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Health Insurance

HI chp 5

QuestionAnswer
What is a legal newspaper published every business day by the National Archives and Records Administration (NARA)? Federal Register
What is reporting multiple codes for a service when a single column 1 code should be assigned? Unbundling
What contains new and changed Medicare policies and/or procedures that are to be incorporated into a specific CMS program manual? Program Transmittals
What "involves actions that are inconsistent with accepted, sound medical, business, or fiscal practices; it directly or indirectly results in unnecessary costs to the program through improper payments." Abuse
What are procedures or services that could not reasonably be performed at the same session by the same provider on the same beneficiary? Mutually Exclusive Codes
What is the measure of whether a health care procedure or service is appropriate for the diagnosis and/or treatment of a condition? Medical Necessity
What column is the major procedure or service when reported with another code listed in? One
What is an organization that contracts with CMS to process health care claims and perform program integrity tasks for Medicare? MAC-Medicare Administrative Contractor
What are two examples of Fraud? Billing for services not furnished; misrepresenting a diagnosis to justify payment; soliciting, offering, or receiving kickbacks; unbundling codes; falsifying certificates of medical necessity, plans of treatment, or medical records to justify payment.
What column is the lesser procedure or service when reported with another code listed in? Two
What is the storage of documentation for an established period of time, usually mandated by federal and/or state law? Record Retention
What is "an intentional deception or misrepresentation that someone makes, knowing it is false, that could result in an unauthorized payment?" Fraud
What are pairs of CPT and/or HCPCS level II codes which are not separately payable except under certain circumstances? CCI Edits
What are two examples of Abuse? Excessive charges for services, equipment, or supplies; submitting claims for items or services not medically necessary; improper billing practices; violations of par-provider agreements with insurance companies.
What are the unique identifiers required as part of the HIPAA administration simplification provision? NPI, EIN, NHPID, and NII
What are laws passed by legislative bodies? Statutes
What is the assignment of an ICD-9-CM diagnosis code that does not match patient record documentation for the purpose of illegally increasing reimbursement? Upcoding
What does the acronym RAC mean? Recovery Audit Contractor
What are the NCCI edits designed to detect? Unbundling
What creates national standards to protect individuals' medical records and other personal health information? HIPAA Privacy Rule
What adopts standards and safeguards to protect health information that is collected, maintained, used, or transmitted electronically? HIPAA Security Rule
Created by: YTIMBC