question

Certified Revenue Cycle Specialist

answer

CRCS

question

The American Association of Healthcare Administrative Management

answer

AAHAM

question

a requirement that all diagnostic or outpatient services furnished in connection with the principle admitting diagnosis within one day prior to the hospital admission are bundled with the inpatient services for Medicare billing.

answer

1-Day Rule

question

a requirement that all diagnostic or outpatient services furnished in connection with the principle admitting diagnosis within three days prior to the hospital admission are bundled with the inpatient services for Medicare billing.

answer

3-Day Rule

question

the American National Standards Institute transaction for a professional claim (the electronic equivalent of the CMS 15000), formerly the 837P

answer

5010A1

question

the American National Standards Institute transaction for an institutional claim; as a result of HIPAA, it is replacing the electronic UB-04.

answer

837I

question

a former American National Standards Institute transaction for a professional claim (the electronic equivalent of the CMS 15000), sincereplaced by the 5010A1.

answer

837P

question

the Advance Beneficiary Notice of Noncoverage; a form given to a Medicare beneficiary before services are furnished when a service does not meet or is not expected to meet medical necessity.

answer

ABN

question

the misuse of a person, substance, service, or financial matter such that harm is caused; some forms of healthcare abuse include excessive or unwarranted use of technology, pharmaceuticals, and services; abuse of authority; and abuse of privacy, confidentiality, or duty to care; it also includes improper billing practices (like billing Medicare instead of primary insurer), increasing charges to Medicare beneficiaries but not to other patients, unbundling of services, and unnecessary transfers of patients.

answer

abuse

question

an estimate, using average current revenues, of the days required to turn over the accounts receivable under normal operating conditions; in simple terms, this is an estimate of the time needed to collect the accounts receivable.

answer

Accounts Receivable (AR) Days Outstanding

question

Administration for Children and Families; one of the DHHS Operating Divisions.

answer

ACF

question

Administration for Community Living; one of the DHHS Operating Divisions.

answer

ACL

question

written or oral agreement by the patient to the treatment outlined.

answer

actual or expressed consent

question

a level of healthcare delivered to patients experiencing acute illness or trauma; it generally occurs in a hospital or emergency room and is generally short-term care rather than long-term or chronic care.

answer

acute inpatient

question

average daily census; the average number of inpatients maintained in the hospital each day for a specific period of time.

answer

ADC

question

Average Days of Revenue in Accounts Receivable; also known as Accounts Receivable (AR) Days Outstanding; an estimate, using average current revenues, of the days required to turn over the accounts receivable under normal operating conditions; in simple terms, this is an estimate of the time needed to collect the accounts receivable.

answer

ADRR

question

the Advance Beneficiary Notice of Noncoverage; a form given to a Medicare beneficiary before services are furnished when a service does not meet or is not expected to meet medical necessity.

answer

Advance Beneficiary Notice

question

Aid to Families with Dependent Children; a financial assistance program provided by DHHS.

answer

AFDC

question

individuals who help consumers and small businesses complete the application process and enroll in healthcare coverage through the Marketplace; they are able to make recommendations about coverage and may only sell plans from specific health insurance companies.

answer

agents

question

the American Hospital Association.

answer

AHA

question

Agency for Healthcare Research and Quality; one of the DHHS Operating Divisions.

answer

AHRQ

question

average length of stay; a metric calculated by dividing the total number of patient days by the number of discharges.

answer

ALOS

question

services other than routine room and board charges that are incidental to the hospital stay; they include operating room; anesthesia; blood administration; pharmacy; radiology; laboratory; medical, surgical, and central supplies; physical, occupational, speech pathology, and inhalation therapies; and other diagnostic services.

answer

ancillary services

question

the American National Standards Institute.

answer

ANSI

question

ambulatory payment classification; a payment methodology in which services paid under the prospective payment system are classified into groups that are similar clinically and in terms of the resources they require; a payment rate is established for each APC.

answer

APC

question

annual percentage rate; one of the elements of disclosure required by the Truth in Lending Act.

answer

APR

question

a written authorization, signed by the policyholder (or the patient, in the absence of the policyholder) to an insurance company, to pay benefits directly to the provider; when assignment is not accepted, the payment will be sent to the patient and the provider will have to collect it.

answer

assignment of benefits

question

aged trial balance; a resource for internal collection efforts.

answer

ATB

question

Agency for Toxic Substances and Disease Registry; one of the DHHS Operating Divisions.

answer

ATSDR

question

the average number of inpatients maintained in the hospital each day for a specific period of time.

answer

average daily census

question

the average amount of revenue or charges generated each day over a specified period of time.

answer

average daily revenue

question

also known as Accounts Receivable (AR) Days Outstanding; an estimate, using average current revenues, of the days required to turn over the accounts receivable under normal operating conditions; in simple terms, this is an estimate of the time needed to collect the accounts receivable.

answer

Average Days of Revenue in Accounts Receivable

question

an uncollectible account resulting from the extension of credit.

answer

bad debt

question

a person who has healthcare insurance through Medicare

answer

beneficiary

question

a rule to determine coordination for benefits for a child covered by both parents; it dictates that the parent with the first birthday in the calendar year will provide the primary coverage; if both parents happen to have the same birthday, the plan that has covered a parent longer pays first.

