Home Health & AI Glossary

A 30-Day Payment Period is the unit of reimbursement under PDGM. Medicare pays home health agencies separately for each 30-day period based on the patient's clinical characteristics and visit utilization.

Abstracting is the process of reviewing medical records and extracting key clinical information, including diagnoses, procedures, demographics, and other key data elements for coding and reporting.

Provider group responsible for care quality and cost outcomes.

Basic self care tasks like bathing, dressing, eating, and walking.

An Activity Code identifies the activity the patient was performing when an injury or other health event occurred

Federal standard requiring Medicaid managed care capitation rates to be adequate and appropriate.

An Acute Condition is a disease, illness, or injury with a sudden onset that generally requires immediate or short-term treatment

Acute Kidney Injury (AKI) Coding identifies sudden declines in kidney function resulting from dehydration, infection, medication toxicity, surgery, or other acute causes.

An Activities of Daily Living (ADL) Assessment evaluates a patient's ability to independently perform essential self-care tasks such as bathing, dressing, grooming, and eating.

Formal start of services for a patient.

Initial evaluation of patient condition and care needs.

The Admission Diagnosis is the condition documented at the time a patient is admitted for evaluation or treatment

Admission Source identifies where the patient came from immediately before starting home health services

An Additional Documentation Request (ADR) is a formal request from Medicare or one of its contractors asking a home health agency to submit records that support a billed claim.

Notice given when Medicare may not cover a service.

ACA marketplace subsidy that lowers your monthly health insurance premium.

A Medicaid managed care plan decision to deny, reduce, or end services.

An Adverse Effect is an unintended harmful reaction that occurs when a medication is correctly prescribed and properly administered at the recommended dosage.

Unexpected harmful patient care outcome.

2010 law, also called Obamacare, that expanded access to health insurance.

An Aftercare Code (typically a Z code) is assigned when a patient is receiving continued care after the active treatment phase of a condition has ended.

Automated warning generated from data or documentation.

AI support for selecting accurate billing or diagnosis codes.

AI Clinical Documentation is the use of artificial intelligence to assist clinicians with creating, reviewing, organizing, and improving patient documentation.

AI Documentation refers to the use of artificial intelligence to assist clinicians in creating, organizing, reviewing, and improving clinical documentation.

Tool that helps clinicians create or improve notes.

AI based prediction of patient or operational risk.

Instructions for home health aide services.

RN oversight of aide care quality and performance.

Step based logic used by software or AI.

APR-DRGs (All Patient Refined Diagnosis-Related Groups) are a patient classification system used by many state Medicaid programs and private payers.

The Alphabetic Index is the alphabetical listing of diseases, conditions, symptoms, injuries, and external causes found within the ICD-10-CM manual.

Alzheimer's Disease Coding identifies Alzheimer's disease as the underlying diagnosis and often requires an additional code for associated dementia or behavioral disturbances.

An Ambulation Assessment specifically evaluates a patient's walking ability, gait, endurance, balance, speed, and need for mobility aids or assistance.

The American Health Information Management Association (AHIMA) is a professional organization that supports health information management professionals.

The American Hospital Association (AHA) is one of the Cooperating Parties responsible for ICD-10-CM coding guidance in the United States.

Rule that a state Medicaid benefit must be sufficient to reasonably achieve its purpose.

Annual ICD-10-CM Updates are revisions released each fiscal year that may add new diagnosis codes, revise existing code descriptions, delete obsolete codes, and update guidelines.

Yearly notice of Medicare Advantage or Part D plan changes, sent by September 30.

Anxiety Disorder Coding includes diagnosis coding for generalized anxiety disorder, panic disorder, phobias, social anxiety disorder, and other anxiety-related conditions.

Request to reverse a payer denial decision.

The decision a Medicaid managed care plan makes about an appeal.

Arrhythmia Coding involves assigning diagnosis codes for abnormal heart rhythms, including atrial fibrillation, atrial flutter, ventricular arrhythmias, and conduction disorders.

AI Coding refers to the use of artificial intelligence technologies to analyze clinical documentation, recommend diagnosis codes, identify documentation gaps, and improve coding accuracy.

Review of patient health, function, and care needs.

Maximum countable resources allowed to qualify for Medicaid.

Provider agreement to accept the Medicare-approved amount as full payment.

Asthma Coding requires documentation of asthma severity and whether the patient is experiencing an exacerbation or status asthmaticus.

Record of system actions, edits, and changes.

Payer approval for requested care or services.

The length of time a Medicaid plan agrees to cover authorized services.

Software review of documentation for errors or gaps.

Software check of coding accuracy and completeness.

Average number of active patients per day.

Average price wholesalers pay drug makers, used to calculate Medicaid rebates.

Administrative team supporting care delivery and billing.

A Bathing Assessment measures the patient's ability to safely bathe or shower, including entering and exiting the bathing area, washing all body areas, and drying off safely.

Bedside Documentation refers to recording clinical information in the patient's presence during the visit

Behavioral Adjustment is a Medicare policy adjustment incorporated into PDGM payment calculations based on CMS assumptions about provider behavior.

A Behavioral Assessment evaluates emotional and behavioral symptoms such as anxiety, depression, agitation, aggression, confusion, or impaired judgment.

Person eligible for Medicare or insurance benefits.

How Part A measures a hospital or nursing stay, ending after 60 days without inpatient care.

Lowest manufacturer price for a drug, used in calculating Medicaid rebates.

Process of submitting claims for payment.

Mistake that can delay or reduce payment.

Temporary pause before claim submission.

Billing Period is the timeframe for which a Medicare claim is submitted

Check of billing details before claim submission.

The Brief Interview for Mental Status (BIMS) is a standardized cognitive assessment that evaluates memory, orientation, and recall.

Former 1980 to 1997 law requiring reasonable and adequate Medicaid facility payment rates.

Lowest-premium ACA metal tier; the plan covers about 60% of costs.

Burn Coding requires documentation of the burn site, depth, and extent of body surface involved.

Staff exhaustion caused by workload or stress.

Data reporting used for operational decisions.

Section 125 employer plan that lets you choose pretax benefits.

Fixed monthly per-member payment a state makes to a Medicaid managed care plan.

Cardiovascular Disease Coding involves assigning ICD-10-CM codes for disorders affecting the heart and blood vessels, including hypertension, coronary artery disease, heart failure, and arrhythmias.

Consistent and coordinated care across visits.

Organizing services across providers and disciplines.

Defined period of patient care.

Completion of documentation and billing for a care period.

Unmet care need or delayed required service.

Desired patient outcome in the care plan.

Oversight of patient services, progress, and outcomes.

Formal plan listing services, goals, and visit frequency.

Care delivered differently from the approved plan.

Care Transitions refer to the movement of patients between healthcare settings, such as from a hospital to home health, home health to outpatient services.

Person supporting the patient at home.

Caregiver Availability refers to the presence, reliability, and capacity of family members, friends, or other caregivers who assist the patient.

Caregiver Education involves teaching family members or caregivers how to safely support the patient's care at home

Excluding certain services, often behavioral health, from a Medicaid managed care contract.

Team discussion about patient care and progress.

Number of patients assigned to a clinician.

Clinician coordinating patient care and services.

Case Mix Calculation combines the patient's clinical grouping, functional impairment level, timing, admission source, and comorbidity adjustment to determine the PDGM payment.

The Case Mix Index (CMI) is a measure of the average clinical complexity and expected resource utilization of a healthcare organization's patient population.

Case-Mix Weight is a numerical value assigned to each PDGM payment group

Final Part D phase where the plan pays 100% after the out-of-pocket cap is met.

Medicaid eligibility limited to specific groups like children, the aged, or people with disabilities.

Mandatory Medicaid eligibility groups that states are required to cover.

Total number of active patients under care.

Approved time period for home health services.

The Certified Coding Associate (CCA) credential, awarded by AHIMA, is an entry-level certification that validates foundational knowledge of medical coding.

The Certified Coding Specialist (CCS) credential, awarded by AHIMA, recognizes advanced expertise in hospital inpatient and outpatient coding using ICD-10-CM, ICD-10-PCS, and CPT.

The Certified Professional Coder (CPC) credential, awarded by AAPC, demonstrates expertise in physician office, outpatient, and professional-fee coding.

Significant change in patient health status.

