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Principles of Healthcare Reimbursement 4th Ed Ch 2 (COMPLETE)
Terms in this set (49)
Unknowing or unintentional submission of an inaccurate claim for payment.
AHA Coding Clinic for ICD-9-CM
Quarterly publication issued by American Hospital Association and approved by CMS to give coding advice and direction for ICD-9-CM.
AHA Coding Clinic for HCPS
Official coding guidance for HCPCS Level II procedure, service, and supply codes.
AHIMA Standards of Ethical Coding
Standards developed by the Council on Coding and Classification and AHIMA to give health information coding professionals ethical guidelines for performing their coding and grouping tasks.
Ambulatory Payment Classification - APC
Hospital Outpatient Prospective Payment System (HOPPS). The classification is a resource based reimbursement system and the payment unit is the ambulatory payment classification group.
Average Length of Stay
Average number of days patients are hospitalized. Statistic is calculated by dividing the total number of hospital bed days in a certain period by the admissions or discharges during the same period.
Balanced Budget Act of 1997
Legislation that affected several aspects of the healthcare industry including HOPPS, fraud, abuse and PACE.
Process of comparing performance with a preestablished standard or performance of another facility or group
Case-mix index (CMI)
Single number that compares the overall complexity of the healthcare organization's patients with the complexity of the average of all hospitals. Typically, CMI is for a specific period and is derived from the sum of all diagnosis-related group DRG weights, divided by the number of Medicare cases.
Category I Code (CPT)
CPT code that represents procedure or service that is consistent with contemporary medical practice and is performed by many physicians, clinical practice in multiple locations.
Category II Code (CPT)
CPT code that represents services or tests that contribute to positive health outcomes and quality patient care.
Category III Code (CPT)
CTP code that represents emerging technologies for which a CPT I code has yet to be established.
1) System for grouping similar diseases and procedures and organizing rlated information for easy retrieval. 2) A system for assigning numeric or alphanumeric numbers to represent specific diseases and/or procedures.
Coding compliance plan
Component of and HIM plan or 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 that govern it.
Designated individual who manages compliance process in facility.
Complication and Comorbidity
Illness or injury that co-exists with the condition for which the patient is primarily seeking care.
Official coding guidance for CPT.
False Claims Act
Legislation passed during the Cival War that prohibits contractors from making false claims to a governmental program.
Intentionally making a false claim for payment.
Healthcare Common Procedure Coding System (HCPCS)
Coding system created and maintained by CMS that provides codes for procedures and services and supplies not represented by CPT.
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.
Hospital Outpatient Prospective Payment System (HOPPS)
Reimbursement system created by BBA of 1997 for hospital outpatient services rendered to Medicare beneficiaries; maintained by CMS.
Improper payment reviews
Evaluation of claims whether the items and/or services are covered, correctly coded and medically necessary.
Coding and Classification system used to report diagnoses in all healthcare settings and inpatient procedures and services.
Length of stay
Number of days patient remains in a healthcare organization. The statistic is the number of calendar days from the admission to discharge including the day of admission but not the day of discharge. This statistic might have an impact on prospective reimbursement.
Local Coverage Determination
Reimbursement and medical-necessity policies established by regional fiscal intermediaries. These vary from state to state.
Major complication and comorbidity
Diagnosis codes in this category reflect the highest level of severity.
Major diagnostic category - MDC
Highest level in hierarchical structure of the federal inpatient prospective payment system.
Medicare administrative contractor - MAC
Contracting authority created by the MMA of 2003 to administer Medicare Part A and B.
Medicare integrity program
First comprehensive Federal strategy to prevent fraud and abuse.
Medicare-severity Diagnosis Related Group (MS-DRG)
Medicare-severity diagnosis related group. Allows for payment to be more closely aligned with resource intensity.
Two-digit code that provides the means by which a physician or facility can indicate that a service provided to the patient was altered by some special circumstance
Incidence of death.
National Center For Health Statistics (NCHS)
Developed the clinical modification to ICD-9 and is responsible for maintaining and updating the diagnosis portion.
National Correct Coding Initiative (NCCI)
set of coding regulations to prevent fraud and abuse in physician and hospital outpatient coding; specifically addresses unbundling and mutually exclusive procedures.
National Coverage Determination (NCD)
National medical necessity and reimbursement regulations.
Office of Inspector General (OIG)
Division of DHHS that investigates issues of noncompliance in the Medicare and Medicaid programs.
Yearly plan released by OIG that outlines the focus for reviews and investigates in various healthcare settings.
Operation Restore Trust
1995 joint effort by OIG, DHHS, CMS and AoA to target Medicare fraud and abuse.
Outpatient Service Mix Index
Sum of the weights of ambulatory payment classification groups for patients treated during a given period, divided by the total volume of patients treated.
Recovery Audit Contractor (RAC)
Resulted from MMA of 2003 - Ensures correct payments are made to providers and facilities for Medicare Part A and B claims
Complication Program Guidance
Committee that reviews utilization issues brought to it by the medical director, often approving or reviewing policy regarding coverage, reviewing utilization patterns of providers, and approving or reviewing the sanctioning process against providers. - See more at: http://www.superglossary.com/Glossary/Health/Health_Insurance/Utilization_Review_Committee.html#sthash.NPrBSk8t.dpuf
International Classification of Diseases
Maintained by the World Health Organization (WHO) TRUE
Used throughout the world for mortality reporting
Updated approximately every 10 years
What ARE THE FIVE AREAS OF A CODING COMPLIANCE PLAN
5Auditing and monitoring
. Name and describe three of the seven OIG elements of an effective compliance plan.
Designation of Compliance officer and committee,
Written policies and proceduresti include standard of conduct, developing open lines of communication, Education and Training, internal Auditing and Monitoring, response to detected deficiencies, enforcement of disciplinary standards
Common forms of fraud and abuse include all of the following except:
. Refiling claims after denials
Name the legislation that created Medicare Summary Notices and describe their use.
Balanced Budget Act of 1997.Legislation that affected several aspects of the healthcare industry including HOPPS, fraud, abuse and PACE.An attempt to
educate Medicare beneficiaries on their role in preventing and reporting fraudulent acts
What resource can managers use to discover current hot areas of compliance?
First, become familiar with the major investigative targets. Key sources of information on "hot" targets include the annual work plan for the Department of Health and Human Services (HHS) Office of Inspector General (OIG), fraud alerts issued by the OIG, and focus medical reviews described in fiscal intermediaries' provider bulletins.
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