Healthcare Glossary

94 defined terms across 9 categories.

Clinic + facility types

The federally-defined clinic categories that determine billing, grant eligibility, and compliance scope.

Rural Health Clinic RHC: A clinic certified by CMS under §1861(aa) of the Social Security Act, located in a non-urbanized area and a designated shortage area. RHCs bill at an all-inclusive rate (AIR) per patient encounter and are eligible for the 10% HPSA Medicare bonus.
Federally Qualified Health Center FQHC: A community-based health center receiving funding from HRSA Section 330 to serve underserved populations on a sliding-fee basis. FQHCs must meet 19 program requirements (governance, services, management/finance) and be governed by a board where at least 51% are patients of the center.
FQHC Look-Alike LAL: An organization that meets all FQHC requirements but does not receive Section 330 grant funding. Eligible for FQHC reimbursement, 340B drug pricing, and federal liability protection — a stepping stone to full FQHC status.
Critical Access Hospital CAH: A small rural hospital (≤25 beds, >35 miles from another hospital) certified by CMS to receive cost-based reimbursement instead of the standard inpatient prospective payment system. Designed to keep small rural hospitals financially viable.
340B Drug Pricing Program: A federal program requiring drug manufacturers to provide outpatient drugs to eligible health-care organizations (FQHCs, RHCs, CAHs, certain disproportionate-share hospitals) at significantly reduced prices. Savings can fund expanded services for low-income patients.
Skilled Nursing Facility SNF: A Medicare-certified facility providing inpatient skilled nursing or rehabilitation services. Discharges from SNF to community (not to another inpatient facility) are a qualifying setting for TCM (CPT 99495/99496) billing.
Related: /blog/tcm-rhc-transitional-care-management
Inpatient Rehabilitation Facility IRF: A facility specializing in intensive multi-disciplinary rehabilitation. Discharges from IRF to community are a qualifying setting for TCM billing.
Related: /blog/tcm-rhc-transitional-care-management
Long-Term Care Hospital LTCH: A hospital with average inpatient length of stay >25 days, certified by CMS for medically complex patients. Discharges qualify for TCM.
Related: /blog/tcm-rhc-transitional-care-management
Community Mental Health Center CMHC: A community-based behavioral-health facility certified by CMS. Partial-hospitalization discharges from a CMHC are a qualifying setting for TCM.
Related: /blog/tcm-rhc-transitional-care-management
Electronic Health Record EHR: A digital, longitudinal record of patient health information maintained by a clinical practice. Distinct from EMR (which is single-practice). EHR systems are the workflow surface for nearly all billing-relevant documentation.

Designations + scoring

How CMS and HRSA classify clinic location, shortage status, and quality performance.

Health Professional Shortage Area HPSA: A geographic area, population group, or facility designated by HRSA as having a shortage of primary-care, dental, or mental-health providers. Scored 0-25 (primary care) or 0-26 (mental/dental); higher scores indicate greater shortage. Unlocks the 10% Medicare bonus, NHSC loan repayment eligibility, J-1 visa waivers, and grant preference.
Related: /blog/hpsa-grant-matching
Medically Underserved Area / Population MUA / MUP: HRSA designations identifying areas (MUA) or populations (MUP) with insufficient health-care services. Distinct from HPSA — measures available services rather than provider supply. Required for FQHC designation.
National Health Service Corps NHSC: A federal program offering scholarships and loan repayment to clinicians who commit to serving in HPSA-designated areas. Each provider serves 2-4 years in exchange for up to $50,000-$120,000 of loan repayment.
Merit-based Incentive Payment System MIPS: CMS's value-based payment program for clinicians billing Medicare Part B. Composite score (0-100) computed annually across four categories: Quality (30%), Cost (30%), Promoting Interoperability (25%), Improvement Activities (15%). Score determines a positive or negative payment adjustment 2 years later, ranging from -9% to +2.15% in PY2023.
Related: /blog/mips-strategy-small-practices
Quality Payment Program QPP: The umbrella CMS program containing MIPS and Advanced APMs. Replaced the prior PQRS, Meaningful Use, and Value Modifier programs. Look up your performance at qpp.cms.gov/participation-lookup.
MIPS Value Pathway MVP: A pre-built measure bundle aligned to a clinical focus area (Primary Care, Diabetes, Heart Disease, Behavioral Health, etc.). Reporting through an MVP simplifies Quality + PI + IA into one aligned set instead of picking measures individually.
Small-practice MIPS bonus: An automatic 6-point composite-score bonus for clinicians billing Medicare under a Tax ID Number with fewer than 15 clinicians. Often flips a borderline-penalty result into bonus territory with zero workflow change. Eligibility verified at qpp.cms.gov/participation-lookup.