Chapter-Specific Guidelines are coding instructions that apply only to certain ICD-10-CM chapters, such as infectious diseases, neoplasms, endocrine disorders, or pregnancy.

Complete patient clinical and administrative record.

Finishing required patient documentation.

Finalizing documentation with controlled future edits.

Low-cost coverage for children in families earning too much for Medicaid.

A Chronic Condition is a long-lasting disease that persists for months or years and often requires ongoing medical management

Chronic Disease Management is the ongoing monitoring, treatment, and education of patients living with long-term conditions such as heart failure, diabetes, and COPD.

CKD Coding involves assigning ICD-10-CM codes based on the documented stage of chronic kidney disease

A financial penalty imposed for Medicaid program violations.

Payment request submitted to a payer.

Payer refusal to pay a submitted claim.

A Claim Rejection occurs before payer adjudication when a claim fails initial validation due to formatting errors, missing information, invalid codes, or patient eligibility issues.

Tool that checks claims before submission.

Claim Submission is the process of electronically or manually sending a healthcare claim to an insurance payer for reimbursement after services have been provided.

Claims Scrubbing is the automated or manual review of healthcare claims before submission to identify coding errors, missing information, invalid codes, and payer-specific issues.

A Clean Claim is a healthcare claim that contains complete, accurate, and valid information, allowing it to be processed and paid without requiring corrections or additional information.

Warning about patient, documentation, or care risk.

Clinical Coding is the process of translating documented patient diagnoses and conditions into standardized ICD-10-CM codes for billing, compliance, and reporting.

Clinical Compliance refers to consistently providing patient care according to evidence-based practice, Medicare regulations, physician orders, and agency policies.

Clinical Data Quality refers to the accuracy, completeness, consistency, and usability of clinical information captured within the medical record.

Software guidance for care decisions.

Written record of patient care and condition.

Clinical Documentation Integrity (CDI) is the process of ensuring patient documentation is complete, accurate, consistent, and sufficiently specific to support coding and billing.

A Clinical Documentation Review is the systematic evaluation of patient records to verify accuracy, completeness, coding support, compliance with regulations, and clinical consistency.

Raising a patient issue for higher clinical attention.

Clinical Governance is the framework through which a healthcare organization is accountable for continuously improving the quality and safety of patient care.

Clinical Grouping is one of the primary factors used by PDGM to determine payment

Professional decision making based on patient status.

Written summary of a visit or care activity.

Measurable result of patient care.

Standard care process for a condition.

A Clinical Record is the comprehensive collection of all patient-related clinical documentation generated throughout an episode of care.

Evaluation of care quality and documentation support.

Clinical Specificity refers to documenting diagnoses with the highest level of detail available, including severity, anatomical location, laterality, and causal relationships.

Confirmation that documentation supports care and rules.

Federal agency overseeing Medicare and Medicaid.

CMS Guidelines are official instructions, manuals, regulations, and policy documents published by CMS to help providers correctly implement Medicare requirements.

The CMS OASIS Manual is another commonly used name for the official OASIS Guidance Manual published by the Centers for Medicare & Medicaid Services.

The CMS Payment Model refers to the methodology developed by the Centers for Medicare & Medicaid Services to determine reimbursement for covered services.

CMS-485 was the traditional Medicare Home Health Certification and Plan of Care form used to document physician orders, diagnoses, treatment orders, and visit frequencies.

Law letting employees keep group health coverage after job loss or reduced hours.

A Code Also instruction advises coders that two conditions may both require reporting when supported by provider documentation

Code Assignment is the process of selecting the most accurate ICD-10-CM code based on the provider's documented diagnosis, official coding guidelines, and applicable coding conventions.

A Code Category is the first three characters of an ICD-10-CM code that identify a general disease or condition group

A Code First Note instructs coders to report the underlying disease or condition before assigning the current diagnosis code

A Code Freeze is a temporary suspension of routine updates to a healthcare coding system, typically implemented during major transitions or public health emergencies.

Code Search is the process of locating diagnosis codes by entering keywords, clinical terms, symptoms, or code numbers into an ICD-10 coding resource.

A Code Set is a standardized collection of healthcare codes used to classify diagnoses, procedures, services, supplies, and other clinical information.

Code Specificity refers to selecting the most detailed ICD-10-CM code supported by provider documentation

Assigning standard codes for diagnosis or billing.

Correct use of diagnosis and billing codes.

A Coding Audit is a systematic review of coded medical records to evaluate coding accuracy, documentation support, guideline compliance, and billing integrity.

Coding Benchmarking is the process of comparing coding performance metrics, such as accuracy, productivity, denial rates, and turnaround times, against internal or industry standards.

Coding Best Practices are recommended methods for assigning diagnosis and procedure codes accurately, consistently, and in compliance with official guidelines.

Coding Clinic is the official publication that provides coding advice and clarification for ICD-10-CM and ICD-10-PCS. It is recognized by CMS as an official source of coding guidance.

Coding Compliance means assigning diagnosis codes according to the Official ICD-10-CM Coding Guidelines, payer requirements, federal regulations, and official coding advice.

Coding Conventions are standardized rules built into the ICD-10-CM classification system

Coding Education refers to ongoing training provided to medical coders, clinicians, Clinical Documentation Integrity (CDI) specialists, and healthcare staff.

Coding Ethics refers to the professional standards that require coders to report diagnoses accurately, honestly, and objectively without altering codes to influence reimbursement.

Coding Governance is the framework of policies, leadership, oversight, auditing, education, and accountability that ensures consistent, compliant, and accurate coding.

Coding Guidelines are the official rules published annually for applying ICD-10-CM codes correctly

Coding Operations encompasses the daily management of coding staff, workflows, quality assurance, productivity monitoring, education, compliance, and reporting.

Coding Performance Metrics are standardized measures used to evaluate coding quality and operational efficiency

Coding Productivity measures the volume of medical records or encounters coded by a medical coder within a defined period while maintaining coding accuracy.

Coding Quality Assurance (QA) is the ongoing process of monitoring coding accuracy, consistency, compliance, and productivity through audits and feedback.

A Coding Query is a formal request from a coder or Clinical Documentation Integrity (CDI) specialist asking the healthcare provider to clarify ambiguous or incomplete documentation.

A Coding Specialist is a trained professional responsible for reviewing medical records, interpreting provider documentation, assigning accurate codes, and supporting compliant billing.

Coding Validation is the process of reviewing assigned diagnosis codes to confirm they accurately reflect provider documentation, comply with coding guidelines, and support billing.

A Coding Workflow is the sequence of activities involved in reviewing documentation, assigning diagnosis and procedure codes, validating code accuracy, and finalizing records for billing.

A Cognitive Assessment measures a patient's memory, attention, orientation, decision-making ability, comprehension, and overall cognitive function.

Cognitive Function refers to a person's ability to think, remember, reason, learn, communicate, and make decisions

Your share of a cost, usually a percentage, paid after the deductible.

A Combination Code is a single ICD-10-CM code that captures multiple related clinical concepts, such as a disease with an associated complication or manifestation.

Community Admission refers to patients who begin home health services without a recent qualifying institutional stay, such as patients referred directly by a community physician.

Additional condition present with the primary diagnosis.

Comorbidity Adjustment is an additional payment adjustment under PDGM that recognizes the increased complexity of caring for patients with qualifying secondary diagnoses.

Rule that Medicaid benefits must be equal across categorically needy beneficiaries.

Following legal, payer, and clinical requirements.

A Compliance Audit is a formal evaluation of an agency's adherence to Medicare regulations, payer requirements, internal policies, and accreditation standards.

Compliance Monitoring is the ongoing process of evaluating whether an agency consistently follows Medicare regulations, payer requirements, agency policies, and accreditation standards.

A Compliance Officer is the individual responsible for overseeing an organization's compliance program, monitoring adherence to healthcare regulations, and coordinating audits and training.

A Compliance Program is a formal organizational framework designed to ensure adherence to healthcare laws, regulations, coding guidelines, payer requirements, and ethical standards.

Chance of violating rules or documentation standards.

A Complication is an unexpected condition or adverse event that develops during the course of a disease, medical treatment, or surgical procedure.

A Complication or Comorbidity (CC) is a secondary diagnosis that increases patient complexity but generally has less impact than an MCC. CCs influence DRG assignment and reimbursement.

A Comprehensive Assessment is the complete clinical evaluation required by CMS to identify a patient's physical, emotional, cognitive, and functional care needs.

