Help
Options
Didn't know it?
click below
click below
Knew it?
click below
click below
Don't Know
Remaining cards (0)
Know
retry
shuffle
restart
0:00
Embed Code - If you would like this activity on your web page, copy the script below and paste it into your web page.
Normal Size Small Size show me how
Normal Size Small Size show me how
CBCS Exam definition
| Question | Answer |
|---|---|
| Abstracting | the extraction of specific data from a medical record, often for use in and external database, such as a cancer registry |
| Abuse | practices that directly or indirectly result in unnecessary costs to the Medicare program |
| Account number | number that identifies specific episode of care, date of service, or patient |
| Accounts receivable department | department that keeps track of what third-party payers the provider is waiting to hear from and what patients are due to make a payment |
| Activity/status date | indicates the most recent activity of an item |
| Actual charge | the amount the provider charges for health care service |
| Administration Simplification Compliance Act (ASCA) | specifically prohibits any payment by Medicare for services or medically necessary supplies that are not submitted electronically |
| Administrative services only (ASO) contract | contract between employers and private insurers under which employers fund the plans themselves, and the private insurers administer the plans for the employers |
| Advance Beneficiary Notice of Noncoverage | form provided if a provider believes that a service may be declined because Medicare might consider it unnecessary |
| Aging report | measures the outstanding balances in each account |
| Allowable charge | the amount an insurer will accept as full payment, minus applicable cost sharing |
| APC grouper | helps coders determine the appropriate ambulatory payment classification (APC) for an outpatient encounter |
| Assignment of benefits | contract in which the provider directly bills the payer and accepts the allowable charge |
| Auditing | review of claims for accuracy and completeness |
| Authorization | permission granted by the patient or the patient's representative to release information for reasons other than treatment, payment or health care operations |
| Balance billing | billing patients for charges in excess of the Medicare fee schedule |
| Batch | a group of submitted claims |
| Blue Cross/Blue Shield Plan | the first prepaid plan in the U.S. that offers health insurance to individuals, small businesses, seniors, and large employer groups |
| Business associate (BA) | individuals, groups, or organizations who are not members of a covered entity's workforce that perform the functions or activities on behalf of or for a covered entity |
| Capitation | the fixed amount a provider receives |
| Case management | review of clinical services being performed |
| Category I CPT codes | codes that covers physicians' services and hospital outpatient coding |
| Category II CPT codes | codes designed to serve as supplemental tracking codes that can be used for performance measurement |
| Category III CPT codes | codes used for temporary coding for new technology and services that have not met the requirements needed to be added to the main section of the CPT book |
| Charge amount | the amount the facility charges for the procedure or service |
| Charge description master (CDM) | information about healthcare services that patients have received and financial transactions have taken place |
| Charge or service code | internally assigned number unique to each facility |
| Claim | a complete record of services provided by a healthcare professional, along with appropriate insurance information, submitted for reimbursement to a third-party payer |
| Claims adjustment reason code (CARC) | provides financial information about claims decisions |
| Claim scrubber | software that reviews a claim prior to submission for correct and complete data, such as accurate gender in alignment with diagnosis/procedure or medical necessity |
| Clean claim | claim that is accurate and complete. They have all the information needed for processing, which is done in a timely fashion |
| Clearinghouse | agency that converts claims into a standardized electronic format, looks for errors, and formats them according to HIPAA and insurance standards |
| Clinical documentation | the record of clinical observations and care a patient receives at a health care facility |
| Commercial innsurance | private and employer-based self-insurance |
| Computer-assisted coding (CAC) | software that scans the entire patient's electronic record and codes the encounter based on the documentation in the record |
| Conditional payment | Medicare payment that is recovered after primary insurance pays |
| Consent | a patient's permission evidenced by signature |
| Contractual obligation | used when a contractual agreement resulted in an adjustment |
| Coordination of benefits rules | determines which insurance plan is primary and which is secondary |
| Correction and renewal | used for correcting a prior claim |
| Cost sharing | the balance the policyholder must pay to the provider |
| Crossover claim | claim submitted by people covered by a primary and secondary insurance plan |
| De-identified information | information that does not identify an individual because unique and personal characteristics have been removed |
| Demographic information | date of birth, sex, marital status, address, telephone number, relationship to subscriber, and circumstances of condition |
