AAPC Certification Definitions
Terms
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- CMS
- Center for Medicare and Medicaid Services
- EOB/EMOB
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Explanation of Benefits
Explanation of Medicare Benefits
- the published explanations that accompany private payor Medicare payments or denials of health care benefits. - POS
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Place of Service
-The place where a medical service is rendered can determine reimbursement and coding conventions applied to medical service codes, i.e In-patient or Out Patient - NCCI
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National Correct Coding Initiative
- a database of CPT coding relationships identifying CPT services that are inherently bundled into other services. - NCQA
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National Committee for Quality Assurance
- A private not-for-profit organization that serves as a watchdog for the preservation of healthcare quality provided by Managed Care Organizations (MCO). - PCP
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Primary Care Provider
-The physcian gatekeeper assisgned by a managed care system usually specializing in general practice, or in another non-specialized medical practice. This practioner manages the general overall care of the patient and referrals to specialists, laboratories and medical services or procedures. - Subrogation of Benefits
- The process of identifying who is financially responsible for payment of an accident claim.
- Golden Rule of Procedural Coding Compliance is...
- If it is not documented it is not done and therefore, it is not billable
- CMP
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Civil Monetary Penalites
-fines attached to fraudulent claims - Two Type of Fraud under Federal False Claims Act:
- Civil and Criminal
- ORT
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Operation Restore Trust
-the Clinton plan to reduce waste & overspending from the Medicare Trust Fund in an effort to preserve it's funding and longevity - PATH (Audits)
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Physician at Teaching Hospital Audits
-teaching hospitals audit billing practices to see if 1) double-billing is being performed because services by residents are being billed as services by attendings which is billing fraud - Prospective Audit
- -pertains to auditing patient records against proposed billing information and is conducted on encounters yet to be billed & is an optimal device to check against accurary of chart/billing information
- Stark Law
- Federal Law against kickbacks, a financial inducement for sending business between either a provider and a hospital or a provider and a DME supplier
- Undercoding
- Fraudulent billing for a service that was less than the service actually performed & misused as an incentive for patients to seek more frequent services
- Upcoding (overcoding)
- Fraudulent practice of billing for a service that is worth more than the lesser actual service provided