answer

birthday rule

question

legislation which provides for medical treatment for coal miners totally disabled from black lung disease.

answer

Black Lung Benefits Act

question

a cross-reference directory used in skip tracing.

answer

Bressers

question

individuals who help consumers and small businesses complete the application process and enroll in healthcare coverage through the Marketplace; they are able to make recommendations about coverage and may only sell plans from specific health insurance companies.

answer

brokers

question

Critical Access Hospital

answer

CAH

question

an option for consumers to ask questions about health coverage options and obtain assistance with the Marketplace application process.

answer

Call centers

question

a method of payment in which a provider is paid a set dollar amount for each patient for a specific time period, and that payment covers all care the group of patients receives for that period, no matter the actual charges.

answer

capitation

question

also known as Utilization Review (UR); an area that performs critical tasks during registration and a patient's stay, such as reducing unnecessary admissions; managing the approved length of stay; ensuring an appropriate level of care for the patient's condition; serving as liaison with the primary and specialty physicians; serving as liaison with the insurance carrier; obtaining approvals, when clinically necessary, for pre-certification/re-certification; advising the patient of discharge; and assisting with appeals for denials, when applicable.

answer

Case Management

question

Centers for Disease Control and Prevention; one of the DHHS Operating Divisions.

answer

CDC

question

charge description master; the chargemaster or master pricing list that includes services, supplies, devices, and medication charges for inpatient or outpatient services by a healthcare facility.

answer

CDM

question

Comprehensive Error Rate Testing.

answer

CERT

question

individuals (staff members or volunteers) who fulfill some of the same roles as Navigators and non-Navigators; they are not responsible for outreach and education but they do provide free information to consumers about insurance programs, they assist them in applying for coverage, and they help to facilitate the enrollment in health coverage.

answer

Certified application counselors

question

Civilian Health and Medical Programs of the Uniformed Services; the programs replaced by Tricare to cover healthcare for active duty and retired members of the uniformed services, their families, and survivors.

answer

CHAMPUS

question

a type of bankruptcy applying to individuals and businesses that cannot pay their debts based on their income; except for exempt property as defined by state laws, the debtor's assets are auctioned to satisfy creditor claims; about 70% of all bankruptcy claims are filed under Chapter 7.

answer

Chapter 7

question

a type of bankruptcy frequently referred to as a "reorganization"; it gives a distressed business a reprieve from creditor claims while it continues to function and works out a repayment plan.

answer

Chapter 11

question

a type of bankruptcy for a family farmer with "regular annual income."

answer

Chapter 12

question

a type of bankruptcy designed for individuals with regular income who desire to pay their debts, but currently are unable to do so; the debtor, under court supervision and protection, may propose and carry out a repayment plan under which creditors are paid over an extended period of time.

answer

Chapter 13

question

also known as charge description master (CDM); the master pricing list that includes services, supplies, devices, and medication charges for inpatient or outpatient services by a healthcare facility.

answer

chargemaster

question

service provided that is never expected to result in cash

answer

charity care

question

the Children's Health Insurance Program; a program for children whose parents have too much money to be eligible for Medicaid, but not enough to buy private insurance; it is jointly financed by the federal and state governments, and administered by the states.

answer

SCHIP

question

the Clinical Laboratory Improvement Amendment of 1988; legislation requiring all clinical laboratory services furnished to Medicare beneficiaries to be performed by a provider who has a CLIA certificate.

answer

CLIA

question

legislation requiring all clinical laboratory services furnished to Medicare beneficiaries to be performed by a provider who has a CLIA certificate.

answer

Clinical Laboratory Improvement Amendment (CLIA) of 1988

question

civil monetary penalty.

answer

CMP

question

Centers for Medicare and Medicaid Services; one of the DHHS Operating Divisions.

answer

CMS

question

another name for the UB-04 uniform bill form.

answer

CMS 1450

question

the billing form used to submit physician and professional service claims to Medicare.

answer

CMS 1500

question

compliance officer.

answer

CO

question

coordination of benefits; the determination of which plan or insurance policy will pay first if two health plans or insurance policies cover the same benefits.

answer

COB

question

a CMS file that contains Medicare patient eligibility and utilization data.

answer

Common Working File

question

a payment made when another payer is responsible, but the claim is not expected to be paid promptly (usually within 120 days from receipt of the claim); it prevents the beneficiary from having to pay out of pocket; Medicare then has the right to recover any payments that should have been made by another payer.

answer

conditional payment

question

a resource to help to address consumers' problems or questions about health coverage.

answer

Consumer assistance programs

question

the first general federal consumer protection legislation; its provisions include the Truth in Lending Act, the Fair Credit Billing Act, the Fair Credit Reporting Act, and the Fair Debt Collection Practices Act.

answer

Consumer Credit Protection Act

question

a contracted entity that assists with the collection, management, and reporting of other health coverage; COB contractors do not process claims for the provider; they gather and disseminate coordination of benefits information to ensure that Medicare is not making primary payment for a service in error.

answer

coordination of benefits contractor

question

a type of discharge in which a patient's financial considerations have been met so he or she is allowed to leave the hospital without going through the usual formalities; the patient is billed at a later date.