| Description of service | an evaluation and management visit, observation, or emergency room visit |
| Diagnosis code | International Classification of Diseases (ICD-10-CM) |
| Dirty claim | claim that is inaccurate, incomplete, or contains other errors |
| Electronic data interchange (EDI) | the transfer of electronic information in a standard format |
| Employer-based self-insurance | insurance that is tied to an individual's place of employment |
| Encoder | software that suggests codes based on documentation or other input |
| Encounter | a direct, professional meeting between a patient and a health care professional who is licensed to provide medical services |
| Encounter form | form that includes information about past history, current history, impatient record, discharge information, and insurance information |
| Explanation of benefits (EOB) | describes the services rendered, payment covered, and benefit limits and denials |
| Fair Debt Collection Practices Acts (FDCPA) | debt collectors cannot use unfair or abusive practices to collect payments |
| False Claims Act | protects the government from being overcharged for services provided or sold, o substandard goods or services |
| Final Rule | strengthens the HIPAA ruling around privacy, security, breach notification, and penalties |
| Formulary | a list of prescription drugs covered by an insurance plan |
| Fraud | making false statements of representations of material facts to obtain some benefit or payment for which no entitlement would otherwise exist |
| Gatekeeper | provider who determines the appropriateness of the health care service, level of health care professional called for, and setting for care |
| General ledger key | two-or three-digit number that makes sure that a line item is assigned to the general ledger in the hospital's accounting system |
| Group code | code that identifies the party financially responsible for a specific service or the general category of payment adjustment |
| Group or plan number | unique code used to identify a set of benefits of one group of type of plan |
| Group practice model | HMO that contracts with an outside medical group for services |
| Health Insurance Portability and Accountability Act (HIPAA) of 1996 | legislation that includes Title II, for the first parameters designed to protect the privacy and security of patient information |
| Health maintenance organization (HMO) | plan that allows patients to only go to physicians, other healthcare professionals, or hospitals on al ist of approved providers, except in an emergency |
| Health record number | number the provider uses to identify an individual patient's record |
| ICD-10-CM | coding and classification system that captures diseases and health-related conditions. Developed by the World Health Organization (WHO) and adapted to the U.S. healthcare system for uses that include securing reimbursement for services provided |
| ICD-10-PCS | coding and classification system developed for use in the U.S. only. Specific to inpatient hospital procedures |
| Implied consent | a patient presents for treatment, such as extending an arm to allow a venipuncture to be performed |
| Independent practice association (IPA) model | HMO that contracts with the IPA, which in turn contracts with individual health providers |
| Individually identifiable | documents that identify the person or provide enough information so that the person could be identified |
| Informed consent | providers explain medical or diagnostic procedures, surgical interventions, and the benefits and risks involved, giving patients an opportunity to ask questions before medical intervention is provided |
| Managed care organization | organization developed to manage the quality of healthcare and control costs |
| Medicaid | a government-based health insurance option that pays for medical assistance for individuals who have low incomes and limited financial resources. Funded at the state and national level. Administered at the state level |
| Medical necessity | the documented need for a particular medical intervention |
| Medicare Administrative Contractor (MAC) | processes Medicare Parts A and B claims from hospitals, physicians, and other providers |
| Medicare Advantage (MA) | combined package of benefits under Medicare Parts A and B that may offer extra coverage for services such as vision, hearing, dental, health and wellness, or prescription drug coverage |
| Medicare | federally funded health insurance provided to people age 65 or older, people younger than 65 who have certain disabilities, and people of all ages with end-stage kidney disease. Funded and administered atthe national level |
| Medicare Part A | provides hospitalization insurance to eligible individuals |
| Medicare Part B | voluntary supplemental medical insurance to help pay for physicians' and other medical professionals' services, medical services, and medical-surgical supplies not covered by Medicare Part A |
| Medicare Part D | a plan run by private insurance companies and other vendors approved by Medicare |
| Medicare specialty plan | plan that provides focused, specialized healthcare for specific groups of people, such as those who have both Medicare and Medicaid, live ina long-term care facility, or have chronic medical conditions |
| Medicare Summary Notice (MSN) | document that outlines the amounts billed by the provider and what the patient must pay the provider |
