How to Navigate the ABCs of Medicine

Having a clear understanding of terms commonly used in the medical practice makes it possible for all involved to work together without misunderstanding. The following “dictionary” defines many of the most commonly used—and often misunderstood—such terms.

ACI: Advancing Care Information/Promoting Interoperability

• Advancing Care Information (ACI) is one of the three performance categories scored under the Merit-Based Incentive Payment System (MIPS).

• The ACI category, which replaced Meaningful Use in 2017, accounts for 25% of a provider’s composite MIPS score. The program offers a base score, a performance score, and a bonus score.

• The base score takes into consideration the following information: security risk analysis; electronic prescribing; providing patient access; sending a summary of care.

• Additional performance measures include view; download or transmit; patient-specific education; secure messaging; medication reconciliation.

• Bonus points: immunization registry, syndromic surveillance reporting, specialized registry reporting.

ACO: Accountable Care Organization

• ACOs are groups of doctors, hospitals, and other healthcare providers who come together voluntarily to give coordinated high-quality care to their Medicare patients.

• The goal of coordinated care is to ensure that patients get the right care at the right time, while avoiding unnecessary duplication of services and preventing medical errors.

• When an ACO succeeds in both delivering high-quality care and spending healthcare dollars more wisely, the ACO will share in the savings it achieves for the Medicare program.

APM: Alternative Payment Model

• Together, the MIPS and APM tracks make up the Quality Payment Program (QPP).

• APMs move away from traditional fee-for-service and toward value-based arrangements that tie payment for healthcare services to quality performance, health outcomes, and value for a specific population.

• Providers in an Advanced APM receive an automatic 5% annual bonus, in addition to any financial bonuses or penalties they receive through the APM itself.

• Under the QPP, an Advanced APM must:

  • Tie payment to quality performance, including at least one outcome measure in the set;

  • Use certified EHR technology (CEHRT); and

  • Bear financial risk. (Those who participate bear financial risk because part of their payment is based on meeting quality metrics and patient satisfaction scores.)

AVS: After-Visit Summary

• The AVS is a paper or electronic document given to patients after a medical appointment that is intended to summarize patients’ health and guide future care, including self-management tasks.

BHI: Behavioral Health Integration

• BHI refers to the integration of behavioral healthcare with primary care. It is a strategy for improving outcomes for patients with mental or behavioral health conditions.

• As of January 1, 2017, Medicare makes separate payments to physicians and nonphysician practitioners for BHI services they furnish to beneficiaries over a calendar month service period.

BMI: Body Mass Index

• BMI is a person’s weight in kilograms (kg) divided by his or her height in meters squared. The National Institutes of Health defines normal weight, overweight, and obesity according to BMI rather than the traditional height/weight charts.

BPMH: Best Possible Medication History

• The BPMH is more comprehensive than a routine primary medication history, which often is a quick preliminary medication history that may not include multiple sources of information. It is a snapshot of the patient’s actual medication use, which may be different from what is contained in his or her records.

• This information is gathered through a systematic process of interviewing the patient and family as well as a review of at least one other reliable source of information to obtain and verify all of a patient’s medication use (prescribed and nonprescribed).

• Complete documentation includes drug name, dosage, route, and frequency.

CCDs: Continuity of Care Documents

• The CCD is an electronic document exchange standard for sharing patient summary information. Summaries include commonly needed pertinent information about current and past health status in a form that can be shared by all computer applications, including web browsers and EHR software systems.

• The key is its ability to pass between health records.

CCM: Chronic Care Management

• Chronic care management is defined as the non–face-to-face services provided to Medicare beneficiaries who have multiple (i.e., two or more), significant chronic conditions.

• In addition to office visits and other face-to face encounters, which are billed separately, these services include communication with the patient and other treating health professionals for care coordination medication management and 24/7 access to clinic staff.

• Only one clinician can bill for any particular patient; therefore, it may be necessary to coordinate with the subspecialists who may be providing a significant amount of care and treatment for one or more of the patient’s conditions.

CEHRT: Certified EHR Technology

• CEHRT is a health IT product that has successfully passed testing on specific standards and criteria selected by the CMS for use in specific programs.