answer

courtesy discharge

question

Current Procedural Terminology; a system of descriptive terms and five-digit numeric codes that are used primarily to identify medical services and procedures furnished by physicians and other healthcare professionals.

answer

CPT

question

central processing unit.

answer

CPU

question

credit reporting agency

answer

CRA

question

a statute that prohibits willfully or knowingly executing a scheme to obtain any money or property owned by or in control of any healthcare benefit program or defrauding any healthcare benefit program.

answer

Criminal Health Care Fraud Statute

question

a non-profit hospital located in a state that has established a Medicare Rural Hospital Flexibility Program; it must have 25 or fewer beds and an ALOS of 96 hours or less, be located a certain minimum distance from other hospitals, and furnish 24-hour emergency care services; Medicare pays CAHs for most inpatient and outpatient services on the basis of reasonable cost.

answer

Critical Access Hospital (CAH)

question

care that is primarily for the purpose of meeting personal needs; persons without professional training may provide custodial care; it is not covered by Medicare.

answer

custodial care

question

Common Working File; a CMS file that contains Medicare patient eligibility and utilization data.

answer

CWF

question

a system-generated, free-form statement that is used to communicate the status of a patient's account and/or to bill the patient for an unpaid amount remaining on the account.

answer

data mailer

question

a policy that discusses and lists specific diagnosis codes, ICD procedure codes, and possibly signs and symptoms to support the need for the item or service being given.

answer

definitive LCD/NCD

question

Department of Health and Human Services; the United States government's principal agency for protecting the health of all Americans and providing essential human services; it is also the federal government's largest grant-making agency.

answer

DHHS

question

a potential outcome of bankruptcy that releases the guarantor/patient from financial responsibility of any and all account balances listed on the bankruptcy petition; the account balance is to be written off to the appropriate transaction code.

answer

discharge of debtor

question

a court ruling whereby a bankruptcy is rejected by the court; the most common reason for dismissal is the failure of the debtor to follow through on the filing process and on payment to the attorney, and failure to provide requested documentation; upon dismissal of a bankruptcy, a creditor can bill the debtor directly, refer the account to a collection agency, or pursue litigation.

answer

dismissal

question

durable medical equipment, such as wheelchairs, hospital beds, oxygen, and walkers.

answer

DME

question

durable medical equipment, prosthetics, orthotics, and supplies.

answer

DMEPOS

question

Department of Justice; one of the entities, along with the Office of Inspector General (OIG), that coordinates fraud and abuse control.

answer

DOJ

question

Diabetes Self-Management Training.

answer

DSMT

question

an individual who is entitled to Medicare Part A and/or Part B, and also eligible for some form of Medicaid benefit.

answer

dual eligible

question

also known as Healthcare Power of Attorney; a document that designates someone else (known as a healthcare surrogate, agent, or proxy) to make decisions on the patient's behalf if he or she is unable to do so.

answer

Durable Power of Attorney for Healthcare

question

Equal Credit Opportunity Act

answer

ECOA

question

a law that prohibits credit discrimination on the basis of race, color, religion, national origin, sex, marital status, age, or because someone receives public assistance.

answer

Equal Credit Opportunity Act

question

evaluation and management; both the process of and the charge for examining a patient and formulating a treatment plan.

answer

E&M

question

Employer Group Health Plan.

answer

EGHP

question

a process by which a minor is freed from parental control based on specific criteria (the minor no longer requires parental guidance or financial support, fathered or gave birth to a child, or has reached the age of majority).

answer

emancipation

question

also known as the Federal Anti-Dumping Statute; legislation enacted in 1986 in response to concerns that hospitals were refusing to treat patients without insurance and even transferring them to other facilities and leaving them there, sometimes without notifying the receiving facility.

answer

Emergency Medical Treatment and Active Labor Act

question

Emergency Medical Treatment and Active Labor Act

answer

EMTALA

question

Explanation of Benefits; the former name for the Medicare Summary Notice, which is a remittance advice.

answer

EOB

question

both the process of and the charge for examining a patient and formulating a treatment plan.

answer

evaluation and management (E&M)

question

an amendment to the Truth in Lending Act; it protects consumers from inaccurate or unfair practices by issuers of open-ended credit, requires creditors to inform debtors of their rights and of the responsibilities of the creditor, and has as its principle thrust to provide for prompt settlement of billing disputes.

answer

Fair Credit Billing Act

question

defines what information from "consumer reports" can be used, by whom, and when; it provides the maximum protection of a consumer's right to privacy and confidentiality of credit reports.

answer

Fair Credit Reporting Act

question

legislation enacted as the result of evidence that debt collectors were using abusive, deceptive, and unfair collection practices; it imposes strict limitations and prohibitions on debt collection practices.

answer

Fair Debt Collection Practices Act

question

a type of skip generally caused by clerical error at the time of registration, such as transposed numbers in the street address, an incorrect zip code, or incomplete information.

answer

false

question

legislation that prohibits making a false record or statement to get a false/fraudulent claim paid by the government, submission of false/fraudulent claims, and conspiring to have false/fraudulent claims paid by the government.

answer

False Claims Act

question

Food and Drug Administration; one of the DHHS Operating Divisions.

answer

FDA

question

Fair Debt Collection Practices Act; legislation enacted as the result of evidence that debt collectors were using abusive, deceptive, and unfair collection practices; it imposes strict limitations and prohibitions on debt collection practices.

