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Billing and Coding
Chapter 6 Terms
| Question | Answer |
|---|---|
| Adjustment | A change, positive or negative, to correct a patient’s account balance for items such as returned check fees. |
| Advisory Opinion | n opinion issued by CMS or OIG that becomes legal advice for the requesting party. A requesting party who acts according to the advice is immune from investigation on the matter; the advisory opinion provides guidance for others in similar matters. |
| Allowed Charge | The maximum charge that a health plan pays for a specific service or procedure; also called allowable charge, maximum fee, and other terms. |
| Assumption coding | Reporting undocumented services that the coder assumes have been provided because of the nature of the case or condition. |
| Audit | Methodical review; in medical insurance, a formal examination of a physician’s accounting or patient medical records. |
| Balanced billing | The difference between a provider’s usual fee and a payer’s lower allowed charge from the insured. |
| Capitation Rate (Cap Rate) | The contractually set periodic prepayment to a provider for specified services to each enrolled plan member. |
| CCI column 1 and column 2 code pair edit | A Medicare code edit under which CPT codes in column 2 will not be paid if reported for the same patient on the same day of service by the same provider as the column 1 code. |
| CCI modifier indicator | A number that shows whether the use of a modifier can bypass a CCI edit. |
| CCI Mutually Exclusive Code (MEC) edit | Under the CCI edits, both services represented by MEC codes that could not have reasonably been done during a single patient encounter, so they will not both be paid by Medicare; only the lower-paid code is reimbursed. |
| Charge-based fee structure | Fees based on the amounts typically charged for similar services. |
| Code linkage | The connection between a service and a patient’s condition or illness; establishes the medical necessity of the procedure. |
| Computer-Assisted Coding (CAC) | A software program that assists providers and medical coders in assigning codes based on the documentation of a visit. |
| Conversion factor | Dollar amount used to multiply a relative value unit to arrive at a charge. |
| Correct Coding Initiative (CCI) | Computerized Medicare system that controls improper coding which would lead to inappropriate payment for Medicare claims. |
| Documentation Template | Physician practice form used to prompt the physician to document a complete review of systems (ROS) when done and the medical necessity for the planned treatment. |
| Downcoding | A payer’s review and reduction of a procedure code (often an E/M code) to a lower level than reported by the provider. |
| Edits | Computerized screening system used to identify improperly or incorrectly reported codes. |
| Excluded parties | Individuals or companies that, because of reasons bearing on professional competence, professional performance, or financial integrity, are not permitted by OIG to participate in any federal healthcare programs. |
| External audit | Audit conducted by an organization outside of the practice, such as a federal agency. |
| Geographic Practice Cost Index (GPCI) | Medicare factor used to adjust providers’ fees to reflect the cost of providing services in a particular geographic area relative to national averages. |
| Internal audit | Self-audit conducted by a staff member or consultant as a routine check of compliance with reporting regulations. |
| Job reference aid | List of a medical practice’s frequently reported procedures and diagnoses. |
| Medically unlikely audits (MUEs) | CMS unit of service edits that check for clerical or software-based coding or billing errors, such as anatomically related mistakes. |
| Medicare Physician Fee Schedule (MPFS) | The RBRVS-based allowed fees that are the basis for Medicare reimbursement. |
| OIG Work Plan | OIG’s annual list of planned projects under the Medicare Fraud and Abuse Initiative. |
| Professional Courtesy | Providing free medical services to other physicians. |
| Prospective Audit | Internal audit of particular claims conducted before they are transmitted to payers. |
| Provider withhold | Amount withheld from a provider’s payment by an MCO under contractual terms; may be paid if stated financial requirements are met. |
| Recovery Audit Contractor (RAC) | A type of contractor hired by CMS to validate claims that have been paid to providers and to collect a payback of any incorrect payments that are identified. |
| Relative Value Scale (RVS) | System of assigning unit values to medical services based on an analysis of the skill and time required of the physician to perform them. |
| Relative Value Unit (RVU) | A factor assigned to a medical service based on the relative skill and time required to perform it. |
| Resourced-based relative value scale (RBRVS) | Federally mandated relative value scale for establishing Medicare charges. |
| Retrospective audit | An internal audit conducted after claims are processed by payers and after RAs have been received for comparison with submitted charges. |
| Truncated coding | Diagnoses that are not coded at the highest level of specificity available. |
| Upcoding | Use of a procedure code that provides a higher payment than the code for the service actually provided. |
| usual, customary, and reasonable (UCR) | Setting fees by comparing the usual fee the provider charges for the service, the customary fee charged by most providers in the community, and the fee that is reasonable considering the circumstances. |
| Usual fee | Fee for a service or procedure that is charged by a provider for most patients under typical circumstances. |
| Walkout receipt | Medical billing program report given to a patient that lists the diagnoses, services provided, fees, and payments received and due after an encounter. |
| Write off | To deduct an amount from a patient’s account because of a contractual agreement to accept a payer’s allowed charge or for other reasons. |
| X modifiers | New HCPCS modifiers that define specific subsets of modifier 59 |
| Capitation | Payment method in which a fixed prepayment covers the provider’s services to a plan member for a specified period of time. |
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