ADM 101
Terms
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- professional association that represents professionals dedicated to the effective management of health insurance claims; its membership includes professional electronic billers who work for providers as well as well as professional claims assistance prof
-
Alliance of Claims Assistance
Professionals
(ACAP) -
offers 4 certification exams for coders
1.Certified Professional Coder Apprentice (CPC-A)
2.Certified Professional Coder-Hospital Apprentice(CPC-HA)
3.Certified Professional Coder (CPC)
4.Certified Professional Coder-Hospital
(C -
American Academy of Professional Coders
(AAPC) -
1. Certified Professional Coder-
Apprentice (CPC-A)
2. Certified Professional Coder-
Hospital Apprentice (CPC-HA)
3. Certified Professional Coder (CPC)
4. Certified Professional Coder (CPC-H) -
American Academy of Professional Coders
(AAPC):established to provide national certification and credential-ing process,
and to support nat'l and local membership by providing educ. prods. and opportunities to network, and to increase and promote nat'l recognition & awareness of professional coding. - Professional association that represents more than 40,000 health information management professionals who work throughout the health care industry.
-
American Health Information Management
Association
(AHIMA) -
An administrative agency within the Federal Dept. of Health and Human Services.
(formally known as HCFA-Health Care Financing Services) -
Centers for Medicare and Medicaid Svcs.
(CMS) - The process of reporting diagnoses, procedures, and services as numeric and alphanumeric characters on the insurance claim.
- CODING
- Published by the American Medical Association and includes five-digit numeric codes and descriptors for procedures and servoes performed by providers (e.g., 99203 identifies a detailed office visit for a new patient)
- Current Procedural Terminology (CPT)
- Sending data in a standardized machine-readable format to an insurance company via disk, telephone, or cable.
- electronic claims processing
- The mutual exchange of data between provider and payer.
- electronic data interchange (EDI)
- The priciple of right or good conduct; rules that govern the conduct of members of a profession.
- ETHICS
- A report that details the results of processing a claim (e.g., payer reimburses prover $80.00 on a submitted charge of $100.00)
- explanation of benefits (EOB)
- A physician or other health care practioner (ex: physician's assistant)
- health care provider
- The coding system that that consists of CPT, national codes (level II), and local codes (level III),;local codes were discontinued in 2003; previously known as HCFA Common Procedure Coding System.
-
Healthcare Common Procedure Coding Sys.
(HCPCS) - Documentation submitted to an insurance plan requesting reimbursement for health care services provided (ex.: CMS-1500 and UB-92)
- health insurance claim
- The patient is not responsible for what the insurance plan denies.
- hold harmless clause
- The coding system used to report diagnoses and reasons for encounters on physician office claims
-
International Classification of Diseases
9th Revision-Clinical Modifications
(ICD-9-CM) - developed by local insurance companies and include five-digit alphanumeric codes for procedures, services, and supplies that are also not classified in CPT
-
local codes
(level III codes) - involves linking every procedure or service reported to the insurance company to a condition that justifies the necessity for performing that procedure or service.
- medical necessity
-
commonly referred to as HCPCS codes, which include five-digit alphanumeric codes for procedures, services, and supplies that are not classified in CPT
ex: J codes are used to assign drugs administered - National Codes (level II codes)
- prior approval
- Prior Authorization