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Health Ins. and Claims Chapter 5

involves actions that are inconsistent with aaccepted, sound medical, business, or fiscal practices abuse
a legal newspaper published every business day by the National Archives and Records Administration (NARA) Federal Register
an intentional deception or misrepresentation that someone makes, knowing it is false, that could result in an unauthorized payment fraud
an organization that acontracts with CMS to process health care claims and perform program integrity tasks for both Medicare Part A and Part B Medicare Administrative Contractor (MAC)
two digit code attached to the main code; indicates that a procedure/service has been altered in some manner. modifier
unique identifier, previously called PAYERID, that will be assigned to third-party payers and is expected tohave 10 numberic positions, including a check digit in the tenth position. National Health PlanID (PlanID)
unique identifier to be assigned to health care providers as an 8 or possibly 10-character alphanumeric identifier, including a check digit in the last position National Provider Identifier (NPI)
funds a provider or beneficiary has received in excess of amounts due and payable under Medicare and Medicaid statutes and regulations. overpayment
document published by MC that contains new and changed policies and/or procedures that are to be incorporated into a specific CMS program manual. program transmittal
storage of documentation for an established period of time, usually mandated by federal and/or state law; its purpose is to ensure the availability of records for use by government agencies and other third parties. record retention
submitting multiple CPT codes when one code should be submitted unbundling
the major procedure or service when reported with another code. The comprehensive code represents greater work, effort, and time than to the other code reported(also called column 1 codes) comprehensive code
the lesser procedure or service when reported with another code. The component code is part of a major procedure or service and is often represented by a lower work relative value unit (RVU) under the MC Dr.fee schedule as compared to the other code repo component code
procedures or services that could not reasonable be performed at the same session by the same provider on the same beneficiary. mutually exclusive codes
involves linking every procedure or service reported to the insurance company to a condition that justifies the necessity for performing that procedure or service medical necessity
pairs of CPT and/or HCPCS level II codes, whicha re not separately payable except under certain circumstances (e.g., reporting appropriate modifier). CCI Edits
laws passed by legislative bodies. eg. federal Congress and state legislatures. statutes
an order of the court that requires a witness to appear at a particular time and place to testify. supoena
the assignment of an ICD-9-CM code that does not match patient record documentation for the purpose of illegally increasing reimbursement upcoding
CMS's HPMP replaced PEEP. The goal is to measure, monitor, and reduce the incidence of Medicare fee-for-service payment errors for short-term, acute care, inpatient PPS hospitals Hospital Payment Monitoring Program (HPMP)
Created by: Kcompleta