Healthcare terms, explained

A group of doctors, hospitals, and other healthcare providers who voluntarily come together to provide coordinated, high-quality care to Medicare patients. ACOs share in savings achieved through improved care coordination.About this care service

Electronic notifications sent when a patient is admitted to, discharged from, or transferred between healthcare facilities. ADT alerts help care teams coordinate transitions and prevent readmissions.

A Medicare service that pays primary care practices a monthly amount for whole-panel care management, tracked by the work performed rather than by time counted. APCM uses HCPCS codes G0556, G0557, and G0558.About this care service

A yearly preventive visit covered by Medicare that focuses on developing a personalized prevention plan. AWV is different from a physical exam and includes health risk assessments and care planning.About this care service

A Medicare-reimbursable service that integrates mental and behavioral health services into primary care settings. BHI uses CPT codes 99484, 99492, 99493, and 99494 for billing.About this care service

Adherence to federal and state regulations governing healthcare billing practices. Includes proper documentation, accurate coding, and following Medicare/Medicaid guidelines to avoid fraud and abuse.

A Medicare program providing ongoing care coordination for patients with two or more chronic conditions. CCM services are billed using CPT codes 99490, 99491, 99487, 99489, and 99439.About this care service

The federal agency that administers Medicare, Medicaid, and the Children's Health Insurance Program (CHIP). CMS sets reimbursement rates and compliance requirements for healthcare programs.

A standardized coding system maintained by the AMA used to report medical procedures and services for billing purposes. Examples include 99490 (CCM) and 99454 (RPM device supply).

The work of mapping how a practice already delivers follow-up care and building that workflow into software so it runs the same way every time, with eligibility, outreach, documentation, and billing defined up front.About this care service

The deliberate organization of patient care activities between two or more participants involved in a patient's care. Effective care coordination improves outcomes and reduces costs.

A discrepancy between recommended care and the care actually received by a patient. Care gaps often relate to preventive services, screenings, or chronic disease management.

Ongoing care for patients with diabetes: glucose and A1c review, medication adjustment, lab follow-up, and education between visits. Often delivered through CCM or RPM and tracked against quality measures.About this care service

A digital version of a patient's medical history maintained by the provider over time. EHRs contain diagnoses, medications, treatment plans, immunization dates, allergies, and test results.

A digital version of a patient's chart within a single practice. Unlike EHRs, EMRs are typically not designed to be shared outside the individual practice.

A standard for exchanging healthcare information electronically. FHIR uses modern web technologies and RESTful APIs to enable seamless data exchange between healthcare systems.

A set of standardized performance measures used by health plans to measure care quality. HEDIS measures cover areas like preventive care, chronic disease management, and patient safety.

Federal law that establishes national standards for protecting sensitive patient health information. HIPAA requires safeguards for PHI and gives patients rights over their health information.

A set of international standards for the exchange, integration, sharing, and retrieval of electronic health information. HL7 v2 is widely used for clinical messaging between systems.

The ability of different healthcare information systems, devices, and applications to access, exchange, integrate, and cooperatively use data in a coordinated manner.

2015 legislation that changed how Medicare pays clinicians. MACRA created the Quality Payment Program (QPP) with two tracks: MIPS and Advanced APMs.

A Medicare program that adjusts payments based on performance in quality, cost, improvement activities, and promoting interoperability. Part of the Quality Payment Program under MACRA.

The oversight body that protects the integrity of HHS programs including Medicare and Medicaid. OIG conducts audits, investigations, and evaluations to identify fraud and abuse.

A Medicare service for patients with a single high-risk chronic condition requiring complex medical decision-making. PCM uses CPT codes 99424, 99425, 99426, and 99427.About this care service

A care delivery model where patient treatment is coordinated through a primary care physician. PCMHs emphasize comprehensive, patient-centered, coordinated, accessible care.

Any individually identifiable health information held or transmitted by a covered entity. PHI includes demographic data, medical history, test results, and insurance information.

The aggregation of patient data across multiple health information technology resources to improve clinical and financial outcomes. Focuses on defined populations rather than individuals.

A Medicare program that rewards value and outcomes in healthcare. QPP includes two tracks: MIPS for most clinicians and Advanced APMs for those in innovative payment models.

The use of digital technologies to collect health data from patients in one location and electronically transmit it to healthcare providers. RPM uses CPT codes 99453, 99454, 99457, and 99458.About this care service

A Medicare program for monitoring non-physiological data like medication adherence, therapy response, and pain levels. RTM uses CPT codes 98975, 98976, 98977, 98980, and 98981.About this care service

The process of assigning a health risk status to a patient based on various factors including diagnoses, utilization history, and social determinants. Used to prioritize care interventions.

Non-medical factors that influence health outcomes including economic stability, education, social context, neighborhood environment, and healthcare access.

A Medicare service for patients transitioning from inpatient to community settings. TCM includes contact within 2 business days of discharge and a face-to-face visit within 7-14 days.About this care service

A healthcare delivery model where providers are paid based on patient health outcomes rather than volume of services. VBC incentivizes quality, efficiency, and patient satisfaction.About this care service