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Improper billing practices that result in financial benefit to the provider but are not faudulent/

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Abuse

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Written notification that must be signed by the patient or guardian prior to the provider rendering a service to a Medicare beneficiary that could be potentially denied or deemed "not medically necessary."

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Advanced beneficiary notice

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Opinion rendered by legal councel that advises a healthcare professional on legal rights of the facility.

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Advisory opinion

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Billing for resonable undocumented services presumably preformed by healthcare professional as part of documented procedure.

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Assumption coding

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process of joining a diagnosis code and a procedure code for the purpose of justifying medical necessity.

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Code linkage

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Any medical device, equipment, or instrument used in the care of a patient.

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Durable medical equipment

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Intentional deception or misrepresentation that an individual knows, or should know, to be false, or does not believe to be true, and makes, knowing the deception could result in some unauthorized benefit to himself or some other person(s).

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Fraud

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an electrical device that converts one form of energy into another

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Transducer

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using a tube (catheter) inserted into the bladder or vessels to obtain specimens, to look, or to keep the vessel open

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Catheterization

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use of radioactive substances as a therapy for in-stent restenosis of a coronary vessel

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Intracoronary Brachytherapy

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removal of material from the surface of an object by vaporization, chipping, or other erosive processes.

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Ablation

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process that uses extreme cold (cryo) to remove tissue (ablation).

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Cryoablation

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instrument for measuring changes in volume within an organ or whole body (usually resulting from fluctuations in the amount of blood or air it contains).

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Plethysmography

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localized, blood-filled balloon-like bulge in the wall of a blood vessel.

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Aneurysm

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visual examination of blood vessels.

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Angioscopy

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a catheter that is inserted into an artery and not manipulated to a further order

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Nonselective (catheter placement)

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a catheter that is inserted into an artery and manipulated to a further order

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Selective (catheter placement)

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group of vessels fed by a primary vessel

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Vascular family

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The 2nd order artery (right common carotid) is the branch off the main artery.

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Second order (vascular family)

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The 3rd order artery (right internal or external carotid), is the next branch off the second order, and so on.

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Third order (vascular family)

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Normal Sinus Rythym

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NSR

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pulse

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P

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premature atrial contraction

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PAC

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peripheral artery disease

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PAD

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Point of Maximum Impulse, the point on the chest where the impulse of the left ventricle is strongest Post-mortem interval, the time that has elapsed since a person has died

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PMI

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percutaneous transluminal coronary angioplasty (balloon angioplasty)

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PTCA

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premature ventricual contraction (abnormal heart rhythm)

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PVC

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peripheral vascular disease

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PVD

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rheumatoid arthritis; right atrium

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RA

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right bundle branch block (RBBB) is a defect in the heart's electrical conduction system. During a right bundle branch block, the right ventricle is not directly activated by impulses travelling through the right bundle branch

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RBBB

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radiofrequency ablation -medical procedure where part of the electrical conduction system of the heart, tumor or other dysfunctional tissue is ablated using the heat generated from the high frequency alternating current to treat a medical disorder.

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RFA

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Radionuclide ventriculography-type of cardiac ventriculography, is a form of nuclear imaging, where a gamma camera is used to create an image following injection of radioactive material, usually Technetium-99m

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RNV

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residual volume; right ventricle

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RV

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the first heart sound which occurs when the atrioventricular valves (mitral and tricuspid) close

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S1

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the second heart sound which occurs when the semilunar valves (aortic and pulmonic) close

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S2

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rare extra heart sound that occurs soon after the normal two "lub-dub" heart sounds (S1 and S2).

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S3

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Fourth heart sound, an abnormal heart sound often indicative of congestive heart failure or cor pulmonale

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S4

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sinoatrial node

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SA

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subacute bacterial endocarditis

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SBE

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CPT codes published by AMA that make up 5 numeric digits. These codes are used to report services and procedures when billing insurance carriers.

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Level 1 HCPCS -

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Alphanumeric codes published by CMS that consist of one letter followed by 4 numbers. These codes are used to report certain med. services not included in CPT. Services by non-physician providers and ambulances, and DME and supplies when billing insurance carriers.

answer

Level 2 HCPCS -

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Local codes used to electronically procxess claims for services where a level1 or 2 code hasnt been established. These codes were orignally developed by Medicare and Medicaid state contractors and were discontinued in 2004.

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Level 3 HCPCS-

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National Correct Coding Initiative- Coding polices to standerdize bundled codes and control improper coding that would lead to inappropriate payment for Medicare claims for physican services.

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NCCI -

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Alerts that are periodically issued and posted on the centers for Medicare and Medicaid Services website to advise providers of problematic actions that have come to the Office of Inspector General's attention.

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OIG Fraud alert -

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Plan that lists the year's planned projects for sampling types of billing to determine if there are any problems.

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OIG Work plan -

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formal exam of patients' medical records and accounts.

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Audit -

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Computer program function which screens for improperly or incorrectly reported procedure codes.

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Code edits -

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Occurs when the procedure code billed is for a procedure that is less involved than the procedure actually documented in the chart. Carriers will downcode or deny payment when the documentation fails to justify the level of service billed.

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Downcode -

question

Investigation performed by an external party to review patient documentation and records.

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External audit -

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Review of claims that is performed by facility to protect against submitting dirty claims.

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Internal audit -

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Completed before the claim is submitted for payment.

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Prospective audit -

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completed after payment has been received from a carrier.

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Retrospective audit -

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Occurs when the procedure code stated is for a procedure that is more involved than the one actually documented in the chart.

answer

Upcode -

Ch. 7: HCPCS & Coding Compliance/ Ch. 8: Auditing – Flashcards

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