| A | B |
|---|
| advisory opinion | legal advise only for requesting parties who, if they act on advise, are immune from investigation on the matter |
| assumptiion coding | reporting items or services not actually documented ,but the coder assumes they were performed |
| code edits | a computerized screening system process used by Medicare to check claims when they are submitted. It indicates which products and services cannot be billed together for same patien t on same day of service |
| correct coding initiative (CCI) | ongoing process to standardise bundled codes and control improper coding that would lead to improper payment for medical claims |
| downcode | when the upcoding is discovered by the payer, it is changed to the lower value code that the payer thinks is correct |
| external audit | private private payers or government investigators review selected records of a practice for compliance |
| internal audit | audits that are routine and performed periodically without a reason to think that a compliance problem exists |
| job reference aids | "cheat sheets" to help the coding process |
| Medicare carrier | insurance companies hired as independent contractors to administer claims for HCFA in a particular geographical area |
| Medicare carrier's manual | rules and interpretations of Medicare program's guidelines |
| OIG(Office of Inspector General) work plan | lists the year's planned projects for sampling particular types of billing to see if there are problems.Points to areas in which government investigations will focus |
| OIG (Office of Inspector General) Fraud alert | issued periodically to advise providers of problematic actions that have come to the OIG's attention |
| overpayment | improper or excessive payments resulting from billing errors for which a refund is owed by the provider |
| prospective audit | done before the claims that are being examined are reported to a payer for reimbursement |
| retrospective audit | conducted after the claims have been submitted for payment and E.O.B.(explanation of benefits) |
| truncated coding | diagnosis codes which are not reported at the highest level of specificity available, which causes rejected claims, as does using codes which are out of date |
| upcode | using a procedure code that provides a higher reimbursement rate than the code that actually reflects the service provided |
