> ## Documentation Index > Fetch the complete documentation index at: https://docs.stratapt.com/llms.txt > Use this file to discover all available pages before exploring further. # EMR and RCM Terminology > Definitions for common terms used in electronic medical records and revenue cycle management for outpatient therapy. This page defines common terms you'll encounter when using StrataEMR, or when working with outpatient therapy billing and documentation in general. Terms are organized by category. If you're looking for StrataPT-specific product terminology, see the [StrataPT Platform](#stratapt-platform) section at the bottom. ## Clinical Documentation The Medicare billing rule that determines how many units of timed CPT codes can be billed based on the total minutes of timed services provided. A minimum of 8 minutes is required to bill one unit. The rule governs how remaining minutes are allocated across multiple timed codes in a single visit. The clinician's professional interpretation of examination findings, test results, and patient presentation. The assessment drives the treatment plan and supports medical necessity for ongoing care. The primary reason the patient is seeking treatment, typically documented in the patient's own words. Also referred to as the reason for visit. A standardized set of codes published by the American Medical Association that describe medical, surgical, and diagnostic services. In outpatient therapy, CPT codes identify the specific treatments and procedures performed during a visit (e.g., therapeutic exercise, manual therapy, neuromuscular re-education). Documentation of a single patient visit that records the services provided, the patient's response, and any changes to the treatment plan. Also referred to as a progress note or visit note. A clinical document completed when a patient's episode of care ends. It summarizes the course of treatment, outcomes achieved, and the patient's status at discharge. In StrataEMR, completing a discharge summary triggers automated case closure. A digital system for creating, storing, and managing patient clinical records. StrataEMR is the EMR component of the StrataPT platform. The first clinical encounter for a new episode of care. The evaluation establishes the patient's baseline, diagnosis, functional limitations, and treatment plan. It is required before treatment can begin and is the foundation for medical necessity. A measurable deficit in a patient's ability to perform activities. Documenting functional limitations is essential for establishing and maintaining medical necessity for therapy services. Functional limitation reporting codes previously required by Medicare for outpatient therapy claims. G-codes have been replaced by other outcome reporting requirements, but the term still appears in some legacy documentation and systems. A specific, measurable outcome the patient is expected to achieve through treatment. Goals are established during the evaluation and updated throughout the episode of care. Goals must be functional, measurable, and tied to the patient's treatment plan. A standardized set of codes used to classify diagnoses and health conditions. ICD-10 codes are required on every claim to identify the medical condition being treated. The clinical justification for providing therapy services. Payers require documentation that demonstrates the services are reasonable, necessary, and expected to result in meaningful improvement. Insufficient medical necessity documentation is one of the most common reasons for claim denials in outpatient therapy. A two-character code appended to a CPT code to provide additional information about the service performed. Common therapy modifiers include GP (physical therapy), GO (occupational therapy), GN (speech-language pathology), 59 (distinct procedural service), and KX (threshold exceeded, medical necessity met). A documented treatment plan that outlines the patient's diagnosis, goals, treatment frequency, expected duration, and planned interventions. The POC is established at evaluation and must be certified (signed) by the referring physician. Recertification is required at regular intervals. See **Daily Note / Treatment Note**. A formal reassessment of the patient's status performed periodically during the episode of care. Re-evaluations update the treatment plan, modify goals, and provide continued justification for ongoing treatment. A documentation format organized into four sections: Subjective (patient-reported information), Objective (measurable findings and services provided), Assessment (clinician interpretation), and Plan (next steps). SOAP is a common documentation structure in outpatient therapy. CPT codes for therapy services are classified as either timed (billed per 15-minute unit based on time spent) or untimed (billed once per session regardless of duration). Accurate time tracking and the 8-minute rule determine how many units of timed codes can be billed. ## Billing and Revenue Cycle The total amount of money owed to the practice for services that have been provided but not yet paid. AR is typically measured in days (AR Days), which indicates the average time between submitting a claim and receiving payment. Lower AR days indicate faster collections. The process a payer follows to evaluate a submitted claim and determine the payment amount. Adjudication results in the claim being paid, denied, or pended for additional information. The maximum amount a payer has agreed to pay for a specific service, as defined by the provider's contract with that payer. The allowed amount may differ from the billed amount. A formal request to a payer to reconsider a denied or underpaid claim. Appeals must include supporting documentation that addresses the reason for the original denial. Approval from a payer that must be obtained before certain services can be provided. Authorizations typically specify the number of visits or units approved, the approved date range, and the approved CPT codes. Failure to obtain required authorization before treatment can result in claim denials. Billing the patient for the difference between the provider's billed charge and the payer's allowed amount. Balance billing rules vary by payer contract and state law. The process of recording billable services performed during a patient visit so they can be included on a claim. In StrataEMR, charge capture is