Billing codes + modifiers

The CPT and HCPCS codes most commonly under-billed (or mis-coded) by small practices.

National Provider Identifier NPI: A 10-digit federally-issued identifier for a health-care provider or organization. Type 1 = individual provider; Type 2 = organizational. The key by which CMS's Medicare Provider Utilization and Payment Data (PUF) is published.
Annual Wellness Visit (initial) G0438: Once-per-lifetime preventive Medicare visit, billable after the first 12 months of Part B enrollment. Distinct from the IPPE (G0402, "Welcome to Medicare"). High-performing clinics capture 60%+ of eligible patients.
Related: /blog/rhc-denial-recovery
Annual Wellness Visit (subsequent) G0439: Annual preventive Medicare visit after the initial AWV. Billable every 12 months for the rest of the patient's Medicare coverage.
Initial Preventive Physical Exam IPPE / G0402: The "Welcome to Medicare" visit, available only in the first 12 months of Part B enrollment. One-time only. Distinct from AWV.
Transitional Care Management TCM / 99495 / 99496: CPT codes for managing a patient's transition from an inpatient or observation setting back to the community. Requires interactive contact within 2 business days of discharge AND a face-to-face visit within 14 days (99495, moderate) or 7 days (99496, high complexity). RHCs commonly bill zero TCM despite being eligible.
Chronic Care Management CCM / 99490: Monthly CPT for non-face-to-face care coordination for patients with 2+ chronic conditions expected to last ≥12 months. Requires ≥20 minutes of clinical staff time per month and a documented care plan.
Remote Patient Monitoring RPM / 99453 / 99454 / 99457 / 99458: Four CPTs covering RPM device-based monitoring. 99453 (initial setup, once per device category, requires 16+ days of data); 99454 (monthly device supply, requires ≥16 transmissions/month); 99457 (initial 20 min RPM care management, requires live interactive communication); 99458 (each additional 20 min). Common $1,500-$4,000/mo uplift when billed disciplined.
Related: /blog/hipaa-compliance-small-practices
Collaborative Care Model CoCM / 99492 / 99493 / 99494 / G0323: Monthly behavioral-health integration codes paid per enrolled patient. Eligible practices contract with a behavioral-health consultant; primary care submits the claims. G0323 (added 2023) expands to billing by clinical social workers and counselors.
RHC Care Management G0511: RHC-specific HCPCS code paid at approximately $68/month per eligible patient for ≥20 minutes of non-face-to-face care management activity. Most RHCs under-bill it because the code is not enabled in the billing system.
Related: /blog/g0511-rhc-chronic-care-management
RHC/FQHC Distant-Site Telehealth G2025: HCPCS code billed by RHCs and FQHCs when a clinic provider renders a telehealth service. Paid at the all-inclusive rate (AIR).
Related: /blog/telehealth-billing-rural-clinics
Virtual Check-In G2012: A 5-10 minute virtual check-in (phone or video) by an established physician or provider. Billable separately from the AIR for RHCs/FQHCs. Often unbilled despite the work being done.
Remote Evaluation of Recorded Patient Image / Video G2010: Asynchronous review of a patient-submitted image or video by a clinician. Small payment, frequently overlooked by RHCs and FQHCs.
Virtual Communication Services G0071: Asynchronous virtual communication services rendered by an RHC or FQHC. Paid separately from the AIR.
Modifier 95: Required modifier on most synchronous audio-video telehealth claims to Medicare. Indicates "synchronous telemedicine service rendered via real-time interactive audio + video."
Modifier 93: Required modifier on audio-only telehealth claims (including behavioral-health audio-only). Missing modifier 93 is one of the most common causes of telehealth denials.
Place of Service 02 POS 02: Place-of-service code indicating the patient was NOT in their home during a telehealth encounter (clinic, facility, etc.). Pays at the lower facility rate.