Comprehensive Error Rate Testing (CERT) is a CMS program that measures improper Medicare fee-for-service payments through random claim reviews.

Computer-Assisted Coding (CAC) uses software to analyze clinical documentation and suggest diagnosis and procedure codes for coder review.

Tracking patient health changes over time.

Keeping current Medicaid services during an appeal if it is filed on time.

Option letting a beneficiary, often a child, stay enrolled for a set period despite income changes.

Program assigning certain members to designated providers and pharmacies.

Record of communication or care coordination.

Fixed amount you pay for a covered service or medication.

COPD Coding is the assignment of diagnosis codes for Chronic Obstructive Pulmonary Disease and its associated manifestations, such as acute exacerbations and lower respiratory infections.

Coronary Artery Disease (CAD) Coding identifies narrowing or blockage of the coronary arteries caused by atherosclerosis

Total care cost during one episode.

Income counted toward Medicaid eligibility after deductions and disregards.

A plan decision on whether it will pay for a service, item, or drug.

The former Part D donut hole, eliminated after 2024.

COVID-19 Coding follows official ICD-10-CM guidelines for reporting confirmed COVID-19 infections, related complications, post-COVID conditions, and history of infection.

A Current Procedural Terminology (CPT) Code is a standardized five-digit code developed by the American Medical Association (AMA) to describe medical services and procedures.

Verification of provider qualifications.

Drug coverage meeting Medicare standards that avoids the Part D late penalty.

A Crosswalk is a mapping tool used to relate one coding system to another, such as ICD-9-CM to ICD-10-CM or ICD-10-CM to HCC categories.

Active patient count on a given day.

Correctness of recorded information.

Collection of patient or operational information.

Visual display of key performance metrics.

Connection of data from multiple systems.

Reliability, completeness, and consistency of data.

Separating Medicaid eligibility from cash-assistance (welfare) eligibility.

A Death at Home Assessment is completed when a patient dies while receiving home health services and was not transferred to an inpatient facility.

Scheduled visit refused by the patient.

Amount you pay each year before your plan begins cost sharing.

A Default Code is the diagnosis code listed in the Alphabetic Index when a condition is documented without additional qualifying information.

Dementia Coding requires documentation of the underlying cause whenever known, as well as associated behavioral disturbances, psychotic symptoms, mood disturbances, and severity.

Refusal of payment by a payer.

Process for resolving and reducing denials.

Denials Management is the process of identifying, analyzing, correcting, and appealing insurance claim denials

HHS body that hears disputes between states and CMS over Medicaid.

Depression Coding identifies depressive disorders based on provider documentation, including type, severity, and remission status.

A Depression Screening evaluates whether a patient may be experiencing symptoms of depression that could affect recovery, treatment adherence, and quality of life.

Diabetes Coding involves assigning ICD-10-CM codes based on the type of diabetes, associated complications, manifestations, and treatment requirements such as insulin use.

Standard code representing a diagnosis.

Diagnosis Coding is the process of translating documented patient conditions into standardized ICD-10-CM diagnosis codes used for billing, compliance, and reimbursement.

Diagnosis Grouping is the process of categorizing ICD-10-CM diagnosis codes into clinically related groups used for reimbursement, reporting, and analytics.

Diagnosis Sequencing is the process of arranging diagnosis codes in the correct order based on CMS coding guidelines

Diagnosis Validation is the process of confirming that a documented diagnosis is supported by clinical evidence such as physician assessment, test results, and treatment documentation.

A Diagnosis-Related Group (DRG) is a Medicare inpatient hospital payment classification that groups patients with similar clinical conditions and resource use for payment purposes.

Digital Documentation refers broadly to clinical documentation created, managed, transmitted, and stored using digital technologies.

CMS denial of federal matching funds a state claimed for Medicaid.

Formal end of patient care.

A Discharge Assessment is completed when a patient is discharged from home health services because goals have been met, services are no longer needed, or the patient transfers to another setting.

Delay in ending care due to missing requirements.

The Discharge Diagnosis is the final diagnosis established after completing the patient's evaluation and treatment

Documentation completed at the end of care.

Preparing the patient for safe care transition.

Care role such as RN, PT, OT, ST, or aide.

Combination of care roles involved in treatment.

Extra Medicaid payments to hospitals that serve many low-income patients.

Portions of income or assets not counted when determining Medicaid eligibility.

Correctness and completeness of patient records.

Review of records for accuracy and compliance.

Documentation Best Practices are proven methods that help clinicians produce clear, consistent, compliant, and defensible clinical records.

Time and effort spent on clinical records.

Documentation Completeness means all required clinical information has been recorded, including assessments, interventions, patient responses, and follow-up plans.

Documentation Compliance is the process of ensuring clinical records meet all applicable Medicare regulations, CMS Conditions of Participation, and payer requirements.

Documentation Consistency means that diagnoses, assessments, physician orders, visit notes, OASIS responses, and billing records all accurately reflect the same clinical picture.

A Documentation Deficiency is any missing, incomplete, inaccurate, inconsistent, or unsupported information within a patient's clinical record.

Documentation Efficiency refers to the ability of clinicians to complete accurate, compliant, and thorough documentation in the least amount of time possible.

Missing, wrong, or inconsistent record information.

Missing information needed for care, compliance, or payment.

A Documentation Improvement Strategy is an organized approach to improving clinical documentation through provider education, CDI programs, workflow redesign, and technology.

Strength, clarity, and completeness of records.

Documentation Requirements are the standards that provider documentation must meet to support accurate ICD-10-CM coding

Documentation Standards are the professional, regulatory, and organizational guidelines that define how clinical information should be recorded.

Documentation Timeliness refers to completing and signing clinical documentation within agency policies and payer-required deadlines.

Time taken to complete and submit documentation.

Documentation Workflow refers to the sequence of activities involved in creating, reviewing, approving, and submitting clinical documentation.

Another name for the now-defunct Part D coverage gap.

Downcoding occurs when diagnosis or procedure codes reflect a lower level of severity or complexity than supported by the provider's documentation.

A Dressing Assessment evaluates the patient's ability to select appropriate clothing, dress and undress independently, manipulate buttons or fasteners, and manage upper and lower body clothing.

Manufacturer payment to states that lowers the net cost of Medicaid drugs.

Review of Medicaid prescriptions for safety and appropriate use.

Qualifying for both Medicare and Medicaid coverage.

Repeated information entered unnecessarily.

Reusable medically necessary equipment like wheelchairs, walkers, and hospital beds.

Ear Disorder Coding includes diagnosis coding for conditions affecting the external, middle, and inner ear, including otitis media, hearing loss, and balance disorders.

Medicaid benefit providing preventive and treatment services for children under 21.

The Early Payment Period is the patient's first 30-day PDGM payment period after admission to home health

An Eating Assessment measures the patient's ability to feed themselves safely, including using utensils, chewing, swallowing, and consuming adequate food and fluids.

The Effective Date is the date on which newly released ICD-10-CM codes and coding guideline revisions become valid for reporting

A procedure that can be scheduled in advance, such as a knee replacement.

Electronic Documentation is the creation, storage, management, and retrieval of patient records using an Electronic Medical Record (EMR) or similar digital system.

Patient qualification for covered services.

Eligibility Documentation consists of the clinical evidence demonstrating that a patient meets Medicare's requirements for home health services.

Confirmation that patient coverage is active.

Emergency Department Coding involves coding diagnoses and procedures for patients evaluated and treated in the emergency department.

Emergency Preparedness involves assessing whether the patient has a plan for emergencies such as severe weather, power outages, natural disasters, or medical emergencies.

An Emergency Preparedness Program is a CMS-required organizational plan that prepares a home health agency to continue providing safe patient care during disasters and emergencies.

Electronic medical record system.

An Encoder is a coding application that guides users through official coding rules to identify appropriate diagnosis and procedure codes while checking for errors and compliance issues.

Encoder Software is a specialized application that assists medical coders in selecting valid ICD-10-CM, ICD-10-PCS, CPT, and HCPCS codes.

Interaction between patient and provider.

Encounter Documentation is the complete clinical record of a patient visit, including the patient's reason for the encounter, history, assessment, and treatment plan.

An Encounter Form, also known as a charge ticket or routing slip, is a document used by providers to record diagnoses, procedures, and services provided during a patient visit.

