GLOSSARY OF ACRONYMS, ABBREVIATIONS, AND TERMS

AAA - AREA AGENCIES ON AGING
Organizations where people over age 60 can find out about services in their
communities. Services can be obtained directly through the network of local area
agencies on aging.

AARP - AMERICAN ASSOCIATION OF RETIRED PERSONS
A nonprofit, nonpartisan organization representing the interests of people age 50 and
older. It serves their needs and interests through information and education,
advocacy, and community services. AARP has about 3300 chapters with 17 million
members.

ABN - ADVANCED BENEFICIARY NOTICE
A notice issued by physicians explaining that Medicare will not reimburse a service.

ACT - (THE) THE SOCIAL SECURITY ACT (TITLE XIX)

AFIB - ATRIAL FIBRILLATION
A cardiac dysrhythmia characterized by disorganized electrical activity in the atria
accompanied by a rapid, irregular ventricular response.

AHRQ - AGENCY FOR HEALTHCARE RESEARCH AND QUALITY
A public health service agency within the Department of Health and Human Services
to support research designed to improve the outcomes and quality of health care,
reduce its costs, address patient safety and medical errors, and broaden access to
effective services. The research sponsored, conducted, and disseminated by the
AHRQ provides information that helps people make better decisions about health
care.

AHIMA - AMERICAN HEALTH INFORMATION MANAGEMENT ASSOCIATION
The professional organization of more than 38,000 experienced specialists in health
information.

AHQA - AMERICAN HEALTH QUALITY ASSOCIATION
A national, not-for-profit membership association of independent, community-based
Quality Improvement Organizations (QIOs) representing the 50 states, the District of
Columbia and the U.S. territories. Also referred to as the Quality Improvement
Organization Trade Association. Sometimes pronounced “ah kwa.”

ALJ - ADMINISTRATIVE LAW JUDGE
Social Security Administration Hearing Officer or State Department of General
Support Services/Personnel representative who adjudicates client/provider appeals and
QIO issues after all appeal rights have been exhausted.

ALOS - AVERAGE LENGTH OF STAY
Mean number of days a client is hospitalized in a hospice program or other health care
facility.

AMI - ACUTE MYOCARDIAL INFARCTION (heart attack)

BBA - BALANCED BUDGET ACT OF 1997
Contains provisions for the Medicare+Choice and includes program prevention
initiatives, rural initiatives, anti-fraud and abuse provisions, program integrity, and
several other provisions related to the Medicare and Medicaid programs.

BPPI - BENEFICIARY PROTECTION AND PROGRAM INTEGRITY

BRFSS - BEHAVIORAL RISK FACTOR SURVEILLANCE SYSTEM
An ongoing, state-based, random-digit-dialed telephone survey of U.S. civilian, noninstitutionalized adults age greater than 18 years. The survey collects state-based
information on health status, health-related behaviors, and preventive services
utilization. In 1995, all 50 states participated in the survey.

CAH - CRITICAL ACCESS HOSPITAL
The Balanced Budget Act of 1997 established the Medicare Rural Hospital Flexibility
Program which allows a state to establish Critical Access Hospitals and at least one
rural health network. A CAH is a limited services, rural hospital that is eligible for
Medicare reimbursement and meets other designated criteria.

CART - CMS ABSTRACTION AND REPORTING TOOL FOR HOSPITALS

CC - CLINICAL COORDINATOR

CDAC - CLINICAL DATA ABSTRACTION CENTER
Government contractor responsible for abstracting information from medical records
to assist QIOs in carrying out the Health Care Quality Improvement Program. The
two CDAC sites are: Coastal CDAC (FMAS CDAC located in Rockville, MD) and
Central CDAC (DynKePRO CDAC, located in York, PA).

CDC - CENTERS FOR DISEASE CONTROL AND PREVENTION
A federal agency of the U.S. government that provides facilities and services for the
investigation, identification, prevention, and control of disease. The CDC is located
in Atlanta, GA.

