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Billing Terms Glossary

Claims Processing Terms: Definitions for Therapists and Psychiatrists

These claims processing terms are defined in plain English for therapists and psychiatrists. Claims processing terms describe how a claim is built, sent, and handled by a payer. These definitions cover claim forms, CPT and ICD-10 codes, modifiers, place of service, and corrected claims.

In this section

108 terms defined
Written for psychotherapists and psychiatrists
Source organization linked on every entry

Back to the full billing terms glossary

Quiet behavioral health practice office with a desk and armchairs, the setting for our claims processing terms glossary

AAPC

General (all payers)

Also called: AAPC; American Academy of Professional Coders

Definition: A professional organization that trains and certifies medical coders and billers.
Why it matters: Coders may hold AAPC credentials, and it publishes coding education.
Illustrative example: A coder holds an AAPC certification.

Related terms CPT Code ICD-10-CM

Reference source AAPC

Categories Claims Processing

Add-On Code

General (all payers)

Also called: add-on code; CPT add-on; plus sign code; +code

Definition: An add-on code is a CPT code, marked with a plus sign, that describes an extra service done together with a primary procedure or service. It is never reported alone.
Why it matters: Examples in behavioral health are +90833, +90836, +90838, +90840, and +90785. Match each add-on to its allowed base codes.
Illustrative example: A psychiatrist bills 99214 as the base and +90833 as the add-on on the same date.

Reference source American Medical Association (AMA) · CMS Coverage Database, Article A57480 (WPS)

Categories Claims Processing

Adjudication

General (all payers)

Also called: claim adjudication; claim processing

Definition: The payer's process of reviewing a claim and deciding to pay, reduce, deny, or pend it.
Why it matters: Understanding adjudication helps identify where a claim stalled.
Illustrative example: A claim is adjudicated and the payer issues an ERA.

Reference source CMS (Centers for Medicare & Medicaid Services)

Categories Claims Processing

American Medical Association (AMA)

General (all payers)

Also called: AMA; CPT Editorial Panel

Definition: The professional association of physicians that publishes and maintains the CPT code set.
Why it matters: CPT code descriptions and rules come from the AMA.
Illustrative example: A practice checks the AMA's CPT manual for a code descriptor.

Related terms CPT Code Modifier

Reference source American Medical Association (AMA)

Categories Claims ProcessingAudits & Compliance

Billed Charge

General (all payers)

Also called: charge; submitted charge; gross charge

Definition: The amount a provider lists for a service on the claim before contractual adjustments.
Why it matters: Charges should be consistent across payers and reasonable relative to the fee schedule.
Illustrative example: A practice bills $200 for a session and is paid the allowed amount.

Reference source CMS (Centers for Medicare & Medicaid Services)

Categories Claims ProcessingPayment & Reimbursement

Box 1 (Type of Coverage)

General (all payers)

Also called: CMS-1500 box 1; item 1; type of health insurance coverage; claim filing indicator on paper claim

Definition: Box 1 on the 1500 claim form shows the type of health insurance coverage that applies to the claim. The choices are Medicare, Medicaid, TRICARE, CHAMPVA, Group Health Plan, FECA Black Lung, and Other.
Why it matters: A wrong choice can send the claim to the wrong payer or cause a rejection. Match the box to the primary payer's program, and note the payer's own rules for commercial plans.
Illustrative example: A biller marks Group Health Plan for a patient with employer coverage and Medicare as secondary.

Verify: Payer-specific instructions can differ from the NUCC manual.

Reference source NUCC, 1500 Claim Form Reference Instruction Manual, Version 13.0 (7/25)

Categories Claims ProcessingEligibility & Benefits

Box 11 (Insured's Policy, Group, or FECA Number)

General (all payers)

Also called: CMS-1500 box 11; item 11; group number on claim

Definition: Box 11 on the 1500 claim form holds the insured's policy, group, or FECA number. It is the alphanumeric identifier for health, auto, or other insurance coverage.
Why it matters: The group number helps the payer find the right employer plan. Copy it from the card exactly. Follow the payer's instruction on whether to use Box 11 for a plan with no group number.
Illustrative example: A biller copies the group number from the insurance card into Box 11.

Reference source NUCC, 1500 Claim Form Reference Instruction Manual, Version 13.0 (7/25)

Categories Claims ProcessingEligibility & Benefits

Box 11d (Another Health Benefit Plan)

General (all payers)

Also called: CMS-1500 box 11d; item 11d; is there another health benefit plan

Definition: Box 11d on the 1500 claim form asks whether the patient has insurance coverage other than the plan named in Box 1.
Why it matters: A yes answer tells the payer to expect a secondary payer. If yes, complete Box 9 through Box 9d. Payers use the answer to coordinate benefits.
Illustrative example: A patient has a spouse's plan as a secondary, so the biller answers yes and completes Box 9.

Reference source NUCC, 1500 Claim Form Reference Instruction Manual, Version 13.0 (7/25)

Categories Claims ProcessingEligibility & Benefits

Box 12 (Patient or Authorized Person's Signature)

General (all payers)

Also called: CMS-1500 box 12; item 12; signature on file SOF; release of information

Definition: Box 12 on the 1500 claim form is the patient's or authorized person's signature, which authorizes release of the medical or other information needed to process the claim.
Why it matters: A payer expects a signed release on file. Many practices enter "Signature on File" when they hold a signed authorization. Keep the signed form in the record.
Illustrative example: A practice has a signed release in the chart and enters Signature on File in Box 12.

Verify: Follow the payer's rules on how to enter the signature.

Reference source NUCC, 1500 Claim Form Reference Instruction Manual, Version 13.0 (7/25)

Categories Claims ProcessingAudits & Compliance

Box 13 (Insured's or Authorized Person's Signature)

General (all payers)

Also called: CMS-1500 box 13; item 13; assignment of benefits signature; authorization of payment

Definition: Box 13 on the 1500 claim form is the insured's or authorized person's signature, which authorizes payment of medical benefits to the provider.
Why it matters: This is how an assignment of benefits is shown on the claim. Without it, a payer may pay the patient instead of the practice. Keep the signed assignment on file.
Illustrative example: A patient signs the assignment on intake forms, and Box 13 shows Signature on File so the plan pays the practice.

Reference source NUCC, 1500 Claim Form Reference Instruction Manual, Version 13.0 (7/25)

Categories Claims ProcessingPayment & Reimbursement

Box 14 (Date of Current Illness, Injury, or Pregnancy)

General (all payers)

Also called: CMS-1500 box 14; item 14; date of onset

Definition: Box 14 on the 1500 claim form identifies the first date of onset of the illness, the date of injury, or the last menstrual period for pregnancy.
Why it matters: Some payers ask for it, and it can matter for accident-related claims. Do not guess; use it only when it is known and payer rules call for it.
Illustrative example: A billing team enters the onset date for an accident-related trauma condition when the payer requires it.

Reference source NUCC, 1500 Claim Form Reference Instruction Manual, Version 13.0 (7/25)

Categories Claims Processing

Box 17 (Name of Referring Provider or Other Source)

General (all payers)

Also called: CMS-1500 box 17; item 17; referring provider; ordering provider; supervising provider

Definition: Box 17 on the 1500 claim form shows the name of the referring, ordering, or supervising provider who directed or ordered the service. Box 17a holds a non-NPI identifier and Box 17b holds the NPI.
Why it matters: Some payers, plans, and referral-based benefits require a referring provider, and supervised clinicians may need a supervising provider listed. A missing or invalid referring NPI is a common rejection.
Illustrative example: A plan requires a referral for therapy, so the biller enters the referring physician's name and NPI in Box 17 and Box 17b.

Verify: Payer rules on whether Box 17 is required vary.