Permanent kidney failure needing dialysis or transplant; qualifies for Medicare at any age.

Endocrine Disorder Coding covers diseases affecting hormone-producing glands, including diabetes mellitus, thyroid disorders, adrenal disorders, and metabolic conditions.

The process of signing up for Medicare or a Medicare plan.

Contractor that helps Medicaid beneficiaries choose a managed care plan.

Legal guarantee of Medicaid coverage to everyone who meets eligibility rules.

Time bound period of patient care.

Episode Completion occurs when all planned services for a 30-day home health payment period have been delivered and documented before discharge, recertification, or transfer.

Oversight of care, visits, and documentation.

Payment tied to a defined care episode.

Episode Utilization measures the total clinical services delivered during a patient's home health payment period, including skilled nursing, therapy, and aide visits.

Measure of incorrect Medicaid eligibility or payment determinations.

Moving an issue to higher attention.

State recovery of Medicaid long-term care costs from a deceased recipient's estate.

An Etiology Code identifies the underlying disease or condition responsible for another diagnosis

Care guided by proven clinical evidence.

Document detailing what a Medicare Advantage or Part D plan covers and costs.

Report showing items outside normal expectations.

An Excludes1 Note means that two conditions cannot be reported together because they are considered mutually exclusive

An Excludes2 Note indicates that the excluded condition is not part of the coded diagnosis, but both conditions may exist at the same time.

Barring a provider from Medicaid participation for fraud or other violations.

Managed-care plan that covers only in-network care except in emergencies.

A Medicaid appeal decided on a shortened timeline.

Statement showing what your plan paid and what you owe; not a bill.

External Cause Codes identify how an injury or health condition occurred, including the mechanism of injury, place of occurrence, activity at the time of injury, and the patient's status.

An External Cause Status Code describes the patient's status at the time an injury occurred, such as whether the injury happened during military service, paid employment, or leisure activity.

Independent entity that reviews Medicaid managed care plan quality.

The Part D Low Income Subsidy that lowers prescription costs for limited-income enrollees.

Eye Disorder Coding covers diseases affecting the eye and visual system, including cataracts, glaucoma, diabetic retinopathy, macular degeneration, and other visual impairments.

Required physician encounter for home health eligibility.

Face-to-Face Documentation records the required encounter between an eligible healthcare provider and the patient that supports the need for home health services.

Face-to-Face Encounter Documentation is the physician or allowed practitioner's documentation confirming that a required face-to-face encounter occurred within the required timeframe.

A beneficiary's right to challenge a Medicaid denial or reduction before an official.

A Fall Risk Assessment identifies factors that increase a patient's likelihood of falling, including impaired mobility, poor balance, cognitive impairment, medications, and home hazards.

Alert that incorrectly identifies a problem.

Law giving eligible employees up to 12 unpaid weeks off while keeping coverage.

A Family History Code identifies diseases or conditions present in a patient's biological relatives that may influence the patient's future health risks.

The federal share of a state's Medicaid spending.

The federal matching rate for state Medicaid spending, known as FMAP.

Annual income benchmark used to set eligibility for Medicaid, CHIP, and subsidies.

Community clinic that receives enhanced Medicaid reimbursement.

Paying providers for each service, with no managed care plan involved.

Clinician delivering care in the patient's home.

Claim submitted after episode completion.

Medicaid eligibility based on income and asset limits.

Revenue lost from missed billing or documentation issues.

First-Pass Resolution refers to a claim being accepted and processed successfully upon its initial submission without rejection, denial, or requests for additional information.

Employer account for paying out-of-pocket health costs with pretax dollars.

A Follow-Up Assessment is an OASIS evaluation completed during ongoing care when significant clinical changes occur

A Follow-up Code (usually from the Z09 category) indicates that a patient is receiving routine follow-up care after completing treatment for a resolved condition.

The list of prescription drugs a Part D plan covers, organized in cost tiers.

Fracture Coding is the process of assigning diagnosis codes for bone fractures while documenting key clinical details such as the fracture site, laterality, and healing stage.

Fraud, Waste, and Abuse (FWA) refers to improper billing or healthcare practices that result in unnecessary costs or unlawful payments.

A Medicaid beneficiary's right to choose any participating provider.

How often visits or services are planned.

Physician approved change to visit frequency.

A Functional Assessment evaluates how well a patient performs activities necessary for daily living, including mobility, transfers, bathing, and dressing.

Functional Impairment Level measures the patient's ability to safely perform daily activities such as bathing, dressing, transferring, walking, and climbing stairs.

Reduced ability to perform daily activities.

Functional Outcomes measure changes in a patient's ability to perform activities of daily living (ADLs), mobility, transfers, ambulation, and self-care over an episode of care.

Evaluation of walking ability and safety.

Comparison of current state with desired state.

Gastrointestinal Disease Coding involves coding disorders affecting the digestive tract, including gastroesophageal reflux disease (GERD), peptic ulcer disease, and inflammatory bowel conditions.

General Equivalence Mappings (GEMs) are reference files developed by CMS and the CDC to assist in translating between ICD-9-CM and ICD-10-CM/PCS code sets.

Lower-cost drugs with the same active ingredients as brand-name versions.

Genitourinary Disorder Coding involves assigning ICD-10-CM codes for diseases affecting the kidneys, bladder, ureters, urethra, and reproductive organs.

Patient movement toward care plan goals.

ACA metal tier with higher premiums and lower out-of-pocket costs.

An acceptable reason for missing a Medicaid deadline or hearing.

A complaint about plan quality or service, different from an appeal.

A Grooming Assessment evaluates a patient's ability to independently perform personal hygiene activities such as brushing teeth, washing the face, and combing hair.

Revenue left after direct care costs.

Employer-sponsored plan covering employees and their dependents.

Protections that let you buy a Medigap plan without medical underwriting.

Hierarchical Condition Category (HCC) Coding is a risk adjustment methodology that uses selected ICD-10-CM diagnosis codes to predict future healthcare costs.

Healthcare Common Procedure Coding System (HCPCS) Level II codes identify medical supplies, durable medical equipment (DME), ambulance services, and other products and services not covered by CPT codes.

Health Information Management (HIM) is the practice of acquiring, organizing, protecting, analyzing, and managing patient health information throughout its lifecycle.

HIFA waiver expanding Medicaid or CHIP coverage using existing funds.

ACA exchange for comparing and buying health plans.

1996 law setting health data privacy, security, and coverage-portability rules.

Plan that covers only in-network providers except in emergencies.

Employer-funded plan that reimburses qualified medical expenses tax-free.

Tax-advantaged account for medical costs, paired with a high-deductible plan.

Healthcare Analytics is the use of clinical, financial, operational, and coding data to identify trends, measure performance, improve patient outcomes, and guide decisions.

A Hearing Assessment measures the patient's ability to hear spoken communication, respond to instructions, and safely participate in care.

Heart Failure Coding requires documentation of the specific type of heart failure whenever possible, including systolic, diastolic, or combined, and whether it is acute or chronic.

HEDIS (Healthcare Effectiveness Data and Information Set) is a widely used performance measurement tool developed by the National Committee for Quality Assurance (NCQA).

Hematologic and Immune Disorder Coding involves assigning ICD-10-CM codes for disorders of the blood, bone marrow, and immune system.

Home Health Agency.

Home Health Consumer Assessment of Healthcare Providers and Systems (HHCAHPS) is the national patient experience survey for Medicare-certified home health agencies.

Home Health Resource Groups (HHRGs) were the patient classification system used before PDGM. HHRGs relied heavily on therapy visit volume and were replaced by PDGM case-mix groups in 2020.

A High Comorbidity Adjustment applies when multiple qualifying secondary diagnoses substantially increase the complexity of patient care, raising the PDGM payment.

Plan with higher deductibles and lower premiums, eligible for an HSA.

The Health Insurance Prospective Payment System (HIPPS) Code is a five-character code generated after Medicare processes the patient's OASIS assessment and determines the PDGM payment rate.

A History Code (commonly a Z code) identifies conditions that existed in the past but are no longer active and may still influence current healthcare decisions.

Worker providing personal care support.

Covered home health services under Medicare.

Home Health Charting is the ongoing process of documenting patient assessments, treatments, skilled interventions, education, physician communications, and patient responses across the episode.

Home Health Coding involves assigning ICD-10-CM diagnosis codes that accurately reflect the patient's medical conditions requiring skilled home health services.

