Medical Coding and Billing Flashcards

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1
Q

Submission

A

The healthcare provider sends the claim to the third-party payer requesting payment. Submissions are made electronically or occasionally by paper bill.

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2
Q

Processing

A

The third-party payer receives the claim and gathers information related to the case.

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3
Q

Adjudication

A

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).

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4
Q

EOB

A

Explanation of benefits

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5
Q

Reconciliation

A

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.

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6
Q

ABN

A

Advance Beneficiary Notice of Noncoverage

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7
Q

LCDs

A

Local coverage determinations

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8
Q

NCDs

A

National coverage determinations

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9
Q

MACs

A

Medicare administrative contractors

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10
Q

An ABN should normally be retained for _____

A

5 years

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11
Q

UB-04

A

Claim form used to bill inpatient and outpatient facility charges: surgery centers, freestanding radiology clinic’s, laboratories, hospitals, skilled nursing, and emergency rooms

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12
Q

CMS-1500

A

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

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13
Q

Administrative law

A

Created by administrative agencies of government

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14
Q

Case law or common law

A

Based on judicial decision

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15
Q

Statutory law

A

Passed by legislative body

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16
Q

CFR

A

Code of federal regulations

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17
Q

HIPAA is what kind of law?

A

Statutory law

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18
Q

HIPAA

A

Health insurance portability and accountability act

19
Q

PHI

A

Protected health information

20
Q

OIG

A

Office of the Inspector General

21
Q

PHR

A

Personal health record

22
Q

EHR

A

Electronica health record

23
Q

UHDDS

A

Uniform hospital discharge data set

24
Q

MPIs

A

Master patient indexes

25
Q

EMPI

A

Enterprise wide master patient index

26
Q

Qualitative analysis

A

Review of the medical record to ensure that standards are met and to determine accuracy of record documentation

27
Q

Quantitative analysis

A

Review of the medical record to determine its completeness

28
Q

Concurrent review

A

Review of the medical record carried out while the patient is actively receiving care

29
Q

Occurrence screening

A

Review technique of medical records of current and discharge patients with the goal of identifying events not consistent with routine.

30
Q

Retrospective review

A

Review of the medical record after the patient has been discharged.

31
Q

Interoperability

A

The ability of various systems to actually network and share and exchange information

32
Q

LAN

A

Local area network

33
Q

WAN

A

Wide area network

34
Q

VPN

A

Virtual private network

35
Q

EDI

A

Electronica data interchange

36
Q

CMS

A

Centers for Medicare and Medicaid services

37
Q

Clearinghouse

A

A company contracted by the third-party payers to handle and format submissions, screen clams and make data available to providers

38
Q

Clean claim

A

A complete and accurate claim form that includes all provider and member information

39
Q

Common data file

A

Overview of claims recently filed on the patient

40
Q

Coinsurance

A

The percentage of the bill the patient pays once the deductible is met

41
Q

EOB

A

Explanation of benefits

41
Q

RA

A

Remittance advice

42
Q

Wright-off

A

The difference between total charge and the allowable amount by the insurance