• CEHRT ensures that an EHR system or module offers the necessary technological capability, functionality, and security to help the practice meet the Meaningful Use criteria.

CGCAPHS: Clinical & Group Consumer Assessment of Healthcare Providers and Systems

• Standard survey developed by the Agency for Healthcare Research and Quality to assess patient perceptions of care provided by physicians and medical groups in doctors’ offices.

• Measures patients’ perceptions of the quality of scheduling appointments, access to care when needed, courtesy of office staff, care coordination, physician communication, and overall rating of physician.

• It is optionally linked to payment when a practice decides to use it as an improvement activity in MIPS.

CMS: Centers for Medicare and Medicaid Services

• Agency within the U.S. Department of Health and Human Services (HHS) that administers the nation’s major healthcare programs. The CMS oversees programs including Medicare, Medicaid, the Children’s Health Insurance Program (CHIP), and the state and federal health insurance marketplaces. CMS collects and analyzes data, produces research reports, and works to eliminate instances of fraud and abuse within the healthcare system.

DM: Direct Message

• DM is an integrated feature of the EHR where patient and provider can securely message each other.

• Patients have the ability to take the information the practice has published to the patient portal, such as Clinical Summaries, and transmit that information securely to other providers. This was a requirement under Meaningful Use Stage 2, and remains an objective under the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). Success in this measure does not require patients to use this feature; however, the functionality must be made available to the patient in order to remain compliant.

• The ultimate goal is to create an environment where patients are empowered to make educated medical decisions with the medical information they’ve been provided in a timely manner, and have the ability to share that information with comanaging providers.

EHR: Electronic Health Record

• Digital version of a patient’s paper chart. EHRs are real-time, patient-centered records that make information available instantly and securely to authorized users.

F2F: Face to Face

• Prior to certifying a patient’s eligibility for home health benefit, the certifying physician must document that they, or an allowed physician extender, has had a F2F encounter with the patient

• Mandated by the Affordable Care Act.

FFS: Fee for Service

• A method in which doctors and other healthcare providers are paid for each service performed. Examples of services include tests and office visits.

FQHC: Federally Qualified Health Center

• Community-based healthcare providers that receive funds from the HRSA Health Center Program to provide primary care services in underserved areas. They must meet a stringent set of requirements, including providing care on a sliding fee scale based on ability to pay and operating under a governing board that includes patients.

GCM: Gross Contribution Margin

• Gross margin: amount of revenue that remains after subtracting costs directly associated with production.

• Contribution margin: measure of the profitability of various individual products.

HCAPHS: Hospital Consumer Assessment of Healthcare Providers and Systems

• Standardized survey instrument to measure patients’ perspectives of hospital care.

• Surveys patients on items such as communication with doctors and nurses, responsiveness of hospital staff, cleanliness of hospital environment, quietness of hospital environment, pain management, communication about medicines, discharge information, overall hospital rating, and recommendation of hospital to others.

HEDIS: Healthcare Effectiveness Data and Information Set

• Created through contract of CMS and NCQA (National Committee for Quality Assurance)

• Performance improvement tool that includes more than 90 measures across 6 domains of care, including effectiveness of care, access/availability of care, experience of care, utilization and risk-adjusted utilization, health plan descriptive information, and measures collected using electronic clinical data systems.

• Allows purchasers and consumers information to compare health plan performance.

HIE: Health Information Exchange

• HIE is the mobilization of healthcare information electronically across organizations within a region, community, or hospital system.

• It allows healthcare professionals and patients to appropriately access and securely share a patient’s medical information electronically. There are many healthcare delivery scenarios driving the technology behind the different forms of HIE.

HIPAA: Health Insurance Portability and Accountability Act

• A U.S. law designed to provide privacy standards to protect patients’ medical records and other health information provided to health plans, doctors, hospitals and other healthcare providers. Developed by HHS, these new standards provide patients with access to their medical records and more control over how their personal health information is used and disclosed. They represent a uniform, federal floor of privacy protections for consumers across the country.

LPN: Licensed Practical Nurse

• A nursing role that requires education in a state-approved program that typically lasts between 12 and 18 months. LPNs assist physicians and RNs.