Home Health Documentation is the complete clinical record created during the delivery of skilled home healthcare services

Defined period of home health care.

The Home Health Primary Diagnosis is the ICD-10-CM diagnosis chiefly responsible for the patient's need for skilled home health services during the 30-day payment period.

The Home Health Prospective Payment System (HH PPS) is Medicare's overall reimbursement framework for home health services

The Home Health Quality Reporting Program (HH QRP) is a CMS program requiring Medicare-certified home health agencies to submit standardized quality data, including OASIS.

Home Health Star Ratings are CMS-generated performance scores that help patients compare Medicare-certified home health agencies

A Home Health Survey is an official inspection conducted by state survey agencies or accreditation organizations to determine whether a home health agency meets required standards.

The Home Health Value-Based Purchasing (HHVBP) Model is a CMS payment program that adjusts Medicare reimbursement based on an agency's quality performance.

A Home Health Visit Pattern describes how skilled visits are distributed throughout a patient's episode of care, including the sequence and spacing of visits across the payment period.

Care service delivered in a patient's home.

Home Visit Documentation is the clinical record completed after every home health visit

Waiver letting Medicaid cover care at home instead of in an institution.

Patient limitation supporting home health eligibility.

Medicare-covered end-of-life care for a terminal illness with a six-month prognosis.

Hospice Coding focuses on assigning diagnosis codes that identify the terminal illness and related conditions for patients receiving end-of-life care.

Patient returning to hospital shortly after discharge.

A Hospital-Acquired Condition (HAC) is a preventable medical condition that develops during a patient's hospital stay and was not present on admission.

Hospitalization Prevention includes interventions designed to reduce avoidable hospital admissions and emergency department visits through early intervention and proactive care.

Likelihood that a patient may need hospital care.

Federal restriction on using Medicaid funds for most abortions.

Hypertension Coding involves assigning ICD-10-CM codes for elevated blood pressure disorders, including essential hypertension and hypertensive heart disease and hypertensive chronic kidney disease.

An Instrumental Activities of Daily Living (IADL) Assessment measures more complex activities necessary for independent living, including meal preparation, medication management, housekeeping, and managing finances.

Standard diagnosis code used in healthcare.

ICD-10 Code Lookup is the process of searching for the correct ICD-10-CM diagnosis code using the Alphabetic Index, Tabular List, coding software, or official references.

The ICD-10-CM Code Structure is the standardized format used to build diagnosis codes

ICD-10-CM (International Classification of Diseases, Tenth Revision, Clinical Modification) is the standardized diagnosis coding system used in the United States.

ICD-10-PCS (Procedure Coding System) is the standardized coding system used to report inpatient hospital procedures in the United States.

ICD-9 to ICD-10 Mapping is the process of translating older ICD-9 diagnosis codes into their ICD-10-CM equivalents

Providers contracted with your plan, offering lower costs.

Record of an unexpected care or safety event.

An Includes Note appears in the ICD-10-CM Tabular List to define conditions that are included within a particular code category

Income-based surcharge added to Part B and Part D premiums for higher earners.

Patient record missing required information.

A Medicare contractor who reviews coverage appeals.

Practices used to prevent infection spread.

Infection Prevention includes the policies, procedures, and clinical practices used to reduce the transmission of infectious diseases during home care visits.

Infectious Disease Coding involves assigning ICD-10-CM codes for bacterial, viral, fungal, and parasitic infections

First clinical review of a patient.

The Part D phase after the deductible where you pay copays and coinsurance.

An Initial Encounter refers to the period during which the patient is receiving active treatment for a condition or injury

Injury Coding involves assigning ICD-10-CM codes for traumatic injuries, including fractures, burns, lacerations, dislocations, sprains, poisonings, and other trauma-related conditions.

Care that requires a hospital admission and overnight stay.

Inpatient Coding is the assignment of ICD-10-CM diagnosis codes and ICD-10-PCS procedure codes for patients formally admitted to a hospital.

Facility mainly treating mental illness, where Medicaid limits payment for adults.

Institutional Admission refers to patients entering home health after discharge from an acute care hospital, inpatient rehabilitation facility, or skilled nursing facility.

Confirmation of active insurance coverage.

Process of receiving and reviewing referrals.

Multiple care disciplines working together.

Transfer of funds between government entities used in Medicaid financing.

Medicaid facility providing care for people with intellectual disabilities.

Ability of systems to exchange and use data.

Employer-sponsored group coverage with shared costs.

Visit completed by more than one clinician.

State option letting certain disabled children qualify for Medicaid regardless of parental income.

Metric used to track performance.

Documentation completed after the required time.

A Late Payment Period includes every eligible 30-day payment period following the initial early payment period during an ongoing episode of care.

Laterality indicates which side of the body is affected by a condition

Total time a patient remains under care.

60 lifetime hospital days used under Part A after a 90-day stay.

Discharge of a patient who is still alive.

Liver Disease Coding includes assigning diagnosis codes for hepatitis, fatty liver disease, cirrhosis, liver failure, alcoholic liver disease, and other hepatic conditions.

A Living Arrangement describes the patient's home environment and identifies who lives with the patient

Ongoing help with daily living; custodial care Medicare generally does not cover.

Long-Term Care Coding involves coding diagnoses for residents of nursing homes and long-term care facilities

A Long-Term Drug Therapy Code identifies patients who are receiving ongoing medication therapy for chronic conditions

The period, usually 60 months, states review assets before long-term care Medicaid.

A Low Comorbidity Adjustment is an additional payment applied when a patient has qualifying secondary diagnoses that modestly increase clinical complexity.

Use of fewer services than expected.

LUPA, or Low Utilization Payment Adjustment, is a Medicare reimbursement rule under the Patient-Driven Groupings Model (PDGM). It applies when a 30-day period has fewer skilled visits than the case-mix threshold, so Medicare pays per visit instead of the full period rate.

LUPA Analytics involves using reports, dashboards, and performance metrics to identify patients at risk of triggering Low Utilization Payment Adjustments.

LUPA Avoidance refers to operational strategies used by home health agencies to prevent unnecessary Low Utilization Payment Adjustments.

A LUPA Dashboard is a reporting tool within an EMR or business intelligence platform that tracks visit counts, projected reimbursement, and episodes at risk of a LUPA.

A LUPA Episode refers to a 30-day PDGM payment period that ends with fewer skilled visits than the applicable LUPA threshold, resulting in reduced reimbursement.

LUPA Management encompasses the clinical, operational, and financial processes used to monitor visit utilization, ensure documentation accuracy, and prevent avoidable LUPAs.

LUPA Monitoring is the ongoing review of patient visit counts, schedules, cancellations, and completed documentation throughout the payment period.

LUPA Payment Reduction is the decrease in Medicare reimbursement that occurs when a patient's episode falls below the required visit threshold.

LUPA Prediction is the process of identifying patients at risk of falling below the required visit threshold before the payment period ends.

LUPA Prevention refers to proactive operational practices such as scheduling, patient engagement, clinician communication, and documentation.

LUPA Reimbursement refers to Medicare's per-visit payment methodology applied when a Low Utilization Payment Adjustment occurs instead of the full 30-day PDGM payment.

LUPA Reporting consists of operational and financial reports that summarize the number of LUPA cases, revenue impact, and performance trends.

LUPA Risk is the likelihood that a patient's payment period will not reach the required number of skilled visits, potentially resulting in reduced reimbursement.

The LUPA Threshold is the minimum number of qualified skilled home health visits required during a 30-day payment period to receive the full PDGM payment rather than reduced per-visit rates.

The LUPA Visit Count refers to the total number of Medicare-qualified skilled visits completed within a PDGM payment period

AI method that learns patterns from data.

The Medicare Access and CHIP Reauthorization Act (MACRA) established Medicare's Quality Payment Program, including MIPS and Advanced Alternative Payment Models.

Therapy focused on preserving current function.

A Major Complication or Comorbidity (MCC) is a diagnosis that significantly increases the severity of illness, expected resource utilization, and DRG payment level.

Malnutrition Coding identifies protein-calorie malnutrition and other nutritional deficiencies based on provider documentation

A system organizing Medicaid care to manage cost, use, and quality.

An organization delivering Medicaid managed care, such as an MCO or PCCM.

Health plan paid a set rate to manage the care of Medicaid members.

