Comprehensive Guide to Medical Abbreviations and Acronyms

Abbreviations

AAMA American Association of Medical Assistants AAMT American Association for Medical Transcription AAPC American Academy of Professional Coders ABN advance beneficiary notice of noncoverage a.c. before meals ACA Affordable Care Act ACO accountable care organization adm admitted ADR Additional Documentation Request ADX admitting diagnosis AHIMA American Health Information Management Association AMA American Medical Association AMT American Medical Technologists ANSI American National Standards Institute AP (1) accounts payable, (2) anterior-posterior APC ambulatory patient classification A/R accounts receivable ASC ambulatory surgical center ASO administrate services only ASU ambulatory surgical unit AWV annual wellness visit BA business associate BCBS BlueCross BlueShield b.i.d. twice a day BLK Lung black lung BMI body mass index BP blood pressure BUN blood urea nitrogen bx biopsy ca cancer CAC computer-assisted coding CAGC claim adjustment group code CARC claim adjustment reason code

C&S culture and sensitivity cc cubic centimeter CC (1) physicians’ records: chief complaint, (2) hospita documentation: comorbidities and complications CCA Certified Coding Associate CCHIT Certification Commission for Healthcare Information Technology CCI Correct Coding Initiative (national; Medicare) CCOF credit card on file CCS Certified Coding Specialist CCS-P Certified Coding Specialist-Physician-Based CCYY year, indicates entry of four digits for the century (CC) and year (YY) CDHP consumer-driven health plan CE covered entity CHAMPUS Civilian Health and Medical Program of the Uniformed Services, now TRICARE CHAMPVA Civilian Health and Medical Program of the Department of Veterans Affairs CHIP Children’s Health Insurance Program CLIA Clinical Laboratory Improvement Amendment cm centimeter CMA Certified Medical Assistant CMS Centers for Medicare and Medicaid Services CNS central nervous system COB coordination of benefits COBRA Consolidated Omnibus Budget Reconciliation Act of 1985 COP conditions of participation CPC Certified Professional Coder CPC-H Certified Professional Coder-Hospital Outpatient Facility CPE complete physical exam CPT Current Procedural Terminology CSRS Civil Service Retirement System CV cardiovascular CWF Common Working File

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Page AB-2 D&C dilation and curettage DD day, indicates entry of two digits for the day DEERS Defense Enrollment Eligibility Reporting System DME durable medical equipment DMEPOS durable medical equipment, prosthetics, orthotics, and supplies DOB date of birth DOJ Department of Justice DOS date of service DPT diphtheria, pertussis, and tetanus DRG diagnosis-related group DRS designated record set dx diagnosis ECOA Equal Credit Opportunity Act EDI electronic data interchange EEG electroencephalogram EENT eyes, ears, nose, and throat EFT electronic funds transfer EHB essential health benefit EHR electronic health record EIN Employee Identification Number EKG electrocardiogram EMC electronic media claim E/M code Evaluation and Management code EMG emergency EMR electronic medical record ENMT ears, nose, mouth, and throat ENT ears, nose, and throat EOB explanation of benefits EOC episode of care EP established patient EPSDT Early and Periodic Screening, Diagnosis, and Treatment ER emergency room ERISA Employee Retirement Income Security Act of 1974

ETOH alcohol F female FACTA Fair and Accurate Credit Transaction Act FCA False Claims Act FCRA Fair Credit Reporting Act FDCPA Fair Debt Collection Practices Act of 1977 FECA Federal Employees’ Compensation Act FEHB Federal Employees Health Benefits program FERA Fraud Enforcement and Recovery Act FERS Federal Employees Retirement System FH family history FI fiscal intermediary FICA Federal Insurance Contribution Act FMAP Federal Medicaid Assistance Percentage FSA flexible savings (spending) account F/U follow-up FUO fever, unknown origin Fx fracture g, gm gram GEM general equivalence mappings GI gastrointestinal GPCI geographic practice cost index gr grain GTIN Global Trade Item Number GU genitourinary GYN gynecologic, gynecologist h hour HAC hospital-acquired condition H&P history and physical HBA health benefits adviser HCERA Health Care and Education Reconciliation Act HCFA Health Care Financing Administration, currently CMS HCPCS Healthcare Common Procedure Coding System HDHP high-deductible health plan HEDIS Health Employer Data and Information Set

HEENT head, eyes, ears, nose, and throat HGB hemoglobin HHA home health agency HHS Department of Health and Human Services HiB hemophilus influenza type B vaccine HIE health information exchange HIM health information management HINN hospital-issued notice of noncoverage HIPAA Health Insurance Portability and Accountability Ac HIT health information technology HITECH Health Information Technology for Economic and Clinical Health Act HMO health maintenance organization HPI history of present illness HPSA Health Professional Shortage Area HPTC Healthcare Provider Taxonomy Code HRA health reimbursement account HS hour of sleep HSA health savings account hx history I&D incision and drainage ID, I.D. identification ID #, I.D. # identification number ICD-10-CM International Classification of Diseases, Tenth Revision, Clinical Modification ICD-10-PCS International Classification of Diseases, Tenth Revision, Procedure Coding System ICU intensive care unit IHP individual health plan IM intramuscular IME independent medical examination INFO information IPA individual practice association IPPE initial physical preventive examination IPPS Inpatient Prospective Payment System IV intravenous

