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Billing Terms Glossary
Risk Adjustment Terms: Definitions for Therapists and Psychiatrists
In this section
- 20 terms defined
- Written for psychotherapists and psychiatrists
- Source organization linked on every entry
Accreditation
General (all payers)Also called: organizational accreditation; accredited provider; accrediting body
- Definition
- Accreditation is a review by an outside organization, such as the Joint Commission, NCQA, or URAC, that finds an organization meets that group's standards.
- Why it matters
- Payers, states, and funders may require it, and it can help a provider's contract or licensing. It is separate from credentialing of individual clinicians.
- Illustrative example
- A clinic tells a payer it holds an accreditation to meet a contracting requirement.
Verify: Confirm what your payers accept.
Related terms The Joint CommissionNCQAURACBehavioral Health Care and Human Services Accreditation
Reference source The Joint Commission · NCQA
Categories Quality & Risk Adjustment TermsAudits & Compliance
Behavioral Health Care and Human Services Accreditation
General (all payers)Also called: Joint Commission behavioral health accreditation; BHC accreditation; BHCHS
- Definition
- Behavioral Health Care and Human Services accreditation is a Joint Commission accreditation program for organizations that provide behavioral health and human services. Its standards apply to those settings.
- Why it matters
- Some payers, state programs, and grants prefer or require accreditation. Confirm what your payer or funder accepts.
- Illustrative example
- A community mental health provider seeks Joint Commission accreditation to meet a state contract requirement.
Verify: Confirm the program's current standards with the Joint Commission.
Related terms The Joint CommissionAccreditationNPSG.15.01.01 Suicide Risk ReductionURAC
Reference source The Joint Commission
Categories Quality & Risk Adjustment TermsAudits & Compliance
CAHPS
General (all payers)Also called: Consumer Assessment of Healthcare Providers and Systems
- Definition
- Standardized surveys of patient experience with care.
- Why it matters
- Feeds quality and payment programs.
- Illustrative example
- A plan surveys members about access to behavioral health care.
Related terms HEDISStar Ratings
Reference source CMS (Centers for Medicare & Medicaid Services)
Categories Quality & Risk Adjustment Terms
Care Gap
General (all payers)Also called: quality gap; gap in care
- Definition
- A recommended service or measure that has not been documented as completed for a patient.
- Why it matters
- Payers use gap lists to target outreach and incentives.
- Illustrative example
- A plan lists a member who has no follow-up visit after hospitalization.
Related terms HEDISPay for Performance (P4P)
Reference source NCQA
Categories Quality & Risk Adjustment TermsValue-Based Care Terminology
Deemed Status
MedicareAlso called: deemed status; deeming authority; CMS deemed accreditation
- Definition
- Deemed status is when CMS accepts accreditation from an approved accrediting organization as evidence that a provider meets Medicare conditions, in place of a state survey, for certain provider types.
- Why it matters
- It applies to certain provider types and programs, not to most independent behavioral health practices. Check whether your provider type is affected.
- Illustrative example
- A hospital's Joint Commission accreditation gives it deemed status for Medicare participation.
Verify: Applies only to certain provider types.
Related terms AccreditationThe Joint CommissionMedicareFederally Qualified Health Center (FQHC)
Reference source The Joint Commission · CMS (Centers for Medicare & Medicaid Services)
Categories Quality & Risk Adjustment TermsMedicare & Medicaid Terms Medicare
HEDIS
General (all payers)Also called: Healthcare Effectiveness Data and Information Set
- Definition
- A set of performance measures maintained by NCQA that health plans use to report quality, including behavioral health measures such as follow-up after hospitalization.
- Why it matters
- Payers may ask practices for records or outreach to close HEDIS gaps.
- Illustrative example
- A plan requests follow-up visit records for HEDIS reporting.
Related terms NCQACare GapStar Ratings
Reference source NCQA
Categories Quality & Risk Adjustment TermsValue-Based Care Terminology
Hierarchical Condition Category (HCC)
General (all payers)Also called: HCC; CMS-HCC
- Definition
- A grouping of diagnosis codes used in risk adjustment models to predict costs.
- Why it matters
- Some mental health diagnoses map to HCCs, making accurate diagnosis coding important.
- Illustrative example
- A diagnosis of major depressive disorder maps to an HCC in a model version.
Verify: model versions change.
Related terms Risk Adjustment Factor (RAF)Risk Adjustment
Reference source CMS (Centers for Medicare & Medicaid Services)
Categories Quality & Risk Adjustment TermsMedicare & Medicaid Terms
Measurement-Based Care
General (all payers)Also called: MBC; outcome measures; PHQ-9 tracking
- Definition
- Routinely using standardized symptom measures during treatment to guide decisions and track progress.