answer

FDCPA

question

another name for the Emergency Medical Treatment and Active Labor Act (EMTALA); legislation enacted in 1986 in response to concerns that hospitals were refusing to treat patients without insurance and even transferring them to other facilities and leaving them there, sometimes without notifying the receiving facility.

answer

Federal Anti-Dumping Statute

question

Freedom of Information Act.

answer

FOIA

question

the intentional or illegal deception or misrepresentation made for the purpose of personal gain, or to harm or manipulate another person or organization; fraud includes incorrect reporting of diagnosis and procedure codes to maximize payments, billing for services not furnished, altering claims to receive payment, accepting kickbacks, the routine waiver of deductible and coinsurance amounts, etc.

answer

fraud

question

generally accepted accounting principles.

answer

GAAP

question

Health Care Financing Administration; the former name for the Centers for Medicare and Medicaid Services.

answer

HCFA

question

Healthcare Common Procedure Coding System; the federal government equivalent to the CPT system.

answer

HCPCS

question

HEAT, a team that uses government resources to help prevent fraud, waste, and abuse in both the Medicare and Medicaid programs.

answer

Health Care Fraud Prevention and Enforcement Action Team

question

also known as Durable Power of Attorney for Healthcare; a document that designates someone else (known as a healthcare surrogate, agent, or proxy) to make decisions on the patient's behalf if he or she is unable to do so.

answer

Healthcare Power of Attorney

question

Medicare Health Insurance Claim Number

answer

HICN

question

the Hospital Survey and Construction Act; legislation designed to assist hospitals by providing loans for construction projects; once the hospitals were operational, the funds that were borrowed were to be paid back in the form of charity; also known as Title I.

answer

Hill-Burton Act

question

Health Insurance Portability and Accountability Act of 1996

answer

HIPAA

question

the Kennedy-Kassenbaum Bill

answer

HIPAA is also know as?

question

also known as the Kennedy-Kassenbaum Bill; it created federal standards for insurers, HMOs, and employer plans including those who are selfinsured.

answer

Health Insurance Portability and Accountability Act of 1996

question

Health Maintenance Organization; one of five types of Medicare Advantage Plans in which members must generally get healthcare from providers in the plan's network.

answer

HMO

question

preventative, supportive, rehabilitative, or therapeutic care provided to a patient at home; to be reimbursed by the Medicare program, a physician must certify that the patient is home bound, in need of skilled nursing care on an intermittent basis for physical, occupational, and/or speech therapy, with an established plan of care.

answer

home health care

question

coordinated, palliative care provided to terminally ill patients and their families by nonprofit organizations.

answer

hospice care

question

Health Resources and Services Administration; one of the DHHS Operating Divisions.

answer

HRSA

question

Health Savings Account (formerly known as Medical Savings Account, or MSA).

answer

HSA

question

an itemized statement.

answer

I-Bill

question

International Classification of Diseases; a standard transaction set used for 1) chief complaint or diagnosis for professional services and inpatient procedures, and 2) for diagnosis and procedure codes for professional and technical services for both inpatient and outpatient procedures.

answer

ICD

question

the newest version of the International Classification of Diseases.

answer

ICD-10

question

Initial Enrollment Questionnaire; a questionnaire mailed about three months before patients become entitled to Medicare; it asks about any other healthcare coverage that may be primary to Medicare.

answer

IEQ

question

Indian Health Service; one of the DHHS Operating Divisions.

answer

IHS

question

consent that occurs in a situation where the patient is unconscious and is taken to the emergency room; the law allows treating the patient.

answer

implied consent - by law

question

consent by silence; the patient implies consent to the treatment by not objecting.

answer

implied consent - in fact

question

petty cash.

answer

imprest

question

an individual with no means of paying for services or treatments, who is not eligible for Medicaid or another public assistance program.

answer

indigent

question

consent given when the risks and benefits of a treatment are understood and the patient makes an informed decision whether to receive that treatment.

answer

informed consent

question

a questionnaire mailed about three months before patients become entitled to Medicare; it asks about any other healthcare coverage that may be primary to Medicare.

answer

Initial Enrollment Questionnaire (IEQ)

question

Initial Enrollment Questionnaire

answer

IEQ

question

the "Welcome to Medicare Physical Exam" that is offered to each beneficiary once in a lifetime.

answer

initial preventive physical examination (IPPE)

question

initial preventive physical examination

answer

IPPE

question

the beginning of the treatment for a new encounter or a new plan of care; one of the times when a triggering event for an ABN can occur.

answer

initiation

question

a type of skip in which someone avoids paying bills by changing his or her residency and failing to leave a forwarding address, purposely changing his or her name, or intentionally giving false information.

answer

intentional

question

a type of bankruptcy in which a debtor can be placed under Chapter 7 or 11 if the debtor has 12 or more creditors, three of which have claims in excess of $5,000 each and are willing to force the issue, or one creditor owed at least $10,775.

answer

involuntary bankruptcy

question

Inpatient Prospective Payment System

answer

IPPS

question

the organization that accredits hospitals; formerly called the Joint Commission on Accreditation of Healthcare Organizations (JCAHO); accreditation is extremely important for hospitals as it is a requirement of participation in the Medicare program.

