Care coordination & privacy
Care coordination & privacy
- Care coordination
- The work of keeping everyone involved in a person's care — family, clinicians, school, agencies — aligned on what's happening and what's next: sharing updates, reconciling plans, closing loops between visits. It's the work families do unpaid and providers do unbilled, and the work coordination platforms exist to capture.Related: Mallowa for families
- Care team
- Everyone with an ongoing role in a person's care: family members, direct-support professionals, therapists, teachers, physicians, and coordinators. A functioning care team shares one picture of the person; a dysfunctional one carries fragments in text threads, binders, and memory.
- Family caregiver
- A family member or friend providing regular, usually unpaid care — managing medications, appointments, behaviors, paperwork, and coordination for someone who needs support. Family caregivers are the largest unpaid workforce in healthcare and the center of most care teams.
- Direct support professional (DSP)
- A paid professional supporting people with disabilities in daily living — at home, in the community, or in residential settings. DSPs often know the person's day-to-day patterns better than anyone and are essential, frequently under-connected members of the care team.
- Person-centered planning
- Planning that starts from the person's own goals, preferences, and strengths rather than from available program slots — the standard for IDD services and HCBS waivers. In practice it means the plan describes a life the person wants, and services are arranged to serve it.
- Supported decision-making
- An alternative to guardianship in which a person with a disability makes their own decisions with chosen supporters helping them understand options and communicate choices. Increasingly recognized in state law as the less-restrictive first option before any guardianship petition.
- Guardianship
- A court arrangement giving one person legal authority to make decisions for another deemed unable to make them independently. Scope varies from limited to plenary; because it removes rights, many families now consider supported decision-making first.
- HCBS waiver
- A state Medicaid program 'waiving' institutional requirements so a person can receive long-term services — personal care, respite, day programs, supported employment — at home and in the community. Each state designs its own waivers, names them differently, and manages its own waitlists.
- Respite care
- Short-term substitute care that gives a primary caregiver time to rest, work, or handle life — hours, days, or occasionally longer. Often funded through HCBS waivers or family-support programs, and one of the most-requested, least-used supports in family caregiving.
- Crisis plan
- A pre-written, shared plan for the hard moments: warning signs, de-escalation steps that work for this person, medications, emergency contacts, and what responders should know. A crisis plan is only as good as the care team's ability to find it fast.
- HIPAA
- The federal law governing how covered entities and their vendors protect and share health information. HIPAA doesn't forbid sharing — it structures it: with consent, for treatment, with safeguards, and with the patient's own right to access their records at its core.
- Protected health information (PHI)
- Health information tied to an identifiable person — diagnoses, medications, notes, appointment history, even the fact of being a patient. PHI is what HIPAA's safeguards protect, what access controls gate, and what should never appear in URLs, logs, or errors.
- Business Associate Agreement (BAA)
- The HIPAA-required contract between a covered entity and any vendor handling PHI on its behalf, binding the vendor to HIPAA's safeguards and breach duties. If a service touches PHI and won't sign a BAA, a HIPAA-regulated organization can't lawfully use it for that data.
- Note visibility
- Per-note access control: deciding who on a care team can see a specific entry — everyone, clinical staff only, family only, or just the author. Visibility at the note level, rather than the whole record, is what lets one shared record serve very different roles safely.Related: Mallowa for families
- Electronic health record (EHR)
- The system a clinical practice or hospital runs its charts on. EHRs are practice-owned and practice-scoped — which is why families spanning multiple providers end up with fragments in several portals, and why a family-owned coordination record is a different layer, not a competing chart.
- FHIR
- Fast Healthcare Interoperability Resources — the modern standard for exchanging health data through APIs, required of certified EHRs by federal rule. FHIR is what lets a person authorize an app to pull their own records from a provider's system, securely and without faxes.
- Interoperability
- The ability of different health systems to exchange data and actually use it — the difference between records that follow the person and records trapped where they were created. Federal information-blocking rules now require providers to share electronic health information rather than silo it.
