CPT Medical Coding - Chapter 1

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DHHS

Department of Health and Human Services; responsible for the administration of the medicare program.

CMS

Centers for Medicare and Medicaid Services; responsible for the daily operation of Medicare.

MACS

Medicare Administrative Contractors; handle the paperwork and are usually insurance companies

QIOs

Quality Improvement Organizations; formerly known as PROs; organization that performs medical peer review of Medicare and Medicaid claims

HIPAA

Health Insurance Portability and Accountability Act of 1996; health coverage portability, health information privacy, administrative simplification, medical savings accounts, long-term care insurance

Administrative Simplification

Electronic transactions and code sets standard requirements, privacy, security and national identifier requirements

Transactions

Activities involving the transfer of health care information

Transmission

The movement of electronic data between two entities and the technology that supports the transfer

EMR

Electronic medical record; computerized health record limited to one practice

EHR

Electronic health record; the entire health record compiled from multiple sources

Federal Register

Official publication for all presidential documents, rules and regulations, proposed rules and notices. Hospital facilities - October edition. Outpatient facilities - November or December edition

RBRVS

Resource Based Relative Value Scale; decrease medicare expenditures, redistribute physicians' payments more equally, and ensure quality health care.

OBRA

Omnibus Budget Reconciliation Act of 1989

Physician Fee Schedule

Updated April 15; RVUs for each service, geographic adjustment factor and national conversion factor

RVU

Relative Value Unit; work, overhead, and malpractice

Fraud

The intentional deception or misrepresentation that an individual knows to be false and makes it knowing that it could result in some unauthorized benefit to himself

Abuse

Unknowingly or unintentionally submitted an inaccurate claim; generally results from unsound medical, business, or fiscal practices

OIG

Office of the Inspector General; responsible for developing an annual work plan that outlines the ways in which the medicare program is monitored to identify fraud and abuse

Privacy

The right of a patient to control disclosure of personal information.

Security

The means to control access and protect information from accidental or intentional disclosure to unauthorized persons and from unauthorized alteration, destruction, or loss.

MCO

Managed Care Organization; responsible for the health care serviced offered to an enrolled group or person

PPO

Preferred Provider Organization; a group of providers who form a network and who have agreed to provide services to enrollees at a discounted rate.

EPO

Exclusive Provider Organization; providers are paid on a fee for service basis

PACE

Program for All-Inclusive Care for the Elderly; program developed to address the needs of long-term care clients, providers, and payers

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