| Question | Answer |
| Define OCE edits | Outpatient Code Editor Edits
apply to hospital OP svcs under the hospital OPPS.
- Determine if a code is payable under hospital OPPS.
- include many of the NCCI edits
-Determines if the ASC limit applies to each bill |
| What does NCCI stand for and what does it do? | National Correct Coding Initiative
- establishes standards of billing
-ID codes that may be fraud/abuse
-ID codes that are bundled
Applies to physician svcs under the MC Physician fee schedule |
| What are the 7 elements of a Compliance Plan as defined by OIG? | -written policies & proc
-Designated compliance office & committee
-Eff training & edu
-Eff lines of communication
-Enforce standards & well-publicized disciplinary proc
-Auditing & monitoring
-responding to offenses & develping corrective actions. |
| What is a claim that has extra attachments in lieu of data on a claim form? | A non standard claim. MC won't accept this. |
| What is an incomplete/invalid claim? | Incomplete: One which is missing required info (ex: no NPI number)
Invalid: One which has incorrect information listed (ex: the wrong NPI number)
Any incomplete/invalid claim will be rejected as Un processable. |
| What does MUE stand for and describe | Medically Unlikely Edits
How many units are likely to be the max for a procedure.
May need a modifier if we are billing more than MUE value.
Developed by Correct Coding Solutions. |
| What defines a cleam claim? | Passes common working file edits
Sent electronically
If investigated, doesn't require further contact
If subject to med rev, includes all complete med evidence
Not developed on a post-pmt basis
Has all info needed to adjudicate/all supporting docs |
| What does MCE stand for and explain | MC Code Editor
edits to detect incorrect billing data
3 basic types of edits to supp assign of an MS-DRG
Code edits: correct ICD10
Cov edits: exam type of pt and proc -covered?
Clinical edits exam consistency of proc & dx to ensure it's reasonabl |
| What is the MSN and what does it do? | Medicare Summary Notice:
A quarterly stmt to the payee/beneficiary to show svcs, charges, expected amts, pt responsibility & amt pd to provider.
AKA: Remittance Advice |
| What is the Administrative Simplification compliance Act | Requires that all MC claims be sent electronically unless certain exceptions are met.
When on paper, no more than 6 lines of svc can be on 1 claim and can contain no special characters. |
| What is another name for a SuperBill and what does it do? | Encounter Form:
Lists most common E&M codes, Procedures, DX codes, labs, etc and space to record other codes.
Provider marks codes and they are entered for billing. |
| What does TOB stand for and describe: | Type of Bill:
1st digit is type of facility
2nd is bill classification
3rd is frequency |
| What is a Revenue Code? | 4 digit code, specifies an accomodation or ancillary svc.
ex:
0120 = Room & board, semi private
0310 = Lab & Pathology general
0450 = ER General |
| What is a Value Code? | 2 digit code and it's related amt/value that, together, clarify an event or condition related to a claim:
ex: 08 - LTR amt
48 - Latest hemoglobin reading
AO 5 digit zip code of location where beneficiary is initially place on ambo |
| What is an Occurrence Span Code? | 2 digit code followed by 2 dates that ID a span of time relevant to claim processing:
70-non-utilization days: PPS inlier (free days) stay for whihc beneficiary has exhausted all regular days/co-ins days but which is covered on the cost report. |
| What is an Occurrence Code? | 2 digit code and date that, together, clarify a significant event or condition relat4ed to a claim.
ex: 11 - onset of symptoms
24 date ins denied
32 date that ABN, Form, etc was given to beneficiary. |
| What is a Condition Code? | 2 digit code that clarifies an event or condition related to the bill that may affect payer processing.
ex: 04 - information only bill
08 - beneficiary would not provide other ins info
21 - billing for denial notice |
| What does NUBC stand for? | National Uniform Billing Committee:
Governs UB-04/837I
UB has field locators (81 data elements)
837I has loops and segments.
UB-04 AKA CMS-1450 |
| What are the common billing forms? | UB-04 (paper facility)
837I (e-facility)
CMS-1500/HCFA (paper physician)
837P (e-physician) |
| What is a Locum Tenens and what are the rules? | A temp sub, especially for a dr or member of clergy
Ex: Provider is on vacation/absent
A sub Phys can be pd for svcs provided to a MC pt as long as:
regular physician is unavailable.
Pt had a previously scheduled appt
sub can't prov svcs > 60 days |
| When are claims NOT required to be submitted for MC patients? | MC is 2nd
pmt from prime is sent to pt
pt didn't prov primary ins info to submit
svcs were provided outside US
claim is for svcs excluded from MC
Pt signed ABN, did not want claims sent
provider opts out of MC
Provider is debarred/excluded from MC |
