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GuntermanINS Ch 6-7
Procedural Coding: intro to HCPCS
| Term | Definition |
|---|---|
| HCPCS stands for | Healthcare common preocedure coding sytem |
| coding system set up for health care providers to report specific products, supplies, and services that patients receive | HCPCS |
| DME stands for | durable medical equipment |
| reusable physical supplies ordered by the provider for home use | DME |
| government committee that maintains the level II HCPCS code set | CMS HCPCS Workgroup |
| HCPCS level II codes that are available for all government and private payers to use. No changes can be make unless all panel members agree. | permanent national codes |
| responsible for helping to determine which HCPCS code describes DMEPOS items | PDAC contractor |
| PDAC contractor stands for | Pricing, Coding Analysis and Coding contractor |
| HCPCS Level II codes available for use but not part of the standard code set | temporary national codes |
| provide additional information about services, supplies, and procedures | Level II modifiers |
| situations when a policy never pays a provider | never event |
| guidelines established by Medicare about coverage for HCPCS Level II services | Medicare Carriers Manual |
| information about Medicare-qualified clinical trials, treatments, therapeutic interventions, diagnostic testing, durable medical equipment, therapies, and services | Coverage Issues Manual |
| document used to assist DME MACs in gathering information | Certificate of Medical Necessity |
| connection between a service and a patient's condition or illness | code linkage |
| computerized Medicare system that prevents overpayment | Correct Coding Initiative |
| computerized system that identifies improper or incorrect codes | edits |
| Medicare code edit where CPT codes in column 2 will not be paid if reported int he same way as the column 1 code | CCI column 1/column 2 code pair edit |
| both services represented by MEC codes that could not have been done during one encounter | CCI mutually exclusive code edit |
| number showing if the use of a modifier can bypass a CCI edit | CCI modifier indicator |
| MUE stands for | medically unlikely edits |
| units of service edits used to lower the Medicare fee-for-service paid claims error rate | MUEs |
| annual list of planned projects | OIG Work Plan |
| issued by CMS or OIG that becomes legal advice | advisory opinion |
| individuals or companies not permitted to participate in federal health care programs | excluded parties |
| diagnoses not coded at the highest level of specificity | truncated coding |
| reporting undocumented services the coder assumes have been provided due to the nature of the case or condition | assumption coding |
| using a procedure code that provides a higher payment than the correct code | upcoding |
| using a lower level code that will result in a lower payment | downcoding |
| providing free services to other physicians and their familes | professional courtesy |
| known as a cheat seet, it is a list of a practice's frequently reported procedure and diagnosis codes | job reference aid |
| allows a software program to assist in assigning codes | computer-assisted coding |
| form used to assist physicians as they document examinations | documentation template |
| a formal examination or review | audit |
| conducted by an outside organization | external audit |
| self conducted by a staff member or consultant hired by the office | internal audit |
| internal augit of claims conducted before transmission | prospective audit |
| internal audit conducted after claims are processed and RAs have been received | retrospective audit |
| normal fee charged by the provider | usual fee |
| setting fees based on relative skill and time required to provide similar services | resource-based fee structure |
| setting fees by comparing usual fees, customary fees,a nd reasonable fees | UCR |
| system of assigning unit values to medical services based on their required skill and time | RVS |
| factor assigned to a medical service based on teh relative skill and required time | RVU |
| amount used to multiply a relative value unit to arrive at a charge | conversion factor |
| RBRVS | resource-based relative value scale |
| relative value scale used for establishing Medicare charges | RBRVS |
| medicare factor used to adjust providers' fees in a particular geographic area | GPCI |
| RBRVS based allowed fees, published by CMS, updated yearly | Medicare Physician Fee Schedule |
| maximum charge a plan pays for a service ro procedure | allowed charge |
| collecting the difference between a provider's usual fee and a payer's lower allowed charge | balance billing |
| to deduct an amount from a patient's account | write off |
| periodic prepayment to a procider for specified services to each plan member | capitation rate |
| amount withheld from a provider's payment by an MCO | provider withhold |
| Medicare typically pays for what percentage of the allowed charge: | 80 percent |
| If a participating provider's usual fee is $400, and the allowed amount is $350, and the balance billing is permitted, what is written off? | $50 |
| If a nonparticipating provider's usual fee is $400, and the allowed amount is $350, what amount is written off? | 0 |
| The usual fee for excluded services are | collected at the time of service |
| How many characters do HCPCS level II codes have | 5 |
| HCPCS level II codes begin with | alphabetic character |
| Level I codes in HCPCS are | CPT codes |
| How many parts are there to the CMN form? | four |
| Who is ultimately responsible for proper documantation and correct coding | Physician |
| CCI is a program of | Medicare |
| If a payer decides the code level is too high for a reported service, the practice would normally | downcode the procedure |
| Routinely waiving deductibles and copayments is | illegal |
Created by:
monicagunterman