Revenue Cycle & Regulatory Compliance
The provider billed for services that were not provided to obtain a higher reimbursement.
What is Fraud?
This is the reason why a patient's portion of the bill should be discussed with the patient before the procedure is performed.
What is to "ensure the patient understands how much they are responsible to pay?"
Chronic Kidney disesae would be included in which code set?
What is ICD-10-CM?
This describes an insurance company that offers plans that pay health care providers who render services to patients.
What is a Third-Party-Payer?
This following security feature is required during the transmission of Protected Health Information and medical claims to third-party-payers.
What is Encryption?
This is a review of documentation to determine whether appropriate billing practices were followed & accurate reimbursement was received.
What is an Audit?
This form is required for Medicare patients. It allows the patient to make an informed decision about a service that might not be covered by Medicare.
What is an Advanced Beneficiary Notice?
A patient has a diagnosis of Hypothyroidism. The thyroid gland is located in this body system.
What is the Endocrine System?
This term describes accounts receivable that are deemed to be "uncollectible."
What is a Bad Debt?
This number is needed to identify the provider on a medical claim.
What is an NPI Number?
National Provider Identifier
These covered entities are affected by HIPAA security rules. They are the middlemen between the provider and the third-party-payer.
What is a Healthcare Clearinghouse?
This is the specified amount of money that a patient who has a PPO(Preferred Provider Organization) plan is required to pay for each visit or medical service.
What is a Copayment?
This will add clarification to a code on whether a procedure was done on the left side, the right side, or bilaterally.
What is a Modifier?
This is used to communicate why a claim line item was denied or paid differently than it was billed.
What are Claim Adjustment Reason Codes?
This electronic form is used for post-reimbursement.
What is an Electronic Remittance Advice(ERA)?
This introduced documentation guidelines to Medicare carriers to ensure that services paid for have been provided and were medically necessary.
What is the Centers for Medicare & Medicaid Services?
This is the first step of the appeal process when working on a Medicare denial.
What is Redetermination?
This should be consulted as a resource to check for proper code assignment based on procedure-to-procedure(PTP) code pair edits & medically unlikely edits(MUEs).
What is the National Correct Coding Initiative(NCCI)?
This should be done when submitting a claim to Medicaid for a patient who has primary & secondary insurance coverage.
What is "attach the Remittance Advice from the primary insurance along with the Medicaid claim?"
A biller is reviewing an operative report for a patient who had a graft. This graft is a tissue transplanted from one person to another.
What is an Allograft?
This identifies improper payments made for CMS claims.
What are Recovery Audit Contractors(RACs)?
This type of claim is automatically adjudicated by Medicare and forwarded to the secondary insurance.
What is Crossover?
The specialist is coding a laceration repair and needs to determine the type of closure. The specialist queries the provider and confirms retention sutures were used. The procedure will be coded as this type of closure.
What is Complex?
This action should be done when claims have been found rejected by the clearinghouse.
What is "Review the scrubbed report?"
This type of diagnosis code is used to identify the presence of a pacemaker.
What is a Status?