Reference source NUCC, 1500 Claim Form Reference Instruction Manual, Version 13.0 (7/25)

Categories Claims Processing

Box 19 (Additional Claim Information)

General (all payers)

Also called: CMS-1500 box 19; item 19; additional claim information

Definition: Box 19 on the 1500 claim form holds additional claim information designated by NUCC and required by the payer.
Why it matters: Payers use it for special information. Use only what the payer instructs, and use the qualifier the payer names.
Illustrative example: A payer asks for a specific note in Box 19 on a corrected claim, and the biller enters it as instructed.

Verify: Payer-specific.

Reference source NUCC, 1500 Claim Form Reference Instruction Manual, Version 13.0 (7/25)

Categories Claims Processing

Box 1a (Insured's ID Number)

General (all payers)

Also called: CMS-1500 box 1a; item 1a; insured's ID; member ID on claim

Definition: Box 1a on the 1500 claim form holds the insured's ID number. It identifies the insured to the payer.
Why it matters: A wrong or truncated ID is a leading cause of eligibility rejections. Copy the ID exactly as printed on the card, including any alpha prefix, and use the format the payer requires.
Illustrative example: A biller copies the alpha prefix and the ID from the card into Box 1a and the claim passes the payer's front-end edits.

Verify: Confirm the ID format with the payer.

Reference source NUCC, 1500 Claim Form Reference Instruction Manual, Version 13.0 (7/25)

Categories Claims ProcessingEligibility & Benefits

Box 21 (Diagnosis or Nature of Illness or Injury)

General (all payers)

Also called: CMS-1500 box 21; item 21; ICD-10 diagnosis codes; ICD indicator

Definition: Box 21 on the 1500 claim form lists the diagnosis codes for the sign, symptom, complaint, or condition related to the services. It also holds the ICD indicator, which is 0 for ICD-10-CM.
Why it matters: Diagnosis codes support medical necessity. Each service line points back to a letter in Box 21. Code to the highest specificity, and list the primary diagnosis first.
Illustrative example: A therapist lists F41.1 as diagnosis A in Box 21, and 90834 points to A.

Verify: Payers may restrict which diagnoses they accept for a service.

Reference source NUCC, 1500 Claim Form Reference Instruction Manual, Version 13.0 (7/25) · CMS ICD-10

Categories Claims Processing

Box 22 (Resubmission and Original Reference Number)

General (all payers)

Also called: CMS-1500 box 22; item 22; resubmission code; frequency code 7 8; corrected claim box

Definition: Box 22 on the 1500 claim form holds the resubmission code and the payer's original reference number for a claim you send again. NUCC lists code 7 for replacement of a prior claim and code 8 for void or cancel of a prior claim.
Why it matters: Use the correct code and the original claim number, or the payer may reject the new claim as a duplicate. Follow the payer's instructions for corrected claims.
Illustrative example: A biller corrects a wrong unit count, enters code 7 and the payer's claim number in Box 22, and resubmits.

Verify: Payers differ on how they want corrected claims sent.

Reference source NUCC, 1500 Claim Form Reference Instruction Manual, Version 13.0 (7/25)

Categories Claims Processing

Box 23 (Prior Authorization Number)

General (all payers)

Also called: CMS-1500 box 23; item 23; prior auth number; referral number on claim

Definition: Box 23 on the 1500 claim form holds the payer-assigned number that authorizes the services or the referral.
Why it matters: Claims for services that need authorization can be denied without a valid number. Enter it exactly, and check the authorized dates and units before you bill.
Illustrative example: A payer authorizes 12 sessions, and the biller enters the authorization number in Box 23 on each claim.

Reference source NUCC, 1500 Claim Form Reference Instruction Manual, Version 13.0 (7/25)

Categories Claims ProcessingPrior Authorization Terminology

Box 24A (Dates of Service)

General (all payers)

Also called: CMS-1500 box 24A; item 24A; date of service on claim line

Definition: Box 24A on the 1500 claim form shows the month, day, and year each service was provided. It is entered for each service line.
Why it matters: The date must match the note. A wrong date can cause a denial, a timely filing problem, or a duplicate rejection.
Illustrative example: A biller enters each session date from the schedule and checks it against the signed note.

Reference source NUCC, 1500 Claim Form Reference Instruction Manual, Version 13.0 (7/25)

Categories Claims Processing

Box 24B (Place of Service)

General (all payers)

Also called: CMS-1500 box 24B; item 24B; POS on claim line

Definition: Box 24B on the 1500 claim form identifies the location where the service was provided, using a two-digit place of service code.
Why it matters: The code affects payment and telehealth rules, such as POS 02 or POS 10 for telehealth and POS 11 for an office. Use the code that matches where the service happened and the payer's policy.
Illustrative example: A therapist sees a client by video while the client is at home. The biller enters the telehealth place of service code the payer requires.

Verify: Payers differ on telehealth place of service and modifier rules.

Reference source NUCC, 1500 Claim Form Reference Instruction Manual, Version 13.0 (7/25) · CMS Place of Service Code Set

Categories Claims ProcessingTelehealth Terms

Box 24C (EMG)

General (all payers)

Also called: CMS-1500 box 24C; item 24C; emergency indicator

Definition: Box 24C on the 1500 claim form identifies whether the service was an emergency. Payers give their own instructions for it.
Why it matters: Most outpatient behavioral health claims leave it blank unless a payer instructs otherwise. A wrong entry can affect payment.
Illustrative example: A biller leaves Box 24C blank for a routine therapy claim, as the payer's manual directs.

Verify: Payer-specific.

Reference source NUCC, 1500 Claim Form Reference Instruction Manual, Version 13.0 (7/25)

Categories Claims Processing

Box 24D (Procedures, Services, or Supplies)

General (all payers)

Also called: CMS-1500 box 24D; item 24D; CPT code and modifier on claim line

Definition: Box 24D on the 1500 claim form identifies the medical services and procedures provided, using CPT or HCPCS codes and up to four modifiers.
Why it matters: This is where the code and any modifier go. A code or modifier mismatch with the note is a common denial cause. Enter add-on codes on the same claim as the base service.
Illustrative example: A psychiatrist enters 99214 with modifier 25 and +90833 on separate lines of the same claim.

Reference source NUCC, 1500 Claim Form Reference Instruction Manual, Version 13.0 (7/25)

Categories Claims Processing

Box 24E (Diagnosis Pointer)

General (all payers)

Also called: CMS-1500 box 24E; item 24E; diagnosis pointer on claim line

Definition: Box 24E on the 1500 claim form holds the diagnosis pointer, which is the letter or letters from Box 21 that show why the service was performed.
Why it matters: A bad pointer links the service to the wrong diagnosis and can cause a medical necessity denial. Point each line to the diagnosis that supports it.
Illustrative example: The biller points 90837 to diagnosis A in Box 24E because A is the diagnosis treated in the session.

Reference source NUCC, 1500 Claim Form Reference Instruction Manual, Version 13.0 (7/25)

Categories Claims Processing

Box 24F (Charges)

General (all payers)

Also called: CMS-1500 box 24F; item 24F; billed charge per line

Definition: Box 24F on the 1500 claim form holds the total billed amount for each service line.
Why it matters: Billed charges usually follow your fee schedule. Payers pay by their own allowed amount, not your billed charge, but the number must be right.
Illustrative example: A practice enters its standard fee for each service line, and the payer adjusts to its allowed amount.

Reference source NUCC, 1500 Claim Form Reference Instruction Manual, Version 13.0 (7/25)

Categories Claims ProcessingPayment & Reimbursement

Box 24G (Days or Units)

General (all payers)

Also called: CMS-1500 box 24G; item 24G; units on claim line

Definition: Box 24G on the 1500 claim form holds the number of days or units of service, as defined in the CPT or HCPCS manuals.
Why it matters: Wrong units cause denials and underpayments. Time-based add-ons and testing codes are billed in units. Check the MUE limit for the code.
Illustrative example: A psychologist bills 96136 with one unit and +96137 with two units.

