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IHMO Ch 6 Key Term
| Question | Answer |
|---|---|
| Alternative billing codes (ABCs) | A code system for integrative health care products and services consisting of five-character alphabetic symbols with appended two-character practitioner modifiers that represent the practitioner type. |
| Bilateral | When coding surgical procedures, this term refers to both sides of the body. |
| Bundled codes | To group more than one component (service or procedure) into one CPT code. |
| Comprehensive code | A single procedural code that describes or covers two or more CPT component codes that are bundled together as one unit. |
| Conversion factor | The dollars and cents amount that is established for one unit as applied to a procedure or service rendered. |
| Current Procedural Terminology (CPT) | A reference procedural code book using a five-digit numerical system to identify and code procedures established by the American Medical Association. |
| Customary fee | The amount that a physician usually charges most of her or his patients. |
| Downcoding | This occurs when the coding system used by the physician's office on a claim does not match the coding system used by the insurance company receiving the claim. |
| Fee schedule | A list of charges or established allowances for specific medical services and procedures. |
| Global surgery policy | A Medicare policy relating to surgical procedures in which preoperative and postoperative visits, usual, intraoperative services, and complications not requiring additional trips to the operating room are included in one fee. |
| Healthcare Common Procedure Coding System (HCPCS) | The CMS's Common Procedure Coding System. Level I = CPT, Level II = national codes. |
| Modifier | In CPT coding, a two-digit add-on number placed after the usual procedure code number to indicate a procedure or service has been altered by specific circumstances. |
| Procedure code numbers | Five-digit numeric codes that describe each service the physician renders to a patient. |
| Professional component (PC) | That portion of a test or procedure which the physician performs. |
| Reasonable fee | A charge is considered reasonable if it is deemed acceptable after peer review even though it does not meet the customary or prevailing criteria. |
| Relative value studies (scale) (RVS) | A list of procedure codes for professional services and procedures that are assigned unit values that indicate the relative value of one procedure over another. |
| Relative value unit (RVU) | A monetary value assigned to each service on the basis of the amount of physician work, practice expenses, and cost of professional liability insurance. |
| Resource-based relative value scale (RBRVS) | A system that ranks physician services by units and provides a formula to determine a Medicare fee schedule. |
| Surgical package | Surgical procedure code numbers include the operation; local infiltration, digital block, or topical anesthesia; and normal, uncomplicated postoperative care. |
| Technical component | Portion of a test or procedure that pertains to the use of the equipment and the operator who performs it. |
| Unbundling | The practice of using numerous CPT codes to identify procedures normally covered by a single code; also known as itemizing, fragmented billing, exploding, or a la carte medicine |
| Upcoding | Deliberate manipulation of CPT codes for increased payment. |
| Usual, customary, and reasonable (UCR) | A method used by insurance companies to establish their fee schedules. UCR uses the conversion factor method of establishing maximums. |
| ABCs | alternative billing codes |
| AHA | American Hospital Association |
| CF | conversion factor |
| CPT | Current Procedural Terminology |
| DME | durable medical equipment |
| ECG | electrocardiogram |
| ED or ER | emergency department or emergency room |
| E/M | evaluation and management) service |
| EMTALA | Emergency Medical Treatment and Active Labor Act |
| EOB | explanation of benefits |
| FTC | Federal Trade Commission |
| GAF | geographic adjustment factor |
| GPCIs | geographic practice cost indices |
| HCPCS | Healthcare Common Procedure Coding System |
| NCCI | National Correct Coding Initiative edits |
| PC | professional component |
| PPS | physician or provider service |
| RBRVS | resource-based relative value scale |
| RVS | relative value studies |
| RVU | relative value unit |
| TC | technical component |
| UCR | usual, customary, and reasonable |
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