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INSUR {CBCS-CPC}
Visit Charges and Compliant Billing
| Term | Definition |
|---|---|
| adjustment | A change, positive or negative, to correct a patient’s account balance for items such as returned check fees. |
| advisory opinion | An opinion issued by CMS or OIG that becomes legal advice for the requesting party. |
| 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. |
| balance 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 edits (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. |
| No Surprises Act | A law that protects patients from unanticipated medical bills from out-of-network providers that they did not choose. |
| 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. |
| resource-based fee structure | Setting fees based on the relative skill and time required to provide similar services. |
| resource-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 fees | 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. |
| also known as (Medicare) NCCI | Correct Coding Initiative (CCI) |
| updated every quarter and has thousands of current procedural terminology code (CPT code) combinations | Correct Coding Initiative (CCI) |
| also called procedure-to-procedure, or PTP edits | CCI edits |
| CCI edit basic categories | column 1 and column 2 code pair edits | mutually exclusive code edits | modifier indicators |
| CCI modifier indicator of "0" | use of a CPT modifier will not change the edit |
| CCI modifier indicator of "9" | the original edit was a mistake and is being withdrawn |
| UOS | units of service |
| based on the maximum units of service that would be reported for a code on the vast majority of correct claims | MUE value |
| designed to reduce errors on claim clerical entries, correct anatomic coding mistakes, CPT/HCPCS code descriptors, CPT coding instructions, Medicare policies, or unlikely services. | medically unlikely edits (MUEs) |
| (AOC) add-on code | CPT codes that describe a service that is usually done in conjunction with another primary service by the same practitioner |
| updated annually based on the new CPT/HCPCS code sets | (AOC) add-on code |
| (LEIE) List of Excluded Individuals/Entities | a database that provides information about excluded parties |
| OIG Audit reports | summarize OIG findings after problems have been investigated |
| apply to Medicare claims only | CCI edits |
| develop code edits similar to those of the CCI | Private payers |
| healthcare payers base their decisions to pay or deny claims | diagnosis and procedure codes |
| uses global periods based on the complexity of the procedure performed | Medicare |
| have a postoperative period of 0 or 10 days, and their preoperative period is just the day of the procedure | global periods for minor procedures |
| have a 90-day postoperative period with a one-day preoperative period | global periods for major procedures |
| can eliminate any impression of duplicate billing or unbundling | CPT modifiers |
| especially important for compliant billing | modifiers: 25, 59, and 91 |
| Modifier 25: | significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service |
| Modifier 59: | distinct procedural service that was distinct or independent from other services performed on the same day |
| Modifier 91: | repeat clinical diagnostic laboratory test performed on the same day that was distinct or separate from earlier test to obtain medically necessary subsequent reportable test values |
| XE: | Separate Encounter: A Service That Is Distinct Because It Occurred During a Separate Encounter |
| XS: | Separate Structure: A Service That Is Distinct Because It Was Performed on a Separate Organ/Structure |
| XP: | Separate Practitioner: A Service That Is Distinct Because It Was Performed by a Different Practitioner |
| XU: | Unusual Non-Overlapping Service: The Use of a Service That Is Distinct Because It Does Not Overlap Usual Components of the Main Service |
| prepayment audit | computer programs of code edits to review claims before they are processed |
| postpayment audit | conducted after payment has been made to ensure that claims correctly reflect performed services |
| RACs analyze claims for the following errors | obvious coding errors | medically unnecessary treatment or wrong setting of care | multiple or excessive number of units billed |
| timeframe within requests for information regarding RAC inquires should be answered | 45 days |
| also called a concurrent audit | prospective audit |
| advantages of retrospective audits | 1. the complete record is available 2. there are more claims to sample |
| 3 parts of CMS/AMA guidelines | 1. general guidelines 2. instructions for office or outpatient services 3. notes for other types of E/M work |
| two main methods of how payers establish rates they pay providers | charge based and resource-based fee structures |
| three resource-based fee structure comparison factors | 1. level of procedure difficulty 2. office overhead procedure cost 3. risk the procedure to the patient and provider |
| originally created in California | relative value scale (RVS) |
| three parts to an RVRVS fee | 1. the nationally uniform RVU 2. geographic adjustment factor 3. nationally uniform conversion factor |
| three main methods to pay providers | 1. allowed charges 2. contracted fee schedule 3. capitation |
| qualifications for provider to receive allowed charge | 1. the provider's usual charge for the procedure or service 2. the provider's status in the plan or program 3. the payer's billing rules |
| also called maximum allowable fee, maximum charge, allowed amount, allowed fee or allowable charge | allowed charge |
Created by:
VA_MedCod3r