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A two digit alpha/numeric codes used in conjunction with the CPT or HCPCS code that may increase or decrease reimbursement
What is a Modifier?
A statistical classification system that arranges diseases and injuries into groups according to established criteria
What is the International Classification of Disease, Ninth Edition, Clinical Modification (ICD-9-CM)?
The American Medical Association (AMA) publishes and maintains this coding system
What is Current Procedural Terminology or CPT?
An inpatient classification system based on: principal diagnosis, secondary diagnosis, surgical factors, age, sex, and discharge status
What is Diagnosis Related Groups or DRGs?
CMS contracts with the AMA to use CPT coding for the Medicare program using this expanded version
What is Healthcare Common Procedure Coding System or HCPCS?
Providers use a billing code that reflects a higher payment rate for a device or service provided than the actual device or service furnished to the patient
What is Upcoding?
Submitting bills by piecemeal or in fragmented fashion to maximize reimbursement
What is Unbundling?
Services commonly furnished in a physician’s office by a nurse practitioner in which there is direct physician personal supervision and are billed under the physician’s provider number
What is “Incident To” Services?
A written form that a provider gives to a Medicare beneficiary that informs the beneficiary that Medicare may not pay for a item or service
What is an Advance Beneficiary Notice or ABN?
Used to identify the correct insurance company that must pay health care bills first when Medicare pays second
What is a Medicare Secondary Payer Questionnaire?
(1) History (2) Examination (3) Medical Decision Making
What are the three key components of Evaluation and Management (E&M) Services?
Problem Focused Expanded Problem Focus Detailed Comprehensive
What are the types of History or Examination?
Straight-forward Low complexity Moderate complexity High complexity
What are the Complexities of Medical Decision Making?
3 out of 3 key elements of E & M Services must be met or exceeded in order to bill for this type of visit
What is an initial patient visit?
2 out of 3 key elements of E & M Services must be met or exceeded in order to bill for this type of visit
What is an established patient visit?
Part of Medicare that reimburses primarily for inpatient services provided by institutions such as hospitals and skilled nursing facilities
What is Medicare Part A?
Part of the Medicare program that reimburses covered physician and supplier services
What is Medicare Part B?
Formerly known as "Medicare+Choice”
What is Medicare Part C or Medicare Advantage?
Part of Medicare that reimburses for outpatient prescription drugs
What is Medicare Part D?
State health insurance that helps many people who can't afford medical care and pays for some or all of their medical bills
What is Medicaid?
Non-institutional providers use this form to bill Medicare, Medicaid, CHAMPUS, and most private insurance companies
What is a 1500 Form?
Institutional providers use this form to bill Medicare, Medicaid, CHAMPUS, and most private insurance companies
What is a CMS 1450 or a UB-04?
An insurance company that contracts with CMS to process Medicare Part A claims
What is a Fiscal Intermediary (FI)?
An insurance company that contracts with CMS to process Medicare Part B claims
What is a Carrier?
HHS Agency that establishes payment policies for providers Conducts research Evaluates the quality of care provided to beneficiaries
What is the Centers for Medicare and Medicaid Services?
Geographic areas that have been designated as primary medical care shortage areas where physicians who furnish medical care are entitled to a Medicare incentive payment.
What is Health Professional Shortage Area?