Question 1

Code linkage

Accepted Answer

the connection between a service
and a patient’s condition or illness

Question 2

CCI

Accepted Answer

Correct Coding Initiative

Question 3

Correct Coding Initiative (CCI)

Accepted Answer

computerized Medicare system that controls improper coding
that would lead to inappropriate payment for Medicare claims

Question 4

Edits

Accepted Answer

used in software programs to identify
improper or incorrect codes.

Question 5

OIG

Accepted Answer

Office of inspector general

Question 6

CCI edits

Accepted Answer

code combinations used by computers
in the Medicare system to check claims

Question 7

CCI column 1/column 2 code pair edit

Accepted Answer

Medicare code edit where CPT codes in column 2 will not be paid if reported on the same day as the column 1 code

Question 8

CCI mutually exclusive code (MEC) edit

Accepted Answer

both services represented by MEC codes that could not have been done during one encounter

Question 9

CCI modifier indicator

Accepted Answer

number showing if the use of a modifier can bypass a CCI edit

Question 10

MUE

Accepted Answer

Medical Unlikely Edits

Question 11

MUE value are based on

Accepted Answer

he maximum units of service

Question 12

MUE  are designed to

Accepted Answer

reduce errors on claims due to clerical entries

Question 13

Correct coding mistakes based on

Accepted Answer

anatomic considerations
• An example of an MUE edit is one that rejects a claim for a
hysterectomy on a male patient.

Question 14

OIG Work Plan

Accepted Answer

OIG’s annual list of planned projects.

Question 15

Advisory opinion

Accepted Answer

opinion issued by CMS or the OIG that becomes legal advice.

Question 16

Excluded parties

Accepted Answer

Individuals or companies not permitted to participate in federal healthcare programs (after being found guilty of fraud)

Question 17

Frequent reasons claims are rejected

Accepted Answer

Errors relating to code linkage and medical necessity Errors relating to the coding process Errors relating to the revenue cycle

Question 18

External audits

Accepted Answer

Prepayment, post-payment, RAC audits

Question 19

Internal audits

Accepted Answer

Prospective, retrospective

Question 20

Auditing tools are used to

Accepted Answer

verify E/M code selection

Question 21

Physician Fee Schedules

Accepted Answer

Physicians set their fee schedules in relation to the fees
that other providers charge for similar services.

Question 22

Usual fee

Accepted Answer

Normal fee charged by a provider.

Question 23

two main methods used by payers to establish the rates they pay providers

Accepted Answer

1. charge-based fee structure.
2. resource-based fee structure.

Question 24

RVS

Accepted Answer

Relative Value Scale

Question 25

Relative value scale (RVS)

Accepted Answer

system of assigning unit values to medical services based on their
required skill and time.

Question 26

First part of RBRVS fees

Accepted Answer

The nationally uniform RVU

Question 27

The nationally uniform RVU

Accepted Answer

The relative value is based on three cost elements—the physician’s work, the practice cost (overhead), and the cost of malpractice insurance.

Question 28

Second part of RBRVS fees

Accepted Answer

A geographic adjustment factor

Question 29

A geographic adjustment factor

Accepted Answer

The geographic practice cost index (GPCI) is a Medicare factor used to adjust providers’ fees in a particular geographic area.

Question 30

Third part of RBRVS fees

Accepted Answer

nationally uniform conversion factor

Question 31

nationally uniform conversion factor:

Accepted Answer

Medicare uses this factor to make adjustments according to changes in the cost of living index.

Question 32

Formula for calculating a Medicare payment Step 1:

Accepted Answer

Determine the procedure code for the service

Question 33

Formula for calculating a Medicare payment Step 2:

Accepted Answer

Use the Medicare Fee Schedule to find the three RVUs

Question	Answer
Code linkage	the connection between a service and a patient’s condition or illness
CCI	Correct Coding Initiative
Correct Coding Initiative (CCI)	computerized Medicare system that controls improper coding that would lead to inappropriate payment for Medicare claims
Edits	used in software programs to identify improper or incorrect codes.
OIG	Office of inspector general
CCI edits	code combinations used by computers in the Medicare system to check claims
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 if the use of a modifier can bypass a CCI edit
MUE	Medical Unlikely Edits
MUE value are based on	he maximum units of service
MUE are designed to	reduce errors on claims due to clerical entries
Correct coding mistakes based on	anatomic considerations • An example of an MUE edit is one that rejects a claim for a hysterectomy on a male patient.
OIG Work Plan	OIG’s annual list of planned projects.
Advisory opinion	opinion issued by CMS or the OIG that becomes legal advice.
Excluded parties	Individuals or companies not permitted to participate in federal healthcare programs (after being found guilty of fraud)
Frequent reasons claims are rejected	Errors relating to code linkage and medical necessity Errors relating to the coding process Errors relating to the revenue cycle
External audits	Prepayment, post-payment, RAC audits
Internal audits	Prospective, retrospective
Auditing tools are used to	verify E/M code selection
Physician Fee Schedules	Physicians set their fee schedules in relation to the fees that other providers charge for similar services.
Usual fee	Normal fee charged by a provider.
two main methods used by payers to establish the rates they pay providers	1. charge-based fee structure. 2. resource-based fee structure.
RVS	Relative Value Scale
Relative value scale (RVS)	system of assigning unit values to medical services based on their required skill and time.
First part of RBRVS fees	The nationally uniform RVU
The nationally uniform RVU	The relative value is based on three cost elements—the physician’s work, the practice cost (overhead), and the cost of malpractice insurance.
Second part of RBRVS fees	A geographic adjustment factor
A geographic adjustment factor	The geographic practice cost index (GPCI) is a Medicare factor used to adjust providers’ fees in a particular geographic area.
Third part of RBRVS fees	nationally uniform conversion factor
nationally uniform conversion factor:	Medicare uses this factor to make adjustments according to changes in the cost of living index.
Formula for calculating a Medicare payment Step 1:	Determine the procedure code for the service
Formula for calculating a Medicare payment Step 2:	Use the Medicare Fee Schedule to find the three RVUs

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MED112 Chapter 6