Reference source NUCC, 1500 Claim Form Reference Instruction Manual, Version 13.0 (7/25)

Categories Claims Processing

Box 24H (EPSDT/Family Plan)

Medicaid (state-specific)

Also called: CMS-1500 box 24H; item 24H; EPSDT indicator

Definition: Box 24H on the 1500 claim form identifies certain services covered under some state Medicaid plans, including Early and Periodic Screening, Diagnostic, and Treatment services.
Why it matters: Only some Medicaid plans require it. Check the state Medicaid or MCO billing manual, since instructions vary by state.
Illustrative example: A biller checks the state Medicaid manual to see if Box 24H is required for a child's screening visit.

Verify: State-specific. Confirm in the state Medicaid manual.

Reference source NUCC, 1500 Claim Form Reference Instruction Manual, Version 13.0 (7/25) · Medicaid.gov

Categories Claims ProcessingMedicare & Medicaid Terms Medicaid

Box 24I (ID Qualifier)

General (all payers)

Also called: CMS-1500 box 24I; item 24I; ID qualifier for rendering provider

Definition: Box 24I on the 1500 claim form identifies whether the rendering provider's number in Box 24J is a non-NPI identifier. It is used with the shaded part of the line.
Why it matters: Use it only when a payer requires a non-NPI identifier. A wrong qualifier can cause a rejection.
Illustrative example: A payer requires a legacy provider number for a rendering clinician, so the biller uses the qualifier the payer names.

Verify: Payer-specific.

Reference source NUCC, 1500 Claim Form Reference Instruction Manual, Version 13.0 (7/25)

Categories Claims Processing

Box 24J (Rendering Provider ID)

General (all payers)

Also called: CMS-1500 box 24J; item 24J; rendering NPI on claim line

Definition: Box 24J on the 1500 claim form holds the identification number of the individual who performed the service. The NPI goes in the unshaded part of the line.
Why it matters: The rendering NPI must match the clinician's enrollment with the payer. A mismatch can deny or misroute the claim. Group practices list the individual clinician here and the group in Box 33a.
Illustrative example: A group practice enters the treating therapist's individual NPI in Box 24J and the group's NPI in Box 33a.

Reference source NUCC, 1500 Claim Form Reference Instruction Manual, Version 13.0 (7/25)

Categories Claims ProcessingProvider Data Management Terms

Box 25 (Federal Tax ID Number)

General (all payers)

Also called: CMS-1500 box 25; item 25; TIN EIN on claim

Definition: Box 25 on the 1500 claim form holds the federal tax ID number that the payer uses to report payments, usually on a 1099. It can be an EIN or a Social Security number.
Why it matters: The number must match the payer's enrollment and W-9 records, or claims and payments can be misapplied.
Illustrative example: A practice enters its EIN in Box 25, matching the W-9 on file with the payer.

Reference source NUCC, 1500 Claim Form Reference Instruction Manual, Version 13.0 (7/25)

Categories Claims ProcessingProvider Data Management Terms

Box 26 (Patient's Account No.)

General (all payers)

Also called: CMS-1500 box 26; item 26; patient account number; PCN

Definition: Box 26 on the 1500 claim form holds the patient's account number that the provider assigns in its own system.
Why it matters: The payer returns this number on the remittance advice, so it lets a biller match payments to accounts. Keep it unique and free of special characters.
Illustrative example: A practice enters its account number in Box 26 and later matches the ERA by that number.

Reference source NUCC, 1500 Claim Form Reference Instruction Manual, Version 13.0 (7/25)

Categories Claims Processing

Box 27 (Accept Assignment)

General (all payers)

Also called: CMS-1500 box 27; item 27; accept assignment yes no

Definition: Box 27 on the 1500 claim form indicates whether the provider agrees to accept assignment under the payer's program.
Why it matters: For Medicare, accepting assignment means the provider accepts the Medicare-approved amount as payment in full. Rules differ by payer, so check the program's instructions.
Illustrative example: A participating provider answers yes to accepting assignment on a Medicare claim.

Verify: Payer-specific.

Reference source NUCC, 1500 Claim Form Reference Instruction Manual, Version 13.0 (7/25) · CMS (Centers for Medicare & Medicaid Services)

Categories Claims ProcessingPayment & Reimbursement

Box 28 (Total Charge)

General (all payers)

Also called: CMS-1500 box 28; item 28; total charges

Definition: Box 28 on the 1500 claim form shows the total billed amount for all services on the claim, the sum of the charges in Box 24F.
Why it matters: A total that does not equal the sum of the lines can reject the claim. Check the math before you send it.
Illustrative example: A biller confirms the sum of the line charges matches Box 28 during claim scrubbing.

Reference source NUCC, 1500 Claim Form Reference Instruction Manual, Version 13.0 (7/25)

Categories Claims ProcessingPayment & Reimbursement

Box 29 (Amount Paid)

General (all payers)

Also called: CMS-1500 box 29; item 29; amount paid on claim

Definition: Box 29 on the 1500 claim form shows the amount the patient or other payers have paid toward the covered services.
Why it matters: Do not list an expected copay. Report only what has been paid, according to payer instructions. Secondary claims often use this box or the payer's electronic fields.
Illustrative example: A biller leaves Box 29 blank on a primary claim, since only a prior payment belongs there.

Verify: Payer-specific rules on prepayments.

Reference source NUCC, 1500 Claim Form Reference Instruction Manual, Version 13.0 (7/25)

Categories Claims ProcessingPayment & Reimbursement

Box 31 (Signature of Physician or Supplier)

General (all payers)

Also called: CMS-1500 box 31; item 31; provider signature; provider credentials on claim

Definition: Box 31 on the 1500 claim form holds the signature of the physician or supplier, including degrees or credentials, or the authorized person's name and title.
Why it matters: It certifies the claim. Follow the payer's rule on signature or "Signature on File," since electronic claims work differently.
Illustrative example: A biller enters the clinician's name and credentials in Box 31 as the payer's manual directs.

Verify: Payer-specific.

Reference source NUCC, 1500 Claim Form Reference Instruction Manual, Version 13.0 (7/25)

Categories Claims ProcessingAudits & Compliance

Box 32 (Service Facility Location Information)

General (all payers)

Also called: CMS-1500 box 32; item 32; service location; facility NPI

Definition: Box 32 on the 1500 claim form holds the name and address of the site where the services were provided. Box 32a holds the facility NPI and Box 32b holds a non-NPI identifier.
Why it matters: Payers may use the address to price the claim and check the place of service. A wrong address can cause a denial. For a home visit, follow the payer's instruction.
Illustrative example: A therapist works at an office address different from the billing address, so the biller lists the office in Box 32.

Verify: Payer-specific instructions for telehealth and home visits.

Reference source NUCC, 1500 Claim Form Reference Instruction Manual, Version 13.0 (7/25)

Categories Claims Processing

Box 33 (Billing Provider Information and Phone Number)

General (all payers)

Also called: CMS-1500 box 33; item 33; billing provider NPI 33a; pay-to provider

Definition: Box 33 on the 1500 claim form holds the billing provider's or supplier's name, address, and phone number. Box 33a holds the billing provider's NPI and Box 33b holds a non-NPI identifier.
Why it matters: The billing provider is the entity that gets paid. For a group, it is the group's name and Type 2 NPI. It must match the payer's enrollment or the claim can be denied.
Illustrative example: A group practice lists its name, address, and group NPI in Box 33 and Box 33a.