Billing & reimbursement
Billing & reimbursement
- Care management
- The umbrella term for Medicare's between-visit service families — CCM, PCM, BHI, CoCM, TCM, RPM, RTM, CHI, PIN, and APCM. Each pays for coordination work furnished outside face-to-face visits, under its own thresholds, consent rules, and billing practitioner requirements.Related: Billing-code library
- Chronic Care Management (CCM)
- A monthly Medicare program paying for coordination of care for patients with two or more chronic conditions — care-plan updates, medication reconciliation, and communication across providers. The base code 99490 covers the first 20 minutes of clinical-staff time in a calendar month.Related: CCM billing guide
- Principal Care Management (PCM)
- CCM's single-condition sibling: monthly management of one serious, high-risk chronic condition, typically by the specialist who owns it. Where CCM requires two or more conditions, PCM requires exactly one that warrants its own dedicated program and disease-specific care plan.Related: PCM billing guide
- Behavioral Health Integration (BHI)
- Monthly care management of a behavioral-health condition — systematic assessment with a validated rating scale, care-plan revision, and coordination — without requiring the full collaborative-care team. Physicians bill 99484; behavioral-health clinicians bill the parallel G0323.Related: BHI billing guide
- Collaborative Care Model (CoCM)
- The evidence-based psychiatric care model Medicare pays for through CPT 99492–99494: a behavioral care manager tracks a registry caseload, a psychiatric consultant reviews it weekly, and the treating practitioner bills. The highest-paying behavioral care-management family, because it requires the most structure.Related: CoCM billing guide
- Transitional Care Management (TCM)
- A 30-day, deadline-driven service after a hospital or facility discharge: interactive contact within two business days, a face-to-face visit within 7 or 14 days depending on complexity, and medication reconciliation by that visit. One claim per discharge, per practitioner.Related: TCM billing guide
- Remote Physiologic Monitoring (RPM)
- Medicare's program for monitoring physiologic data — blood pressure, weight, glucose, oxygen saturation — from a connected device the patient uses at home, plus the clinical time managing what the data shows. Device-supply and management codes bill monthly under day-count and minute thresholds.Related: RPM billing guide
- Remote Therapeutic Monitoring (RTM)
- The therapy-side monitoring family: non-physiologic data such as musculoskeletal or respiratory status, therapy adherence, and response. Its defining feature is that physical therapists, occupational therapists, and speech-language pathologists can bill it directly under their own NPIs.Related: RTM billing guide
- Community Health Integration (CHI)
- Medicare codes (G0019/G0022, created 2024) paying for community-health-worker time spent addressing a documented upstream driver of health — housing, food, transportation — that interferes with a treatment plan. Furnished by auxiliary personnel under a billing practitioner's general supervision.Related: CHI billing guide
- Principal Illness Navigation (PIN)
- Monthly Medicare codes (G0023/G0024) paying for a trained navigator guiding a patient through a serious, high-risk illness such as cancer or serious mental illness. PIN bills per condition — two practitioners can each bill for different conditions in the same month.Related: PIN billing guide
- Peer support specialist
- A person certified to support others' recovery on the strength of trained, lived experience of a behavioral-health condition. Medicare's PIN Peer Support codes (G0140/G0146) are the first national lane paying for certified peer-specialist time tied to a treatment plan.Related: PIN Peer Support billing guide
- Advanced Primary Care Management (APCM)
- Medicare's no-stopwatch alternative to CCM: a flat monthly bundle (G0556–G0558) tiered by condition count and QMB status instead of counted minutes. Billing an APCM month is a deliberate confirmation — and it excludes CCM, PCM, and TCM for that patient-month.Related: APCM billing guide
- Caregiver Training Services (CTS)
- Codes paying clinicians to train the caregiver — parent, spouse, or direct-support professional — in the strategies and skills that carry out a treatment plan, furnished without the patient present. Lanes exist for functional strategies, behavior management, and direct-care skills.Related: Caregiver training billing guide
- Interprofessional consultation
- Practitioner-to-practitioner advice by phone or record review — a treating clinician consults a specialist without moving the patient, and both sides can bill for their time. The requesting practitioner, not the consultant, must obtain and document the patient's verbal consent.Related: Consult billing guide
- CPT code
- A five-digit code from the AMA's Current Procedural Terminology set identifying a medical service on a claim — 99490 for base CCM, for example. Payers attach payment rates and rules to CPT codes; billing the right one is a factual claim about the work performed.
- HCPCS code
- The Healthcare Common Procedure Coding System — CMS's coding layer that includes CPT plus letter-prefixed codes CMS creates itself (G0019, G0556). Many new care-management services debut as Medicare-first G-codes before commercial payers adopt them, which is why commercial denials often lag.