Place of Service 10 POS 10: Introduced in 2022. Place-of-service code indicating the patient WAS in their home during a telehealth encounter. Pays at the higher non-facility (office) rate. Many EHRs still default to POS 02 from pre-2022 setup.
Healthcare Common Procedure Coding System HCPCS: The two-tier billing code system used by Medicare. Level I = CPT codes (AMA-maintained, the 99213/99214 office visits etc.). Level II = HCPCS G-codes, J-codes, etc. (CMS-maintained, the G2012/G0511/G0438 RHC-specific codes etc.). When people say 'HCPCS' colloquially they usually mean Level II G-codes.
Current Procedural Terminology CPT: AMA-maintained code set used to describe medical, surgical, and diagnostic services. CPT codes form HCPCS Level I. Examples: 99213/99214 (office visits), 99490 (CCM), 99495/99496 (TCM), 99497 (ACP).
International Classification of Diseases (ICD-10) ICD-10: WHO-maintained diagnosis coding system used by all U.S. payers since 2015. ICD-10-CM is the U.S. clinical modification. Examples: E11.9 (type 2 diabetes without complications), I10 (essential hypertension), F32.9 (major depressive disorder, unspecified).
Evaluation and Management E/M: The CPT code family describing standard office and inpatient visits — 99202-99215 for outpatient, 99221-99239 for inpatient. The volume codes for primary care. Modifier -25 attaches an E/M to the same date as a procedure or preventive service when it represents a significant, separately identifiable service.
Medical Decision-Making MDM: The structured rubric CMS uses to score E/M complexity (straightforward, low, moderate, high). Determines which CPT level (99213/99214/99215) is billable. For TCM, MDM complexity differentiates 99495 (moderate) from 99496 (high).
Related: /blog/tcm-rhc-transitional-care-management
Principal Care Management PCM / 99424 / 99425 / 99426 / 99427: Care management for a single complex chronic condition (vs CCM's ≥2 conditions). Provider-personally-performed (99424/99425, 30 min units, ~$84/$60) or clinical-staff-performed under supervision (99426/99427, 30 min units, ~$60/$50). Part of the post-CY2024 G0511 unbundling for RHCs/FQHCs.
Related: /blog/rhc-care-management-cy2024-transition
Remote Therapeutic Monitoring RTM / 98980 / 98981: Remote monitoring of non-physiologic data — musculoskeletal, respiratory, cognitive-behavioral therapy adherence, etc. Distinct from RPM (which monitors physiologic data via FDA-defined medical devices). Cannot be billed in the same month as RPM 99457/99458 for the same patient. Initial 20 min/month ~$50; additional 20 min ~$40.
Related: /blog/rhc-care-management-cy2024-transition
Advance Care Planning ACP / 99497 / 99498: Provider-led discussion of end-of-life preferences, advance directives, and care goals. CPT 99497 covers the first 30 min (~$87); 99498 each additional 30 min (~$77). When ACP is performed during an Annual Wellness Visit (G0438/G0439), patient coinsurance is waived (Medicare covers 100%). Standalone or non-AWV ACP carries standard coinsurance.
Related: /blog/awv-medicare-annual-wellness-visit-rhc
Cognitive Assessment and Care Plan 99483: CPT code for a comprehensive cognitive evaluation and care-plan creation, typically billed as a follow-up after the AWV cognitive function detection identifies impairment. ~$272 average national. Cannot be billed at the same encounter as the AWV; schedule as a separate visit.
Related: /blog/awv-medicare-annual-wellness-visit-rhc
Behavioral Health Integration BHI / 99492 / 99493 / 99494: Care management for a diagnosed behavioral-health condition delivered through a structured collaborative-care arrangement (designated BH care manager + psychiatric consultant). 99492 = 70 min initial month (~$165); 99493 = 60 min subsequent months (~$130); 99494 = additional 30 min (~$70). Cannot be billed in the same month as CCM (99490 series) for the same patient.
Related: /blog/rhc-care-management-cy2024-transition

Denials + remittance

How payers communicate why a claim was denied or adjusted, and what is appealable.

