AAHAM CRCS-P Study – Flashcards

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Certified Revenue Cycle Specialist
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CRCS
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The American Association of Healthcare Administrative Management
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AAHAM
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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.
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1-Day Rule
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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.
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3-Day Rule
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the American National Standards Institute transaction for a professional claim (the electronic equivalent of the CMS 15000), formerly the 837P
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5010A1
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the American National Standards Institute transaction for an institutional claim; as a result of HIPAA, it is replacing the electronic UB-04.
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837I
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a former American National Standards Institute transaction for a professional claim (the electronic equivalent of the CMS 15000), sincereplaced by the 5010A1.
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837P
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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.
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ABN
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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.
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abuse
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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.
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Accounts Receivable (AR) Days Outstanding
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Administration for Children and Families; one of the DHHS Operating Divisions.
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ACF
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Administration for Community Living; one of the DHHS Operating Divisions.
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ACL
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written or oral agreement by the patient to the treatment outlined.
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actual or expressed consent
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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.
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acute inpatient
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average daily census; the average number of inpatients maintained in the hospital each day for a specific period of time.
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ADC
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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.
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ADRR
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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.
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Advance Beneficiary Notice
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Aid to Families with Dependent Children; a financial assistance program provided by DHHS.
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AFDC
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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.
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agents
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the American Hospital Association.
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AHA
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Agency for Healthcare Research and Quality; one of the DHHS Operating Divisions.
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AHRQ
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average length of stay; a metric calculated by dividing the total number of patient days by the number of discharges.
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ALOS
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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.
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ancillary services
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the American National Standards Institute.
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ANSI
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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.
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APC
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annual percentage rate; one of the elements of disclosure required by the Truth in Lending Act.
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APR
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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.
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assignment of benefits
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aged trial balance; a resource for internal collection efforts.
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ATB
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Agency for Toxic Substances and Disease Registry; one of the DHHS Operating Divisions.
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ATSDR
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the average number of inpatients maintained in the hospital each day for a specific period of time.
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average daily census
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the average amount of revenue or charges generated each day over a specified period of time.
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average daily revenue
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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.
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Average Days of Revenue in Accounts Receivable
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an uncollectible account resulting from the extension of credit.
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bad debt
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a person who has healthcare insurance through Medicare
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beneficiary
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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.
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birthday rule
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legislation which provides for medical treatment for coal miners totally disabled from black lung disease.
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Black Lung Benefits Act
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a cross-reference directory used in skip tracing.
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Bressers
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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.
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brokers
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Critical Access Hospital
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CAH
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an option for consumers to ask questions about health coverage options and obtain assistance with the Marketplace application process.
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Call centers
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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.
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capitation
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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.
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Case Management
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Centers for Disease Control and Prevention; one of the DHHS Operating Divisions.
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CDC
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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.
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CDM
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Comprehensive Error Rate Testing.
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CERT
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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.
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Certified application counselors
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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.
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CHAMPUS
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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.
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Chapter 7
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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.
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Chapter 11
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a type of bankruptcy for a family farmer with "regular annual income."
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Chapter 12
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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.
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Chapter 13
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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.
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chargemaster
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service provided that is never expected to result in cash
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charity care
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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.
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SCHIP
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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.
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CLIA
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legislation requiring all clinical laboratory services furnished to Medicare beneficiaries to be performed by a provider who has a CLIA certificate.
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Clinical Laboratory Improvement Amendment (CLIA) of 1988
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civil monetary penalty.
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CMP
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Centers for Medicare and Medicaid Services; one of the DHHS Operating Divisions.
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CMS
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another name for the UB-04 uniform bill form.
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CMS 1450
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the billing form used to submit physician and professional service claims to Medicare.
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CMS 1500
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compliance officer.
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CO
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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.
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COB
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a CMS file that contains Medicare patient eligibility and utilization data.
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Common Working File
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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.
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conditional payment
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a resource to help to address consumers' problems or questions about health coverage.
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Consumer assistance programs
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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.