| Medigap | a private health insurance that pays for most of the charges not covered by Parts A and B |
| Modifier | additional information about types of services, and part of valid CPT or HCPCS codes |
| Morbidity | the number of cases of disease in a specific population |
| Mortality | the incidence of death in a specific population |
| MS-DRG grouper | software that helps coders assign the appropriate Medicare severity diagnosis-related group based on the level of services provided, severity of the illness or injury, and other factors |
| National Provider Identifier (NPI) | unique 10-digit code for providers required by HIPAA |
| Network model | HMO that contracts with two or more independent practices |
| Notice of Exclusions from MEdicare Benefits | notification by the physician to a patient that a service will not be paid |
| Ordering provider | a physician or other licensed healthcare professional (e.g., physician assistant, nurse practitioner) who prescribes services for a patient |
| Other adjustment | used when no other code applies to the adjustment |
| Out-of-network | not contracted with the health plan |
| Out-of-pocket maximum | a predetermined amount after which the insurance company will pay 100% of the cost of medical services |
| Patient responsibility | the amount the patient owes |
| Preauthorization | the health plan is notified that a hospital stay or significant procedure is coming up, giving the plan the opportunity to determine if it is medically necessary and, in an inpatient admission, how many days the patient most likely will need to stay |
| Precertification | a review that looks at whether the procedure could be performed safely but less expensively in an outpatient setting |
| Predetermination | a written request for verification of benefits |
| Preferred Provider Organization (PPO) | plan that allows patients to use physicians, specialists, and hospitals in the plan's network |
| Preferred provider | Tier II provider |
| Primary insurance | insurance that pays first, up to the limits of its coverage |
| Prior approval number | number indicating that the insurance company has been notified and has approved services before they are rendered |
| Privacy Rule | a HIPAA rule that establishes protections for the privacy of individual's health information |
| Private-fee-for-service plan | plan that allows patients to go to any physician, other healthcare professional, or hospital as long as the providers agree to treat those patients |
| Private insurance | health care subsidized through premiums paid directly to the company |
| Procedure code | ICD procedure codes (ICD-10-PCS), Current Procedural Terminology (CPT) codes, of Healthcare Common Procedures Coding System (HCPCS) that represents the procedure or service |
| Protected health information (PHI) | individually identifiable health information |
| Provider-level adjustment reason code | codes that are not related to a specific claim |
| Referral | written recommendation to a specialist |
| Referring provider | the physician or other licensed healthcare professional who requests a service for a patient |
| Reimbursement | payment for services rendered from a third-party payer |
| Remittance advice (RA) | the report sent from the third-party payer to the provider that reflects any changes made to the original billing |
| Remittance advice remark code (RARC) | code that explains the reason for a payment adjustment |
| Revenue code | four-digit code that identifies specific accommodation, ancillary service, or billing calculation related to services on a bill |
| Staff model | HMO that provides hospitalization and physician services through its own staff |
| Stark Law | physicians are not allowed to refer patients to a practitioner with whom they have a financial relationship |
| State Children's Health Insurance Program (SCHIP) | a program jointly funded by the federal government and the states |
| Subscriber number | unique code used to identify a subscriber's policy |
| Subscriber | purchaser of the insurance or the member of the group for which an employer or association as purchased insurance |
| Supervising provider | the physician monitoring a patient's care |
| Third-party payer | organization other than a patient who pays for services, such as insurance companies, Medicare, ans Medicaid |
| Tier 1 | providers and facilities in a PPO's network |
| Tier 2 | providers and facilities within a broader, contracted network of the insurance company |
| Tier 3 | providers and facilities out of the network |
| Tier 4 | providers and facilities not on the formulary |
| Timely filing requirement | within 1 calendar year of a claim's date of service |
| UB-04 code | three-digit code that describes a classification of a product or service provided to the patient |
| Unbundling | using multiple codes that describe different components of a treatment instead of using a single code that describes all steps of the procedure |
| Upcoding | assigning a diagnosis or procedure code at a higher level than the documentation supports, such as coding bronchitis as pneumonia |
| Utilization review | a process used to determine the medical necessity of a particular procedure or service, designed to ensure that the procedure or service is appropriate and is being provided in the most cost-effective way |
| Write-off | the difference between the provider's actual charge and the allowable charge |
Created by:
crystal_r
Popular Medical sets