LUPA: Low Utilization Payment Adjustment

• A LUPA occurs when there are four or fewer visits during a 60-day episode of home healthcare. When this occurs, the agency is not reimbursed for the 60-day episode of home health, but is instead reimbursed a standard per-visit payment.

MA: Medical Assistant

• Medical staff with both clinical and administrative duties.

• Many are graduates of formal programs of medical assisting.

MAC: Medicare Administrative Contractor

• MACs are multistate, regional contractors responsible for administering both Medicare Part A and Medicare Part B claims.

• A MAC is a private healthcare insurer that has been awarded a geographic jurisdiction to process Medicare Part A and Part B (A/B) medical claims or durable medical equipment (DME) claims for Medicare fee-for-service beneficiaries.

Med Rec: Medication Reconciliation

• Medication reconciliation is the process of creating the most accurate list possible of all medications a patient is taking—including drug name, dosage, frequency, and route

MIPS: Merit Based Incentive Payment System

• Together, the MIPS and APM tracks make up the QPP.

• MIPS builds on the traditional fee-for-service architecture in Medicare but is structured so that payment rewards providers for delivering high-quality care and achieving better health outcomes.

• Although most Medicare providers will be in MIPS when the program starts, the law intends for providers to transition into APMs.

• Providers in MIPS will earn a composite score between 1 and 100 based on the following four performance categories: quality, cost, improvement activities, and promoting interoperability.

MSW: Master of Social Work

• Medical social workers specialize in public health and in geriatric, palliative, and inpatient medical or mental healthcare. They work in hospitals or other specialized medical settings, such as nursing homes, rehabilitative care centers, or related home-care services (e.g., hospice).

• Medical social workers often collaborate with other medical professionals such as doctors, nurses, discharge coordinators, administrative staff, and physical therapists as part of an interdisciplinary team.

MOU: Memorandum of Understanding

• An agreement between two or more parties outlined in a formal document. It is not legally binding but signals the willingness of the parties to move forward with a contract.

• The MOU can be seen as the starting point for negotiations, as it defines the scope and purpose of the talks.

• When contracting with third-party vendors, this specifies rules that need to be followed.

MU: Meaningful Use

• A federal incentive program introduced in 2009 to promote the use of certified EHR technology among healthcare providers. CMS provides financial incentives to eligible providers who are able to show that they “meaningfully use” their EHR to positively impact patient care. Providers do this by attesting to a number of objectives laid out in the program.

• The concepts and practices underlying Meaningful Use are still in use today, but the activities are now reported under the ACI portion of MIPS, which was ushered in by MACRA.

NPI: National Provider Identification

• The NPI is a unique identification number for covered healthcare providers. It is an HIPAA administrative simplification standard.

OASIS: Outcome and Assessment Information Set

• OASIS is a comprehensive assessment designed to collect information on nearly 100 items related to a home care recipient’s demographic information, clinical status, functional status, and service needs.

• The OASIS is completed upon admission, discharge, transfer, and change in condition for all Medicare and Medicaid, nonmaternity, and nonpediatric beneficiaries.

• OASIS data are collected by a home care clinician (e.g., nurse or therapist) via direct observation and interview of the care recipient and/or caregiver. Select OASIS indicators are used to assign patients to a Home Health Resource Group (HHRG) for each 60-day home care episode. The HHRG is then used to calculate each patient’s reimbursement rate under the Prospective Payment System (PPS).

• The purpose of OASIS was to provide a standardized assessment tool that would support a case mix–adjusted PPS and a mechanism to monitor the quality of care.

ONC: Office of National Coordinator

• ONC is the principal federal entity charged with coordination of nationwide efforts to implement and use the most advanced health information technology and the electronic exchange of health information.

• ONC is organizationally located within the Office of the Secretary for HHS.

PatSat: Patient Satisfaction

• CGCAPHS and HCAPHS are two examples of patient satisfaction surveys that are offered to patients so they can evaluate their office or hospital experience.

• Patient satisfaction is the extent to which patients are happy with their healthcare, both inside and outside of the doctor’s office. A measure of care quality, patient satisfaction gives providers insights into various aspects of medicine, including the effectiveness of their care and their level of empathy.

PCP: Primary Care Physician

• Healthcare professional who practices general medicine.