answer

Joint Commission, The (TJC)

question

a legally verified claim against a debtor; a legal right to collect a debt that can be used to obtain a lien.

answer

judgment

question

another name for the Health Insurance Portability and Accountability Act of 1996 (HIPAA); it created federal standards for insurers, HMOs, and employer plans including those who are self-insured.

answer

Kennedy-Kassenbaum Bill

question

policies developed by Medicare area contractors that specify criteria for services and show under what clinical circumstances an item or service is considered to be reasonable, necessary, and appropriate.

answer

Local Coverage Determination (LCD)

question

a recorded claim against real or personal property; if the property is sold, the creditor must be paid out of the proceeds of that sale.

answer

lien

question

a document that specifies what treatments a patient does and does not wish to receive; it means that difficult decisions about future care are made while the person is alert; patients can choose the circumstances under which they will die; and patients' desires regarding organ donation are made known.

answer

living will

question

care generally provided to the chronically ill or disabled in a nursing facility or rest home; among the services provided by nursing facilities are 24-hour nursing care; rehabilitative services such as physical, occupational, and speech therapy; and assistance with daily activities like eating, bathing, and dressing.

answer

long term care

question

lifetime reserve.

answer

LTR

question

maximum allowable actual charge.

answer

MAAC

question

Medicare Code Editor; software that edits claims to detect incorrect billing data that is being submitted.

answer

MCE

question

major diagnostic category; one of 25 groups of DRGs (diagnosisrelated groups).

answer

MDC

question

Minimum Data Set; part of the federally required process for clinical assessment of all residents in Medicare- or Medicaid-certified nursing homes; the MDS then determines the Resource Utilization Group (RUG) and hence the payment.

answer

MDS

question

a health insurance program for certain low-income people; it is funded and administered through a state-federal partnership.

answer

Medicaid

question

a health insurance program for the elderly (age 65 or older) and those under age 65 who have permanent disabilities or end stage renal disease (ESRD).

answer

Medicare

question

another name for Medicare Part C; managed care coverage provided by private insurance companies approved by Medicare.

answer

Medicare Advantage Plans

question

software that edits claims to detect incorrect billing data that is being submitted.

answer

Medicare Code Editor (MCE)

question

a program that enables providers to accept assignment of benefits.

answer

Medicare Participating Physician Program

question

laws that shifted costs from the Medicare program to other sources of payment; MSP information is gathered from each beneficiary to determine the proper coordination of benefits.

answer

Medicare Secondary Payer (MSP)

question

a remittance advice; formerly called the Explanation of Benefits (EOB).

answer

Medicare Summary Notice (MSN)

question

also known as Medicare supplemental insurance; health insurance sold by private insurance companies to fill in the "gaps" in coverage (like deductibles, coinsurance, and copayments) under the Original Medicare Plan; some Medigap policies also cover benefits that Medicare doesn't cover, like emergency healthcare while traveling outside the United States.

answer

Medigap

question

Medicaid Integrity Contractors; review, audit, and educate providers to combat fraud and abuse.

answer

MIC

question

the number of patients in the hospital at midnight census; determined from the census count for the previous midnight, minus any discharges, plus any admissions, plus/minus any status changes.

answer

midnight census

question

Medicare Summary Notice; a remittance advice; formerly called the Explanation of Benefits (EOB).

answer

MSN

question

Medicare Secondary Payer

answer

MSP

question

a questionnaire completed on an ongoing basis to help determine if Medicare is primary or secondary; it asks about employment, accidents, and several other relevant subjects.

answer

MSP Questionnaire

question

Military Treatment Facility

answer

MTF

question

Medically Unlikely Edit

answer

MUE

question

an automated edit for HCPCS/CPT codes for services rendered by a provider to a single beneficiary on the same date of service; it helps to prevent inappropriate payments due to clerical entries and incorrect coding based on anatomic considerations.

answer

Medically Unlikely Edit

question

Medicare Volume Performance Standard; the element of the Resource Based Relative Value Scale (RBRVS) for the rates of increase in Medicare expenditures for physician services.

answer

MVPS

question

Non-Availability Statement

answer

NAS

question

a Medicare initiative to promote correct coding methodologies and strive to eliminate improper coding; it dentifies mutually exclusive CPT-4 and HCPCS codes or those that should not be billed together.

answer

National Correct Coding Initiative (NCCI)

question

medical review policies issued by CMS which identify specific medical items, services, treatment procedures, or technologies that can be covered and paid for by the Medicare program.

answer

National Coverage Determination (NCD)

question

individuals who help consumers fill out applications for health coverage through the Marketplace; they help determine if consumers qualify for programs to help lower their costs.

answer

Navigators

question

National Correct Coding Initiative

answer

NCCI

question

National Institutes of Health; one of the DHHS Operating Divisions.

answer

NIH

question

a requirement before any nonemergent inpatient services may be provided to a Tricare Extra or Standard eligible beneficiary by a non-Military Treatment Facility (MTF).

answer

Non-Availability Statement (NAS)

question

a policy that provides potential coverage circumstances, but most likely does not provide specific diagnoses, signs, symptoms, or ICD-9-CM codes that will be covered or noncovered; when the Medicare contractor considers or utilizes factors and information other than that in the LCD/NCD when making a coverage determination.