Reference source NUCC, 1500 Claim Form Reference Instruction Manual, Version 13.0 (7/25)

Categories Claims ProcessingProvider Data Management Terms

Box 4 (Insured's Name)

General (all payers)

Also called: CMS-1500 box 4; item 4; policyholder name; subscriber name on claim

Definition: Box 4 on the 1500 claim form shows the insured's name. The insured is the person who holds the policy, typically the employee under employer coverage.
Why it matters: If the patient is not the policyholder, Box 4 is the subscriber, not the patient. A mismatch with the payer's records can reject the claim.
Illustrative example: A child is treated under a parent's plan. Box 2 lists the child, and Box 4 lists the parent as the insured.

Reference source NUCC, 1500 Claim Form Reference Instruction Manual, Version 13.0 (7/25)

Categories Claims ProcessingEligibility & Benefits

Box 6 (Patient Relationship to Insured)

General (all payers)

Also called: CMS-1500 box 6; item 6; patient relationship; self spouse child other

Definition: Box 6 on the 1500 claim form shows how the patient is related to the insured: self, spouse, child, or other.
Why it matters: The relationship tells the payer whether the patient is the subscriber or a dependent. A wrong choice can cause a rejection or misdirect an EOB.
Illustrative example: A therapist bills for a spouse on a partner's plan and marks Box 6 as spouse.

Reference source NUCC, 1500 Claim Form Reference Instruction Manual, Version 13.0 (7/25)

Categories Claims ProcessingEligibility & Benefits

Box 9 (Other Insured's Information)

General (all payers)

Also called: CMS-1500 box 9; item 9; other insured; secondary insurance on claim

Definition: Box 9 on the 1500 claim form identifies another policy that may cover the patient. It includes the other insured's name and the policy or group number (Box 9a) and the plan or program name (Box 9d).
Why it matters: Use it when a secondary payer exists. Payers use it for coordination of benefits and crossover claims. Follow the payer's instructions on when to fill it.
Illustrative example: A patient has a commercial primary plan and a spouse's secondary plan. The biller fills Box 9 for the spouse's plan.

Verify: Payer-specific rules vary on how Box 9 is used with electronic crossover.

Reference source NUCC, 1500 Claim Form Reference Instruction Manual, Version 13.0 (7/25)

Categories Claims ProcessingEligibility & Benefits

Bundling

General (all payers)

Also called: bundled services

Definition: Combining payment for services that a payer considers part of one another, so one is not separately paid.
Why it matters: Leads to denials or reductions for multiple same-day codes.
Illustrative example: A payer bundles a screening code with an evaluation.

Related terms NCCI Edits Modifier 59

Reference source CMS (Centers for Medicare & Medicaid Services) · CMS National Correct Coding Initiative (NCCI)

Categories Claims ProcessingDenials & Appeals

Category I CPT Code

General (all payers)

Also called: Category I code; CPT Category I; established procedure code

Definition: A Category I CPT code is a five-digit code, from 00100 through 99499, that describes an established procedure or service. Psychotherapy and E/M codes are examples.
Why it matters: Most of what a practice bills is Category I. Payers pay on Category I codes according to their own policies.
Illustrative example: Codes such as 90834 and 99213 are Category I codes.

Reference source AMA, CPT code set overview · AMA, CPT Editorial Panel and code approval

Categories Claims Processing

Category II CPT Code

General (all payers)

Also called: Category II code; CPT Category II; performance measurement code; tracking code

Definition: A Category II CPT code is an alphanumeric tracking code that supports performance measurement. Category II codes are supplemental and are used to collect data on quality of care.
Why it matters: They usually carry no payment and are reported for quality programs. Practices may report them to meet payer or program measures.
Illustrative example: A practice reports a Category II code for a depression screening result to support a quality measure.

Reference source AMA, CPT code set overview · AMA, CPT Editorial Panel and code approval

Categories Claims ProcessingQuality & Risk Adjustment Terms

Category III CPT Code

General (all payers)

Also called: Category III code; CPT Category III; emerging technology code

Definition: A Category III CPT code is a temporary alphanumeric code for new and developing technology, procedures, and services. It lets the AMA and others track and evaluate emerging services.
Why it matters: Payers often treat Category III codes as investigational and may not pay for them. Check the payer's policy before you bill.
Illustrative example: A practice asks a payer whether it covers a Category III code for a new digital mental health service.

Verify: Payer coverage varies.

Reference source AMA, CPT code set overview · AMA, CPT Editorial Panel and code approval

Categories Claims ProcessingAI & Healthcare Automation Terms

Claim

General (all payers)

Also called: health insurance claim; insurance claim; medical claim

Definition: A request for payment that a provider sends to a payer for services delivered to a covered member.
Why it matters: Every downstream metric, from denial rate to days in A/R, starts with a claim submitted correctly.
Illustrative example: A therapist submits a claim for a 53-minute session with the date of service, codes, and diagnosis.

Reference source CMS (Centers for Medicare & Medicaid Services)

Categories Claims Processing

Claim Form

General (all payers)

Also called: claim forms; CMS-1500; UB-04

Definition: The standard form for submitting claims. The CMS-1500 is used for professional services and the UB-04 for institutional services, and each has an electronic equivalent.
Why it matters: Behavioral health practices bill professional services on the CMS-1500 or 837P.
Illustrative example: A therapist uses the CMS-1500 layout for paper claims and 837P for electronic.

Related terms CMS-1500 UB-04 (CMS-1450)837P 837I

Reference source NUCC · NUBC

Categories Claims ProcessingEDI & Clearinghouse Terms

Claim Frequency Code

General (all payers)

Also called: claim frequency type code; frequency code 7; frequency code 8

Definition: A code on a claim that shows whether it is original (1), replacement (7), or void/cancel (8), among others.
Why it matters: Using the right frequency code prevents duplicate denials.
Illustrative example: A corrected claim is sent with frequency code 7 and the original claim number.

Reference source X12 · NUBC

Categories Claims ProcessingEDI & Clearinghouse Terms

Claim Rejection

General (all payers)

Also called: rejected claim; payer rejection

Definition: A claim returned unprocessed because of a format, data, or eligibility error; it must be corrected and resubmitted, and it does not start the appeal process.
Why it matters: Confusing a rejection with a denial wastes time on appeals when a correction is needed.
Illustrative example: A claim is rejected because the patient's date of birth does not match.

Reference source CMS (Centers for Medicare & Medicaid Services) · X12

Categories Claims ProcessingDenials & Appeals

Claim Scrubbing

General (all payers)

Also called: claim scrubber; scrubber edits; claim edits

Definition: Automated checks that review claims for errors before they go to the payer, such as missing fields, invalid codes, or mismatched data.
Why it matters: Catching errors before submission reduces rejections and denials.
Illustrative example: A scrubber flags a missing rendering NPI before the claim is sent.

Reference source X12

Categories Claims ProcessingEDI & Clearinghouse Terms

Claim Status

General (all payers)

Also called: claim status inquiry; 276/277

Definition: A request to a payer, by portal, phone, or electronic transaction, to learn where a submitted claim is in processing.
Why it matters: Regular status checks are part of A/R follow-up.
Illustrative example: A biller checks status on claims unpaid after the expected window.

Reference source X12

Categories Claims ProcessingEDI & Clearinghouse Terms

Clean Claim

General (all payers)

Also called: clean claim rate; error-free claim

Definition: A claim with all required data, correctly formatted, that a payer can process without further information. Definitions of 'clean' for payment deadlines differ by law and contract.
Why it matters: Clean claims pay faster and drive first-pass resolution.
Illustrative example: A claim with correct member ID, NPI, and codes pays on first submission.

