Acronyms & Abbreviations Flashcards
HIPAA
Health Insurance Portability and Accountability Act
This act was passed in 1996 to protect privacy and security in the exchange of electronic health records.
NCCI
National Correct Coding Initiative
NCCI is the CMS development intended to promote national correct coding methodologies and discourage improper medical coding that may lead to incorrect payment for Medicare Part B claims. It involves two categories of edits: Physician Edits, which apply to physician and non‐physician providers in addition to ambulatory surgery centers; and Hospital Outpatient Prospective Payment System Edits (Outpatient Edits), which apply to other providers such as hospitals.
Both sets of edits are maintained to identify codes that bundle together and indicate when unbundling may be permissible with the proper use of a particular modifier. They also indicate when unbundling is never appropriate. NCCI edits are maintained and revised if necessary on a quarterly basis.
EHR
Electronic Health Record
The EHR is a digital record that may be shared by providers from more than one practice or entity such as a hospital. It is a key provision of the American Recovery and Reinvestment Act of 2009, which went into effect January 1, 2014, and required all public and private healthcare providers to adopt the use of electronic health records in order to avoid penalties that affect reimbursement.
The EHR differs from the EMR (electronic medical record), which is simply a digital version of a paper chart and is not shared outside the practice.
Medicare Part A
Part A covers hospital stays, although not doctors’ fees. Part A also covers some home health services, skilled nursing care after a hospital stay and hospice care. If one has paid medicare taxes for 40 quarters (10 years) during his or her working career there is no monthly premium for Part A.
Medicare Part B
Part B covers doctor fees, some home health care, medical equipment, outpatient procedures, rehabilitation therapy, laboratory tests, X-rays, mental health services, ambulance services and blood. Part B coverage is optional and incurs a monthly premium.
Medicare Part C
Part C plans are optional plans provided by private insurance companies rather than the Federal government. Parts A and B have deductibles which the patient is responsible for and then usually cover only 80% of the costs. Part C plans help the patient meet these costs; they usually work with PPOs or HMOs. Some Part C Medicare Advantge Plans also cover prescription drugs
Medicare Part D
Part D plans are offered by private insurance companies and help cover the cost of prescription drugs.
PPO
Preferred Provider Organization
A health management plan that allows patients to visit any providers contracted with their insurance companies. If the patient visits a non-contracted provider, the claim is considered out-of-network.
HMO
Health Maintenance Organization
A health management plan that requires the patient use a primary care physician who acts as a “gatekeeper.” In HMOs, patients much seek treatment from the primary physician first, who, if she feels the situation warrants it, can refer the patient to a specialist within the network.
CMS
Centers for Medicare and Medicaid Services
Part of HHS, CMS is the federal agency that develops the policies and procedures for paying Medicare and Medicaid claims. CMS is responsible for updating ICD-10-PCS procedure classifications.
NCHS
National Center for Health Statistics
Part of the CDC, NCHS is the principal health statistics agency in the US. It provides a public resource of statistical health information.
CDC
Centers for Disease Control and Prevention
Part of HHS, the main goal of the CDC is to protect public health and safety through the control and prevention of disease, injury, and disability.
WHO
World Health Organization
WHO is an agency of the United Nations that is concerned with international public health
CAC system
Computer Assisted Coding system
CAC systems scan an EHR, identify key terms, and suggest medical codes that match the terms. The term ‘cancer’ may appear in an EHR indicating that there is a family history, but current systems will assume it is a diagnosis of cancer. A medical coder must review the suggested codes and approve them for medical claims.
DRG
Diagnosis-Related Group
A DRG is a system of classifying any inpatient stay into groups for the purposes of payment. The DRG classification system divides possible diagnoses into more than 20 major body systems and subdivides them into almost 500 groups for the purpose of Medicare reimbursement.
APC
Ambulatory Payment Classification
APC codes are used by hospitals to bill Medicare for outpatient services.
NCD
National Coverage Determination
Medicare coverage is limited to items and services that are considered ‘reasonable and necessary’ for the diagnosis or treatment of an illness or injury. A National Coverage Determination (NCD) is a nationwide determination that Medicare will pay for an item or service. In the absence of a NCD, an item or service is covered at the discretion of the Medicare contractors based on a Local Coverage Determination (LCD).
LCD
Local Coverage Determination
Medicare coverage is limited to items and services that are considered ‘reasonable and necessary’ for the diagnosis or treatment of an illness or injury. A National Coverage Determination (NCD) is a nationwide determination that Medicare will pay for an item or service. In the absence of a NCD, an item or service is covered at the discretion of the Medicare contractors based on a Local Coverage Determination (LCD).
