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CPT Medical Coding - Chapter 1

STUDY
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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