Reference source CMS (Centers for Medicare & Medicaid Services)

Categories Claims ProcessingRevenue Cycle Metrics

Clearinghouse Rejection

General (all payers)

Also called: front-end rejection; clearinghouse reject; 277CA rejection

Definition: A claim returned by the clearinghouse for failing format or data checks, before it is accepted by the payer.
Why it matters: Rejected claims are not denied; they never entered adjudication and must be fixed and resubmitted.
Illustrative example: A claim is rejected for an invalid subscriber ID and fixed and resent the same day.

Reference source X12

Categories Claims ProcessingEDI & Clearinghouse Terms

CMS-1500

General (all payers)

Also called: CMS-1500 form; HCFA-1500; professional claim form

Definition: The standard paper claim form for professional services, maintained by the NUCC, whose electronic equivalent is the 837P.
Why it matters: Most outpatient therapy and psychiatry claims use it or its 837P equivalent.
Illustrative example: A practice mails a CMS-1500 to a payer that does not accept electronic claims.

Reference source NUCC

Categories Claims ProcessingEDI & Clearinghouse Terms

Code Crosswalk

General (all payers)

Also called: CPT crosswalk; code mapping

Definition: A table that maps one code set or code to another, such as a payer's local code to a standard CPT or HCPCS code.
Why it matters: Useful when payers or state Medicaid programs use local codes.
Illustrative example: A billing team maps a state code to a CPT code.

Verify: confirm mappings in the payer or state manual.

Reference source CMS (Centers for Medicare & Medicaid Services) · CMS HCPCS

Categories Claims ProcessingEHR & Healthcare Technology Terms

Corrected Claim

General (all payers)

Also called: claim correction; resubmission; rebilling

Definition: A new claim sent to fix an error on a claim the payer already accepted, usually marked as a replacement.
Why it matters: Corrections have their own deadlines and rules; sending a duplicate can cause a denial.
Illustrative example: A practice sends a replacement claim to fix a wrong modifier.

Reference source CMS (Centers for Medicare & Medicaid Services)

Categories Claims ProcessingDenials & Appeals

CPT Assistant

General (all payers)

Also called: AMA CPT Assistant; CPT Assistant newsletter

Definition: CPT Assistant is an AMA publication that gives coding guidance and examples for CPT codes.
Why it matters: Coders and auditors cite it for guidance on how to apply a code. It is guidance, not law, and payers may have their own policies.
Illustrative example: A coder checks CPT Assistant to decide how to report a psychotherapy add-on.

Verify: Confirm the current publication and issue.

Reference source American Medical Association (AMA)

Categories Claims Processing

CPT Code

General (all payers)

Also called: CPT; Current Procedural Terminology

Definition: A five-character code set, published and copyrighted by the AMA, that describes medical, surgical, and diagnostic services and procedures.
Why it matters: CPT codes tell the payer what service was delivered and how much to pay.
Illustrative example: A therapist bills 90837 for a 60-minute session.

Reference source American Medical Association (AMA)

Categories Claims ProcessingBehavioral Health Specific Terms

CPT Code Descriptor

General (all payers)

Also called: CPT descriptor; code descriptor; CPT code definition; AMA descriptor

Definition: A CPT code descriptor is the AMA's official wording that defines what a code represents. It includes the service, and often the time or the level of medical decision making.
Why it matters: Bill by the descriptor, not by a nickname. If the service you provided does not match the descriptor, choose a different code.
Illustrative example: A biller reads the 90837 descriptor to confirm the session met the time required.

Reference source AMA, CPT code set overview

Categories Claims Processing

CPT Editorial Panel

General (all payers)

Also called: AMA CPT Editorial Panel; CPT panel

Definition: The CPT Editorial Panel is an independent group of clinical expert volunteers, appointed by the AMA Board of Trustees, that oversees the development and maintenance of the CPT code set. It meets three times a year to review applications for new or revised codes.
Why it matters: New psychotherapy or E/M codes and descriptor changes come through this panel. The AMA publishes updates for each year, and payers adopt them on their own schedules.
Illustrative example: A specialty society applies to the panel for a new digital mental health code.

Reference source AMA, CPT Editorial Panel and code approval · AMA, CPT code set overview

Categories Claims ProcessingAudits & Compliance

Crisis Psychotherapy (90839 / 90840)

General (all payers)

Also called: 90839; 90840; crisis therapy

Definition: CPT codes for psychotherapy for crisis: 90839 for the first 60 minutes and +90840 as an add-on for each additional 30 minutes.
Why it matters: Payer time thresholds differ, so verify before billing.
Illustrative example: A therapist bills 90839 for a crisis session under payer rules.

Verify: check payer thresholds.

Related terms CPT Code Add-On Code

Reference source American Medical Association (AMA)

Categories Claims ProcessingBehavioral Health Specific Terms

Crossover Claim

General (all payers)

Also called: Medicare crossover; automatic crossover

Definition: A claim that Medicare automatically forwards to a secondary payer, such as a Medicaid or supplemental plan, after processing.
Why it matters: Explains why some secondary claims do not need separate submission, and why some do.
Illustrative example: A dual-eligible patient's claim crosses over to Medicaid after Medicare pays.

Verify: crossover setup varies by MAC and state.

Reference source CMS (Centers for Medicare & Medicaid Services)

Categories Claims ProcessingMedicare & Medicaid Terms

Date of Service (DOS)

General (all payers)

Also called: DOS; service date

Definition: The date the billed service was delivered.
Why it matters: It drives timely filing, eligibility, authorization, and coverage checks.
Illustrative example: A claim for a session on the 3rd must be filed within the payer's timely filing window from that date.

Reference source CMS (Centers for Medicare & Medicaid Services)

Categories Claims Processing

Diagnosis Pointer

General (all payers)

Also called: dx pointer; diagnosis pointer letter

Definition: The field on a service line that links the procedure to one or more diagnoses on the claim.
Why it matters: A missing or wrong pointer can cause rejections or denials.
Illustrative example: Line 1 points to diagnosis A, the primary diagnosis.

Related terms Primary Diagnosis ICD-10-CM Claim Form

Reference source NUCC

Categories Claims ProcessingEDI & Clearinghouse Terms

Diagnostic Evaluation (90791 / 90792)

General (all payers)

Also called: 90791; 90792; psychiatric diagnostic evaluation; intake evaluation

Definition: CPT codes for a psychiatric diagnostic evaluation: 90791 without medical services and 90792 with medical services, generally used by prescribers.
Why it matters: Determines the correct intake code for therapists versus psychiatrists.
Illustrative example: A therapist bills 90791 for an intake; a psychiatrist bills 90792.

Reference source American Medical Association (AMA)

Categories Claims ProcessingBehavioral Health Specific Terms

Duplicate Claim

General (all payers)

Also called: duplicate claim denial

Definition: A claim that repeats one the payer already has, often triggering a denial.
Why it matters: Resubmitting an unpaid claim without checking status is a common cause.
Illustrative example: A practice resubmits a claim still in process and receives a duplicate denial.

Related terms Claim Status Corrected Claim

Reference source CMS (Centers for Medicare & Medicaid Services)

Categories Claims ProcessingDenials & Appeals

E/M Code

General (all payers)

Also called: E/M; evaluation and management; office visit code

Definition: A CPT code for office or other outpatient visits that assesses and manages a patient's condition. Psychiatrists use E/M codes for medication management visits.
Why it matters: Psychiatrists bill E/M codes; psychotherapists usually bill non-E/M psychotherapy codes.
Illustrative example: A psychiatrist bills an established-patient E/M for a medication visit.

Reference source American Medical Association (AMA)

Categories Claims ProcessingBehavioral Health Specific Terms

Encounter Form

General (all payers)

Also called: superbill form; charge ticket

Definition: A form or record of the services delivered in a visit that supports charge entry.
Why it matters: Helps make sure every service is captured for billing.
Illustrative example: A clinician completes the encounter form after each session.

