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Reimbursement Chapter 2 vocab
Terms in this set (34)
Unknowing or unintentional submission of an inaccurate claim for payment.
AHIMA Standards of Ethical Coding
Standards developed by the Council on Coding and Classification of the American Health Information Management Association (AHIMA) to give health information coding professionals ethical guidelines for performing their coding and grouping tasks.
Balanced Budget Act (BBA) of 1997
Legislation that affected several aspects of the healthcare industry, including the Hospital Outpatient Prospective Payment System (HOPPS), fraud and abuse, and Programs of All-Inclusive Care for the Elderly (PACE).
The process of comparing performance with a preestablished standard or performance of another facility or group.
Category I code (CPT)
A current Procedural Terminology (CPT) code that represents a procedure or service that is consistent with contemporary medical practice and that is performed by many physicians in clinical practice in multiple locations.
Category II code (CPT)
A Current Procedural Terminology (CPT) code that represents services and/or test results contributing to positive health outcomes and high-quality patient care.
Category III code (CPT)
A Current Procedural Terminology (CPT) code that represents emerging technologies for which a Category I Code has yet to be established.
Centers for Medicare and Medicaid Services (CMS)
A division of the Department of Health and Human Services (DHHS) that is responsible for administering the Medicare program and the federal portion of the Medicaid program; responsible for maintaining the procedure portion of the International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM). Before 2001, CMS was named the Health Care Financing Administration (HCFA).
1. A system for grouping similar diseases and procedures and organizing related information for easy retrieval. 2. A system for assigning numeric or alphanumeric code numbers to represent specific diseases and/or procedures.
Coding compliance plan
A component of a health information management compliance plan or a corporate compliance plan that focuses on the unique regulations and guidelines with which coding professionals must comply.
Managing a coding or billing department according to the laws, regulations, and guidelines governing it.
Designated individual who monitors the compliance process at a healthcare facility.
Compliance Program Guidance
Information provided by the Office of Inspector General (OIG) of the Department of Health and Human Services (DHHS) to assist healthcare organizations with the development of compliance plans and programs.
Comprehensive Error Rate Testing (CERT) program
Measures improper payments for the Medicare fee for services payment systems as mandated by the Improper Payments Elimination and Recovery Improvement Act of 2012.
Official coding guidance for Current Procedural Terminology (CPT) codes.
Current Procedural Terminology (CPT)
Coding system created and maintained by the American Medical Association that is used to report diagnostic and surgical services and procedures.
False Claims Act
Legislation passed during the Civil War that prohibits contractors from making a false claim to a governmental program; used to reinforce healthcare against fraud and abuse.
Intentionally making a claim for payment that one knows to be false.
Healthcare Common Procedure Coding System (HCPCS)
Coding system created and maintained by the Centers for Medicare and Medicaid Services (CMS) that provides codes for procedures, services, and supplies not represented by a Current Procedural Terminology (CPT) code.
Health Insurance Portability and Accountability Act (HIPAA) of 1996
Significant piece of legislation aimed at improving healthcare data transmission among providers and insurers; designated code sets to be used for electronic transmission of claims.
ICD-10-CM Coordination and Maintenance Committee
Committee composed of representatives from the National Center for Health Statistics (NCHS) and the Centers for Medicare and Medicaid Services (CMS) that is responsible for maintaining the US clinical modification version of the International Classification of Diseases, 10th Revision, Clinical Modification and Procedure Coding System (ICD-10-CM/PCS) code sets.
Improper payment reviews
Evaluation of claims to determine whether the items and/or services are covered, correctly coded and medically necessary.
International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM)
Coding and classification system used to report diagnoses in all healthcare settings and inpatient procedures and services.
International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM/PCS)
Coding and classification system used to report diagnoses in all healthcare settings and inpatient procedures and services. The procedure code set is separate from the diagnosis code set and is referred to as Procedure Coding System (PCS).
Medicare administrative contractor (MAC)
Newly established contracting authority to administer Medicare Part A and Part B as required by section 911 of the Medicare Modernization Act of 2003. Fifteen Medicare Administrative Contractors will replace Medicare Carriers and Fiscal Intermediaries by 2011. Each MAC will process and manage both Part A and Part B claims.
Medicare integrity program
First comprehensive federal strategy to prevent and reduce provider fraud, waste, and abuse.
Two-digit alpha/alphanumeric/numeric code that provides the means by which a physician or facility can indicate that a service provided to the patient has been altered by some special circumstance(s), but for which the basic code description itself has not changed.
The incidence of death.
National Center for Health Statistics (NCHS)
Organization that developed the clinical modification to the International Classification of Diseases, 9th Revision (ICD-9); responsible for maintaining and updating the diagnosis portion of the International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM).
Office of Inspector General (OIG)
A division of the Department of Health and Human Services (DHHS) that investigates issues of noncompliance in the Medicare and Medicaid programs, such as fraud and abuse.
Office of Inspector General Workplan
Yearly plan released by the OIG that outlines the focus for reviews and investigates in various healthcare settings.
Operation Restore Trust
A 1995 joint effort of the Department of Health and Human Services (DHHS), Office of Inspector General (OIG), the Centers for Medicare and Medicaid (CMS), and the Administration of Aging (AOA) to target fraud and abuse among healthcare providers.
Recovery Audit Contractor (RAC)
The result of a successful demonstration project required by the Medicare Modernization Act of 2003. RACs ensure that correct payments are made to providers and facilities by Medicare for Part A and Part B claims.
World Health Organization (WHO)
Organization that created and that maintains the International Classification of Diseases (ICD) used throughout the world to collect morbidity and mortality information.
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