Claim Adjustment Reason Code CARC: Standardized code on a remittance advice (835/EOB) explaining why a claim or claim line was adjusted. Examples: CO-16 (missing info), CO-50 (non-covered service), CO-97 (bundling).
Remittance Advice Remark Code RARC: Supplemental codes that accompany CARCs to provide additional context (e.g. "patient eligibility issue").
CO-16 (Missing Information): Most common appealable denial reason. Usually a missing modifier (typically -25, -59, 95, or 93) or a missing/incorrect place-of-service code. Resubmit with the correction.
Related: /blog/rhc-denial-recovery
CO-50 (Non-Covered Services): Service determined not medically necessary by the payer. Appealable with supporting documentation of medical necessity (clinical notes, guideline citations, prior treatment history).
CO-97 (Bundling): Service was determined to be included in another billed service. Sometimes correct, often disputable. Review the National Correct Coding Initiative (NCCI) edits for the specific code pair.
CO-29 (Timely Filing): Submitted past the payer's timely-filing deadline. Typically unrecoverable. Prevention is the only reliable fix — focus on submission-workflow timeliness instead of appeals.
PR-204 (Not Covered Under Patient Plan): Patient-side denial. Bill the patient or verify coverage at point of service. Not the payer's fault.
CO-170 (Performed Service Not Consistent with Provider Type): The billing provider is not credentialed for that service or modality with that payer. Verify credentialing — common on telehealth claims after a credential lapses.
National Correct Coding Initiative NCCI: CMS-published edits identifying which CPT code pairs are bundled (one is not separately payable in the presence of the other). Updated quarterly. Critical reference for working CO-97 denials.
Medicare Provider Utilization and Payment Data PUF: A public CMS dataset, refreshed annually, showing total services rendered, average submitted charge, average Medicare-allowed amount, and average payment amount per CPT code per NPI. The gap between average allowed and average paid reveals denial + adjustment leakage.
All-Inclusive Rate AIR: The single per-encounter rate Medicare pays an RHC or FQHC, intended to cover all services rendered during the visit. Distinct from fee-for-service codes paid à la carte to non-RHC/FQHC providers.
Medicare Administrative Contractor MAC: A regional private contractor designated by CMS to process Medicare Part A and Part B claims. Each U.S. region has a Part A/B MAC and a separate DME MAC. MACs publish jurisdiction-specific guidance via Local Coverage Determinations (LCDs) and articles that supersede generic CMS guidance for billing purposes. Always confirm with your MAC before changing billing workflow.
Local Coverage Determination LCD: A MAC-specific decision on whether a particular service or item is reasonable and necessary for Medicare coverage in that MAC's jurisdiction. LCDs and accompanying articles are the authoritative billing guidance for claims in that jurisdiction — they may differ from generic CMS national guidance.
Physician Fee Schedule PFS: The annual CMS rule that sets Medicare Part B payment rates for physician and clinician services. Published as a proposed rule (mid-summer) and final rule (Nov 1) each year. The CY2024 PFS Final Rule (CMS-1784-F) introduced the RHC/FQHC G0511 unbundling. Each year's PFS contains the rate updates and policy changes for the upcoming calendar year.

Compliance + privacy

The federal frameworks that govern PHI handling, clinic operations, and audit posture.