CE - CONTINUING EDUCATION

CFR - CODE OF FEDERAL REGULATIONS
The general and permanent rules published by executive departments and agencies of
the federal government.

CHAMPUS - CIVILIAN HEALTH AND MEDICAL PROGRAM FOR THE UNIFORMED
SERVICES
Now TRICARE.

CHF - CONGESTIVE HEART FAILURE

CM - COMPREHENSIVE CASE MANAGEMENT

CME - CONTINUING MEDICAL EDUCATION

CMS - CENTERS FOR MEDICARE AND MEDICAID SERVICES
A branch of the federal Department of Health and Human Services. This federal
agency is responsible for administering the Medicare and Medicaid programs.
Formerly known as HCFA.

CO - CENTRAL OFFICE
CMS Central Office located in Baltimore, Maryland

COBRA - CONSOLIDATED OMNIBUS BUDGET RECONCILIATION ACT OF 1985,
P.L. 99-272, ENACTED APRIL 7, 1986
This is the Act of 1985, which had far-reaching effects including the Anti-Dumping
Statute. The Act provides significant penalties for hospitals found guilty of violating
the statute, that is, not providing the appropriate treatment, screening, and/or
evaluation or stabilization prior to transfer of a patient in active labor or with an
emergency medical condition. There are other changes mandated by COBRA
including the yet to be implemented denial of payment for substandard care.

CQI - CONTINUOUS QUALITY IMPROVEMENT
An integrated, comprehensive approach to continuously examine, refine, and revise
organizational processes to meet and exceed customers’ expectations. Integrates
fundamental management approaches, improvement efforts, tools, and training.

CPT-4 - CURRENT PROCEDURAL TERMINOLOGY, 4TH EDITION (PHYSICIANS)
Comprehensive listing of medical terms and codes for the uniform designation of
diagnostic and therapeutic procedures Its purpose is to provide standard terminology
and coding for the consistency and comparability in reporting for third-party payment.
Proprietary coding system for physician services developed by the American Medical
Association used for identification of services in the ambulatory setting and is the
basis of the HCPCS coding system.

CPR   - CUSTOMARY, PREVAILING AND REASONABLE
Current method of paying physician under Medicare. Payment for a service is limited
to the lowest of 1) the physician’s billed charge for the service, 2) the physician’s
customary charge for the service, or 3) the prevailing charge for that service in the
community.

CSR - CONTINUED STAY REVIEW

DCAA - DEFENSE CONTRACT AUDIT AGENCY

DCI - DATA COLLECTION INSTRUMENT

DHHS - DEPARTMENT OF HEALTH AND HUMAN SERVICES
Administers many of the “social” programs at the federal level dealing with the health
and welfare of the citizens of the U.S. It is the “parent” of CMS.

DME - DURABLE MEDICAL EQUIPMENT
Medical equipment and appliances which are suitable for use in the home, with an
obvious medical purpose, which can withstand repeated use, and would not be useful
to the client in the absence of illness, injury, or disability.

DOD - DEPARTMENT OF DEFENSE
Division of federal government under which TRICARE is administered.

DRG - DIAGNOSIS RELATED GROUP
A classification system for hospitalized patients using major diagnostic categories
related to body organ systems and surgical procedures. Each hospital admission is
classified into one of the groups based on diagnosis, procedures, age, sex, and
discharge status determined by similarity of resource consumption.

EBD - ELDERLY, BLIND, AND DISABLED

ELOS - ESTIMATED LENGTH OF STAY

EMTALA - EMERGENCY MEDICAL TREATMENT AND ACTIVE LABOR ACT
The law states that hospital emergency departments must provide an appropriate
medical screening examination for any individual presenting to the ED and requesting
examination or treatment. The law stipulates when a patient who has an emergency
medical condition or is in labor must receive stabilizing treatment before the patient
can be transferred to another medical facility.

