Chapter 6 Visit Charges And Compliant Billing

audit

methodical review in medical insurance, a formal examination of a physician's accounting or patient medical records.

advisory opinion

opinion issued by CMS or OIG that becomes legal advice.

documentation template

physician practice form used to prompt the physician to document a complete review of systems when done and the medical necessity for the planned treatment.

professional courtesy

providing free medical services to other physicians.

assumption coding

reporting undocumented services that the coder assumes have been provided because of the nature of the case or condition.

internal audit

self-audit conducted by a staff member or consultant as a routine check of compliance with reporting regulations.

resource-based fee structure

setting fees based on the relative skill and time required to provide similar services.

usual, customary, and reasonable

setting fees by comparing the usual fee the provider charges for the service, the customary fee charged by most providers in the community, and the fee that is reasonable considering the circumstances.

relative value scale

system of assigning unit values to medical services based on an analysis of the skill and time required of the physician to perform them.

medicare physician fee schedule

the RBRVS-based allowed fees that are the basis for Medicare reimbursement.

code linkage

the connection between a service and a patient's condition or illness; establishes the medical necessity of the procedure.

capitation rate (cap rate)

the contractually set periodic prepayment to a provider for specified services to each enrolled plan member.

write off

to deduct an amount from a patient's account because of a contractual agreement to accept a payer's allowed charge of for other reasons.

upcoding

use of a procedure code that provides a higher payment than the code for the service actually provided.

resource-based relative value scale

federally mandated relative value scale for establishing Medicare charges.

usual fee

fee for a service or procedure that is charged by a provider for most patients under typical circumstances.

charge-based fee structure

fees based on the amounts typically charged for similar services.

recovery audit contractor

hired by CMS to validate claims that have been paid to providers and to collect a payback of any incorrect payments that are identified.

excluded parties

individuals or companies not permitted to participate in federal healthcare programs.

prospective audit

internal audit of particular claims conducted before they are transmitted to payers.

job reference aid

list of a medical practice's frequently reported procedures and diagnoses.

allowed charge

maximum charge that a health plan pays for a specific service or procedure; also called allowable charge, maximum fee, and other terms.

walkout receipt

medical billing program report given to a patient that lists the diagnoses, services provided, fees, and payments received and due after an encounter.

CCI column 1/column 2 code pair edit

medicare code edit where CPT codes in column 2 will not be paid if reported in the same day as the column 1 code.

geographic practice cost index

medicare factor used to adjust provider's fess to reflect the cost of providing services in a particular area relative to national averages.

medically unlikely edits

CMS unit of service edits that check for clerical or software-based coding or billing errors, such as anatomically related mistakes.

truncated coding

diagnoses that are not coded at the highest level of specificity available.

adjustment

a change, positive or negative, to correct a patient's account balance for items such as returned check fees.

relative value unit

a factor assigned to a medical service based on the relative skill and time required to perform it.

CCI modifier indicator

a number that shows whether the use of a modifier can bypass a CCI edit.

downcoding

a payer's review and reduction of a procedure code (often an E/M code) to a lower level than reported by the provider.

computer-assisted coding

a software program that assists providers and medical coders in assigning codes based on the documentation of a visit.

provider withhold

amount withheld from a provider's payment by an MCO under contractual terms, may be paid if stated financial requirements are met.

bundle payment

an experimental medicare payment method by which an entire of care is paid for by a predetermined single payment.

retrospective audit

an internal conducted after claims are processed by payers and after RA's have been received for comparison with submitted charges.

OIG work plan

annual list of planned projects under the Medicare Fraud and Abuse Initiative.

external audit

audit conducted by an organization outside of the practice, such as a federal agency.

CCI mutually exclusive code edit

both services represent by MEC codes that could not have been done during one encounter.

balance billing

collecting the difference between a provider's usual fee and a payer's lower allowed charge from the insure.

correct coding initiative

computerized medicare system to prevent overpayment for procedures.

edits

computerized screening system used to identify improperly or incorrectly reported codes.

conversion factor

dollar amount used to multiply a relative value unit to arrive at a charge.