Chapter 9 - Clinical Documentation Improvement And Coding Compliance Flashcards
Abuse
Describes practices that, either directly or indirectly, result in unnecessary costs to the Medicare Program. Abuse includes any practice that is not consistent with the goals of providing patients with services that are medically necessary, meet professionally recognized standards, and are fairly priced.
Benchmarks
A comparison of one’s own results of measure and performance statistics with the results of other individuals, departments, or organizations
Case Mix
A description of a patient population based on any number of specific characteristics, including age, gender, type of insurance, diagnosis, risk factors, treatment received, and resources used. 2. The distribution of patient into categories reflecting differences in severity of illness or resource consumption
Case-mix Index
The average relative weight of all cases treated at a given facility or by a given physician, which reflects the resource intensity or clinical severity of a specific group in relation to the other groups in the classification system; calculated by dividing the sum of the weights of diagnosis-related groups for patients discharged during a given period by the total number of patients discharged
Clinical
Refers to work done with real patients, about or relating to the medical treatment that is given to patients in facilities such as hospitals and clinics
Clinical Documentation Improvement (CDI)
The process an organization undertakes that will improve clinical specificity and documentation that will allow coders to assign more concise disease classification codes
Compliance
The process of establishing an organizational culture that promotes the prevention, detection, and resolution of instances of conduct that do not conform to federal, state, or private payer healthcare organization’s ethical and business policies. 2. The act of adhering to official requirements. 3. Managing a coding or building department according to the laws, regulations, and guidelines that govern it
Computer-assisted Coding
The process of extracting and translating dictated and then transcribed free-text data into ICD-10-CM and CPT evaluation and management codes for billing and coding purposes
Concurrent Review
Review that occurs while the patient care is ongoing, often the reviewers are alongside the healthcare providers on the patient care units to facilitate communication
Extrapolation Method
This method of auditing claims looks at a small sample of records and applies the correction in payment/reimbursement across a large number of claims in a time period or service area
Federal False Claims Act
Legislation passed during the Civil War, amended in 1986, that prohibits contractors from making a false claim to a governmental program; used to reinforce the prevention of healthcare fraud and abuse
Fraud
The intentional deception or misrepresentation that an individual knows, or should know, to be knowing the deception could result in some unauthorized benefit to himself or some other persons
Maximization
Using unbundling or upcoding to make the most of reimbursement to the highest possible amount through coded data
Optimization
Seeking the most accurate documentation, coded data, and resulting payment in the amount the provider is rightly and legally entitled to receive; includes activities that extend use of information systems beyond the basic functionality
Physician Champion
An individual who assists in communicating and educating medical staff in areas such as documentation procedures for accurate billing and appropriate EHR processes; also known as physician advisor
