Cclass legal aspects of coding
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15 terms
Terms | Definitions |
|---|---|
 medical ethics | carrying out one's responsibilities with integrity,decency,respect,honesty,competence,fairness and trust. |
| compliance regulations | billing related cases are based on HIPAA and false claims act |
| HIPAA title I | insurance reform |
| HIPAA title II | administrative simplification |
| false claims act | federal law that prohibits submitting a fraudulent claim or making a false statement or representation in connection with a claim. Rewards and protects those involved in whistle blower cases. |
| national correct coding initiative (NCCI) | developed by CMS to promote national correct coding methodologies and to control improper coding that leads to inappropriate payment of part B health insurance claims. |
| NCCI column1/column2 edits | identifies code pairs that should not be billed together because one code includes all the services described by another code. |
| NCCI mutually exclusive edits | identifies code pairs that for clinical reasons are unlikely to be performed on the same patient on the same day. |
| fraud | knowingly and intentionally deceiving or misrepresenting information that may result in unauthorized benefits. |
| abuse | submitting a claim for a service or procedure performed that was not medically necessary to treat the patients condition. |
| employer liability | physicians are legally responsible for their own conduct and any actions of their employees. |
| Errors and omissions insurance | protection against loss of monies caused by failure through error or unintentional omission on the of the individual or service submitting the insurance claims. |
| medical records | documentation on the patients social and medical history,family history,physical examination findings,progress note, radiology and lab results,consultation reports and correspondence to patient. |
| reason for documentation | avoidance of denied or delayed payments,enforcement of medical record keeping rules by insurance carriers,subpoena of medical records ,defense of a professional liability claim. |
| retention of medical records | most physicians are required to retain records indefinitely; deceased patient records should be kept for at least five years. governed by the state and local laws The rules may vary from state to state |
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