dummies

10 Must-Know Medical Billing and Coding Acronyms

By Karen Smiley

Part of Medical Billing & Coding For Dummies Cheat Sheet

The world of medical billing and coding is like one big bowl of alphabet soup because using abbreviations and acronyms in medical records saves time. Each medical office will have its own most frequently used acronyms based on its area of expertise; but here are some of the most common abbreviations and acronyms used in all medical offices:

  • CMS (Centers for Medicare & Medicaid Services): The division of the United States Department of Health and Human Services that administers Medicare, Medicaid, and the Children’s Health Insurance Program.

  • EDI (Electronic Data Interchange): The electronic systems that carry claims to a central clearinghouse for distribution to individual carriers.

  • EOB (Explanation of Benefits). A document, issued by the insurance company in response to a claim submission, that outlines what services are covered (or not) and at what level of reimbursement. Each payer has its own EOB form.

  • HIPAA (Health Insurance Portability and Accountability Act): The law, sometimes called the Privacy rule, outlining how certain entities like health plans or clearinghouses can use or disclose personal health information. Under HIPAA, patients must be allowed access to their medical records.

  • HMO (Health Maintenance Organization): A health management plan that requires the patient use a primary care physician who acts as a “gatekeeper.” In HMOs, patients much seek treatment from the primary physician first, who, if she feels the situation warrants it, can refer the patient to a specialist within the network.

  • INN (in-network): A provider who has a contract with either the insurance company or the network with whom the payer participates.

  • OON (out-of-network): An out-of-network provider is one who does not have a contract with the patient’s insurance company.

  • POS (Point of Service): A health insurance plan that offers the low cost of HMOs if the patient sees only network providers.

  • PPO (Preferred Provider Organization): A health management plan that allows patients to visit any providers contracted with their insurance companies. If the patient visits a non-contracted provider, the claim is considered out-of-network.

  • WC (Workers’ Compensation): U.S. Department of Labor program that insures employees who are injured at work.