- Superbill
- An itemized, claim-ready document of services rendered — codes, dates, charges, diagnosis pointers, and the rendering practitioner's identifiers — that a practice or its billing service uses to submit the actual claim. A superbill is the input to claim submission, not the claim itself.
- Modifier (billing)
- A two-character suffix refining what a code claims: GP/GO/GN mark the therapy discipline on RTM claims, and CQ/CO mark that a therapy assistant furnished the service — which also reduces payment to 85%. Wrong or missing modifiers are a leading cause of avoidable denials.Related: RTM billing guide
- Medically Unlikely Edit (MUE)
- CMS's per-code cap on how many units one patient can receive from one provider in one day — the reason add-on codes like 99439 stop at two units. Claims exceeding an MUE deny automatically, though some caps are clinically appealable with documentation.
- Relative Value Unit (RVU)
- The workload measure behind Medicare pricing: each code carries RVUs for work, practice expense, and malpractice, and payment is the RVU total multiplied by the year's conversion factor, adjusted for geography. When a dollar rate looks arbitrary, the RVU math underneath usually isn't.
- Medicare Physician Fee Schedule (PFS)
- The annual CMS rule setting payment rates and policy for practitioner services — including every care-management family. Each calendar year's final rule can revalue codes, create new ones, and retire others, which is why every rate deserves a 'which year?' question.
- National Provider Identifier (NPI)
- The 10-digit identifier every healthcare provider uses on claims. A claim states who rendered the service by NPI — no NPI on file means no lawful claim, which is why care-management platforms hold billing until the rendering practitioner's identity is complete.
- Billing practitioner
- The practitioner whose name and NPI carry a claim — for care management, the one directing the work and taking responsibility for it. Clinical-staff minutes count toward thresholds under this practitioner's direction, and single-biller rules attach to this role, not to the staff.
- General supervision
- A Medicare supervision level where the billing practitioner directs the service and remains responsible, but doesn't need to be physically present — the arrangement under which clinical staff, community health workers, and navigators furnish care-management time that counts toward billing thresholds.
- Single-biller rule
- The care-management principle that only one practitioner may furnish and bill a given program for a patient in a given month — and that the patient must be told so during consent. A consent form missing this disclosure is not valid consent for billing.Related: CCM billing guide
- Initiating visit
- The qualifying face-to-face visit required before certain care-management programs begin for a patient who is new to the billing practitioner or hasn't been seen within a year. The requirement follows the practitioner — a colleague's earlier visit doesn't transfer.
- Qualified Medicare Beneficiary (QMB)
- A Medicare beneficiary whose cost-sharing is covered by Medicaid — and who therefore cannot lawfully be billed Medicare deductibles or coinsurance. Balance-billing a QMB patient is a compliance violation; APCM's level 3 bundle exists specifically for QMB patients with multiple conditions.Related: APCM billing guide
- Dual-eligible
- A person enrolled in both Medicare and Medicaid — often the highest-need patients in a caseload, and frequently QMB-protected on cost-sharing. Dual-eligible clients are a common center of gravity for care-management programs because coordination is exactly what their care requires.
- CO-181 denial
- A claim-adjustment reason code meaning the procedure code is invalid for this payer — the classic result of billing a Medicare-first G-code to a commercial payer that hasn't adopted it. The fix is payer verification before billing, not resubmission.
- Medicare Administrative Contractor (MAC)
- The regional contractor that processes Medicare claims for your area, publishes local coverage policy, and prices carrier-priced codes that have no national rate. When a rate 'depends on your MAC,' this is the organization it depends on.
- Measurement-based care (MBC)
- The practice of tracking treatment with validated instruments — PHQ-9, GAD-7, and similar — and adjusting care when scores say so. In billing terms, BHI and CoCM require a validated scale captured every billed month; clinically, it's how behavioral care proves it's working.Related: BHI billing guide
- Medication reconciliation
- Comparing everything a person is actually taking against what the record says — after every transition of care, and on a schedule between them. In TCM it's a billing requirement with a deadline: completed on or before the post-discharge face-to-face visit.Related: TCM billing guide
- Upstream drivers of health
- CMS's current term (replacing 'social determinants of health' in the CY2026 rule) for non-medical conditions — housing instability, food insecurity, transportation barriers — that keep treatment plans from working. A documented unmet upstream driver is the qualifying basis for CHI billing.Related: CHI billing guide
- Community health worker (CHW)
- A frontline public-health worker who is a trusted member of the community served, helping people navigate resources, appointments, and systems. Since 2024, Medicare pays for CHW time directly through the CHI codes, furnished under a practitioner's general supervision.Related: CHI billing guide
- Telehealth
- Real-time clinical visits furnished remotely, governed by their own coverage rules and expiration dates. Care-management services are not telehealth — they are between-visit services by definition — so telehealth policy cliffs don't apply to CCM, BHI, RPM, or their siblings.