Related terms Charge Capture Superbill

Reference source MGMA

Categories Claims Processing

Established Patient (CPT)

General (all payers)

Also called: CPT established patient; established patient definition

Definition: Under CPT, an established patient is one who has received professional services from the physician or another physician of the exact same specialty and subspecialty in the same group practice within the past three years.
Why it matters: Established patient status decides whether you use 99211 to 99215. Payers may apply the rule differently for different specialties within a group.
Illustrative example: A patient seen last year by any psychiatrist in the group is established for the group's psychiatrists.

Verify: Confirm the definition in the current CPT manual and each payer's policy.

Reference source AMA, CPT code set overview

Categories Claims Processing

Face-to-Face Time

General (all payers)

Also called: face to face time; direct patient time

Definition: Face-to-face time is the time the clinician spends in direct contact with the patient, in person or by video, for a service coded by time. For psychotherapy codes, the patient must be present for all or some of the service.
Why it matters: The time on a psychotherapy claim is face-to-face time, not the total time on the chart. Time spent on notes or calls without the patient does not count toward psychotherapy time.
Illustrative example: A therapist's 50-minute session includes 45 minutes with the client, and the note shows the start and end time.

Reference source CMS Coverage Database, Article A57520 (First Coast) · American Medical Association (AMA)

Categories Claims ProcessingBehavioral Health Specific Terms

Family Psychotherapy (90846 / 90847)

General (all payers)

Also called: 90846; 90847; family therapy codes

Definition: CPT codes for family psychotherapy: 90846 without the patient present and 90847 with the patient present.
Why it matters: Payers differ on coverage and on which family member's plan is billed.
Illustrative example: A family session with the patient present is billed as 90847.

Reference source American Medical Association (AMA)

Categories Claims ProcessingBehavioral Health Specific Terms

Frequency Limit

General (all payers)

Also called: frequency limitation; visit frequency rule

Definition: A payer or program rule that limits how often a service can be billed, such as how many times a diagnostic evaluation can be billed in a period.
Why it matters: Billing beyond the limit leads to denials.
Illustrative example: A payer allows one diagnostic evaluation per patient per period unless there is a change in condition.

Verify: payer-specific.

Reference source CMS (Centers for Medicare & Medicaid Services)

Categories Claims ProcessingBehavioral Health Specific Terms

Group Psychotherapy (90853)

General (all payers)

Also called: 90853; group therapy code

Definition: A CPT code for group psychotherapy other than of a multiple-family group.
Why it matters: Coverage, documentation, and unit rules vary by payer.
Illustrative example: A therapist bills 90853 per patient in a group session.

Reference source American Medical Association (AMA)

Categories Claims ProcessingBehavioral Health Specific Terms

HCPCS (Healthcare Common Procedure Coding System)

General (all payers)

Also called: HCPCS; HCPCS Level II; HCPCS codes

Definition: A code set with two levels: Level I is CPT, and Level II covers supplies, services, and items not in CPT, including many Medicaid behavioral health services.
Why it matters: State Medicaid programs commonly use HCPCS Level II codes for community-based behavioral health services.
Illustrative example: A state Medicaid manual lists an H-code for psychosocial rehabilitation.

Verify: state Medicaid definitions vary.

Related terms CPT Code Medicaid HCPCS Code Modifier

Reference source CMS (Centers for Medicare & Medicaid Services) · CMS HCPCS

Categories Claims ProcessingMedicare & Medicaid Terms

ICD-10-CM

General (all payers)

Also called: ICD-10; diagnosis code; ICD-10-CM code

Definition: The diagnosis code set used in U.S. outpatient settings, maintained by CMS and the National Center for Health Statistics. Mental health diagnoses are in the F chapter.
Why it matters: The diagnosis code supports medical necessity for the CPT code billed.
Illustrative example: A claim lists F41.1 as the diagnosis for a patient's therapy visits.

Verify: code sets update each October 1.

Reference source CMS (Centers for Medicare & Medicaid Services) · CMS ICD-10

Categories Claims ProcessingBehavioral Health Specific Terms

Incident-To Billing

General (all payers)

Also called: incident to; incident-to services

Definition: A Medicare rule that lets certain services of non-physician staff be billed under a supervising physician when specific conditions are met. Commercial payers often differ.
Why it matters: Misusing incident-to is an audit and repayment risk, so payer policy must be confirmed.
Illustrative example: A physician's practice bills a staff member's service under the physician only where the payer's incident-to rules are met.

Verify: payer-specific; consult counsel or a compliance officer.

Reference source CMS (Centers for Medicare & Medicaid Services)

Categories Claims ProcessingMedicare & Medicaid Terms

Interactive Complexity (90785)

General (all payers)

Also called: 90785; interactive complexity add-on

Definition: A CPT add-on code for psychiatric diagnostic or psychotherapy services when specific communication factors make the service more complex.
Why it matters: Payers audit it; it applies only when documented factors are met.
Illustrative example: A session involves a third party with conflict that complicates the service.

Reference source American Medical Association (AMA)

Categories Claims ProcessingBehavioral Health Specific Terms

Internal Control Number (ICN)

General (all payers)

Also called: ICN; claim control number; DCN; payer claim number

Definition: The identifier a payer assigns to a claim when it receives it, used to reference the claim on calls, appeals, and corrected claims.
Why it matters: Needed for replacement and void claims and for follow-up.
Illustrative example: A corrected claim lists the original payer claim number.

Reference source CMS (Centers for Medicare & Medicaid Services)

Categories Claims ProcessingEDI & Clearinghouse Terms

Medical Decision Making (MDM)

General (all payers)

Also called: MDM; level of medical decision making; E/M MDM

Definition: Medical decision making is the way a clinician's work is measured for many E/M codes. It looks at the number and complexity of problems addressed, the amount and complexity of data reviewed, and the risk of complications or management.
Why it matters: A prescriber can choose the E/M level by MDM or by total time on the date of the encounter. Use MDM to pick the level when a psychotherapy add-on is billed.
Illustrative example: A psychiatrist manages one stable condition with a prescription refill, which supports low MDM and a 99213.

Verify: Confirm the current CPT MDM table.

Reference source AMA, CPT code set overview · CMS Coverage Database, Article A57480 (WPS)

Categories Claims Processing

Medically Unlikely Edit (MUE)

General (all payers)

Also called: MUE; units of service edit

Definition: A CMS edit setting the maximum units of a service that a provider would normally bill for one patient on one date of service.
Why it matters: Explains unit-based denials.
Illustrative example: A claim billing more units than the MUE is reduced.

Verify: MUE values update periodically.

Related terms NCCI Edits Units

Reference source CMS (Centers for Medicare & Medicaid Services) · CMS National Correct Coding Initiative (NCCI)

Categories Claims ProcessingAudits & Compliance

Midpoint Rule (Timed Codes)

General (all payers)

Also called: midpoint rule; time rule CPT; when a unit of time is met

Definition: The midpoint rule is a CPT convention that a unit of time is attained when the midpoint is passed. It underlies why psychotherapy minute ranges start at 16, 38, and 53 minutes.
Why it matters: Payers apply time rules in different ways, so always use the payer's stated range. Do not round up. Record exact start and stop times.
Illustrative example: A therapist's 37-minute session is billed 90832, not 90834, because it did not reach 38 minutes.

Verify: Confirm with the current CPT manual and each payer.

Reference source American Medical Association (AMA)

Categories Claims Processing

Modifier

General (all payers)

Also called: CPT modifier; HCPCS modifier; billing modifier

Definition: A two-character code appended to a procedure code to give more information, such as telehealth delivery, distinct services, or provider type.
Why it matters: Missing or wrong modifiers cause denials or wrong payment.
Illustrative example: A telehealth session is billed with modifier 95 when the payer requires it.