Health Insurance Portability and Accountability Act HIPAA: The federal law (1996) governing how Protected Health Information (PHI) is used and disclosed. Three rule sets matter for small practices: Privacy Rule (45 CFR 164.500), Security Rule (45 CFR 164.302), and Breach Notification Rule (45 CFR 164.400).
Related: /blog/hipaa-compliance-small-practices
Protected Health Information PHI: Individually-identifiable health information held by a covered entity or business associate. Includes name, address, dates, MRN, NPI of the patient, etc. Electronic PHI (ePHI) is the subset stored or transmitted electronically.
Business Associate Agreement BAA: A contract required by HIPAA between a covered entity and any vendor that handles PHI on its behalf. Specifies safeguards, breach notification obligations, and permitted uses.
Conditions of Participation CoP: CMS regulations a hospital, RHC, or FQHC must satisfy to be eligible to bill Medicare and Medicaid. Cover governance, infection control, staffing, physical environment, patient rights, and clinical records. CoP violations are the leading cause of CMS provider-decertification actions against rural clinics.
Office for Civil Rights OCR: The HHS office that enforces the HIPAA Privacy and Security Rules and investigates complaints. Publishes enforcement-action data showing the most-commonly-cited violation categories — predominantly continuity failures (active-user drift, expired BAAs, stopped audit logs), not absence of policy.
Security Risk Assessment SRA: An annual written assessment required by both the HIPAA Security Rule (§ 164.308) and the MIPS Promoting Interoperability category. The single most-commonly-skipped PI item — usually because nobody owns it.

Telehealth + interoperability

Post-PHE telehealth coverage rules and the federal data-exchange framework.

Public Health Emergency PHE: The COVID-era federal declaration that enabled broad telehealth flexibilities (audio-only coverage, home as originating site for all services, etc.). Officially ended May 11, 2023; many flexibilities extended through Dec 31, 2026 under the Consolidated Appropriations Act.
Consolidated Appropriations Act CAA: Annual federal appropriations packages that have repeatedly extended telehealth flexibilities post-PHE. The CAA 2023 §4113 permanently expanded behavioral-health telehealth (including audio-only, with home as originating site).
Trusted Exchange Framework and Common Agreement TEFCA: A federal framework for interoperable health information exchange across networks. QHINs (Qualified Health Information Networks) are the participating exchange networks.
Qualified Health Information Network QHIN: An ONC-designated network qualified to participate in TEFCA exchange. Examples: Health Gorilla, eHealth Exchange, KONZA, Epic Nexus, Commonwell.
Fast Healthcare Interoperability Resources FHIR: The HL7 standard for representing and exchanging clinical and administrative data. FHIR R4 is the current widely-adopted version. The protocol every modern EHR API speaks.
Continuity of Care Document CCD: An older XML-based clinical-summary document (HL7 CDA-based) used for patient transitions. Largely superseded by FHIR but still common in legacy EHR exports.
Recognized Coordinating Entity RCE: The entity selected by ONC/ASTP to operate the TEFCA framework — currently The Sequoia Project. The RCE designates QHINs, manages the Common Agreement, and publishes the live list of designated QHINs and the TEFCA exchange volume metrics.
Related: /blog/tefca-qhin-rural-clinics-2026
Office of the National Coordinator for Health IT ONC / ASTP: The HHS office responsible for federal health-information-technology policy, including TEFCA, EHR certification, and information blocking enforcement. Renamed the Assistant Secretary for Technology Policy (ASTP) in 2024 as part of an HHS reorganization; many CMS documents still reference 'ONC' and the URL healthit.gov.
Admit/Discharge/Transfer Feed ADT: Real-time HL7 message stream from a hospital information system notifying receiving entities (PCP offices, HIEs, payers) when a patient is admitted, discharged, or transferred. ADT feed integration is the gold-standard mechanism for capturing TCM-eligible discharges within the 2-business-day contact window — usually accessed via a state HIE or QHIN.
Related: /blog/tcm-rhc-transitional-care-management

Surveillance + public-health data

The federal data feeds that inform population-health and operational decisions.

National Wastewater Surveillance System NWSS: CDC-operated network of wastewater treatment plants measuring SARS-CoV-2, influenza A/B, and RSV viral loads. Provides 4-7 days of lead time on respiratory surges. Approximately 1,500 sites in 45+ states. Updated weekly.
Related: /blog/wastewater-lead-time
National Notifiable Disease Surveillance System NNDSS: CDC system collecting reports of notifiable diseases from state and territorial health departments. Used for outbreak detection, public health response, and pandemic preparedness.
CDC PLACES: CDC dataset publishing county-level prevalence estimates for chronic diseases, health behaviors, and preventive services. Used in HRSA grant applications (D04 in particular) to demonstrate community need.
Uniform Data System UDS: HRSA's annual reporting system for FQHCs. Captures patient demographics, services, clinical quality measures, and financial data. UDS reports are public — comparable benchmarks across all HRSA-funded centers.
Community Health Needs Assessment CHNA: A federally-required assessment of community health needs that tax-exempt hospitals must complete every 3 years (IRS § 501(r)(3)). FQHCs use similar assessments to inform Section 330 grant renewals.
Social Determinants of Health SDOH: Non-medical factors that influence health outcomes — housing, food security, transportation, income, education. Increasingly tracked in EHRs and required for several MIPS Improvement Activities.
American Community Survey ACS: US Census Bureau survey providing annual demographic and socioeconomic data at the county and tract level. Source of most federal SDOH overlays.