answer

non-definitive LCD/NCD

question

individuals who perform the same functions as Navigators but only in a state-based Marketplace or state partnership Marketplace.

answer

non-Navigators

question

a claim with extraneous attachments in lieu of data entered correctly in the claim form.

answer

non-standard claim

question

CMS' name for an entity that issues ABNs

answer

notifier

question

National Provider Identification; a unique identifier for covered healthcare providers.

answer

NPI

question

non physician practitioner

answer

NPP

question

National Uniform Billing Committee

answer

NUBC

question

the entity that determined the data elements used in the UB-04 final format as a cooperative effort with the American Hospital Association (AHA).

answer

National Uniform Billing Committee (NUBC)

question

one of the common names for the Patient Protection and Affordable Care Act, PPACA.

answer

Obamacare

question

Omnibus Budget Reconciliation Act (OBRA) of 1989; it provided for the Resource Based Relative Value Scale (RBRVS) as a payment reform provision.

answer

OBRA

question

services furnished on a hospital premises, including use of a bed and periodic monitoring by a hospital's nursing staff; services should be reasonable and necessary to evaluate an outpatient condition to assess the need for admission to the hospital; observation services usually do not exceed 24 hours; however, there is no hourly limit on the extent to which they may be used (CMS has indicated that instances would be rare that a patient would remain in observation for more than 48 hours).

answer

observation

question

care provided in a practitioner's place of business; a practitioner may be a medical doctor, podiatrist, chiropractor, dentist, advanced practice nurse, registered dietitian, physical therapist, psychologist, or one of many other professions.

answer

office

question

Office of Inspector General

answer

OIG

question

one of the entities, along with the Department of Justice, that coordinates fraud and abuse control; it also has identified seven elements of a compliance plan.

answer

Office of Inspector General (OIG)

question

a physician who orders non physician services for a patient, such as diagnostic x-rays.

answer

ordering physician

question

treatment received at a hospital, clinic, or dispensary by someone who is not hospitalized; emergency room patients, ambulatory patients, clinic patients, and same-day surgery patients are all examples of the outpatient classification.

answer

outpatient

question

the hospital insurance component of Medicare that helps pay for medically necessary inpatient hospitalization, care in a SNF following a three-day hospital stay, home health care, hospice care, and blood.

answer

Part A

question

the medical insurance component of Medicare that helps pay for doctor services, outpatient hospital care, and some other medical services that Part A does not cover (such as the services of physical and occupational therapists, and some home health care).

answer

Part B

question

also known as Medicare Advantage Plans; managed care coverage provided by private insurance companies approved by Medicare.

answer

Part C

question

the component of Medicare that helps pay for prescription drugs.

answer

Part D

question

pre-admission testing; the diagnostic medical screening of patients in advance of surgical or invasive procedures to determine hospitalization and/or surgical suitability.

answer

PAT

question

a development by the American Medical Association that guarantees a patient the right to receive courteous, considerate, respectful treatment in a clean/safe environment; appropriate healthcare; information about his/her health treatment plan in a way that he or she understands; continuity of care; confidentiality; privacy; participation in planning care and treatment; refusal of care; use of grievance mechanisms; treatment without discrimination; an itemized bill and explanation of all charges; and review of the medical record and/or a copy at a reasonable fee.

answer

Patient Bill of Rights

question

primary care physician.

answer

PCP

question

Latin for "for each day"; a payment methodology in which providers are paid a predetermined amount for each day an inpatient is in the facility, regardless of actual charges or costs incurred.

answer

per diem

question

the ratio of actual patient days to the maximum patient days as determined by bed capacity; a low percentage of occupancy indicates inefficiency while a percentage that is too high will mean difficulty finding available beds, long hold times in ER, etc.

answer

percentage of occupancy

question

physician assistant, nurse practitioner, etc.

answer

physician extender

question

Preferred Provider Organization

answer

PPO

question

one of five types of Medicare Advantage Plans in which members can see any doctor or provider that accepts Medicare and they don't need a referral to see a specialist.

answer

Preferred Provider Organization (PPO)

question

prospective payment system.

answer

PPS

question

the process of obtaining authorization from an insurance company review organization approving the medical necessity of a hospitalization.

answer

pre-certification

question

legislation that governs patient confidentiality and provides safeguards against an invasion of privacy through the misuse of records by federal agencies.

answer

Privacy Act of 1974

question

Physician Scarcity Area.

answer

PSA

question

Patient Self Determination Act of 1990

answer

PSDA

question

legislation that ensures that patients understood their right to participate in decisions about their own healthcare.

answer

Patient Self Determination Act of 1990

question

Quality Improvement Organization

answer

QIO

question

part of a CMS program to monitor and improve utilization and quality of care for Medicare beneficiaries.

answer

Quality Improvement Organization;

question

Resource Based Relative Value Scale

answer

RBRVS

question

a payment reform provision comprising three major elements: a fee schedule for payment of physician services, based on the relative value unit (RVU); the Medicare Volume Performance Standard (MVPS) for the rates of increase in Medicare expenditures for physician services; and limits on the amount non-participating physicians can charge beneficiaries, referred to as the limiting charge.

answer

Resource Based Relative Value Scale

question

a decrease in the frequency or duration of care; one of the times when a triggering event for an ABN can occur.