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Consumer Credit Protection Act
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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.
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coordination of benefits contractor
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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.
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courtesy discharge
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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.
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CPT
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central processing unit.
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CPU
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credit reporting agency
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CRA
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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.
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Criminal Health Care Fraud Statute
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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.
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Critical Access Hospital (CAH)
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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.
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custodial care
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Common Working File; a CMS file that contains Medicare patient eligibility and utilization data.
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CWF
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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.
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data mailer
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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.
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definitive LCD/NCD
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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.
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DHHS
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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.
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discharge of debtor
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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.
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dismissal
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durable medical equipment, such as wheelchairs, hospital beds, oxygen, and walkers.
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DME
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durable medical equipment, prosthetics, orthotics, and supplies.
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DMEPOS
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Department of Justice; one of the entities, along with the Office of Inspector General (OIG), that coordinates fraud and abuse control.
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DOJ
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Diabetes Self-Management Training.
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DSMT
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an individual who is entitled to Medicare Part A and/or Part B, and also eligible for some form of Medicaid benefit.
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dual eligible
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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.
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Durable Power of Attorney for Healthcare
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Equal Credit Opportunity Act
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ECOA
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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.
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Equal Credit Opportunity Act
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evaluation and management; both the process of and the charge for examining a patient and formulating a treatment plan.
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E&M
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Employer Group Health Plan.
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EGHP
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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).
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emancipation
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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.
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Emergency Medical Treatment and Active Labor Act
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Emergency Medical Treatment and Active Labor Act
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EMTALA
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Explanation of Benefits; the former name for the Medicare Summary Notice, which is a remittance advice.
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EOB
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both the process of and the charge for examining a patient and formulating a treatment plan.
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evaluation and management (E&M)
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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.
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Fair Credit Billing Act
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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.
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Fair Credit Reporting Act
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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.
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Fair Debt Collection Practices Act
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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.
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false
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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.
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False Claims Act
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Food and Drug Administration; one of the DHHS Operating Divisions.
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FDA
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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.
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FDCPA
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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.
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Federal Anti-Dumping Statute
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Freedom of Information Act.
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FOIA
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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.
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fraud
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generally accepted accounting principles.
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GAAP
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Health Care Financing Administration; the former name for the Centers for Medicare and Medicaid Services.
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HCFA
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Healthcare Common Procedure Coding System; the federal government equivalent to the CPT system.
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HCPCS
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HEAT, a team that uses government resources to help prevent fraud, waste, and abuse in both the Medicare and Medicaid programs.
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Health Care Fraud Prevention and Enforcement Action Team
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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.
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Healthcare Power of Attorney
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Medicare Health Insurance Claim Number
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HICN
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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.
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Hill-Burton Act
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Health Insurance Portability and Accountability Act of 1996
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HIPAA
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the Kennedy-Kassenbaum Bill
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HIPAA is also know as?
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also known as the Kennedy-Kassenbaum Bill; it created federal standards for insurers, HMOs, and employer plans including those who are selfinsured.
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Health Insurance Portability and Accountability Act of 1996
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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.
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HMO
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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.
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home health care
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coordinated, palliative care provided to terminally ill patients and their families by nonprofit organizations.
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hospice care
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Health Resources and Services Administration; one of the DHHS Operating Divisions.
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HRSA
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Health Savings Account (formerly known as Medical Savings Account, or MSA).
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HSA
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an itemized statement.
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I-Bill
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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.
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ICD
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the newest version of the International Classification of Diseases.
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ICD-10
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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.
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IEQ
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Indian Health Service; one of the DHHS Operating Divisions.
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IHS
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consent that occurs in a situation where the patient is unconscious and is taken to the emergency room; the law allows treating the patient.
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implied consent - by law
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consent by silence; the patient implies consent to the treatment by not objecting.
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implied consent - in fact
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petty cash.
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imprest
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an individual with no means of paying for services or treatments, who is not eligible for Medicaid or another public assistance program.