Reference source American Medical Association (AMA) · CMS HCPCS

Categories Claims Processing

Modifier 25

General (all payers)

Also called: 25 modifier; significant separately identifiable E/M

Definition: A modifier appended to an E/M code to show it was significant and separately identifiable from another service performed the same day, such as a procedure.
Why it matters: Used by psychiatrists when an E/M and another procedure are billed the same day.
Illustrative example: A psychiatrist bills an E/M with modifier 25 alongside a separately reportable procedure.

Verify: payer policies vary.

Related terms Modifier E/M Code NCCI Edits

Reference source American Medical Association (AMA) · CMS National Correct Coding Initiative (NCCI)

Categories Claims ProcessingBehavioral Health Specific Terms

Modifier 59

General (all payers)

Also called: 59 modifier; distinct procedural service; X modifiers

Definition: A modifier indicating a procedure is distinct from another performed the same day, used to bypass certain bundling edits. Medicare also has more specific X{EPSU} modifiers.
Why it matters: Misuse is an audit target; it should be used only when documentation supports it.
Illustrative example: A payer edit bundles two codes and modifier 59 is used only if documentation supports separate services.

Verify: check the payer's policy before using.

Related terms NCCI Edits Modifier Audit

Reference source CMS (Centers for Medicare & Medicaid Services) · CMS National Correct Coding Initiative (NCCI)

Categories Claims Processing

Modifier AH

General (all payers)

Also called: AH modifier; clinical psychologist modifier

Definition: A HCPCS modifier Medicare has used to identify services of a clinical psychologist.
Why it matters: Some payers require provider-type modifiers on claims.
Illustrative example: A clinical psychologist adds AH where required.

Verify: confirm current Medicare requirements.

Related terms Modifier Modifier AJ

Reference source CMS (Centers for Medicare & Medicaid Services) · CMS HCPCS

Categories Claims ProcessingMedicare & Medicaid Terms

Modifier AJ

General (all payers)

Also called: AJ modifier; clinical social worker modifier

Definition: A HCPCS modifier Medicare has used to identify services of a clinical social worker.
Why it matters: Provider-type modifiers can affect payment and processing.
Illustrative example: A licensed clinical social worker adds AJ where required.

Verify: confirm current Medicare requirements.

Related terms Modifier Modifier AH

Reference source CMS (Centers for Medicare & Medicaid Services) · CMS HCPCS

Categories Claims ProcessingMedicare & Medicaid Terms

Modifier HN

General (all payers)

Also called: HN modifier; bachelor's-level modifier

Definition: A HCPCS modifier that some payers use to indicate services delivered by a bachelor's-level clinician.
Why it matters: Used in state-specific rate tiers.
Illustrative example: A community program bills with modifier HN.

Verify: state-specific.

Related terms Modifier HO Modifier HP Modifier

Reference source CMS (Centers for Medicare & Medicaid Services) · CMS HCPCS

Categories Claims ProcessingMedicare & Medicaid Terms

Modifier HO

General (all payers)

Also called: HO modifier; master's-level modifier

Definition: A HCPCS modifier that some Medicaid programs and payers use to indicate services delivered by a master's-level clinician.
Why it matters: Some state Medicaid programs require HO, HN, or HP to set rate levels by clinician degree.
Illustrative example: A state pays a different rate for services with modifier HO than with HP.

Verify: state-specific.

Reference source CMS (Centers for Medicare & Medicaid Services) · CMS HCPCS

Categories Claims ProcessingMedicare & Medicaid Terms

Modifier HP

General (all payers)

Also called: HP modifier; doctoral-level modifier

Definition: A HCPCS modifier that some payers use to indicate services delivered by a doctoral-level clinician.
Why it matters: Affects rate differentiation in some Medicaid programs.
Illustrative example: A psychologist's Medicaid claim carries modifier HP.

Verify: state-specific.

Related terms Modifier HO Modifier HN Modifier

Reference source CMS (Centers for Medicare & Medicaid Services) · CMS HCPCS

Categories Claims ProcessingMedicare & Medicaid Terms

NCCI Edits

General (all payers)

Also called: National Correct Coding Initiative; NCCI; procedure-to-procedure edits; MUE

Definition: CMS edits that prevent improper payment when certain codes are billed together or in excess of medically unlikely units. Many commercial payers use similar edits.
Why it matters: Explains many bundling denials and the correct use of modifiers.
Illustrative example: A code pair is bundled under an NCCI edit unless an appropriate modifier applies.

Verify: edits update at least quarterly.

Reference source CMS (Centers for Medicare & Medicaid Services) · CMS National Correct Coding Initiative (NCCI)

Categories Claims ProcessingAudits & Compliance

New Patient (CPT)

General (all payers)

Also called: CPT new patient; new patient definition; three year rule

Definition: Under CPT, a new patient is one who has not received professional services from the physician or another physician of the exact same specialty and subspecialty in the same group practice within the past three years.
Why it matters: New patient status decides whether you use 99202 to 99205 or 99211 to 99215. The definition is about the group, so an intake for a returning patient may be established.
Illustrative example: A patient last seen by a group psychiatrist four years ago is a new patient to the group.

Verify: Confirm the definition in the current CPT manual and each payer's policy.

Reference source AMA, CPT code set overview

Categories Claims Processing

NUCC 1500 Claim Form Instruction Manual

General (all payers)

Also called: 1500 instruction manual; CMS-1500 instructions; NUCC manual; claim form manual

Definition: The NUCC 1500 Claim Form Reference Instruction Manual is the National Uniform Claim Committee's guide to completing the 1500 Health Insurance Claim Form. NUCC states that its purpose is to help standardize nationally how the form is completed. The version on the NUCC site when checked was Version 13.0, dated July 2025.
Why it matters: Payers may add their own rules, but the manual is the starting point for what each box means. Use it to settle disputes about how to fill a box, and check the payer's own instructions for special cases.
Illustrative example: A biller checks the NUCC manual to see what Box 22 needs for a replacement claim before resubmitting.

Time-sensitive: NUCC updates the manual, usually each July. Confirm the current version at nucc.org.

Reference source NUCC, 1500 Claim Form Reference Instruction Manual, Version 13.0 (7/25) · NUCC

Categories Claims Processing

Patient Control Number (PCN)

General (all payers)

Also called: patient account number; PCN

Definition: The provider's own account number for a patient or claim, sent on the claim and returned on the remittance to help match payments.
Why it matters: Helps auto-post payments to the right account.
Illustrative example: The ERA returns the practice's account number on each line.

Reference source X12

Categories Claims ProcessingEDI & Clearinghouse Terms

Pended Claim

General (all payers)

Also called: pending claim; claim in process; suspended claim

Definition: A claim the payer has received but not finalized, held for review, additional information, or a system reason.
Why it matters: Pended claims can hide problems and delay payment.
Illustrative example: A claim is pended for a COB questionnaire.

Reference source CMS (Centers for Medicare & Medicaid Services)

Categories Claims Processing

Place of Service (POS)

General (all payers)

Also called: POS code; place of service code

Definition: A two-digit code on the claim that shows where the service took place, such as office, home, or telehealth.
Why it matters: POS affects payment rate and telehealth rules.
Illustrative example: A claim lists POS 11 for an office visit.

Reference source CMS (Centers for Medicare & Medicaid Services) · CMS Place of Service Code Set

Categories Claims ProcessingTelehealth Terms

Place of Service 11

General (all payers)

Also called: POS 11; office

Definition: The place of service code for services delivered in a physician's or practitioner's office.
Why it matters: In-person outpatient sessions commonly use POS 11.
Illustrative example: A therapist bills an in-person office session with POS 11.