answer

reduction

question

a physician who requests an item or service for a beneficiary for which payment may be made under Medicare.

answer

referring physician

question

another name for Title I of the Consumer Credit Protection Act, or the Truth in Lending Act; it requires disclosure of information before credit is extended.

answer

Regulation Z

question

another name for the Medicare Summary Notice; formerly called the Medicare Explanation of Benefits (EOB).

answer

remittance advice

question

a system to determine the payment rate for most skilled nursing care; the provider completes the Minimum Data Set as part of the federally required process for clinical assessment of all residents in Medicare- or Medicaid-certified nursing homes; the MDS then determines the RUG and hence the payment; the patient is reevaluated at intervals during his or her stay and the RUG rate may be changed.

answer

Resource Utilization Group (RUG)

question

short-term, temporary custodial care that allows a family member or other unpaid caregiver to get relief from caring for a physically frail or dependant person at home.

answer

respite care

question

Resource Utilization Group

answer

RUG

question

relative value unit

answer

RVU

question

the basis for the fee schedule for payment of physician services that is one of the elements of the Resource Based Relative Value Scale (RBRVS).

answer

relative value unit

question

Substance Abuse and Mental Health Services Administration; one of the DHHS Operating Divisions.

answer

SAMHSA

question

a debtor who cannot be located by a creditor; there are three types: intentional; unintentional, and false.

answer

skip

question

skilled nursing facility

answer

SNF

question

a separate wing of a hospital, a nursing home, or a freestanding facility; to qualify for SNF coverage, Medicare requires a person to have been a hospital inpatient for at least three consecutive days (not including the day of discharge).

answer

skilled nursing facility

question

also known as the benefit period; the period of time that begins when a beneficiary enters the hospital and ends 60 days after discharge from the hospital or from a SNF.

answer

spell of an illness

question

the amount of time in which a claim must be collected before it is deemed paid or satisfied.

answer

statute of limitations

question

an invoice used to document the services ordered or rendered during a patient visit; it is often referred to as a face sheet and includes patient demographic data plus the CPT, ICD-9-CM, and HCPCS codes for the most common procedures performed in the practice or department; upon completion of treatment, the physician completes the superbill to document all services provided; thus a superbill essentially is a tool to eliminate the need for transcribing medical record notes from a patient chart and streamline the charge capture process.

answer

superbill

question

a discontinuation in the services being provided; one of the times when a triggering event for an ABN can occur.

answer

termination

question

Medicare

answer

Title XVIII

question

Medicaid

answer

Title XIX

question

The Joint Commission; the organization that accredits hospitals; accreditation is extremely important for hospitals as it is a requirement of participation in the Medicare program.

answer

TJC

question

a liability for an injury or wrongdoing by one person to another resulting from a breach of legal duty.

answer

tort liability

question

third party administrator

answer

TPA

question

a regionally-managed healthcare program for active duty and retired members of the uniformed services, their families, and survivors.

answer

Tricare

question

an event that occurs during initiation, reduction, or termination of a course of treatment that triggers the need for an ABN.

answer

triggering event

question

another name for Title I of the Consumer Credit Protection Act; also known as Regulation Z; it requires disclosure of information before credit is extended.

answer

Truth in Lending Act

question

CMS guideline stating that when a physician expects a Medicare patient to remain in the hospital for at least two midnights, the physician should write an inpatient admission order.

answer

Two Midnight Rule

question

the uniform bill required of hospital inpatient and outpatient departments, skilled nursing facilities, home health practitioners, comprehensive outpatient rehabilitation facilities, community mental health centers, and the like when billing Medicare.

answer

UB-04

question

usual, customary, and reasonable

answer

UCR

question

a method to determine the value of services used by many third party payers; it relies on physiciancharge data accumulated over time; after ranking the charges for a given service from lowest to highest, the payer uses a specific point (for example, the 75th percentile) as the basis for UCR payments.

answer

usual, customary, and reasonable

question

a type of skip in which someone moves or changes residence and fails to notify creditors; a forwarding address is normally available.

answer

unintentional

question

a claim that is considered incomplete or invalid due to missing claim form data elements.

answer

unprocessable

question

Utilization Review

answer

UR

question

also known as Case Management; an area that performs critical tasks during registration and a patient's stay, such as reducing unnecessary admissions; managing the approved length of stay; ensuring an appropriate level of care for the patient's condition; serving as liaison with the primary and specialty physicians; serving as liaison with the insurance carrier; obtaining approvals, when clinically necessary, for pre-certification/re-certification; advising the patient of discharge; and assisting with appeals for denials, when applicable.

answer

Utilization Review

question

a type of ICD-9-CM code used when services or visits relate to circumstances other than disease or injury.

answer

V code

question

the U.S. Department of Veterans Affairs

answer

VA

question

voice case information system

answer

VCIS

question

a telephonic system used to perform an on-site check at the bankruptcy clerk's office.

answer

voice case information system

question

a plan that covers injuries sustained by a worker in the course of performing his or her job duties.