ESRD - END-STAGE RENAL DISEASE

FA - FISCAL AGENT
An agency acting as the payer of state-funded Medicaid services.

FAR - FEDERAL ACQUISITION REGULATIONS

FATHOM - FIRST-LOOK ANALYSIS TOOL FOR HOSPITAL MONITORING
Tool used by QIOs to look at specific hospital data related to target areas defined by
CMS.

FEIN - FEDERAL EMPLOYER IDENTIFICATION NUMBER

FFS - FEE-FOR-SERVICE

FI - FISCAL INTERMEDIARY
An agency acting as the payer of federally funded Medicare services.

GAAP - GENERALLY ACCEPTED ACCOUNTING PRINCIPALS

GSA - GENERAL SERVICES ADMINISTRATION

HCBS - HOME AND COMMUNITY-BASED SERVICES

HCPOTP - HEALTH CARE PRACTITIONERS OTHER THAN PHYSICIANS

HCPCS - HCFA COMMON PROCEDURE CODING SYSTEM
Coding system based on CPT, but supplemented with additional codes for nonphysician
services, and required for coding by Medicare carriers.

HCQIP - HEALTH CARE QUALITY IMPROVEMENT PROGRAM
Pronounced “hiccup.” A collaborative project, funded by CMS, using quality
indicators, designed to measurably improve the delivery and quality of health care
services.

HEDIS - HEALTH PLAN EMPLOYER DATA INFORMATION SET
The measurement tool that helps consumers, corporations, and public purchasers of
health care evaluate the quality of care delivered by managed care plans.

HF - HEART FAILURE

HHA - HOME HEALTH AGENCY
A health agency providing nursing and other health or educational services in a
patient’s home.

HIM - HEALTH INFORMATION MANAGEMENT

HINN - HOSPITAL ISSUED NOTICE OF NON-COVERAGE
Hospital notice to the patient that hospital or swing bed services are not required.
May be given either at admission or during continued stay.

HIPAA - HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT OF
1996
This act is designed to protect health insurance coverage for workers and their
families when they change or lose their jobs, and to protect confidentiality of
protected health information (PHI).

HMO - HEALTH MAINTENANCE ORGANIZATION
An organization that provides a comprehensive range of health maintenance and
treatment services for a pre-established fee, regardless of the number of office visits,
hospitalizations, or medications.

HPMP - HOSPITAL PAYMENT MONITORING PROGRAM
A program in which the QIO develops the functional capability to determine the types
of payment errors occurring in its state. The QIO then develops interventions to
reduce or minimize the occurrence of the errors identified. An entity within the 7th
scope of work.

HPTI - HUMAN PERFORMANCE TRAINING INSTITUTE

ICD-9-CM - INTERNATIONAL CLASSIFICATION OF DISEASES, 9TH REVISION,
CLINICAL MODIFICATION
A coding system developed by the World Health Organization and modified for use in
the United States for classifying diseases and procedures for the purpose of indexing
hospital records and reimbursement.

ICF - INTERMEDIATE CARE FACILITY
A health facility that provides medical-related services to persons with a variety of
physical or emotional conditions requiring institutional facilities but without the
degree of care provided by a hospital or skilled nursing facility.

IHI - INSTITUTE FOR HEALTHCARE IMPROVEMENT
A Boston-based, independent, non-profit organization working since 1991 to
accelerate improvement in health care systems in the U.S., Canada, and Europe.

IPA - INDEPENDENT PRACTICE ASSOCIATION
An HMO, which contracts directly with physicians who continue to practice in their
private offices.

IQC - INTERNAL QUALITY CONTROL

IRR - INTER-RATER RELIABILITY
Statistic that measures the extent to which two or more data abstractors perform their
work in the same manner and obtain the same information from the medical record.
Used to ensure accuracy of data collection instrument.