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indigent
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consent given when the risks and benefits of a treatment are understood and the patient makes an informed decision whether to receive that treatment.
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informed consent
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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.
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Initial Enrollment Questionnaire (IEQ)
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Initial Enrollment Questionnaire
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IEQ
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the "Welcome to Medicare Physical Exam" that is offered to each beneficiary once in a lifetime.
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initial preventive physical examination (IPPE)
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initial preventive physical examination
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IPPE
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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.
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initiation
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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.
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intentional
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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.
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involuntary bankruptcy
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Inpatient Prospective Payment System
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IPPS
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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.
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Joint Commission, The (TJC)
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a legally verified claim against a debtor; a legal right to collect a debt that can be used to obtain a lien.
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judgment
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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.
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Kennedy-Kassenbaum Bill
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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.
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Local Coverage Determination (LCD)
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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.
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lien
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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.
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living will
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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.
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long term care
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lifetime reserve.
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LTR
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maximum allowable actual charge.
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MAAC
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Medicare Code Editor; software that edits claims to detect incorrect billing data that is being submitted.
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MCE
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major diagnostic category; one of 25 groups of DRGs (diagnosisrelated groups).
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MDC
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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.
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MDS
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a health insurance program for certain low-income people; it is funded and administered through a state-federal partnership.
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Medicaid
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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).
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Medicare
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another name for Medicare Part C; managed care coverage provided by private insurance companies approved by Medicare.
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Medicare Advantage Plans
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software that edits claims to detect incorrect billing data that is being submitted.
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Medicare Code Editor (MCE)
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a program that enables providers to accept assignment of benefits.
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Medicare Participating Physician Program
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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.
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Medicare Secondary Payer (MSP)
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a remittance advice; formerly called the Explanation of Benefits (EOB).
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Medicare Summary Notice (MSN)
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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.
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Medigap
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Medicaid Integrity Contractors; review, audit, and educate providers to combat fraud and abuse.
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MIC
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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.
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midnight census
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Medicare Summary Notice; a remittance advice; formerly called the Explanation of Benefits (EOB).
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MSN
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Medicare Secondary Payer
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MSP
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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.
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MSP Questionnaire
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Military Treatment Facility
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MTF
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Medically Unlikely Edit
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MUE
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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.
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Medically Unlikely Edit
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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.
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MVPS
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Non-Availability Statement
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NAS
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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.
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National Correct Coding Initiative (NCCI)
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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.
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National Coverage Determination (NCD)
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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.
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Navigators
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National Correct Coding Initiative
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NCCI
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National Institutes of Health; one of the DHHS Operating Divisions.
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NIH
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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).
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Non-Availability Statement (NAS)
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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.
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non-definitive LCD/NCD
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individuals who perform the same functions as Navigators but only in a state-based Marketplace or state partnership Marketplace.
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non-Navigators
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a claim with extraneous attachments in lieu of data entered correctly in the claim form.
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non-standard claim
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CMS' name for an entity that issues ABNs
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notifier
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National Provider Identification; a unique identifier for covered healthcare providers.
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NPI
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non physician practitioner
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NPP
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National Uniform Billing Committee
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NUBC
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the entity that determined the data elements used in the UB-04 final format as a cooperative effort with the American Hospital Association (AHA).
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National Uniform Billing Committee (NUBC)
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one of the common names for the Patient Protection and Affordable Care Act, PPACA.
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Obamacare
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Omnibus Budget Reconciliation Act (OBRA) of 1989; it provided for the Resource Based Relative Value Scale (RBRVS) as a payment reform provision.
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OBRA
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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).
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observation
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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.
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office
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Office of Inspector General
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OIG
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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.
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Office of Inspector General (OIG)
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a physician who orders non physician services for a patient, such as diagnostic x-rays.
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ordering physician
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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.
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outpatient
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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.
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Part A
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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).
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Part B
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also known as Medicare Advantage Plans; managed care coverage provided by private insurance companies approved by Medicare.