Groups states are required to cover under Medicaid.

A Manifestation Code identifies the condition or complication resulting from an underlying disease

Determining eligibility based on income and assets.

Government health coverage program for eligible groups.

State unit that investigates and prosecutes Medicaid fraud.

State system for processing and tracking Medicaid claims.

Another name for Medicaid coverage of health services.

Medical Billing is the process of preparing, submitting, tracking, and following up on insurance claims for healthcare services

A Medical Coder is a healthcare professional who reviews clinical documentation and assigns standardized diagnosis and procedure codes for billing.

Medical Coding is the process of translating healthcare diagnoses, conditions, symptoms, procedures, and services into standardized alphanumeric codes.

Requirement that services are clinically justified.

A Medical Necessity Audit reviews documentation to determine whether healthcare services were reasonable, appropriate, and supported by the documented clinical condition.

Medical Record Documentation refers to the complete collection of clinical information maintained throughout a patient's home health episode.

A Medical Record Review is the examination of clinical documentation to verify that reported diagnosis and procedure codes accurately reflect the documented care provided.

A Medical Review is the examination of clinical documentation to determine whether services provided were medically necessary, properly documented, and correctly billed.

Insurer health review used to decide coverage and pricing.

Optional Medicaid group for people with high medical costs relative to income.

Federal health insurance program for eligible individuals.

Private Part C plans that replace Original Medicare, often adding drug and extra benefits.

Medicare Advantage Coding focuses on accurately documenting and coding all active chronic and acute conditions that affect patient care during the coverage year.

A Medicare Audit is a detailed review of claims, documentation, coding, billing practices, and medical necessity to determine whether Medicare payments were appropriate.

Medicare Billing is the process of submitting accurate home health claims using documented services, OASIS data, diagnosis coding, and physician orders.

Medicaid paying Medicare premiums and cost-sharing for eligible low-income people.

Medicare Certification is the official approval granted by CMS allowing a home health agency to participate in the Medicare program and bill for covered services.

The Medicare Conditions of Participation (CoPs) are the federal regulations that every Medicare-certified home health agency must follow to maintain certification and bill Medicare.

The Medicare Home Health Benefit is a federal healthcare program that covers eligible home health services for beneficiaries who meet Medicare's eligibility criteria.

Hospital insurance covering inpatient stays, skilled nursing, hospice, and some home health.

Medical insurance covering outpatient care, preventive services, and supplies.

Another name for Medicare Advantage, the private alternative to Original Medicare.

Prescription drug coverage sold stand-alone or within Medicare Advantage.

Official tool for comparing Part D and Medicare Advantage plans by ZIP code.

Option to spread Part D out-of-pocket drug costs across monthly payments.

Medicare Reimbursement is the payment home health agencies receive for providing medically necessary skilled services to eligible Medicare beneficiaries.

State-run programs that help limited-income enrollees pay Medicare costs.

MS-DRGs (Medicare Severity Diagnosis-Related Groups) are an enhanced version of the traditional DRG system

Periodic statement of Part A and Part B services billed to Medicare; not a bill.

Medication Adherence is the extent to which a patient takes medications exactly as prescribed, including the correct dose, timing, and duration.

A Medication Assessment evaluates every medication a patient is taking, including prescription drugs, over-the-counter medications, vitamins, and supplements.

Risk caused by combining certain medications.

Oversight of medication use and safety.

Review and matching of patient medications.

A Medication Review is a detailed evaluation of a patient's medication regimen to ensure each medication is appropriate, effective, safe, and taken as prescribed.

Private supplement insurance that helps cover Original Medicare out-of-pocket costs.

Mental and Behavioral Disorder Coding includes diagnosis coding for psychiatric illnesses such as depression, anxiety disorders, bipolar disorder, schizophrenia, and substance use disorders.

The Merit-based Incentive Payment System (MIPS) is a Medicare quality payment program that adjusts reimbursement for eligible clinicians based on performance measures.

Failure to capture documentation or coding affecting payment.

Missing required clinician or physician signature.

Scheduled visit that did not occur.

Missed Visit Documentation records any scheduled home health visit that did not occur, including the reason for the missed visit, attempts to reschedule, and physician notification.

Clinical documentation completed on a mobile device.

A Mobility Assessment evaluates the patient's ability to move safely within the home, including walking, standing, changing positions, navigating stairs, and using mobility aids.

Income figure used to set IRMAA surcharges and Medicaid eligibility.

Medical social worker.

Musculoskeletal Disorder Coding covers diseases and injuries involving bones, joints, muscles, tendons, ligaments, and connective tissues.

Narrative Documentation is the descriptive portion of a clinical record where clinicians explain patient observations, skilled interventions, and patient responses in free-text form.

The National Center for Health Statistics (NCHS), part of the CDC, is responsible for maintaining and updating the ICD-10-CM diagnosis classification system in the United States.

AI method that understands language.

NEC (Not Elsewhere Classified) indicates that provider documentation is sufficiently detailed, but ICD-10-CM does not contain a more specific code for the condition.

Wound treatment using controlled suction.

Neoplasm Coding involves assigning ICD-10-CM codes for benign, malignant, in situ, uncertain behavior, and unspecified neoplasms

The providers, hospitals, and suppliers your insurer contracts with.

Neurological Disorder Coding includes diagnosis coding for diseases affecting the brain, spinal cord, peripheral nerves, and neuromuscular system.

Newborn Coding is the assignment of ICD-10-CM diagnosis codes for live-born infants and conditions originating during the perinatal period.

A Notice of Admission (NOA) is the electronic notification submitted to Medicare indicating that a beneficiary has started receiving home health care under the Medicare benefit.

Patient not following care instructions.

Failure to follow care plan, rules, or requirements.

NOS (Not Otherwise Specified) indicates that provider documentation lacks enough clinical detail to assign a more specific diagnosis code.

A written letter explaining a Medicaid action and the right to appeal.

Nurse Charting is the documentation completed by registered nurses (RNs) or licensed practical/vocational nurses (LPNs/LVNs) after providing patient care.

Clinical evaluation performed by a nurse.

Nursing Documentation is the official clinical record created by licensed nurses to document patient assessments, skilled interventions, and patient responses to care.

Nursing Visit Count is the total number of skilled nursing visits documented during a payment period

Standard home health patient assessment dataset.

Correctness of OASIS responses.

OASIS Certification refers to professional training programs and certifications that demonstrate advanced knowledge of OASIS assessment, coding accuracy, and CMS guidance.

Coding tied to OASIS and patient conditions.

OASIS Completion means all required assessment items have been fully documented, reviewed, and finalized within CMS-required timeframes.

OASIS Compliance is the process of ensuring all OASIS assessments are completed according to CMS regulations, submission timelines, and official guidance.

An OASIS Coordinator oversees an agency's OASIS program by providing clinician education, monitoring documentation quality, ensuring timely submission, and supporting compliance.

An OASIS Correction is the process of updating a previously submitted assessment when errors or omissions are discovered

OASIS Data Collection is the structured process of gathering standardized clinical information during patient assessments

OASIS Diagnosis Matching is the process of ensuring that diagnoses documented in the OASIS assessment are consistent with the diagnoses reported on the plan of care and claim.

OASIS Documentation refers to the complete clinical record supporting every response entered on an OASIS assessment

An OASIS Documentation Audit is a structured review of completed OASIS assessments and supporting clinical documentation to verify compliance with CMS requirements.

OASIS Documentation Best Practices are evidence-based documentation techniques that help clinicians produce accurate, complete, and defensible OASIS assessments.

OASIS Error Prevention includes the policies, workflows, technology, and education programs designed to reduce documentation mistakes before OASIS submission.

The OASIS Guidance Manual is the official CMS reference that explains how every OASIS assessment item should be interpreted and completed.

OASIS Items are the individual questions contained within the OASIS assessment dataset

OASIS Quality Measures are performance indicators developed by CMS using data collected through OASIS assessments

Check of OASIS documentation for accuracy.

An OASIS Reviewer is an individual responsible for reviewing completed OASIS assessments to verify accuracy, completeness, coding consistency, and CMS compliance.

OASIS Scoring refers to the standardized methods CMS uses to evaluate responses collected during OASIS assessments

OASIS Submission is the process of electronically transmitting completed OASIS assessment data to CMS through the required federal reporting system.