• For the purposes of an insurance carrier, a PCP is a physician who is chosen by or assigned to a patient and both provides primary care and acts as a gatekeeper to control access to other medical services.

PCR: Pre-Claim Review

• Pre-claim review is a review process managed by MACs prior to a final reimbursement.

• Home health agencies will request a provisional affirmation of coverage before a final claim is submitted for payment. Submission and affirmation of pre-claims confirms that all certification and coverage requirements are met.

• Pre-claim review does not require any additional documentation. This new step requires that the same documentation as before be presented—just earlier in the process.

PDGM: Patient Driven Grouping Model

• A case-mix classification model created by CMS to determine home health reimbursement. The intent is to better align reimbursement with patient needs.

• Under PDGM, each episode of care will be categorized based on five factors:

  • Early or late: Is this the patient’s first 30-day episode of home health?

  • Institutional or community: Was the patient admitted to home health during hospitalization or within the first 14 days after discharge?

  • Clinical grouping: Based on principal diagnosis, patients will be assigned to one of six major clinical groups.

  • Functional level: This will use the OASIS questions to group patients into low, medium, or high impairment.

  • Comorbidity adjustment: This breaks down into no adjustment, low adjustment, or high adjustment based on secondary diagnoses reported on claims.

• PDGM led to a number of new payment categories, each with its own Low Utilization Payment Adjustment (LUPA).

PDSA: Plan, Do, Study, Act

• The PDSA cycle is shorthand method for testing a change—by planning it, trying it, observing the results, and acting on what is learned.

PECOS: Provider Enrollment Chain and Ownership Programs

• A national database of Medicare provider, physician, and supplier enrollment information. PECOS is used to collect and maintain the data submitted on CMS-855 enrollment forms.

• Practices can use it in lieu of the Medicare enrollment application (i.e., paper CMS-855) to:

  • Submit an initial Medicare enrollment application;

  • View or change enrollment information;

  • Track an enrollment application through the Web submission process;

  • Add or change a reassignment of benefits;

  • Submit changes to existing Medicare enrollment information;

  • Reactivate an existing enrollment record;

  • Withdraw from the Medicare program; or

  • Submit a change of ownership (CHOW) of the Medicare-enrolled provider.

PEP: Partial Episode Payment

• In home healthcare, a patient may reach their treatment goals or transfer to a different home health agency before the end of the 60-day episode of home health treatment. If this occurs, Medicare payment will be adjusted based on the amount of time the patient was under the agency’s care.

PHI: Protected Health Information

• PHI is the term given to health data created, received, stored, or transmitted by HIPAA-covered entities and their business associates in relation to the provision of healthcare, healthcare operations, and payment for healthcare services.

PIM: Practice Improvement Manager

• PIMs handle a variety of duties that all support one main goal: ensuring that data-driven performance management and quality improvement programs are designed and implemented in a manner that aligns with an organization’s overall strategy.

• In a healthcare setting, this always involves providing more effective and efficient care to patients.

POC: Plan of Care

• A care plan is a detailed approach to care customized to an individual patient’s needs.

PRN: Per Diem Nurse

• A per diem nurse is not a regularly employed nurse, working for only one division in a hospital, but someone who works on a variety of units and sometimes in a variety of hospitals and other facilities.

PTN: Practice Transformation Network

• A PTN is a peer-based learning network designed to coach, mentor, and assist clinicians in developing core competencies specific to practice transformation. This approach allows clinician practices to become actively engaged in the transformation and ensures collaboration among a broad community of practices that creates, promotes, and sustains learning and improvement across the healthcare system.

QCDR: Qualified Clinical Data Registry

• A QCDR is a CMS-approved vendor that is in the business of improving healthcare quality. These organizations may include specialty societies, regional health collaboratives, large health systems, or software vendors working in collaboration with one of these medical entities

• QCDR submission differs from qualified registry submission in that QCDRs can submit non-MIPS measures, called QCDR measures, as well as MIPS quality measures. (As a reminder, MIPS measures were quality, cost, improvement activities, and promoting interoperability.)

• QCDRs can develop and/or submit measures to CMS for CMS approval. These measures are called QCDR measures. A QCDR may submit no more than 30 approved or provisionally approved QCDR measures for a clinician.