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Part C
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the component of Medicare that helps pay for prescription drugs.
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Part D
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pre-admission testing; the diagnostic medical screening of patients in advance of surgical or invasive procedures to determine hospitalization and/or surgical suitability.
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PAT
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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.
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Patient Bill of Rights
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primary care physician.
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PCP
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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.
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per diem
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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.
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percentage of occupancy
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physician assistant, nurse practitioner, etc.
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physician extender
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Preferred Provider Organization
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PPO
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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.
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Preferred Provider Organization (PPO)
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prospective payment system.
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PPS
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the process of obtaining authorization from an insurance company review organization approving the medical necessity of a hospitalization.
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pre-certification
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legislation that governs patient confidentiality and provides safeguards against an invasion of privacy through the misuse of records by federal agencies.
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Privacy Act of 1974
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Physician Scarcity Area.
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PSA
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Patient Self Determination Act of 1990
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PSDA
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legislation that ensures that patients understood their right to participate in decisions about their own healthcare.
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Patient Self Determination Act of 1990
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Quality Improvement Organization
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QIO
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part of a CMS program to monitor and improve utilization and quality of care for Medicare beneficiaries.
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Quality Improvement Organization;
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Resource Based Relative Value Scale
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RBRVS
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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.
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Resource Based Relative Value Scale
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a decrease in the frequency or duration of care; one of the times when a triggering event for an ABN can occur.
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reduction
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a physician who requests an item or service for a beneficiary for which payment may be made under Medicare.
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referring physician
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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.
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Regulation Z
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another name for the Medicare Summary Notice; formerly called the Medicare Explanation of Benefits (EOB).
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remittance advice
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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.
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Resource Utilization Group (RUG)
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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.
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respite care
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Resource Utilization Group
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RUG
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relative value unit
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RVU
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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).
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relative value unit
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Substance Abuse and Mental Health Services Administration; one of the DHHS Operating Divisions.
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SAMHSA
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a debtor who cannot be located by a creditor; there are three types: intentional; unintentional, and false.
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skip
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skilled nursing facility
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SNF
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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).
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skilled nursing facility
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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.
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spell of an illness
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the amount of time in which a claim must be collected before it is deemed paid or satisfied.
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statute of limitations
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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.
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superbill
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a discontinuation in the services being provided; one of the times when a triggering event for an ABN can occur.
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termination
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Medicare
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Title XVIII
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Medicaid
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Title XIX
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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.
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TJC
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a liability for an injury or wrongdoing by one person to another resulting from a breach of legal duty.
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tort liability
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third party administrator
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TPA
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a regionally-managed healthcare program for active duty and retired members of the uniformed services, their families, and survivors.
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Tricare
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an event that occurs during initiation, reduction, or termination of a course of treatment that triggers the need for an ABN.
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triggering event
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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.
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Truth in Lending Act
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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.
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Two Midnight Rule
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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.
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UB-04
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usual, customary, and reasonable
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UCR
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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.
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usual, customary, and reasonable
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a type of skip in which someone moves or changes residence and fails to notify creditors; a forwarding address is normally available.
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unintentional
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a claim that is considered incomplete or invalid due to missing claim form data elements.
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unprocessable
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Utilization Review
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UR
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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.
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Utilization Review
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a type of ICD-9-CM code used when services or visits relate to circumstances other than disease or injury.
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V code
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the U.S. Department of Veterans Affairs
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VA
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voice case information system
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VCIS
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a telephonic system used to perform an on-site check at the bankruptcy clerk's office.
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voice case information system
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a plan that covers injuries sustained by a worker in the course of performing his or her job duties.
