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Billing/ Coding


code linkage connection between a service and a patient’s condition or illness
Correct Coding Initiative (CCI) prevents billing two procedures that, according to Medicare, could not possibly have been performed together.
edits computerized system that identifies improper or incorrect codes
CCI column 1/column 2 code pair edit Medicare code edit where CPT codes in column 2 will not be paid if reported on the same day as the column 1 code
CCI mutually exclusive code (MEC) edit both services represented by MEC codes that could not have been done during one encounter
CCI modifier indicator number showing whether the use of a modifier can bypass a CCI edit
medically unlikely edits (MUEs) units of service edits used to lower the Medicare fee-for-service paid claims error rate
OIG Work Plan annual list of planned projects
advisory opinion opinion issued by CMS or OIG that becomes legal advice
excluded parties individuals or companies not permitted to participate in federal healthcare programs
truncated coding diagnoses not coded at the highest level of specificity
assumption coding reporting undocumented services that the coder assumes have been provided due to the nature of the case or condition
upcoding use of a procedure code that provides a higher payment
downcoding payer’s review and reduction of a procedure code
X modifiers modifiers that define specific subsets of modifier 59
professional courtesy providing free services to other physicians and their families
job reference aid list of a practice’s frequently reported procedures and diagnoses
computer-assisted coding (CAC) feature that allows a software program to assist in assigning codes
documentation template form used to prompt a physician to document a complete review of systems (ROS) and a treatment’s medical necessity
audit formal examination or methodical review
external audit audit conducted by an outside organization
prepayment audit Payers use computer programs of code edits to review claims before they are processed
Created by: baybro9933