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
storage of documentation for an established period of time, usually mandated by federal and/or state law; its purpose is to ensure the availability of records for use by government agencies and other third parties.
record retention
pairs of CPT and/or HCPCS level II codes, whicha re not separately payable except under certain circumstances (e.g., reporting appropriate modifier).
CCI Edits
document published by MC that contains new and changed policies and/or procedures that are to be incorporated into a specific CMS program manual.
program transmittal
unique identifier to be assigned to health care providers as an 8 or possibly 10-character alphanumeric identifier, including a check digit in the last position
National Provider Identifier (NPI)
funds a provider or beneficiary has received in excess of amounts due and payable under Medicare and Medicaid statutes and regulations.
overpayment
the lesser procedure or service when reported with another code. The component code is part of a major procedure or service and is often represented by a lower work relative value unit (RVU) under the MC Dr.fee schedule as compared to the other code repo
component code
unique identifier, previously called PAYERID, that will be assigned to third-party payers and is expected tohave 10 numberic positions, including a check digit in the tenth position.
National Health PlanID (PlanID)
two digit code attached to the main code; indicates that a procedure/service has been altered in some manner.
modifier
CMS's HPMP replaced PEEP. The goal is to measure, monitor, and reduce the incidence of Medicare fee-for-service payment errors for short-term, acute care, inpatient PPS hospitals