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workers' compensation
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Agency for Health Care Administration
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AHCA
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Against Medical Advice or American Medical Association
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AMA
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Ambulatory Surgical Center
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ASC
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Aged Trial Balance
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ATB
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Balanced Budget Act
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BBA
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Beneficiary Notices Initiative
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BNI
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Correct Coding Initiative
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CCI
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Crippled Children's Service
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CCS
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Current Dental Terminology
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CDT
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Chief Executive Officer
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CEO
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Chief Financial Officer
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CFO
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Civilian Health and Medical Program of the Uniformed Services
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CHAMPUS
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Civilian Health and Medical Program of the Veterans Administration
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CHAMPVA
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Continued Health Care Benefit Program
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CHCBP
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Community Mental Health Clinic
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CMHC
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Consolidated Omnibus Budget Reconciliation Act
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COBRA
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Comprehensive Outpatient Rehabilitation Facility
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CORF
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Defense Enrollment Eligibility Reporting System
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DEERS
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Deficit Equity and Reduction Act
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DEFRA
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Deficit Reduction Act
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DRA
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Diagnosis Related Groups
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DRG
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Electronic Data Interchange
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EDI
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Employer Identification Number
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EIN
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End Stage Renal Disease
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ESRD
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Fair Credit Reporting Act
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FCRA
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Federal Employees' Compensation Act
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FECA
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Federal Employee Program
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FEP
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FEP
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Federal Employee Program
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Fiscal Intermediary
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FI
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General accounting office
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GAO
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Government printing office
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GPO
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Healthcare Common Procedure Coding System
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HCPCS
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HCPCS
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Healthcare Common Procedure Coding System
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Health Provider Shortage Area
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HPSA
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Healthcare Savings Accounts
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HSA
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International Classification of Diseases, Volume 9, Clinical Modification
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ICD-9-CM
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Intermediate Care Facility
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ICF
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Image Character Recognition
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ICR
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Investigational Device Exemption
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IDE
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Implementation Guide
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IG
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Local Medical Review Policies
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LMRP
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Medicare Administrative Contractor
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MAC
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Maximum Allowable Actual Charge
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MAAC
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Managed Care Organizations
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MCO
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Doctorate of Medicine
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MD
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Major Diagnostic Categories
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MDC
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Medicare Hospital Insurance
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MHI
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Medicaid Integrity Contractors
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MIC
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Medicaid Integrity Program
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MIP
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Medicare Modernization Act
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MMA
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National Association of Insurance Commissioners
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NAIC
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National Coverage Determinations
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NCD
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National Drug Code
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NDC
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Not Otherwise Classified
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NOC
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Not Otherwise Classified
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Not Otherwise Classified
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Non Physician Practitioner
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NPP
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Operation Restore Trust
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ORT
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Occupational Safety and Health Act
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OSHA
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Pre-admission testing
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PAT
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Periodic Interim Payment
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PIP
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Program Memorandums
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PM
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Parallel Operating Environment
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POE
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Prospective Payment System
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PPS
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Professional Review Organization
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PRO
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Quality Assurance
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QA
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Recovery Audit Contractors
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RAC
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Railroad Retirement Board
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RRB
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Residential Treatment Centers
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RTC
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State Children's Health Insurance Program
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SCHIP
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Social Security Administration
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SSA
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Supplemental Security Income
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SSI
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Social Security Number
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SSN
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Treatment Authorization Number
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TAN
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Tax, Equity and Fiscal Responsibility Act
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TEFRA
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Hill Burton
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Title I
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Maternal Health and Child
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Title V
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State Children's Health Insurance Program
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Title XXI
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Type of Bill
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TOB
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Unique Physician Identification Number
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UPIN
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USPHS
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US Public Health Service
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Uniformed Service Treatment Facility
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USTF
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World Health Organization
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WHO
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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.
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Benefit Period
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Refers to the number of patients in the hospital at a particular point in time.
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Census
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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.
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Clean Claim
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Admission, pre-admission, in-house, at discharge and after discharge.
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Collection Controls
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The shortest time period between providers discharge and claim completion mailed or carried to the patient's insurance company.
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Timely Filing
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DHHS
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the goverment's largest grant-making agency
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NIH, FDA, CDC, ATSDR, IHS, HRSA, SAMHSA, AHRQ, CMS, ACF, ACL
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11 DHHS Operating Divisions
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