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Medical Coding Terms
Abbreviations used in Medical Coding and Billing
| Term | Definition |
|---|---|
| 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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