Reference source CMS (Centers for Medicare & Medicaid Services) · CMS Place of Service Code Set

Categories Claims Processing

Place of Service 12

General (all payers)

Also called: POS 12; home

Definition: The place of service code for services delivered in the patient's home in person.
Why it matters: In-home therapy uses POS 12, and Medicaid in-home programs may have their own rules.
Illustrative example: A clinician provides in-person therapy at a patient's home.

Verify: payer- and state-specific.

Reference source CMS (Centers for Medicare & Medicaid Services) · CMS Place of Service Code Set

Categories Claims Processing

Primary Diagnosis

General (all payers)

Also called: principal diagnosis; first-listed diagnosis

Definition: The main diagnosis that the service addresses, listed first on the claim.
Why it matters: Payers check that the diagnosis supports the service and any coverage rules.
Illustrative example: The first listed diagnosis is the condition treated in that session.

Related terms ICD-10-CM Diagnosis Pointer

Reference source CMS (Centers for Medicare & Medicaid Services)

Categories Claims Processing

Prolonged Service

General (all payers)

Also called: prolonged services; prolonged E/M; 99417 G2212

Definition: A prolonged service is extra time beyond what is required for the highest level of an E/M service, reported with a prolonged-service add-on code. Medicare and commercial payers use different codes and thresholds.
Why it matters: A prolonged code is not billed with a psychotherapy add-on in the same time. Follow the payer's rule.
Illustrative example: A prescriber's level 5 visit runs long, and the practice checks the payer's prolonged-service rule before billing an add-on.

Verify: Payer-specific thresholds.

Reference source American Medical Association (AMA) · CMS (Centers for Medicare & Medicaid Services)

Categories Claims Processing

Psychotherapy Add-On Code

General (all payers)

Also called: add-on code; 90833; 90836; 90838

Definition: A CPT add-on code that lets a prescriber bill psychotherapy time on the same day as an E/M service. Codes 90833, 90836, and 90838 correspond to different time ranges.
Why it matters: Both the E/M and the add-on must be supported by documentation; psychotherapy time cannot be counted toward the E/M.
Illustrative example: A psychiatrist bills an E/M plus a psychotherapy add-on for the same visit.

Verify: confirm times and payer rules.

Reference source American Medical Association (AMA)

Categories Claims ProcessingBehavioral Health Specific Terms

Psychotherapy Time Ranges

General (all payers)

Also called: 90832; 90834; 90837; time-based psychotherapy codes

Definition: The CPT time ranges for individual psychotherapy codes: 90832 is 16 to 37 minutes, 90834 is 38 to 52 minutes, and 90837 is 53 minutes or more. The midpoint rule sets each range.
Why it matters: Billing above the documented time is a leading audit and denial cause.
Illustrative example: A 50-minute session is 90834, not 90837.

Verify: CPT-defined ranges; confirm in the current CPT manual and payer policy.

Related terms CPT Code Documentation Audit

Reference source American Medical Association (AMA)

Categories Claims ProcessingBehavioral Health Specific Terms

Replacement Claim

General (all payers)

Also called: frequency code 7 claim

Definition: A corrected claim that replaces an earlier claim, sent with the original claim number.
Why it matters: Ensures the payer updates the original instead of treating it as a duplicate.
Illustrative example: A biller sends a replacement claim with the payer claim number in the correct field.

Reference source X12 · NUBC

Categories Claims Processing

Signature on File (SOF)

General (all payers)

Also called: SOF; signature on file; SOF box 12 13

Definition: Signature on File, or SOF, is the notation a practice enters in Box 12 or Box 13 of the 1500 claim form to show it holds the patient's signed release of information or assignment of benefits.
Why it matters: The signed forms must actually be in the record. If a payer audits, it can ask for them.
Illustrative example: A practice enters SOF in Boxes 12 and 13 because the patient signed both authorizations at intake.

Reference source NUCC, 1500 Claim Form Reference Instruction Manual, Version 13.0 (7/25)

Categories Claims ProcessingAudits & Compliance

Significant, Separately Identifiable E/M

General (all payers)

Also called: significant separately identifiable; E/M with psychotherapy; separately identifiable service

Definition: A significant, separately identifiable E/M is an evaluation and management service that goes beyond the usual work of another service billed on the same date and is documented on its own.
Why it matters: Psychotherapy add-on codes need an E/M that is significant and separately identifiable, and the same applies to modifier 25 on some procedures. The note should show the E/M work and the psychotherapy work apart.
Illustrative example: A psychiatrist documents a medication review and a separate 30-minute psychotherapy portion and bills both.

Verify: Confirm payer policy.

Reference source American Medical Association (AMA) · CMS Coverage Database, Article A57480 (WPS)

Categories Claims ProcessingBehavioral Health Specific Terms

Timely Filing

General (all payers)

Also called: timely filing limit; filing deadline; claim submission deadline

Definition: The deadline by which a claim must be received by a payer, counted from the date of service or another trigger set by law or contract.
Why it matters: Claims filed late are usually denied and not recoverable.
Illustrative example: A payer's contract allows 90 days from the date of service.

Verify: limits vary by payer and contract; Medicare generally allows one calendar year from the date of service.

Reference source CMS (Centers for Medicare & Medicaid Services)

Categories Claims ProcessingDenials & Appeals

Total Time on the Date of the Encounter

General (all payers)

Also called: total time E/M; time-based E/M; E/M time rule

Definition: Total time on the date of the encounter is the sum of the physician's or other qualified professional's face-to-face and non-face-to-face work on the date of the visit. It can be used to select an office E/M level.
Why it matters: Count only the clinician's own time on that date. Do not count time for a separately reported service, such as a psychotherapy add-on, and do not count travel for a home visit. Document the total.
Illustrative example: A psychiatrist records 32 minutes of total time, including chart review and documentation on the visit date.

Verify: Confirm current CPT rules on what counts.

Reference source American College of Surgeons, E/M office visit time thresholds · AMA, CPT code set overview · UTHealth Houston, 2023 Home or Residence Services

Categories Claims Processing

UB-04 (CMS-1450)

General (all payers)

Also called: UB-04; CMS-1450; institutional claim form

Definition: The standard claim form for institutional providers such as hospitals and facilities, maintained by the NUBC, whose electronic equivalent is the 837I.
Why it matters: Facility-based behavioral health programs bill on it, while private practices usually do not.
Illustrative example: A partial hospitalization program bills on the UB-04.

Reference source NUBC

Categories Claims ProcessingEDI & Clearinghouse Terms

Units

General (all payers)

Also called: billing units; service units

Definition: The quantity of a service billed, such as 1 for a session or multiple for time-based HCPCS codes.
Why it matters: Wrong units cause underpayment or denial.
Illustrative example: A 15-minute HCPCS code for a 45-minute service is billed as 3 units where the payer allows.

Reference source CMS (Centers for Medicare & Medicaid Services)

Categories Claims Processing

Unlisted Procedure Code

General (all payers)

Also called: unlisted code; 90899; unlisted psychiatric service; not otherwise classified

Definition: An unlisted procedure code is a CPT code used when no specific code describes the service provided. Psychiatry has its own unlisted code, and every unlisted claim needs a description of the service.
Why it matters: Payers usually require a written description and often pay by their own review. Use it only when no code fits.
Illustrative example: A provider bills an unlisted psychiatric service with a description and supporting documents.

Verify: Confirm the correct unlisted code for the section and the payer's process.

Reference source American Medical Association (AMA)

Categories Claims Processing

Void Claim

General (all payers)

Also called: frequency code 8 claim; cancel claim

Definition: A claim sent to cancel a previously paid or accepted claim.
Why it matters: Used to remove an incorrect claim before rebilling.
Illustrative example: A claim billed under the wrong provider is voided and rebilled.

Reference source X12 · NUBC

Categories Claims Processing

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Claims Processing Terms: Definitions for Therapists and Psychiatrists

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CPT & E/M Code Guide

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