IRS - INTERNAL REVENUE SERVICE

JCAHO - JOINT COMMISSION ON ACCREDITATION OF HEALTH CARE
ORGANIZATIONS
An independent, non-profit organization which evaluates and accredits hospitals,
health care networks, home care organizations, nursing homes, behavioral health care
organizations, ambulatory care providers, and clinical laboratories. Based in a suburb
of Chicago.

LMRP - LOCAL MEDICAL REVIEW POLICY
Medicare coverage policies for Parts A & B.

LOS - LENGTH OF STAY
Number of days the patient is hospitalized, remains in a hospice, LTC or other health
care facility.

LTAC - LONG TERM ACUTE CARE

LTC - LONG TERM CARE
Nursing homes, extended care facilities, transitional care units, usually providing
intermediate, custodial, and/or skilled nursing care.

LTCH - LONG TERM CARE HOSPITAL

M+CO - MEDICARE + CHOICE

MCO - MANAGED CARE ORGANIZATION
An arrangement whereby a third party payer (e.g., insurance company, federal
government, or corporation) mediates between physicians and patients, negotiating
fees for service, and overseeing types of treatments given.

MDS - MINIMUM DATA SET
A tool used for nursing home resident assessment and care screening.

MIS - MANAGEMENT INFORMATION SYSTEM

MMA - MEDICARE MODERNIZATION ACT OF 2003

MMIS - MEDICAID MANAGEMENT INFORMATION SYSTEMS
The on-line information system that provides Medicaid client data.

MN/LOC - MEDICAL NECESSITY/LEVEL OF CARE
Guidelines used in determining medical need and appropriateness of admission and/or
continued stay.

MOA - (Medicare) MEMORANDUM OF AGREEMENT
A written agreement between QIOs and providers, payers, state licensing and
certification agencies, and accreditation bodies to perform functions mandated by Part
B of Title XI of the Social Security Act. Specifies QIO administrative and review
responsibilities necessary to accomplish all requirements including improvement
project activities under the QIO contract.

MOU - (Medicaid) MEMORANDUM OF UNDERSTANDING
An agreement between QIOs, and health care providers, defining responsibilities of
both parties in meeting the requirements outlined in the CFR as they pertain to
Medicaid review work.

MPS - MINIMUM PERFORMANCE STANDARDS
One standard dictated by CMS by which all QIOs are evaluated for
contract performance.

MSA - MEDICAL SAVINGS ACCOUNT
A Medicare health plan option – a private insurance plan that only pays after a high
deductible is met, perhaps $6000, combined with a Medicare-funded private account
to pay some costs below deductible.

MR - MEDICAL RECORD

NCQA - NATIONAL COMMITTEE FOR QUALITY ASSURANCE
Organization sponsored jointly by insurers, health care providers, employers, and
unions that is chiefly responsible for the accreditation of health maintenance
organizations.

NH - NURSING HOME

Non-PPS - NON-PROSPECTIVE PAYMENT SYSTEM
A per diem reimbursement arrangement for services provided as specific facilities.

NRMI - NATIONAL REGISTRY FOR MYOCARDIAL INFARCTION

OBQI - OUTCOME-BASED QUALITY IMPROVEMENT FOR HOME HEALTH

OBRA - OMNIBUS BUDGET RECONCILIATION ACT

OIG - OFFICE OF THE INSPECTOR GENERAL, U.S. DHHS
An organizational component of the Office of the Secretary, HHS, which is
responsible for conducting and supervising audits, investigations, and inspections
relating to the programs and operations of DHHS.

OMB - OFFICE OF MANAGEMENT AND BUDGET

OSCAR - ONLINE SURVEY CERTIFICATION AND REPORTING SYSTEM

P VALUE - P VALUE CALCULATION
A statistic that expresses the degree to which a finding is not related to chance. Its
calculation is heavily dependent on the number of subjects.

PAR - PRIOR AUTHORIZATION REVIEW
A review to authorize payment which occurs prior to delivery of medical services or
equipment.

