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Medical Coding Terms

Abbreviations used in Medical Coding and Billing

TermDefinition
RBRVS Resource-Based Relative Value Scale
MEI Medicare Economic Index
OBRA (Medicare) Omnibus Budget Reconciliation Act of 1989
RVU Relative Value Unit
Three Part of RVU Work, Overhead, Malpractice
Work Part of RVU that addresses the amount of time, intensity of effort, and technical expertise required to provide service.
Overhead Part of RVU that addresses the practice expenses
Malpractice Part of RVU that addresses the risk associated with providing the service.
CF Conversion Factor
Annually How often is the CF updated?
Annual Updates to CF Percent change to MEI, physician expenditures, relationship of expenditures to volume performance standards, and change in access and quality
Changes to CF varies according to these type of service provided (medical, surgical, non-surgical)
MVPS Medicare Volume Performance Standards
MVPS government's estimation of how much growth is appropriate for nationwide physician expenditures paid for by Part B of Medicare.
Medicare claims must be paid by when? within one year
Are providers allowed to charge for filing claims for Medicare patients? No
If a claim is filed later than required, will the claim be paid? No
Beneficiary Protection requires that participating providers accept payment how? Accept the amount paid for eligible Medicaid services as payment in full.
Accepting Medicaid payment as payment in full was mandated by which law? OBRA act of 1989
MAAC Maximum Actual Allowable Charge
What does the MAAC limit? Limitations are placed on nonparticipating physician charges -- in that the amount charged to Medicare beneficiaries cannot be more than the stated limiting charge.
Beneficiary Protections 1. Claims must be filed within 12 months; 2. Accept Medicaid as payment in full; 3 Limiting Charges to Medicare beneficiaries by nonparticipating providers
Limiting Charge does NOT apply to what types of services? When a nonphysician performs the technical component of a service that is on the Medicare Physician Fee Schedule, the Limiting Charge does not apply. Use Modifier TC.
What is included under Limiting Charges? Global, Professional, & Technical Services performed by any nonparticipating provider.
To whom do the Limiting Charges apply? Non-participating physicians
How much is the Limiting Amount currently? 115% of the Allowable amount
What does the Limiting Amount mean to the beneficiary? That is the maximum amount that a nonparticipating provider can charge the Medicare beneficiary. The max of the balance-billing after M'care pays.
What percentage of the Allowable Amount will Medicare pay to participating providers? 80% of the Fee Schedule amount
What is the maximum payment to non-participating providers? 95% of the Fee Schedule amount
Where are Adjustments listed? In the Physician Disclosure provided to all physicians during the participating enrollment period each year.
Are Participating Providers allowed to balance bill the Medicare beneficiary? No.
Are Non-participating providers allowed to balance bill the Medicare beneficiary? Yes, up to 115% of the Allowed Amount
Created by: ZonaB2
 

 



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