QM: Quality measures

• QMs are tools that help measure or quantify healthcare processes, outcomes, patient perceptions, and organizational structure. These measures are used to reach goals, including that healthcare be effective, safe, efficient, patient-centered, equitable, and timely.

• CMS uses QMs in its quality improvement, public reporting, and pay-for-reporting programs for specific healthcare providers.

QPP: Quality Payment Program

• Initiated by MACRA, QPP is an incentive program to reward high-value, high-quality Medicare clinicians with payment increases—while at the same time reducing payments to those clinicians who aren’t meeting performance standards.

• Clinicians have two tracks to choose from in the QPP based on their practice size, specialty, location, or patient population: MIPS or APM

RAP: Request for Anticipated Payment

• Medicare designed the RAP payment for home healthcare billing as a way for providers to stabilize their cash flow.

• RAP claims obtain 50% to 60% of the anticipated payment at the beginning of a patient’s care episode. This payment is determined based on the codes generated by the home health agency’s OASIS assessment.

• Industry standards suggest RAP claims should be billed within 7 days of the episode start date.

RHC: Rural Health Clinic

• RHCs can be public, nonprofit, or for-profit healthcare facilities. To receive certification, they must be located in rural, underserved areas. They are required to use a team approach of physicians working with nonphysician providers to provide services. The clinic must be staffed at least 50% of the time with a NP, PA, or CNM. RHCs are required to provide outpatient primary care services and basic laboratory services.

SBIRT: Screening, Brief Intervention, and Referral to Treatment

• An evidence-based practice used to identify, reduce, and prevent problematic use, abuse, and dependence on alcohol and illicit drugs. The SBIRT model was incited by an Institute of Medicine recommendation that called for community-based screening for health risk behaviors, including substance use.

SHP: Strategic Healthcare Programs

• SHP automates transfer of data from the skilled nursing facility’s EHR systems. The combination of real-time data with SHP’s post–acute care knowledge and analytics engine will help SNFs quickly answer some core operational questions, such as:

  • How do I improve my quality scores?

  • How do I better manage residents at risk for readmission?

  • How do I demonstrate to my referral sources their high-acuity patients are being managed appropriately?

  • How do I measure that my therapy program achieves maximum functional improvement for a specific group of residents?

• Although skilled nursing facilities have access to information from their EHRs, SHP reports bring the ability to segment data across many different metrics such as referral source, diagnosis, PDPM clinical category, and readmission risk, to name a few. This suite of reports will incorporate SHP’s proprietary risk for readmission, overall quality, and functional scores.

TCM: Transitional Care Management

• TCM is the ongoing support of patients and their families over time as they navigate care and relationships among more than one provider and/or more than one healthcare setting and/or more than one healthcare service.

• Transitional care is defined as a set of actions designed to ensure the coordination and continuity of healthcare as patients transfer between different locations or different levels of care within the same location.

• The essence of TCM is that a healthcare provider takes charge of the patient’s care from the instant he or she is discharged. Transitional care management is designed to last 30 days. It involves a medical professional engaging in one face-to-face visit with the patient and then additional non–face-to-face meetings (e.g., by telephone or a video call, as is the case with telemedicine).

• Designed to reduce gaps in care with the hope to have fewer readmissions and relapses

TCPI: Transforming Clinical Practice Initiative

• TCPI was launched in 2015 by CMS to provide technical assistance to clinicians in both primary and specialty care, over a four-year period in sharing, adapting, and further developing their comprehensive quality improvement strategies. TCPI created a nationwide, collaborative, and peer-based learning network designed to prepare practices to successfully participate in value-based payment arrangements.

TIN: Tax Identification Number

• A tax identification number (TIN) is a nine-digit number used as a tracking number by the IRS and is required information on all tax returns filed with the IRS.

TOC: Transition of Care

• The movement of a patient from one setting of care (e.g., hospital, ambulatory primary care practice, ambulatory specialty care practice, long-term care, home health, rehabilitation facility) to another.

Further Reading

For additional information please refer to these resources:

• Agency for Healthcare Research and Quality

• Centers for Medicare & Medicaid Services

• National Committee for Quality Assurance