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Ch.2 Insurance
documentation
| Question | Answer |
|---|---|
| auditing process | review of patient records and CMS-1500 (or UB-04) claims to assess coding accuracy and whether documentation is complete. |
| clinical documentation improvement (CDI) | ensures accurate and thorough documentation in patient records through the identification of discrepancies between provider documentation and codes to be assigned. |
| clinical documentation integrity (CDI) | ensures accurate and thorough documentation in patient records through the identification of discrepancies between provider documentation and codes to be assigned. |
| coding compliance | conformity to established coding guidelines and regulations. |
| coding compliance programs | developed by health information management departments and similar areas, such as the coding and billing section of a physician’s practice, to ensure coding accuracy and conformance with guidelines and regulations; |
| coding for medical necessity | involves assigning ICD-10-CM codes to diagnoses and CPT/HCPCS Level II codes to procedures/services, and then matching an appropriate ICD-10-CM code with each CPT or HCPCS Level II code. |
| compliance program guidance | documents published by the DHHS OIG to encourage the development and use of internal controls by health care organizations (e.g., hospitals) for the purpose of monitoring adherence to applicable statutes, regulations, and program requirements. |
| local coverage determinations (LCDs) | formerly called local medical review policy (LMRP); Medicare administrative contractors create edits for national coverage determination rules that are called LCDs. |
| medically managed | a particular diagnosis (e.g., hypertension) may not receive direct treatment during an office visit, but the provider had to consider that diagnosis when considering treatment for other conditions. |
| medically unlikely edit (MUE) | used to compare units of service (UOS) with CPT and HCPCS Level II codes reported on claims; indicates the maximum number of UOS allowable by the same provider for the same beneficiary on the same date of service under most circumstances; |
| Medicare code editor (MCE) | software program used to detect and report errors in ICD-10-CM/PCS coded data during processing of inpatient hospital Medicare claims. |
| Medicare coverage database (MCD) | used to determine whether a procedure or service is reasonable and necessary for the diagnosis or treatment of an illness or injury; |
| narrative clinic note | using paragraph format to document health care. |
| National Correct Coding Initiative (NCCI) program | developed by CMS to promote national correct coding methodologies and to eliminate improper coding practices. |
| national coverage determinations (NCD) | rules that specify under what clinical circumstances a service or procedure is covered and correctly coded; Medicare administrative contractors create edits for NCD rules called local coverage determinations (LCDs). |
| operative reports | varies from a short narrative description of a minor procedure that is performed in the physician’s office to a more formal report dictated by the surgeon in a format required by the hospitals and ambulatory surgical centers (ASCs). |
| outpatient code editor (OCE) | software that edits outpatient claims submitted by health care facilities; the software reviews submissions for coding validity OCE edits result in one of the following dispositions: rejection, denial, return to provider (RTP), or suspension. |
| procedure-to-procedure (PTP) code pair edits | automated prepayment NCCI program edits that prevent improper payment when certain codes are submitted together for Medicare Part B covered services. |
| SOAP note | outline format for documenting health care; “SOAP” is an acronym derived from the first letter of the headings used in the note: Subjective, Objective, Assessment, and Plan. |
| assessment | contains the diagnostic statement and may include the provider’s rationale for the diagnosis. |
| objective | documentation of measurable or objective observations made during physical examination and diagnostic testing. |
| plan | statement of the physician’s future plans for the work-up and medical management of the case. |
| subjective | part of the note that contains the chief complaint and the patient’s description of the presenting problem. |
Created by:
Hannah Q