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Clinical Coding

Abuse Unknowing or unintentional submission of an inaccurate claim for payment.
ICD-9-CM A publication issued quarterly by AHA and approved by CMS to give coding advice and direction for 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 AHIMA to give health information coding professional ethical guidelines for performing their coding and grouping tasks.
Ambulatory payment classifications (APC) Hospital Outpatient Prospective Payment System (HOPPS). The classification is a resource-based reimbursement system. The payment unit is the ambulatory payment classification group (APC group).
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
Benchmarking The process of comparing performance with a preestablished standard or performance of another facility or group.
Case-mix index (CMI) Single number that compares the overall complexity of the healthcare organizations patients with the complexity of the average of all hospitals. specific period/ sum all DRG weights divide # Medicare cases.
Catagory 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.
Catagory 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.
Catagory III code (CPT) A Current Procedural Terminology (CPT) code that represents emerging technologies for which a Catagory I Code has yet to be established.
Centers for Medicare and Medicaid Services (CMS) Devision of the Department of Health and Human Services (DHHS)responsible for administoring Medicare and Medicaid and ICD-9-CM
Classification system 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.
Compliance Managing a coding or billing department according to the laws, regulations, and guidelines that govern it.
Compliance officer Designated individual who monitors the compliance process at a healthcare facility.
Compliance Program Guidance Information provided by the OIG of the Dept of Health & Human Services DHHS to assist healthcare organizations with the development of compliance plans and programs.
Complication and comorbidity (CC) Illness or injury that coexits with the condition for which the patient is primarily seeking healthcare.
CPT assistant Official coding guidance for Current Procedural Terminology (CPT) code
Current Procedural Terminology (CPT) Coding system created and maintained by the AMA 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.
Fraud Intentionally making a claim for payment that one knows to be false.
Healthcare Common Prodedure Coding System (HCPCS) Coding system created and maintained by the 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: degisnated code sets to be used for electronic transmission of claims.
Hospital Outpatient Prospective Payment System (HOPPS) The reimbursement system created by the Balanced Budget Act of 1997 for hospital outpatient services rendered to Medicare beneficiaries; maintained by CMS.
ICD-9-CM Coordination & Maintenance Committee Committee composed of reps from NCHS and CMS that is reponsible for maintaining the US clinical modification version of ICD-9-CM code sets.
Improper payment reviews Evaluation of claims to determine whether the items and/or services are covered, correctly coded and medically necessary.
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 day of admission but not the day of discharge. The 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 (LMRP), LCDs and LMRPs vary from state to state.
Major complication or comorbidity (MCC) Diagnosis codes classified as MCCs reflect the highest level of severity.
Major Diagnostic catagory MDC Highest level in hierchical structure of the federal inpatient prospective payment system IPPS The 25 MDCs are primarily based on body system involvement. A few categories are based on disease etiology.
Medicare administrative contractor (MAC) Newly established contracting authority to administer Medicare Part A & B as required by section 911of the Medicare Modernization Act of 2003. 15 Medicare Admin Contractors will replace Medicare Carriers and Fiscal Interme by 2011. Each will handle A
Medicare integrity program First comprehensive Federal stategy to prevent and reduce provider fraud, waste and abuse.
Medicare-severity diagnosis-related group (MS-DRG) Medicare refinement to the diagnostic-related group(DRG) classification system, which allows for payment to be more closely aligned with resource intensity.
Modifier Two-digit alph/alphanumeric/numeric code that provides the means by which a physician of facility can indicate that a service provided to patient has been altered by some special circumstance(s) but for which basic code description itself has not changed.
Mortality The incidence of death.
National Center for Health Statistics (NHCS) Organization that developed the clinical modification to the ICD-9 responsible for maintaining and updating the diagnosis portion of the 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 regulation.
Office of Inspector General (OIG) A division of the Department of Health and Human Service (DHHS) that investigates issues of noncompliance in the Medicare and Medicaid programs, such as fraud and abuse.
Office of Inspector General 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 DHHS, OIG, and 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 & B claims.
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 disease ICD used throughout the world to collect morbidity and mortality information.
Created by: Lyn Slough