OASIS Time Points are the required occasions when Medicare mandates completion of an OASIS assessment

OASIS Timeliness measures whether required assessments are completed and submitted within CMS-established deadlines

OASIS Validation is the process of reviewing assessment data to identify incomplete fields, logical inconsistencies, formatting errors, or missing responses before submission.

OASIS-E is the current version of the Outcome and Assessment Information Set

The OASIS-E Data Set is the complete collection of standardized assessment items required for eligible Medicare home health patients.

OASIS-E1 is an updated version of the OASIS-E assessment released by CMS to incorporate revisions, clarifications, and additional standardized items.

Obesity Coding identifies overweight, obesity, morbid obesity, and body mass index (BMI) when documented by the provider

Observation Coding applies to patients placed under observation status for short-term monitoring and evaluation to determine whether inpatient admission is necessary.

Obstetric Coding refers to the application of ICD-10-CM guidelines specific to pregnancy, childbirth, and the puerperium

Therapy focused on daily function and independence.

Occupational Therapy (OT) Documentation records interventions that help patients improve or regain the ability to perform everyday activities such as bathing, dressing, and meal preparation.

HHS office enforcing civil rights and health-privacy laws.

HHS office that investigates fraud, waste, and abuse in Medicaid and Medicare.

The Official Guidelines for Coding and Reporting are the nationally recognized rules governing the assignment and sequencing of ICD-10-CM and ICD-10-PCS codes.

OIG Compliance refers to following compliance guidance issued by the Office of Inspector General (OIG) to prevent fraud, waste, and abuse in federal healthcare programs.

Annual window, October 15 to December 7, to join, drop, or switch Medicare plans.

Groups and benefits states may choose to cover under Medicaid.

Monitoring physician orders through completion.

The federal fee-for-service program made up of Part A and Part B.

Osteoarthritis Coding identifies degenerative joint disease while documenting the affected joint, laterality, and whether the condition is primary, secondary, or post-traumatic.

Osteoporosis Coding identifies decreased bone density with or without current pathological fractures

An Other Specified Code is used when the provider documents a condition with sufficient clinical detail, but ICD-10-CM does not contain a unique code for the condition.

Providers not contracted with your plan, usually costing more.

Your share of expenses, including deductibles, copays, and coinsurance.

The yearly limit on covered costs, after which the plan pays 100%.

The Outcome and Assessment Information Set (OASIS) is the complete clinical dataset used by Medicare-certified home health agencies to assess adult patients and drive payment and quality reporting.

Metric used to assess care results.

Outcome Measures evaluate the results of patient care by assessing changes in a patient's health, function, or well-being over time.

Care that does not require an overnight hospital stay.

Outpatient Coding involves assigning ICD-10-CM diagnosis codes and CPT/HCPCS procedure codes for services provided without a formal hospital admission.

Placing Medicaid eligibility workers at sites like hospitals and clinics.

Use of more services than clinically necessary.

A Pain Assessment evaluates the presence, location, intensity, frequency, duration, and impact of pain on the patient's daily activities and quality of life.

Parkinson's Disease Coding identifies Parkinson's disease and related neurological disorders

Level of patient care complexity.

A Patient Assessment is the systematic collection of clinical information about the patient's health status, symptoms, diagnoses, medications, and care needs.

Total number of active patients under care.

Current health status and care need.

Patient Education is the process of teaching patients about their medical conditions, medications, treatments, safety precautions, symptom recognition, and self-care.

Patient participation in care decisions.

Patient Goals are measurable, individualized outcomes established collaboratively by the patient, caregiver, physician, and clinical team.

Patient Outcomes are the measurable results of healthcare services, including improvements in health status, independence, symptom control, and quality of life.

Patient Rights are the legal and ethical protections that ensure every patient receives respectful, safe, and informed healthcare

Summary of clinical and operational risk factors.

Patient perception of care quality.

Organization responsible for payment.

Requirement set by an insurance or government payer.

Payment Accuracy means receiving the correct Medicare reimbursement based on complete documentation, proper coding, and compliance with PDGM rules.

Payment Grouping is the classification Medicare assigns after analyzing all PDGM variables

Payment Integrity encompasses the policies, processes, and technologies used to ensure healthcare claims are paid accurately according to clinical documentation and payer rules.

Medicare home health payment model.

A PDGM Clinical Grouping categorizes the home health primary diagnosis into one of twelve clinical groups under the Patient-Driven Groupings Model (PDGM).

The PDGM Grouper is Medicare software that analyzes OASIS responses, diagnosis codes, and patient characteristics to assign the correct HIPPS code.

The PDGM LUPA Threshold is the CMS-assigned minimum visit requirement for a specific HIPPS code

Group reviewing the quality and necessity of care provided to beneficiaries.

Performance Improvement is the systematic effort to enhance patient outcomes, documentation quality, operational efficiency, and organizational performance.

Money a Medicaid nursing home resident keeps for personal expenses.

The Patient Health Questionnaire-2 (PHQ-2) is a brief two-question screening tool used to identify possible depression

The Patient Health Questionnaire-9 (PHQ-9) is a validated depression assessment tool that measures the severity of depressive symptoms using nine standardized questions.

Physical Therapy (PT) Documentation records assessments and treatments focused on improving mobility, strength, balance, endurance, gait, and functional independence.

Physician confirmation that home health care is needed.

Physician Office Coding is the process of assigning diagnosis and procedure codes for services provided in a physician's office or ambulatory practice.

Doctor approved instruction for care or service changes.

Physician Oversight refers to the physician's ongoing responsibility for directing and supervising a patient's home health care

A Place of Occurrence Code identifies where an injury or health event occurred, such as at home, school, workplace, highway, sports facility, or public place.

The Placeholder Character (X) is used in ICD-10-CM codes when a code requires a seventh character but does not contain enough existing characters.

Formal plan for services, goals, and frequency.

A Plan of Care Diagnosis is a documented diagnosis included in the physician-certified home health plan of care that supports the patient's need for skilled services.

A Planned Visit Schedule outlines the anticipated frequency and timing of skilled nursing, therapy, and other home health visits during a patient's episode of care.

Highest-premium ACA tier; the plan covers about 90% of costs.

Pneumonia Coding involves assigning diagnosis codes based on the documented cause of pneumonia whenever possible, such as bacterial, viral, aspiration, or other specified causes.

Review of the plan of care for accuracy.

Point-of-Care (POC) Documentation is the practice of documenting patient assessments and interventions during or immediately after the home visit.

Managed plan needing a primary doctor and referrals, with out-of-network flexibility.

Poisoning occurs when a medication, biological substance, or chemical is taken incorrectly, in excessive amounts, or with harmful intent.

Population Health Coding is the accurate documentation and coding of diagnoses across patient populations to support population health management, risk adjustment, and quality reporting.

Medicaid eligibility groups defined by income relative to the federal poverty level.

A health condition you had before coverage; the ACA bars denial for it.

Screening of nursing facility applicants for mental illness or disability.

Use of data to forecast risk or outcomes.

Plan with a provider network and optional higher-cost out-of-network care.

Pregnancy Coding includes diagnosis coding for prenatal care, maternal conditions, pregnancy complications, labor, delivery, and the postpartum period.

The recurring, usually monthly, payment for insurance coverage.

ACA subsidy based on income and household size that lowers premiums.

Present on Admission (POA) indicates whether a diagnosis was already present when a patient was admitted to an inpatient hospital

Pressure Injury Coding assigns diagnosis codes based on the injury site and documented stage.

A Pressure Ulcer Assessment is the systematic evaluation of pressure injuries (also called pressure ulcers or bedsores) during a home health visit.

Temporary Medicaid coverage granted before a full eligibility determination.

Routine screenings and checkups that detect or prevent health problems.

Provider paid to manage and coordinate a Medicaid member's care.

The Primary Diagnosis is the chief medical condition chiefly responsible for the patient's need for home health services

The insurance that pays a claim first when you have more than one plan.

Principal Diagnosis is the ICD-10-CM diagnosis code that most accurately represents the main reason the patient requires home health services.

The Principal Procedure is the procedure performed during an inpatient hospital stay that is most closely related to the principal diagnosis or that was performed for definitive treatment.

Although often used interchangeably, Principal Diagnosis and Primary Diagnosis have different meanings depending on the healthcare setting.

Payer approval required before service coverage.

Visit provided as needed based on patient condition.