- Why it matters
- Increasingly requested by payers and required in some value-based contracts.
- Illustrative example
- A therapist records PHQ-9 scores at each visit.
Related terms Value-Based CareBrief Emotional or Behavioral Assessment (96127)
Reference source American Psychiatric Association
Categories Quality & Risk Adjustment TermsBehavioral Health Specific Terms
Measurement-Based Care (Joint Commission)
General (all payers)Also called: Joint Commission measurement-based care standard; CTS.03.01.09; standardized tool progress monitoring
- Definition
- The Joint Commission's measurement-based care standard for behavioral health requires accredited organizations to use standardized tools to monitor a person's progress and to use the results to inform care.
- Why it matters
- It links clinical practice and quality, and can link to billing through screening codes such as 96127. Ask your accreditor for the current requirement.
- Illustrative example
- An accredited clinic gives the PHQ-9 at intake and at set intervals and reviews scores with the client.
Verify: Confirm the standard number and wording with the Joint Commission.
Related terms Measurement-Based CareCPT 96127PHQ-9Behavioral Health Care and Human Services Accreditation
Reference source The Joint Commission
Categories Quality & Risk Adjustment TermsBehavioral Health Specific Terms
Medical Loss Ratio (MLR)
General (all payers)Also called: MLR
- Definition
- The share of premium revenue that an insurer spends on medical claims and quality improvement, rather than administration and profit; some markets have minimum MLR rules.
- Why it matters
- Affects plan financial behavior and rebates.
- Illustrative example
- An insurer must rebate if its MLR falls below a required level.
Verify: rules apply to specific markets.
Related terms CapitationValue-Based Care
Reference source CMS (Centers for Medicare & Medicaid Services)
Categories Quality & Risk Adjustment TermsBCBS, UHC & Commercial Payer Terms
National Patient Safety Goals (NPSG)
General (all payers)Also called: Joint Commission NPSG; NPSGs; patient safety goals
- Definition
- National Patient Safety Goals are requirements the Joint Commission has used to address specific patient safety problems in accredited organizations. Goals differ by accreditation program.
- Why it matters
- Accredited behavioral health organizations track the goals for their program, such as suicide risk reduction. Joint Commission announced National Performance Goals in 2025 for hospital and critical access hospital programs starting in 2026, so check what applies to your program.
- Illustrative example
- An accredited outpatient behavioral health organization checks its program's current goals during its survey preparation.
Time-sensitive: The Joint Commission introduced National Performance Goals in 2026 for hospital programs. Confirm how your program is affected.
Related terms NPSG.15.01.01 Suicide Risk ReductionThe Joint CommissionBehavioral Health Care and Human Services AccreditationSuicide Risk Screening
Reference source The Joint Commission · The Joint Commission, NPSG suicide risk FAQ (2/1/2022)
Categories Quality & Risk Adjustment TermsAudits & Compliance
NPSG.15.01.01 Suicide Risk Reduction
General (all payers)Also called: NPSG 15.01.01; Joint Commission suicide prevention goal; suicide risk assessment requirement
- Definition
- NPSG.15.01.01 is a Joint Commission goal on reducing suicide risk. A Joint Commission FAQ dated February 1, 2022 says it applies to all patients in organizations surveyed under the Behavioral Health Care and Human Services standards, along with other settings for patients being evaluated or treated for a behavioral condition as the main reason for care and patients who express suicidal ideation.
- Why it matters
- Accredited behavioral health organizations use it to shape screening, assessment, and safety planning. Payers do not usually bill for it, but accreditors and surveyors look for it.
- Illustrative example
- An accredited clinic screens each patient for suicide risk and documents the assessment and the safety plan.
Time-sensitive: The Joint Commission announced National Performance Goals for 2026 for hospital and critical access hospital programs. Confirm whether this goal still applies to your accreditation program.
Related terms Suicide Risk ScreeningNational Patient Safety Goals (NPSG)The Joint Commission988 Suicide and Crisis Lifeline
Reference source The Joint Commission · The Joint Commission, NPSG suicide risk FAQ (2/1/2022)
Categories Quality & Risk Adjustment TermsBehavioral Health Specific Terms
NQF (National Quality Forum)
General (all payers)Also called: NQF
- Definition
- A nonprofit that historically endorsed health care quality measures used in federal programs.
- Why it matters
- Measure endorsement history appears in quality documentation.
- Illustrative example
- A quality measure notes its NQF endorsement number.
Verify: confirm current measure endorsement status.
Related terms HEDISMIPS (Merit-Based Incentive Payment System)
Reference source National Quality Forum (NQF)
Categories Quality & Risk Adjustment Terms
RADV (Risk Adjustment Data Validation)
General (all payers)Also called: RADV audit
- Definition
- A CMS audit process that checks whether diagnoses submitted for Medicare Advantage risk adjustment are supported by medical records.
