Ch 6 Flashcards
The connection between a service in a patient’s condition or illness.
Code linkage
What is the importance of code linkage on healthcare claims?
Diagnoses and procedures must be correctly linked on healthcare claims so payers can analyze the connection and determine the medical necessity of charges.
Computerized Medicare system that prevents overpayment.
Correct coding initiative (CCI)
Code combinations used by computers in the Medicare system to check claims.
CCI edits
Medicare code edit where CPT codes in column 2 will not be paid if reported in the same way as the column one code.
CCI column 1/ column 2 code pair edit
Both services represented by MEC codes that could not have been done during one encounter.
CCI mutually exclusive code (MEC)
Number showing if the use of a modifier can bypass a CCI edit.
CCI modifier indicator
Units of service edits used to the lower the Medicare fee-for-service paid claims error rate.
Medically unlikely edits (MUEs)
OIG’s annual list of planned projects
OIG workplan
Opinion issued by CMS or the OIG that becomes legal advice.
Advisory opinion
Individuals or companies not permitted to participate in federal healthcare programs.
Excluded parties
Claims are rejected or downcoded because? (3)
- Medical necessity errors
- Coding error
- Errors related to billing
Diagnoses not coded at the highest level of specificity.
Truncated coding
Reporting undocumented services, the coder assumes have been approved due to the nature of the case or condition.
Assumption coding
Use of a procedure code that provides a higher payment.
Upcoding
Payers review and reduction of a procedure code.
Downcoding
What major strategies ensure compliance billing?
Carefully define bundled codes and know global periods, benchmark the practices E/M codes with national averages, use modifiers appropriately, be clear on professional courtesy and discounts to uninsured/low income patients, maintain compliant job reference aids documentation templates.
Providing free services to other physicians.
Professional courtesy
List of practices frequently reported procedures and diagnoses.
Job reference aid
Allows a software program to assist in the assigning codes.
Computer-assisted coding (CAC)
Form used to prompt a physician to document a complete review of systems ROS and a treatments medical necessity.
Documentation template
A formal examination or review.
Audit
Program designed to audit Medicare claims.
Recovery audit contractor (RAC)
Audit conducted by an outside organization.
External audit
Self-audit conducted by a staff member or consultant.
Internal audit
Internal audit of claims conducted before transmission.
Prospective audit
Internal audit conducted after claims are processed and RA’s have been received.
Retrospective audit
How do physicians set their fee schedules?
Physicians set their fee schedules in relation to this fees that other providers charge for similar services.
Normal fee charged by a provider.
usual fee
Fees based on typically charged amounts.
Charge-based fee structure
What structure is built by comparing three factors? What are the three factors?
Resource-based fee structure
- How difficult it is for the provider to do the procedure
- How much office overhead the procedure involves
- The relative risk that the procedure presents to the patient and to the provider
Setting fees by comparing usual fees, customary fees, and reasonable fees.
Usual, customary, and reasonable (UCR)
System of assigning unit values to medical services based on their required time and skill.
Relative value scale (RVS)
Factor assigned to a medical service based on the relative scale and required time.
Relative value units (RVU)
Amount used to multiply a relative value unit to arrive at a change.
Conversion factor
Relative value scale for establishing Medicare charges.
Resource-based relative value scale (RBRVS)
Medicare factor used to adjust providers fees any particular geographic area.
Geographic practice cost index (GPCI)
The RBRVS-based allowed fees.
Medicare physician fee schedule (MPFS)
What are the following steps used to calculate the RBRVS payments under the MPFS?
Determine the procedure code for the service, use the MPF to find three RVUs-work, practice expense, and malpractice-for the procedure, use the Medicare GPC I list to find the three geographic practice cost in disses, multiply each RV you abides GP CI to calculate the adjusted value, add the three adjusted totals, and multiplied somebody in a conversion factor to determine the payment.
What are the three main methods to pay providers?
Allowed charges
Contracted fee schedule
Capitation
Maximum charge a plan pays for a service or procedure.
Allowed charge
Collecting the difference between a providers usual fee and a payers lower allowed charge.
Balance billing
To deduct an amount from a patients account.
Write off
The periodic prepayment to a provider for specified services to each plan member.
Capitation rate
Amount withheld from a providers payment by an MCO.
Provider withhold
Changes to a patients account.
Adjustments
Types of payment methods
Cash, check, credit or debit card.
What is a walkout receipt? How can it be used?
A walkout receipt summaries services and charges as well as any payments made.
A patient can use a walkout reciept to report charges to their insurance company.
