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Completa
Health Ins. and Claims Chapter 5
| Question | Answer |
|---|---|
| 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) |
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