Medical Insurance Chap. 6

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1

code linkage

connection between a service and a patient's condition or illness

2

Correct Code Initiative (CCI)

computerized Medicare system that prevents overpayment

3

edits

computerized system that identifies improper or incorrect codes

4

CCI column 1/column 2 code pair edit

Medicare code edit where CPT codes in column 2 will not be pair in reported in the same day as column 1 codes

5

CCI mutually exclusive code (MEC) edit

both services represented by MEC codes that could not have been done during an encounter

6

CCI modifier indicator

number shoeing in the used of a modifier can bypass CCI edit

7

medically unlikely edits

units of service edits used to lower Medicare fee-for-service paid claims error rate

8

OIG Work Plan

OIG's annual list of planned projects

9

advisory opinion

opinion issued by CMS or OIG that becomes legal advice

10

excluded parties

individuals or companies not permitted to participate in federal healthcare programs

11

truncated coding

diagnoses not coded at the highest level of specificity

12

assumption coding

reporting undocumented services that coder assumes have been provided due to the nature of the case or condition

13

upcoding

use of a procedure code that provides a higher payment

14

downcoding

payer's review and reduction of a procedure code

15

professional courtesy

providing free services to other physicians and their families

16

job reference aid

list of a practice's frequently reported procedures and diagnoses

17

computer-assisted coding (CAC)

feature that allows a software program to assist in assigned codes

18

documentation template

form used to prompts physician to document a complete review of systems (ROS) and a treatment's medical necessity

19

audit

methodical review

20

external audit

audit conducted by an outside organization

21

Recovery Audit Contractor (RAC)

program designed to audit Medicare claims

22

internal audit

self-audit contracted by a staff member or consultant

23

prospective audit

internal audit of claims conducted before transmission

24

retrospective audit

internal audit conducted after claims are processed and RAs have been received

25

usual fee

normal fee charged by a provider

26

charge-based fee structure

fee based on typically charged amounts

27

resource-based fee structure

setting fee based on relative skill and time required to provide similar services

28

relative value scale (RVS)

system of assigning unit values to medical services based on their required skill and time

29

relative value unit (RVU)

factor assigned to a medical service based on the relative skill and required time

30

conversion factor

amount used to multiply a relative value unit to arrive at a charge

31

resource-based relative value scale (RBRVS)

relative value scale for establishing Medicare charges

32

geographic practice cost index (GPCI)

Medicare factor used to adjust provider's fee in a particular geographic area

33

Medicare Physician Fee Schedule (MPFS)

the RBRVS-based allowed fees

34

allowed charge

maximum charge a plan pays for a service or procedure

35

bundled payment

method by which an entire episode of care is paid for by a predetermined single payment

36

balance biling

collecting the difference between a provider's usual fee and a payer's lower allowed charge

37

write off

to deduct an amount for a patient's account

38

capitation rate (cap rate)

periodic prepayment to a provider for specified services to each plan member

39

adjustment

change to a patient's account

40

walkout receipt

report that lists the diagnoses, services provided, and payments received and due after an encounter