answer

workers' compensation

question

Agency for Health Care Administration

answer

AHCA

question

Against Medical Advice or American Medical Association

answer

AMA

question

Ambulatory Surgical Center

answer

ASC

question

Aged Trial Balance

answer

ATB

question

Balanced Budget Act

answer

BBA

question

Beneficiary Notices Initiative

answer

BNI

question

Correct Coding Initiative

answer

CCI

question

Crippled Children's Service

answer

CCS

question

Current Dental Terminology

answer

CDT

question

Chief Executive Officer

answer

CEO

question

Chief Financial Officer

answer

CFO

question

Civilian Health and Medical Program of the Uniformed Services

answer

CHAMPUS

question

Civilian Health and Medical Program of the Veterans Administration

answer

CHAMPVA

question

Continued Health Care Benefit Program

answer

CHCBP

question

Community Mental Health Clinic

answer

CMHC

question

Consolidated Omnibus Budget Reconciliation Act

answer

COBRA

question

Comprehensive Outpatient Rehabilitation Facility

answer

CORF

question

Defense Enrollment Eligibility Reporting System

answer

DEERS

question

Deficit Equity and Reduction Act

answer

DEFRA

question

Deficit Reduction Act

answer

DRA

question

Diagnosis Related Groups

answer

DRG

question

Electronic Data Interchange

answer

EDI

question

Employer Identification Number

answer

EIN

question

End Stage Renal Disease

answer

ESRD

question

Fair Credit Reporting Act

answer

FCRA

question

Federal Employees' Compensation Act

answer

FECA

question

Federal Employee Program

answer

FEP

question

FEP

answer

Federal Employee Program

question

Fiscal Intermediary

answer

FI

question

General accounting office

answer

GAO

question

Government printing office

answer

GPO

question

Healthcare Common Procedure Coding System

answer

HCPCS

question

HCPCS

answer

Healthcare Common Procedure Coding System

question

Health Provider Shortage Area

answer

HPSA

question

Healthcare Savings Accounts

answer

HSA

question

International Classification of Diseases, Volume 9, Clinical Modification

answer

ICD-9-CM

question

Intermediate Care Facility

answer

ICF

question

Image Character Recognition

answer

ICR

question

Investigational Device Exemption

answer

IDE

question

Implementation Guide

answer

IG

question

Local Medical Review Policies

answer

LMRP

question

Medicare Administrative Contractor

answer

MAC

question

Maximum Allowable Actual Charge

answer

MAAC

question

Managed Care Organizations

answer

MCO

question

Doctorate of Medicine

answer

MD

question

Major Diagnostic Categories

answer

MDC

question

Medicare Hospital Insurance

answer

MHI

question

Medicaid Integrity Contractors

answer

MIC

question

Medicaid Integrity Program

answer

MIP

question

Medicare Modernization Act

answer

MMA

question

National Association of Insurance Commissioners

answer

NAIC

question

National Coverage Determinations

answer

NCD

question

National Drug Code

answer

NDC

question

Not Otherwise Classified

answer

NOC

question

Not Otherwise Classified

answer

Not Otherwise Classified

question

Non Physician Practitioner

answer

NPP

question

Operation Restore Trust

answer

ORT

question

Occupational Safety and Health Act

answer

OSHA

question

Pre-admission testing

answer

PAT

question

Periodic Interim Payment

answer

PIP

question

Program Memorandums

answer

PM

question

Parallel Operating Environment

answer

POE

question

Prospective Payment System

answer

PPS

question

Professional Review Organization

answer

PRO

question

Quality Assurance

answer

QA

question

Recovery Audit Contractors

answer

RAC

question

Railroad Retirement Board

answer

RRB

question

Residential Treatment Centers

answer

RTC

question

State Children's Health Insurance Program

answer

SCHIP

question

Social Security Administration

answer

SSA

question

Supplemental Security Income

answer

SSI

question

Social Security Number

answer

SSN

question

Treatment Authorization Number

answer

TAN

question

Tax, Equity and Fiscal Responsibility Act

answer

TEFRA

question

Hill Burton

answer

Title I

question

Maternal Health and Child

answer

Title V

question

State Children's Health Insurance Program

answer

Title XXI

question

Type of Bill

answer

TOB

question

Unique Physician Identification Number

answer

UPIN

question

USPHS

answer

US Public Health Service

question

Uniformed Service Treatment Facility

answer

USTF

question

World Health Organization

answer

WHO

question

A benefit period is a way of measuring a beneficiary's use of hospital and skilled nursing facility services covered by Medicare. A benefit period begins the day the beneficiary is hospitalized. It ends after the beneficiary has been out of the hospital or other facility that primarily provides skilled nursing or rehabilitation services for 60 days in a row.

answer

Benefit Period

question

Refers to the number of patients in the hospital at a particular point in time.

answer

Census

question

A _______ ________ is one that does not require the fiscal intermediary to investigate or develop external to their Medicare operation on a prepayment basis. It is a claim that will pass all Common Working File edits, and are processed electronically, and the claim does not require any external development by the intermediary.

answer

Clean Claim

question

Admission, pre-admission, in-house, at discharge and after discharge.

answer

Collection Controls

question

The shortest time period between providers discharge and claim completion mailed or carried to the patient's insurance company.

answer

Timely Filing

question

DHHS

answer

the goverment's largest grant-making agency

question

NIH, FDA, CDC, ATSDR, IHS, HRSA, SAMHSA, AHRQ, CMS, ACF, ACL

answer

11 DHHS Operating Divisions

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