Chapter One: Introduction To Coding

Front 1

Abuse

Back 1

Incidents that are inconsistent with good business practices and result

Front 2

CCI edits

Back 2

Also known as NCCI, or National Correct Coding Initiative. Series of CPT® code sets in which one code is excluded from use because of its direct correlation to the other.

Front 3

Capitation

Back 3

A predetermined amount of reimbursement based “per capita” or per person. Commonly used by HMO’s and certain federal programs.

Front 4

Bundling

Back 4

Individual procedures that are considered part of a larger operation and are grouped together, or “bundled.”

Front 5

Clean claim

Back 5

A complete, correct health insurance claim that passes through age, sex, diagnosis to procedure and other edits set up by third-party payers, Medicare and Medicaid.

Front 6

CMS

Back 6

A federal agency, the Center for Medicare and Medicaid Services, formerly HCFA (Health Care Financing Administration)

Front 7

Clustering

Back 7

: Assigning codes to one or two middle levels of service codes exclusively, under the philosophy that some will be higher, some lower, and they will average out over an extended period. In reality, this overcharges some patients while undercharging others.

Front 8

Compliance Plan

Back 8

A written statement by a healthcare entity, describing the ethical actions of that business. It must contain all the steps required by the federal government.

Front 9

Denial

Back 9

Claim that is rejected by insurance companies, Medicare, or Medicaid after failing the edit system.

Front 10

False Claims Act

Back 10

Prohibits knowingly presenting a false or fraudulent claim to the federal government for payment or presenting false records or statements in order to get a claim paid.

Front 11

Fraud

Back 11

To purposely bill for services that were never given or to bill for a service that has a higher reimbursement than the service provided.

Front 12

Fee for Service

Back 12

Basic reimbursement method based on individual physician charges.

Front 13

HIPPA

Back 13

Health Insurance Portability and Accountability Act