connected to clinical documentation, so charges are generated from the services documented in the patient's note. A formal request submitted to a payer for payment for services rendered. Claims include patient information, diagnosis codes (ICD-10), procedure codes (CPT), modifiers, and other required data. A claim that contains all required information, is free of errors, and can be processed by the payer without additional follow-up. Higher clean claim rates mean faster payments and less rework. An intermediary that receives claims from providers, validates them for errors, and forwards them to the appropriate payer. Clearinghouses help standardize claim formatting and catch errors before submission. The percentage of the allowed amount the patient is responsible for paying after their deductible has been met. For example, if the co-insurance is 20%, the patient pays 20% of the allowed amount and the payer pays 80%. A fixed dollar amount the patient pays at the time of service, as defined by their insurance plan. Co-pays are typically collected at check-in. The amount a patient must pay out of pocket before their insurance begins covering services. Deductible amounts reset annually for most plans. A payer's decision to not pay a submitted claim, in full or in part. Denials have specific reason codes that indicate why the claim was rejected. Common therapy denial reasons include missing authorization, insufficient medical necessity documentation, and exceeded visit limits. The electronic exchange of standardized business documents (claims, remittances, eligibility inquiries) between providers and payers. EDI uses standard transaction formats defined by HIPAA. The process of confirming a patient's insurance coverage, benefits, and financial responsibility before or at the time of service. Verifying eligibility before treatment reduces claim denials for coverage-related issues. A document sent by the payer to the patient (and sometimes the provider) that explains how a claim was processed, what was paid, and what the patient owes. The electronic equivalent of a paper remittance. ERAs are sent by payers to providers and contain detailed payment information for processed claims, including payment amounts, adjustments, and denial reasons. ERAs enable automated payment posting. A list of the provider's standard charges for each CPT code. Fee schedules are set by the practice and are typically higher than payer allowed amounts. The fee schedule serves as the starting point for billing, and payer contracts determine the actual payment. A coding system that includes CPT codes (Level I) and additional codes for supplies, equipment, and non-physician services (Level II). In outpatient therapy, HCPCS Level II codes are less common but may apply for durable medical equipment or specific supplies. The total amount the patient owes for services received, including co-pays, co-insurance, deductible amounts, and any balance after insurance payment. The process of recording payments received from payers and patients against the corresponding claims and charges. Accurate payment posting is essential for maintaining clean AR and identifying underpayments. The end-to-end process of managing the financial aspects of patient care, from scheduling and eligibility verification through charge capture, claim submission, payment posting, and collections. StrataPT's managed RCM services handle this for your practice. A document from a payer that details how claims were processed, including payment amounts, adjustments, and denials. See also **ERA**. An amount the practice removes from a patient's or payer's balance, typically because it's contractually adjusted (the difference between billed amount and allowed amount) or deemed uncollectible. ## Insurance and Payers The specific services covered by a patient's insurance plan, including any limitations on visit counts, dollar amounts, or service types. A payment arrangement where the provider receives a fixed amount per patient per period, regardless of how many services are provided. Capitation is less common in outpatient therapy but exists in some managed care arrangements. Whether a provider has a contract with a specific payer. In-network providers have agreed to the payer's fee schedule and terms. Out-of-network providers do not, which typically results in higher patient costs and different reimbursement rules. A dollar limit on the amount Medicare will pay for outpatient therapy services per beneficiary per year. Once the threshold is reached, additional services require documentation of medical necessity (indicated by the KX modifier). The therapy cap has been subject to legislative changes over time. A unique 10-digit identification number assigned to healthcare providers. There are two types: Type 1 (individual providers) and Type 2 (organizations). NPIs are required on all claims. The insurance company or entity responsible for paying claims for covered services. Common payer types include commercial insurance, Medicare, Medicaid, and workers' compensation. A directive from a physician or other authorized provider that the patient should receive therapy services. Some payers require a referral before therapy can begin. A referral is distinct from a prescription. A written or electronic order from a physician or authorized provider for therapy services. Prescriptions may specify the diagnosis, therapy type, frequency, and duration. State practice acts and payer requirements determine when a prescription is needed. ## StrataPT Platform StrataPT's AI assistant. Mako supports clinical and administrative teams by surfacing relevant information, reducing repetitive tasks, and assisting with decision-making. StrataPT's revenue cycle management services. A dedicated billing team manages claims, payments, denials, patient billing, and collections on your behalf, operating on the same platform your clinicians use. The clinical workspace within the StrataPT platform. Patient charts, documentation, scheduling, and clinical workflows are managed through StrataEMR. The integrated platform that combines a billing-first EMR with managed RCM services for outpatient therapy clinics. *** **Related:** * [Welcome to StrataEMR](/welcome) -- Overview of the StrataPT platform and how this Knowledge Base is organized. * [Getting Help](/after-go-live/getting-help) -- How to find answers and contact support.