NHA CBCS Certification Study Guide

abstracting - correct answer the extraction of specific data from a medical record, often for use in an external database, such as a cancer registry abuse - correct answer practices that directly or indirectly result in unnecessary costs to the Medicare program account number - correct answer number that identifies specific episode of care, date of service, or patient accounts receivable department - correct answer Department that keeps track of what third-party payers the provider is waiting to hear from and what patients are due to make a payment. activity/status date - correct answer Indicates the most recent activity of an item. actual charge - correct answer the amount the provider charges for the health care service Administration Simplification Compliance Act (ASCA) - correct answer specifically prohibits any payment by Medicare for services or medically necessary supplies that are not submitted electronically administrative services only (ASO) contract - correct answer Contract between employers and private insurers under which employers fund the plans themselves, and the private insurers administer the plans for the employers. Advance Beneficiary Notice of Noncoverage (ABN) - correct answer Form provided if a provider believes that a service may be declined because Medicare might consider it unnecessary. aging report - correct answer Measures the outstanding balances in each account. allowable charge - correct answer The amount an insurer will accept as full payment, minus applicable cost sharing. APC grouper - correct answer Helps coders determine the appropriate ambulatory payment classification (APC) for an outpatient encounter. assignment of benefits - correct answer Contract in which the provider directly bills the payer and accepts the allowable charge. auditing - correct answer review of claims for accuracy and completeness authorization - correct answer Permission granted by the patient or the patient's representative to release information for reasons other than treatment, payment, or health care operations. balance billing - correct answer Billing patients for charges in excess of the Medicare fee schedule. batch - correct answer a group of submitted claims Blue Cross and Blue Shield plan - correct answer The first prepaid plan in the U.S. that offers health insurance to individuals, small businesses, seniors, and large employer groups. business associate (BA) - correct answer Individuals, groups, or organizations, who are not members of a covered entity's workforce, that perform functions or activities on behalf of or for a covered entity. capitation - correct answer the fixed amount a provider receives case management - correct answer a review of clinical services being performed Category I CPT code - correct answer Code that covers physicians' services and hospital outpatient coding. Category II CPT code - correct answer code designed to serve as supplemental tracking codes that can be used for performance measurement Category III CPT code - correct answer Code used for temporary coding for new technology and services that have not met the requirements needed to be added to the main section of the CPT book. charge amount - correct answer The amount the facility charges for the procedure or service. Charge Description Master (CDM) - correct answer Information about health care services that patients have received and financial transactions that have taken place. charge or service code - correct answer internally assigned number unique to each facility claim - correct answer a complete record of services provided by a health care professional, along with appropriate insurance information, submitted for reimbursement to a third-party payer claims adjustment reason code (CARC) - correct answer Provides financial information about claims decisions. claim scrubber - correct answer Software that reviews a claim prior to submission for correct and complete data, such as accurate gender in alignment with diagnosis/procedure or medical necessity. clean claim - correct answer Claim that is accurate and complete. They have all the information needed for processing, which is done in a timely fashion. clearinghouse - correct answer Agency that converts claims into a standardized electronic format, looks for errors, and formats them according to HIPAA and insurance standards. clinical documentation - correct answer The record of clinical observations and care a patient receives at a health care facility. commercial insurance - correct answer private and employer-based self-insurance computer-assisted coding (CAC) - correct answer software that scans the entire patient's electronic record and codes the encounter based on the documentation in the record conditional payment - correct answer Medicare payment that is recovered after primary insurance pays. consent - correct answer a patient's permission evidenced by a signature contractual obligation - correct answer Used when a contractual agreement resulted in an adjustment coordination of benefits rules - correct answer Determines which insurance plan is primary and which is secondary. correction and renewal - correct answer used for correcting a prior claim cost sharing - correct answer The balance the policyholder must pay to the provider. crossover claim - correct answer claim submitted by people covered by a primary and secondary insurance plan de-identified information - correct answer Information that does not identify an individual because unique and personal characteristics have been removed. demographic information - correct answer Date of birth, sex, marital status, address, telephone number, relationship to subscriber, and circumstances of condition. description of service - correct answer An evaluation and management visit, observation, or emergency room visit. diagnosis code - correct answer International Classification of Diseases (ICD-10-CM) dirty claim - correct answer claim that is inaccurate, incomplete, or contains other errors Electronic Data Interchange (EDI) - correct answer The transfer of electronic information in a standard format Employer-based self-insurance - correct answer Insurance that is tied to an individual's place of employment. encounter - correct answer software that suggests codes based on documentation or other input encoder - correct answer a direct, professional meeting between a patient and a health care professional who is licensed to provide medical services encounter form - correct answer Form that includes information about past history, current history, inpatient record, discharge information and insurance information. Explanation of Benefits (EOB) - correct answer Describes the services rendered, payment covered, and benefit limits and denials. Fair Debt Collection Practices Act (FDCPA) - correct answer Debt collectors cannot use unfair or abusive practices to collect payments. False Claims Act (FCA) - correct answer protects the government from being overcharged for services provided or sold, or substandard goods or services Final Rule - correct answer strengthens the HIPAA ruling around privacy, security, breach notification, and penalties formulary - correct answer A list of prescription drugs covered by an insurance plan. fraud - correct answer making false statements of representations of material facts to obtain some benefit or payment for which no entitlement would otherwise exist gatekeeper - correct answer provider who determines the appropriateness of the health care service, level of health care professional called for, and setting for care general ledger key - correct answer A two- or three-digit number that makes sure that a line item is assigned to the general ledger in the hospital's accounting system. group code - correct answer Code that identifies the party financially responsible for a specific service or the general category of payment adjustment. group or plan number - correct answer unique code used to identify a set of benefits of one group of type of plan group practice model - correct answer HMO that contracts with an outside medical group for services Health Insurance Portability and Accountability Act (HIPAA) - correct answer legislation that includes Title II, the first parameters designed to protect the privacy and security of patient information Health Maintenance Organization (HMO) - correct answer Plan that allows patients to only go to physicians, other health care professionals, or hospitals on a list of approved providers, except in an emergency. health record number - correct answer Number the provider uses to identify an individual patient's record. ICD-10-CM - correct answer Coding and classification system that captures diseases and health-related conditions. Developed by the World Health Organization (WHO) and adapted to the U.S. health care system for uses that include securing reimbursement for services provided. ICD-10-PCS - correct answer Coding and classification system developed for use in the U.S. only. Specific to inpatient hospital procedures implied consent - correct answer A patient presents for treatment, such as extending an arm to allow a venipuncture to be performed.