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23 terms

Procedural Coding Ch. 6 key terms

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alternative billing codes
ABCs, A code system for integrative health care products and services consisting of five-character alphabetic symbols with appended two-character practitioner type
bilateral
relating to both sides of the body
bundled codes
To group more than one component (service or procedure) into one CPT code.
comprehensive code
A single procedural code that describes or covers two or more CPT component codes that are bundled together as one unit.
conversion factor
The dollars and cents amount that is established for one unit a applied to a procedure or service rendered. This unit is then used to convert various procedures into fee-scheduled payment amounts by multiplying the relative value unit by the conversion factor
Current Procedural Terminology
CPT, A reference procedural code book using a five-digit numerical system to identify and code procedures established by the American Medical Association
customary fee
The amount that a physician usually charges most of her or his patients
downcoding
This occurs when the coding system used by the physician's office on a claim does not match the coding system used by the insurance company receiving the claim. The insurance company computer system converts the code submitted to the closest code in use, which is usually down one level from the submitted code, generating decreased payment.
fee schedule
List of charges or established allowances for specific medical services and procedures.
global surgery policy
A Medicre policy relating to surgical procedures in which preoperative and postoperative visits (24 hours before [major] and day of [minor]), usual, intraoperative services, and complications not requiring additional trips to the operating room are included in one fee.
Healthcare Common Procedure Coding System
HCPCS, A three-tier national uniform coding system developed by the Centers for Medicare and Medicaid Services, formerly HCFA, used for reporting physician or supplier services and procedures under the Medicare program. Level I codes are national CPT codes. Level II codes are HCPCS national codes used to report items not covered under CPT. Level III codes are HCPCS regional or local codes used to identify new procedures or items for which there is no national code, Pronounced "hick-picks".
modifier
In CPT coding, a two-digit add-on number placed after the usual procedure code number to indicate a procedure or service has been altered by specific circumstances. The two-digit modifier may be separated by a hyphen. In HCPCS level II codign, one-digit or two-digit add-on alpha characters, placed after the usual procedure code number
procedure code numbers
Five-digit numeric codes that describe each service the physician renders to a patient
professional component
PC, That portion of a test or procedure (containing both a professional and technical component) which the physician performs (e.g., interpreting an electrocardiogram [ECG], reading an x-ray, or making an observation and determination using a microscope).
reasonable fee
A charge is considered reasonable if it is deemed acceptable after peer review even though it does not meet the customary or prevailig criteria. This includes unusual circumstances or complications requiring additional time, skill,ore experience in connection with a particular service or procedure. In Medicare, the amount on which payment is based for participating physicians
relative value studies
RVS, A list of procedure codes for professional services and procedures that are assigned unit values taht indicate the relative value of one procedure over another
relative value unit
RVU, A monetary value assigned to each service based on the amount of physician work, practice expenses, and the cost of professional liability insurance. These three RVUs are then adjusted according to geographic area and used in a formula to determine Medicare fees.
resource-based relative value scale
RBRVS, A system that ranks physician services by units an provides a formula to determine a Medicare fee schedule
surgical package
Unstarred surgical procedure code numbers include the operation; local infiltration, digital block, or topical anesthesia; and normal, uncomplicated postoperative care. This is referred to as a package, and one fee covers the whole package.
technical component
TC, That portion of a test or procedure (containing both a technical and a prfessional component) which pertains to the use of the equipment and the operator who performs it. (e.g., ECG machine and technician, radiography machine and technician, and microscope and technician).
unbundling
The practice of using numerous CPT codes to identify procedures normally covered by a single code; also known as itemizing, fragmented billing, exploding, or a la carte medicine.
upcoding
Deliberate manipulation of CPT codes for increased payment
usual, customary, and reasonable
UCR, A method used by insurance companies to establish their fee schedules in which three fees are considered in calculating payment: 1 . eh usual fee is the fee typically submitted by the physician, 2. the customary fee falls within the range of usual fees charged by providers of similar training in a geographic area, and 3. the reasonable fee meets the aforementioned criteria or is considered justifiable because of special circumstances. UCR uses the conversion factor method of establishing maximums; the method of reimbursement used under Medicaid by which state Medicaid programs set reimbursement rates using the Mecicare method or a fee schedule, whichever is lower