Medical Coding and Billing Flashcards
Submission
The healthcare provider sends the claim to the third-party payer requesting payment. Submissions are made electronically or occasionally by paper bill.
Processing
The third-party payer receives the claim and gathers information related to the case.
Adjudication
The third-party payers process of checking the details of the claim against the information they have on the patient and his or her insurance benefits. This process also checks for completeness of the claim, bundling issues for CPT codes, medical necessity, and recent claims (to avoid unnecessary service or duplicate claims).
EOB
Explanation of benefits
Reconciliation
The process the healthcare provider analyzes receive payment information compared to submit a claim information for accuracy. If the provider believe the claim was inappropriately denied by the payer the dispute process begins until satisfactory reconciliation is achieved by the provider in the third-party payer.
ABN
Advance Beneficiary Notice of Noncoverage
LCDs
Local coverage determinations
NCDs
National coverage determinations
MACs
Medicare administrative contractors
An ABN should normally be retained for _____
5 years
UB-04
Claim form used to bill inpatient and outpatient facility charges: surgery centers, freestanding radiology clinic’s, laboratories, hospitals, skilled nursing, and emergency rooms
CMS-1500
The claim form used to bill professional services: surgeons fees for surgery performed at an outpatient surgery center or an emergency physicians fee for professional services provided in the emergency room
Administrative law
Created by administrative agencies of government
Case law or common law
Based on judicial decision
Statutory law
Passed by legislative body
CFR
Code of federal regulations
HIPAA is what kind of law?
Statutory law
HIPAA
Health insurance portability and accountability act
PHI
Protected health information
OIG
Office of the Inspector General
PHR
Personal health record
EHR
Electronica health record
UHDDS
Uniform hospital discharge data set
MPIs
Master patient indexes
EMPI
Enterprise wide master patient index
Qualitative analysis
Review of the medical record to ensure that standards are met and to determine accuracy of record documentation
Quantitative analysis
Review of the medical record to determine its completeness
Concurrent review
Review of the medical record carried out while the patient is actively receiving care
Occurrence screening
Review technique of medical records of current and discharge patients with the goal of identifying events not consistent with routine.
Retrospective review
Review of the medical record after the patient has been discharged.
Interoperability
The ability of various systems to actually network and share and exchange information
LAN
Local area network
WAN
Wide area network
VPN
Virtual private network
EDI
Electronica data interchange
CMS
Centers for Medicare and Medicaid services
Clearinghouse
A company contracted by the third-party payers to handle and format submissions, screen clams and make data available to providers
Clean claim
A complete and accurate claim form that includes all provider and member information
Common data file
Overview of claims recently filed on the patient
Coinsurance
The percentage of the bill the patient pays once the deductible is met
EOB
Explanation of benefits
RA
Remittance advice
Wright-off
The difference between total charge and the allowable amount by the insurance