Risk + quality scoring

How clinicians stratify patient populations and what scores drive billing or alerts.

Hierarchical Condition Categories HCC: CMS's risk-adjustment model that translates ICD-10 diagnoses into a Risk Adjustment Factor (RAF) score. Used to adjust Medicare Advantage payments for the expected cost of caring for a patient.
LACE Index: A 4-component score (Length of stay, Acuity of admission, Comorbidities, ED visits) predicting 30-day readmission risk after a hospital discharge. LACE ≥10 is high risk and triggers TCM/CCM workflow priority.
Healthcare Effectiveness Data and Information Set HEDIS: A standardized set of performance measures used to compare health-plan and provider quality. Many MIPS quality measures align with HEDIS specs.
Patient-Centered Medical Home PCMH: NCQA recognition for a primary-care practice that meets specific care-coordination, access, and quality standards. Recognition counts as a high-weight MIPS Improvement Activity.
Health Risk Assessment HRA: A structured questionnaire (patient-completed or staff-completed) that captures health behaviors, family history, screening status, and risk factors. Required element of every Medicare AWV (G0438 initial, G0439 subsequent). Forms the basis for the personalized prevention plan that the AWV must produce.
Related: /blog/awv-medicare-annual-wellness-visit-rhc
Mini-Cog Cognitive Screening: A brief 3-minute cognitive screening tool combining 3-item recall + clock-drawing test. The most commonly-used method to satisfy the AWV cognitive function detection requirement. Sensitivity ~76%, specificity ~89% for cognitive impairment in primary-care populations. Alternative tools: GPCOG, MoCA, Mini-Mental State Examination (MMSE).
Related: /blog/awv-medicare-annual-wellness-visit-rhc
Abdominal Aortic Aneurysm Screening AAA Screening: A one-time ultrasound screening for AAA, covered by Medicare without coinsurance for men aged 65-75 with smoking history (or with family history). Required as a screening-recommendation conversation during the IPPE (G0402); AWV providers should confirm completion or refer.

Federal agencies + offices

Who funds and regulates rural and community healthcare.

Centers for Medicare & Medicaid Services CMS: The HHS agency that administers Medicare, Medicaid, the Children's Health Insurance Program (CHIP), and the QPP. Sets payment rules, conditions of participation, and value-based payment policy.
CMS Innovation Center CMMI: CMS unit testing alternative payment models that aim to improve quality and reduce cost. Operates rolling Primary Cares Models, ACO REACH, and other shared-savings programs.
Health Resources & Services Administration HRSA: The HHS agency funding safety-net providers (FQHCs via Section 330, RHC technical assistance via FORHP, NHSC scholarships). Also administers HPSA and MUA designations.
Federal Office of Rural Health Policy FORHP: The HRSA office focused on rural health. Administers RHC programs, Rural Hospital Flexibility (FLEX) grants, Small Hospital Improvement Program (SHIP) grants, and rural-priority emergency funding.
State Office of Rural Health SORH: A FORHP-designated office in each state coordinating rural health funding and policy. Often administers state-level innovation grants alongside federal pass-through funding. Highest-ROI underused contact for rural clinics.
National Association of Rural Health Clinics NARHC: The national membership organization for RHCs. Publishes regulatory updates, runs the certification program for Certified RHC Professionals, and lobbies on RHC payment policy.
National Association of Community Health Centers NACHC: The national membership organization for FQHCs and Look-Alikes. Publishes the annual Community Health Center Chartbook and lobbies on Section 330 funding.