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CPC Exam

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Terms in this set (134)

hospital employee who converts documented procedurs and diangoses into medical codes

coding practices that lead to improper reimbursement by error because they do not meet medical necessity, ex. changing diagnosis to be covered by insurance

an examination process the healthcare facility goes through to evaluate the facilities policies, procedures, and performance to meet higher standards.

Having seal of approval after being evaluated and demonstrating quality standards

Act/ Law/ Statute

Legislation passed through Congress and signed by President or passed over his veto

The amount the provider charges for medical services or supplies. Not always paid in full.

Additional Benefits

Health care services not covered by Medicare and are offered through the Medicare Advantage Organization for no additional premium. The benefits must equal the ACR (Adjusted Community Rating)

Health Insurance Claims process at the insurance company

Adjusted Average Per Capita Cost (AAPCC)

Estimate of how much Medicare will spend in a year for an average beneficiary

Administrative Code Sets

Non medical code sets that characterize a general business situation rather than a medical condition.

Administrative Costs

Medicare, Medicaid, CMS refer to this as their expenses to have the program, operating expenses, program management, etc.

Administrative Data

Health insurance information stored in automated information system about enrollment, eligibility, claims, etc.

Administrative Law Judge (ALJ)

hearing officer who presides over appeal conflicts between providers or beneficiaries, and Medicare contractors (MAC's)

Administrative Simplification

Part of HIPAA authorizing HHS (Health and Human Services) to 1. adopt standards for transactions & code sets; 2. adopt standard identifiers for health plans; 3. adopt standards to protect security & privacy of personally identifiable health information.

Administrative Simplification Act

Signed 12/17/01 allows HHS (Health & Human Services) to exclude providers from Medicare for HIPAA non-compliance of electronic claims and prohibit paper claims except in certain situations