PASARR - PREADMISSION SCREENING AND ANNUAL RESIDENT REVIEW

PATH - PREVENTIVE ACTION TOWARDS HEALTH PROJECT

PBSC - PERFORMANCE-BASED SERVICE CONTRACT
A contract that bases level of payment on the level of performance.

PC - PROJECT COORDINATOR

PCC - PRINCIPAL CLINICAL COORDINATOR
QIO employee whose role is to serve as a focus for change within the QIO and in the
provider and practitioner community, as the HCQIP develops.

PCP - PRIMARY CARE PHYSICIAN
The physician who is responsible for a client’s basic care and for referrals to
specialists.

PDC - PROJECT DATA COLLECTION
The act of abstracting information from the medical record for use in projects or other
mandatory reviews.

PDCA - PLAN, DO, CHECK, ACT
A systematic, scientific method for improving processes.

PDSA - PLAN, DO, STUDY, ACT
A systematic, scientific method for improving processes.

PEPP - PAYMENT ERROR PREVENTION PROGRAM
Part of 6th SOW. 7th SOW activities occurring in Hospital Payment Monitoring
Program.

PFFS - PRIVATE FEE FOR SERVICE PLAN
A Medicare health plan option in which the beneficiary can use any doctor or hospital.
The plan sets its own payment levels and pays its own bills.

PHP - PARTIAL HOSPITALIZATION PROGRAM

PHI - PROTECTED HEALTH INFORMATION
All individually identifiable health information held or transmitted by a covered entity
or its business associate, in any form or media, whether electronic, paper, or oral.

PM - PROJECT MANAGER

PM & AS - PROJECT MANAGEMENT AND ANALYTIC SERVICES

PMP - PERFORMANCE MANAGEMENT PLAN

P&P - POLICY AND PROCEDURE

PPO - PREFERRED PROVIDER ORGANIZATION
A health plan option in which there is a recommended group of doctors and hospitals.
Beneficiaries can go to other doctors but this option is more costly.

PPS - PROSPECTIVE PAYMENT SYSTEM
A reimbursement arrangement with a predetermined fixed payment for each of the
diagnosis related groups.

PR - PHYSICIAN REVIEWER
A credentialed physician who performs peer reviews medically related to utilization,
quality, and diagnosis related group issues.

PRAF - PHYSICIAN REVIEWER ASSESSMENT FORM

PRO - PEER REVIEW ORGANIZATION
Now QIO. An organization contracting with CMS to review the medical necessity
and the quality of care provided to Medicare beneficiaries.

PSO - PROVIDER SPONSORED ORGANIZATION
A Medicare health plan option – A required group of doctors and hospitals providing
services under agreed supervision.

QAC - CMS’s QUALITY ADVISORY COUNCIL

QAPI M+CO QUALITY ASSESSMENT AND PERFORMANCE IMPROVEMENT
PROGRAM

Q&C - QUALITY AND COMPLIANCE

QC - QUALITY COUNCIL

QI - QUALITY IMPROVEMENT
An approach that focuses on improvements throughout an entire process in order to
improve the outcome/output of the process.

QI - QUALITY INDICATOR
A quantitative measure that provides data to assess and monitor processes, products,
or services. The purpose of the indicators is to provide measurements that are useful
to support quality improvement efforts.

QIO - QUALITY IMPROVEMENT ORGANIZATION
New term for peer review organizations. An organization contracting with CMS to
review the medical necessity and the quality of care provided to Medicare
beneficiaries. Formerly PRO.

QIOSC - QUALITY IMPROVEMENT ORGANIZATION SUPPORT CONTRACTOR
A QIO team contracted with CMS to coordinate activities, conduct analyses, act as a
clearinghouse, convene expert panels, identify and develop intervention materials and
disseminate information in each of the national clinical project areas.

