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HIM 2543 Healthcare Billing and Reimbursement
Terms in this set (49)
Unknowing or unintentional submission of an inaccurate claim for payment.
AHA Coding Clinic for ICD-9-CM
A publication issued quarterly by the American Hospital Association and approved by the Centers for Medicare and Medicaid Services (CMS) to give coding advice and direction for International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM).
AHA Coding Clinic for HCPCS
Official coding guidance for Healthcare Common Procedure Coding System (HCPCS) Level II procedure, service, and supply codes.
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.
Ambulatory payment classification group (APC
Basic unit of the ambulatory payment classification (APC) system. Within a group, the diagnoses and procedures are similar in terms of resources used, complexity of illness, and conditions represented.
A single payment is made for the outpatient services provided. APC groups are based on HCPCS/CPT codes. A single visit can result in multiple APC groups. APC groups consist of five types of service: significant procedures, surgical services, medical visits, ancillary
services, and partial hospitalization. The APC group was formerly known as ambulatory visit group (AVG) and ambulatory patient group (APG).
Average length of stay (ALOS)
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 (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 pre established 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, the 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)
A Current Procedural Terminology (CPT) code that represents a procedure or service that is consistent with contemporary medical practice and 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 that contribute to positive health outcomes and 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 that govern 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.
Illness or injury that coexists with the condition for which the patient is primarily seeking healthcare.
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 fraud and abuse.
Intentionally making a claim for payment that one knows to be false.
Healthcare Common Procedure Coding System
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.
Hospital Outpatient Prospective Payment System
The reimbursement system created by the Balanced Budget Act of 1997 for hospital outpatient services rendered to Medicare beneficiaries; maintained by the Centers for Medicare and Medicaid Services (CMS).
ICD-9-CM Coordination and Maintenance Com-
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, 9th Revision, Clinical Modification (ICD-9-CM) code sets.
Improper payment review
Evaluation of claims to determine whether the items and/or services are covered, correctly coded and medically necessary.
International Classification of Diseases, 9th Revision,
Clinical Modification (ICD-9-CM)
Coding and classification system used to report diagnoses in all health-care settings and inpatient procedures and services.
Length of stay (LOS)
Number of days a patient remains in a healthcare organization. The statistic is the number of calendar days from admission to discharge, including the day of admission but not the day of discharge. This statistic may have an impact on prospective reimbursement
Local Coverage Determination (LCD)
Reimbursement and medical-necessity policies established by regional fiscal intermediaries. New format for Local Medical Review Policies (LMRPs). LCDs and LMRPs vary from state to state.
Major complication/comorbidity (MCC)
Diagnosis codes classified as MCCs reflect the highest level of severity. See Complications/commodities (CC).
Major diagnostic category (MDC)
Highest level in hierarchical structure of the federal inpatient prospective payment system (IPPS). The 25 MDCs are primarily based on body system involvement, such as MDC No. 06, Diseases and Disorders of the Digestive System. However, a few categories are based on disease etiology, for example, Human Immunodeficiency Virus Infections.
Medicare Administrative Contractor (MAC)
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.
Medicare-severity diagnosis-related group (MS-
Medicare refinement to the diagnosis-related group (DRG) classification system, which allows for payment to be more closely aligned with resource intensity.
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).
National Correct Coding Initiative (NCCI)
A 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)
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 (OIG) 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 Services (CMS), and the Administration of Aging (AOA) to target fraud and abuse among healthcare providers.
Outpatient service-mix index (SMI)
The 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)
The result of a successful a demonstration project required by the Medicare Modernization Act of 2003. RACs ensure correct payments are made to providers and facilities by Medicare for Part A and Part B claims.
Insurance company or health agency that pays the physician, clinic, or other health-care provider (second party) for the care or services to the patient (first party). An insurance company or healthcare benefits program that reimburses healthcare providers and/or patients for covered medical services.
Utilization review committee
Consists of representatives from health information management (HIM), quality, utilization, and medical staff, and is responsible for determining whether a patient's medical care is necessary according to established guidelines and regulations.
World Health Organization (WHO)
Organization that created and maintains the International Classification of Diseases (ICD) used throughout the world to collect morbidity and mortality information.
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