SNOMED CT
Systematic Nomenclature of Medicine - Clinical Terms
SNOMED CT is a computer accessible collection of medical terms, synonyms and definitions used in clinical documentation and reporting. Considered to be the most comprehensive, multilingual clinical healthcare terminology in the world SNOMED CT provides the core terminology for electronic health records (EHR).
CPT
Current Procedural Terminology
CPT is a medical code set that is used to report medical, surgical, and diagnostic procedures and services. Its name reflects that it was developed by the American Medical Association (AMA) for standardizing the terminology used to describe medical services and procedures, but the term is now the copyrighted name for the AMA owned coding system.
HCPCS
Healthcare Common Procedure Coding System
HCPCS “hicks-pics” is the coding system providers use to report medical procedures and professional services furnished in ambulatory / outpatient settings, including physician visits to inpatients. Level I of HCPCS is identical to the PCS codes developed and copyrighted by the AMA.
ICD-10-CM
International Classification of Diseases, Tenth Revision, Clinical Modification
ICD-10-CM is a system for classifying diagnoses and reason for visits by patients in all American health care settings. The ICD-10-CM is based on classification of disease published by the World Health Organization (WHO).
ICD-10-PCS
International Classification of Diseases, Tenth Revision, Procedure Coding System
The ICD-10-PCS is a system approved by the American Hospital Association (AHA), the American Health Information Management Association (AHIMA), the Centers for Medicare and Medicade Services (CMS), and the National Center for Health Statistics (NCHS) for classifying procedures performed in hospital inpatient health care settings.
UHDDS
Uniform Hospital Discharge Data Set
UHDDS is used for reporting inpatient data in acute care, short-term care, and long-term care hospitals. It is required for reporting Medicare and Medicaid patients, but many other health care payers also use most of the UHDDS for the uniform billing system.
POA
Present on Admission
In order to assign the proper Diagnosis-Related Group (DRG), conditions present on admission must be differentiated from conditions developed during treatment.
MS-DRG
Medicare Severity Diagnosis Related Group
MS-DRG expands the number of DRGs to facilitate potential increases in diagnosable services and provide better recognition of the severity of illness than the traditional DRG system.
OPPS
Hospital Outpatient Prospective Payment System
OPPS enables CMS to better predict and manage program expenditures by assigning fixed payment amounts to groups of services similarly to the inpatient prospective payment system (based on DRGs). The Outpatient Code Editor (OCE) is a software tool that combines editing logic with the new APC assignment program designed to meet the mandated OPPS implementation.
OCE
Outpatient Code Editor
The Outpatient Code Editor (OCE) is a software tool that combines editing logic with the new APC assignment program designed to meet the OPPS requirement for hospital outpatient services.
OIG
Office of Inspector General
The OIG is the section of the U.S. Department of Health & Human Services (HHS) at the forefront of the Nation’s efforts to fight waste, fraud, and abuse in Medicare, Medicaid and more than 100 other HHS programs.
MAC
Medicare Administrative Contractor
Originally Medicare claims were processed by private health care insurers known as Fiscal Intermediaries (FI). Since 2003 this role has been transferred to regional Medicare Administrative Contractors (MAC)
EDMS
Electronic Document Management System
Hospitals that have not adopted full Electronic Health Records (EHR) sometimes use EDMSs to scan all paper records making them available online.
NLP
Natural Language Processing
NLP is an artificial intelligence field which can convert natural language into computer understandable code. “Seri” and “Echo” use NLP to understand spoken commands. NLP can be used in medical coding to read written records and suggest proper codes.
Grouper
A software program called a ‘grouper’ can take ICD-10-CM/CPS and/or CPT/HCPCS codes and assign the proper DRG for billing.
DEEDS
Data Elements for Emergency Departments Systems
Data set originally compiled by the CDC to smooth integration between emergency response systems
EMEDS
Expeditionary Medical Support Systems
The Expeditionary Medical Support System (EMEDS) is a modular field hospital system developed by the U.S. military for mobile deployment of medical treatment facilities in any location.
UACDS
Uniform Ambulatory Care Data Set
Standardized record similar to the Uniform Hospital Discharge Data Set (UHDDS) but for ambulatory care facilities (physician offices, medical clinics, same-day surgery centers, outpatient hospital clinics and diagnostic departments, emergency treatment centers, and hospital emergency departments)
UHDDS
Uniform Hospital Discharge Data Set
Hospitals that provide medical services for those covered by Medicare and Medicaid must compile these records but it is standard practice for all insurance companies to gather information similar to the UHDDS because of the recognized value of having comparable data. The data set includes:
1. Hospital or facility identification number or code 2. Expected insurance payer number or code 3. Sex, age, and race of the patient 4. Significant medical procedures performed 5. Principal diagnosis 6. Additional significant diagnoses