School, therapy & developmental services
School, therapy & developmental services
- Individualized Education Program (IEP)
- The legally binding plan a school team writes for a student eligible for special education under IDEA: measurable goals, services with minutes, accommodations, and placement. Parents are equal members of the IEP team, and the document — not verbal assurances — is what's enforceable.
- 504 plan
- A plan of accommodations under Section 504 of the Rehabilitation Act for a student with a disability who doesn't need specialized instruction — extended time, sensory breaks, modified assignments. Lighter-weight than an IEP, but still a civil-rights obligation, not a favor.
- IDEA
- The Individuals with Disabilities Education Act — the federal law entitling eligible children to a free appropriate public education in the least restrictive environment, through an IEP. IDEA is why evaluations, services, and parental participation in school decisions are rights, not requests.
- Least restrictive environment (LRE)
- IDEA's requirement that students with disabilities learn alongside non-disabled peers to the maximum extent appropriate, with removals justified — not defaulted. LRE is a presumption of inclusion the IEP team must engage with, placement by placement.
- Transition planning (IEP)
- The IDEA-required part of an IEP, starting by age 16, that plans the path to adult life: postsecondary goals, work experiences, daily-living skills, and agency linkages. Strong transition planning connects the school years to adult services before the school-based entitlements end.
- Applied Behavior Analysis (ABA)
- The therapy discipline that applies learning principles to build skills and reduce behaviors that interfere with life — the most common intensive intervention for autistic children. Delivered by behavior technicians under a behavior analyst's supervision, with data collection at its core.
- Board Certified Behavior Analyst (BCBA)
- The graduate-level certification for behavior analysts who assess, design, and supervise ABA programs. In a typical ABA organization the BCBA writes and adjusts the treatment plan, supervises RBTs delivering it, and leads parent training on the strategies.
- Registered Behavior Technician (RBT)
- The credential for technicians delivering ABA session-by-session under a BCBA's supervision — running programs, collecting trial data, and implementing behavior plans. RBTs are usually the team members spending the most direct hours with the person.
- Functional Behavior Assessment (FBA)
- The structured assessment answering why a behavior happens — what precedes it, what follows it, and what function it serves (escape, attention, access, sensory). The FBA's answer drives the behavior intervention plan; interventions chosen without one are guesses.
- Behavior Intervention Plan (BIP)
- The plan built from an FBA's findings: prevention strategies, replacement skills to teach, and how everyone responds when the behavior occurs. A BIP works when every setting — home, school, therapy — runs the same plan, which makes it a care-coordination document as much as a clinical one.
- Occupational therapy (OT)
- Therapy for the skills of daily living — fine motor, self-care, sensory regulation, handwriting, executive functioning. OTs work across clinics, homes, and schools, and in 2026 can bill Medicare's RTM codes directly for remote monitoring of therapy programs.Related: RTM billing guide
- Speech-language pathology (SLP)
- The discipline treating communication and swallowing — articulation, language, fluency, AAC, and feeding. SLPs appear on IEP teams as related-service providers and on medical teams as treating clinicians, and can bill Medicare's RTM codes directly.Related: RTM billing guide
- Sensory profile
- A documented picture of how a person experiences sensory input — what overwhelms, what regulates, what helps in a meltdown, what environments to prepare for. Shared with the whole care team, it prevents each new caregiver from rediscovering the hard way.
- Progress monitoring
- Regular, structured measurement of whether goals are being met — trial data in ABA, curriculum-based measures at school, standardized scales in therapy. It's how a team knows a plan is working before months pass, and the evidence base for changing course when it isn't.
This glossary is general information, not billing, coding, legal, or medical advice. Billing terms follow CY2026 Medicare policy; verify current requirements with the relevant payer.