QIP - QUALITY IMPROVEMENT PROGRAM

QISMC - QUALITY IMPROVEMENT SYSTEM FOR MANAGED CARE

QMB - QUALIFIED MEDICARE BENEFICIARY
A Medicaid client who is eligible for both Medicaid and Medicare.

RAF - REMITTANCE ADVICE FORM
Notification from the fiscal intermediary to the provider regarding status and payment
of claims.

RCDC - REVIEW CRITERIA DEVELOPMENT COMMITTEE
Review Criteria Development Committee (RCDC) is responsible for reviewing
medical criteria and making recommendations for revisions and approval of medical
criteria. Committee members are typically physicians who represent a variety of
medical specialty areas.

RFP - REQUEST FOR PROPOSAL
Document prepared by an organization to stimulate response from potential
contributors or participants. Often used by CMS and other federal and state agencies
to start the contracting process.

RHIA - REGISTERED HEALTH INFORMATION ADMINISTRATOR
An individual with at least a bachelor’s degree who has successfully completed the
national accreditation examination. Individuals skilled in the collection,
interpretation, and analysis of patient data. They also receive the training necessary to
assume managerial positions related to these functions.

RHIT - REGISTERED HEALTH INFORMATION TECHNICIAN
An individual with at least an associate’s degree who ensures the quality of medical
records by verifying their completeness, accuracy, and proper entry into computer
systems. RHITs often specialize in coding diagnoses and procedures in patient
records for reimbursement and research.

RNRC - REGISTERED NURSE REVIEW COORDINATOR
A registered nurse who uses professional clinical expertise and physician-developed
criteria to make utilization determinations and identify potential quality concerns.

RO - REGIONAL OFFICE
CMS Regional Office. There are 10 regional offices nationwide. Four of those 10
regional offices are responsible for monitoring the functions of QIOs in defined
geographical areas. The Region X Office, located in Seattle, Washington monitors
Colorado.

RTC - RESIDENTIAL TREATMENT CENTER

RUGS - RESOURCE UTILIZATION GROUPS
System utilizes resident assessment data (from MDS) completed by SNFs to assign
residents into one of 44 groups.

SDPS - STANDARD DATA PROCESSING SYSTEM

SEER - SURVEILLANCE, EPIDEMIOLOGY, AND END RESULTS

SHIP - SENIOR HEALTH INSURANCE ASSISTANCE PROGRAM
Formerly Insurance Counseling Association (ICA). A counseling program for
Medicare recipients and their families seeking assistance in understanding Medicare
benefits and coverage gaps, medical bills, and other insurance options.

SIP - SURGICAL INFECTION PREVENTION PROJECT

SNF - SKILLED NURSING FACILITY
A specially qualified facility that has the staff and equipment to provide nursing care
or rehabilitation services and other health related services.

SOW - SCOPE OF WORK
QIO contracts with CMS.

SSA - SOCIAL SECURITY ADMINISTRATION

SSA - STATE SURVEY AGENCY

SSN - SOCIAL SECURITY NUMBER

SUDRF - SUBTANCE USE DISORDER REHABILITATION FACILITY

TEP - TECHNICAL EXPERT PANEL

TMA - TRICARE MANAGEMENT ACTIVITY
Formerly CHAMPUS. Benefits program for the military services.

TQM - TOTAL QUALITY MANAGEMENT

UB-92 - UNIFORM BILL OR UNIBILL (Now using UB-04)
The provider billing statement, which combines demographic, financial, and medical
data that is submitted to the fiscal intermediary following services to
Medicare/Medicaid beneficiaries.

UQIOSC - UNDERSERVED QUALITY IMPROVEMENT ORGANIZATION SUPPORT
CONTRACTOR

UR - UTILIZATION REVIEW
A review of services delivered by a health care provider or supplier to determine
whether the services were medically necessary and appropriate.

VHA - VETERAN’S HEALTH ADMINISTRATION

VHA - VOLUNTARY HOSPITAL ASSOCIATION, MOUNTAIN STATES