Process Measures assess whether recommended clinical activities were performed during patient care

Amount of work completed efficiently.

PACE program providing comprehensive care to frail elderly in the community.

Documentation of patient status and care progress.

Provider Documentation is the clinical information recorded by physicians and other qualified healthcare professionals to describe a patient's conditions, care, and treatment decisions.

A Provider Query is a communication sent to a physician or other qualified healthcare provider requesting clarification regarding documentation that is incomplete, ambiguous, or conflicting.

A tax on providers that states use to help fund Medicaid.

Quality Assurance and Performance Improvement (QAPI) is a CMS-required, agency-wide program that combines quality assurance activities with performance improvement projects.

Medicaid program paying Medicare premiums and cost-sharing for very low-income enrollees.

Medicaid program paying Part B premiums for certain low-income Medicare enrollees.

Process of checking service quality and compliance.

System for measuring the accuracy of Medicaid eligibility and payments.

Metric used to measure care quality.

Quality Indicators are measurable metrics used to evaluate clinical performance, patient safety, documentation quality, and operational effectiveness.

Performance metrics behind Medicare star ratings for plans and providers.

Quality Reporting is the collection and submission of standardized healthcare performance data to government agencies and private payers.

Evaluation of care records and outcomes.

Query Rate is a performance metric that measures how frequently coders or Clinical Documentation Integrity (CDI) specialists submit provider queries to clarify documentation.

A Recovery Audit Contractor (RAC) Audit is a review conducted by a CMS-authorized Recovery Audit Contractor to identify Medicare overpayments and underpayments.

RAP Elimination refers to Medicare's discontinuation of Requests for Anticipated Payment (RAPs) beginning in 2022

Patient admission to hospital after discharge.

Likelihood of hospital readmission.

Documents needed to continue services.

Renewal of home health services for another period.

A Recovery Audit Contractor (RAC) is a CMS-contracted organization responsible for identifying and correcting improper Medicare payments, including overpayments and underpayments.

Request to begin home health services.

Percentage of referrals accepted into care.

Person or organization sending patients to the agency.

Regulatory Compliance is the process of adhering to all applicable federal, state, accreditation, payer, and professional requirements governing home health operations.

Rehabilitation Coding involves assigning diagnosis codes for patients receiving physical therapy, occupational therapy, speech-language pathology, or other rehabilitative services.

Likelihood of a patient being readmitted to hospital.

Reimbursement Optimization is the practice of improving documentation accuracy, coding quality, and operational workflows to ensure agencies receive full, accurate reimbursement.

Relative Weight is a numeric value assigned to each DRG that represents the average resources required to treat patients in that group.

A Remittance Advice (RA) is a document sent by an insurance payer explaining how a submitted healthcare claim was processed

Use of devices to track patient health remotely.

Respiratory Disease Coding includes assigning ICD-10-CM codes for disorders affecting the lungs and respiratory tract, such as COPD, asthma, pneumonia, and respiratory failure.

Process from service delivery to payment collection.

Revenue Cycle Management (RCM) is the financial process healthcare organizations use to manage patient revenue from scheduling and registration through final payment.

Revenue Integrity is the process of ensuring that clinical documentation, diagnosis coding, charge capture, billing, and reimbursement accurately align with the care provided.

Revenue Leakage refers to lost reimbursement resulting from coding errors, incomplete documentation, missed diagnoses, billing mistakes, denied claims, and missed charges.

Revenue Loss Due to LUPA is the financial reduction experienced by a home health agency when reimbursement shifts from the full PDGM payment to lower per-visit LUPA rates.

Frequency of repeat or additional visits.

Rheumatoid Arthritis Coding identifies autoimmune inflammatory arthritis and may include documentation regarding

Method of accounting for patient complexity.

Risk Adjustment Coding is the assignment of diagnosis codes that accurately capture the patient's disease burden and expected healthcare needs for risk-adjusted payment models.

The Risk Adjustment Factor (RAF) is a numerical score used primarily in Medicare Advantage and value-based care programs to estimate a patient's expected healthcare costs.

Contract where a Medicaid plan assumes financial risk for members' care.

Risk Management is the process of identifying, evaluating, and reducing clinical, operational, financial, and legal risks within a home health agency.

Risk of Mortality (ROM) estimates the likelihood that a patient may die based on documented diagnoses, comorbidities, procedures, age, and overall clinical condition.

Grouping patients by level of risk.

Registered nurse.

Resumption of Care after inpatient stay.

Return gained from an investment.

Planning travel routes for efficiency.

Clinic in an underserved area receiving enhanced Medicaid reimbursement.

Planning clinician visits and assignments.

A Screening Code identifies healthcare encounters performed to detect disease in individuals who have no signs or symptoms of the condition being evaluated.

A Secondary Diagnosis is any additional medical condition that affects the patient's care, treatment, recovery, or resource needs during the home health episode.

Secondary Diagnosis Reporting involves documenting and coding additional active medical conditions that affect patient assessment, care planning, and reimbursement.

The insurance that pays after the primary payer, often covering remaining costs.

Waiver allowing states to test new Medicaid approaches.

Waiver letting states require Medicaid managed care enrollment.

Medicaid eligibility pathway for low-income families.

Option to mandate Medicaid managed care without a waiver.

A state using more restrictive Medicaid eligibility rules than SSI.

A Sensory Assessment evaluates impairments related to vision, hearing, speech, touch, and other sensory functions that may affect communication, safety, or daily function.

AI review of language for emotion or tone.

Sepsis Coding requires careful application of ICD-10-CM guidelines to identify systemic infection, the causative organism (when known), associated organ dysfunction, and severity.

A Sequela is a residual condition or complication that remains after the acute phase of an illness or injury has resolved

The geographic region where a Medicare plan provides in-network coverage.

Amount of care services used.

The Seventh Character provides additional information about certain diagnoses, particularly injuries, fractures, poisonings, and obstetric conditions.

Severity of Illness (SOI) measures the extent of a patient's physiological decompensation or organ system loss of function

Signs and Symptoms Codes describe patient complaints or clinical findings when a definitive diagnosis has not yet been established or when coding guidelines direct their use.

ACA benchmark tier with moderate premiums; the plan covers about 70% of costs.

The one state agency responsible for the Medicaid program.

Clinical need requiring skilled professional care.

Skilled Need Documentation explains why a patient's condition requires the expertise of a licensed clinician rather than services that could be provided by a non-skilled caregiver.

Nursing care requiring licensed clinical skill.

Skilled Nursing Documentation records nursing services that require the clinical expertise of a licensed nurse

Inpatient rehab or nursing setting covered short-term under Part A after a hospital stay.

Skilled Nursing Facility (SNF) Coding involves assigning ICD-10-CM diagnosis codes for residents receiving skilled nursing or rehabilitation services.

Monitoring that requires clinical judgment.

Skilled Service Documentation is the detailed record demonstrating that the care provided required the expertise of a licensed clinician and met Medicare skilled-care requirements.

Skilled Services are healthcare services that require the knowledge, judgment, and expertise of licensed healthcare professionals such as nurses and therapists.

Skilled Visit Count is the total number of Medicare-qualified nursing and therapy visits completed during a payment period

Skin Disorder Coding includes diagnosis coding for dermatitis, eczema, cellulitis, psoriasis, skin infections, ulcers, wounds, pressure injuries, and other dermatologic conditions.

A SOAP Note is a structured documentation format organized into four sections: Subjective, Objective, Assessment, and Plan.

Official Start of Care date.

Federal agency that enrolls people in Medicare and administers retirement and disability benefits.

A chance to change Medicare coverage outside open enrollment after a qualifying life event.

Medicare Advantage plans tailored to chronic condition, dual eligible, or institutional populations.

Medicaid program paying Medicare Part B premiums for certain enrollees.

Therapy for communication or swallowing needs.

Speech Therapy Documentation records services provided to patients experiencing communication, language, speech, voice, cognitive, or swallowing disorders.

Using medical expenses to reduce income enough to qualify for Medicaid.

Rules protecting income and assets for the spouse of a Medicaid nursing home resident.

Available workforce to complete patient care.

Output delivered by clinical or administrative staff.

Medicare one-to-five quality ratings for plans, hospitals, and nursing homes.

Formal beginning of home health services.

SHIP offers free, unbiased local Medicare counseling.

The agreement describing how a state operates its Medicaid program.