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JCAHO Joint Commission on Accreditation of Healthcare Organizations kg kilogram L liter LCD local coverage determination LLQ left lower quadrant LMP last menstrual period LPN licensed practical nurse LUQ left upper quadrant m meter M male MA medical assistant MAC Medicare Administrative Contractor MACRA Medicare Access and CHIP Reauthorization Act of 2015 MBI Medicare Beneficiary Number mcg microgram MCM Medicare Carriers Manual MCO managed care organization MD medical doctor MEC CCI mutually exclusive code edit mEq milliequivalent MFS Medicare Fee Schedule mg milligram MIP Medicare Integrity Program mL milliliter MLN Medicare Learning Network mm millimeter MM month, indicates entry of two digits for the month MMA Medicare Modernization Act MMR measles, mumps, and rubella MOA Medicare Outpatient Adjudication remark code MPFS Medicare Physician Fee Schedule MPI master patient index MR Medical Review Program

Page AB-3 MRN (1) Medicare Remittance Notice, (2) Medicare Redetermination Notice, (3) Medical Record Number MS musculoskeletal MSA Medicare Savings Account MS-DRGs Medicare-Severity DRGs MSN Medicare Summary Notice MSP Medicare Secondary Payer MTF Military Treatment Facility MTS Medicare Transaction System MUE medically unlikely edit NCCI National Correct Coding Initiative NCD national coverage determination NCQA National Committee for Quality Assurance NDC National Drug Code NEC not elsewhere classifiable NEMB notice of exclusion from Medicare benefits Neuro neurologic, neurological NO. number nonPAR nonparticipating NOS not otherwise specified NP (1) new patient, (2) nurse-practitioner NPI National Provider Identifier n.p.o. nothing per os (by mouth) NPP Notice of Privacy Practices NPPES National Plan and Provider Enumerator System NSF nonsufficient funds NUCC National Uniform Claim Committee OB obstetrics OCR Office of Civil Rights OESS Office of E-Health Standards and Services OIG Office of the Inspector General OMB Office of Management and Budget op operative OPPS Outpatient Prospective Payment System opt optional

OSHA Occupational Safety and Health Administration OV office visit OWCP Office of Workers’ Compensation Programs OZ product number, Health Care Uniform Code Council P4P pay-for-performance PA physician assistant P&A percussion and auscultation PAR participating provider PC professional component p.c. after meals PCM Primary Care Manager (TRICARE) PCP primary care physician/provider PDX principal diagnosis PE physical exam PECOS Provider Enrollment Chain and Ownership System PH # phone number PHI protected health information PHR personal health record PIN provider identifier number PIP personal injury protection PM/EHR practice management/electronic health record PMH past medical history PMP practice management program PMPM per member per month po postoperative p.o. per os (by mouth) POA present on admission POS (1) place of service, (2) point-of-service option PPACA Patient Protection and Affordable Care Act PPD purified protein derivative of tuberculin test PPO preferred provider organization PPS Prospective Payment System PR patient responsibility p.r.n. as desired or as needed PSA prostate-specific antigen

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PSO provider-sponsored organization psych psychiatric pt patient q. every q.d. every day q.h. every hour q.i.d. four times a day q.o.d. every other day QIO quality improvement organization QPP Quality Payment Program q.2h. every two hours QUAL. qualifier RA remittance advice RAC Recovery Audit Contractor RARC remittance advice remark code RBRVS Resource-Based Relative Value Scale (Medicare) RCA real-time adjudication REF. reference Resp respiratory RHIA Registered Health Information Administration RHIT Registered Health Information Technology RLQ right lower quadrant RMA Registered Medical Assistant RN registered nurse R/O rule out ROS review of systems RTC return to clinic RUG Resource Utilization Group RUQ right upper quadrant RVS relative value scale RVU relative value unit Rx prescription SDA same-day appointment SDI state disability insurance SDOH Social Determinants of Health SH social history

Page AB-4 SMI Supplementary Medical Insurance SNF skilled nursing facility SOAP subjective/objective/assessment/plan SOF signature on file S/P status post SPD Summary Plan Description SSDI Social Security Disability Insurance SSI Supplemental Security Income SSN Social Security number stat, STAT immediately STD sexually transmitted disease subq, subcu subcutaneous T&A tonsillectomy and adenoidectomy TANF Temporary Assistance for Needy Families TC technical component TCS (HIPAA Electronic) Transaction and Code Sets temp temperature t.i.d. three times a day TM tympanic membrane TPA third-party claims administrator TPO treatment, payment, and healthcare operations TPR temperature, pulse, and respirations TRN reassociation trace number UA urinalysis UC urine culture UCR usual, customary, and reasonable UHDDS Uniform Hospital Discharge Data Set UPC Universal Product Code UPIN Unique Physician Identification Number UR utilization review URI upper respiratory infection URO utilization review organization USIN Unique Supplier Identification Number USPSTF United States Preventive Services Task Force UTI urinary tract infection VD venereal disease

VIS vaccine information sheet VP Vendor Product Number VS vital signs wbc white blood cells WBC white blood count yo year old YY year, indicates entry of two digits for the year; may also be noted as CCYY, which allows for entry of four digits for the century (CC) and year (YY) ZPIC Zone Program Integrity Contractor

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Abbreviations

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