- Why it matters
- Plans may request records from providers to support diagnoses.
- Illustrative example
- A plan asks a practice for records supporting a diagnosis.
Related terms Risk AdjustmentAudit
Reference source CMS (Centers for Medicare & Medicaid Services)
Categories Quality & Risk Adjustment TermsAudits & Compliance
Risk Adjustment
General (all payers)Also called: risk adjustment model; risk scoring
- Definition
- A method that adjusts payment or expected costs based on the health status of a population.
- Why it matters
- Drives diagnosis documentation and coding priorities for plans and providers.
- Illustrative example
- A Medicare Advantage plan pays more for members with documented chronic conditions.
Related terms Hierarchical Condition Category (HCC)Risk Adjustment Factor (RAF)
Reference source CMS (Centers for Medicare & Medicaid Services)
Categories Quality & Risk Adjustment TermsValue-Based Care Terminology
Risk Adjustment Factor (RAF)
General (all payers)Also called: RAF; RAF score; risk score
- Definition
- A number that reflects the expected relative cost of a patient or population under a risk adjustment model.
- Why it matters
- Higher scores can raise plan payments, so accuracy in documentation matters.
- Illustrative example
- A patient's RAF score reflects demographic and diagnosis factors.
Related terms Hierarchical Condition Category (HCC)Risk Adjustment
Reference source CMS (Centers for Medicare & Medicaid Services)
Categories Quality & Risk Adjustment TermsMedicare & Medicaid Terms
Sentinel Event
General (all payers)Also called: Joint Commission sentinel event; serious safety event
- Definition
- A sentinel event, as the Joint Commission defines it, is a patient safety event that reaches a patient and results in death, permanent harm, or severe temporary harm. Suicide of a patient in some settings is one type.
- Why it matters
- Accredited organizations are expected to review such events and take action. It is a safety and quality term, not a billing term.
- Illustrative example
- An accredited clinic reviews a serious event and creates a corrective action plan.
Verify: Confirm the current definition and policy with the Joint Commission.
Related terms The Joint CommissionRoot Cause AnalysisNPSG.15.01.01 Suicide Risk ReductionCompliance Program
Reference source The Joint Commission
Categories Quality & Risk Adjustment TermsAudits & Compliance
Social Determinants of Health (SDOH)
General (all payers)Also called: SDOH; Z codes
- Definition
- Non-medical factors such as housing and food security that influence health, some tracked with ICD-10-CM Z codes.
- Why it matters
- Increasingly requested in quality programs and risk models.
- Illustrative example
- A clinician documents housing instability with a Z code.
Related terms ICD-10-CMValue-Based Care
Reference source CMS (Centers for Medicare & Medicaid Services)
Categories Quality & Risk Adjustment TermsValue-Based Care Terminology
Star Ratings
General (all payers)Also called: Medicare Advantage Star Ratings; Stars
- Definition
- A CMS rating system that scores Medicare Advantage and Part D plans on quality and member experience.
- Why it matters
- Plans focus on measures that affect Star Ratings.
- Illustrative example
- A plan invests in outreach to improve its Stars.
Related terms Medicare AdvantageHEDIS
Reference source CMS (Centers for Medicare & Medicaid Services)
Categories Quality & Risk Adjustment TermsMedicare & Medicaid Terms
Tracer Methodology
General (all payers)Also called: Joint Commission tracer; patient tracer; survey tracer
- Definition
- Tracer methodology is a survey method in which reviewers follow a patient's actual experience through an organization to see how the systems work in practice.
- Why it matters
- Practices prepare by making sure their records and processes match what they say they do.
- Illustrative example
- A surveyor follows one patient's chart from intake to discharge and asks staff to explain each step.
Verify: Confirm how the method applies to your program.
Related terms The Joint CommissionAccreditationDocumentationCompliance Program
Reference source The Joint Commission
Categories Quality & Risk Adjustment Terms
More billing terms
- Credentialing & Enrollment 58
- Contracting & Network Management 22
- Claims Processing 172
- Eligibility & Benefits 75
- Payment & Reimbursement 61
- Denials & Appeals 46
- Audits & Compliance 115
- Behavioral Health Specific Terms 148
- CPT, E/M & HCPCS Code Entries 54
- Telehealth Terms 23
- Revenue Cycle Metrics 44
- EDI & Clearinghouse Terms 63
- BCBS, UHC & Commercial Payer Terms 54
- Medicare & Medicaid Terms 145
- Value-Based Care Terminology 23
- Prior Authorization Terminology 22
- EHR & Healthcare Technology Terms 54
- Provider Data Management Terms 26
- Patient Financial Responsibility Terms 35
- AI & Healthcare Automation Terms 12
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