| This law designated the code sets for healthcare services reporting to public and private insurers | The Health Insurance Portability and Accountability Act (HIPAA) of 1996 |
| The ICD-10-CM coding set is used to communicate ________ to private and public reimbursement systems. | diagnoses |
| ICD-10-CM was developed by | the National Center for Health Statistics (NCHS) |
| Uses of ICD-10-CM include | 1) collect administrative data on medical processes and outcomes 2) for reimbursement systems and 3) integrating into EHRs |
| ICD-10-PCS is used to communicate __________ to private and public reimbursement systems. | inpatient procedures |
| The ICD (International Classification of Diseases) was developed by the | World Health Organization (WHO) |
| ICD-10-PCS was developed by | CMS |
| ICD-10-CM and ICD-10-PCS serve as | the communication vehicle between providers and insurers |
| The ______ Coding Clinic provides additional guidance to be used for ICD-10-CM/PCS | AHA (American Hospital Association) |
| The Healthcare Common Procedure Coding System (HCPCS) is a 2-tiered system of procedural codes used primarily for ________ and __________. | ambulatory care, physician services |
| The first tier of HCPCS is __________, and the second tier is ____________. | CPT, HCPCS Level II |
| CDMs stand for | Charge description masters |
| CPT is used by | 1) physicians to report services they performed (inpatient and outpatient) and 2) facilities for outpatient services and procedures |
| The CPT was developed and is maintained by | AMA (American Medical Association) |
| Category II codes in CPT are used for | performance measurement |
| Category III codes in CPT are | temporary codes that represent new and emerging technologies |
| Failure to have supporting documentation to support code selection and/or modifier selection can lead to | claim denials and fraud or abuse penalties |
| HCPCS Level II was developed by _________ in the19____. | CMS, 1980s |
| HCPCS level II is used to report codes for | supplies, services, and procedures not represented in CPT |
| HCPCS level II modifiers indicate | body areas |
| This publication gives coding advice for HCPCS level II | AHA Coding Clinic for HCPCS |
| This publication gives coding advice for CPT | CPT Assistant |
| The purpose of the CMS hierarchical condition categories (HCC) model is to | provide fair and accurate payments while rewarding efficiency and high-quality care for Medicare's chronically ill patients |
| This type of code directly impacts risk scores that are calculated in HCCs | ICD-10-CM diagnosis codes |
| The cooperating parties of ICD-10-CM/PCS are | CMS, AHA, NCHS, and AHIMA |
| "intentional misrepresentation that an individual knows to be false" in order to benefit him/herself or someone else is known as | fraud |
| When a healthcare provider unknowingly or unintentionally submits an inaccurate claim for payment, this is known as | abuse |
| This bill was passed during the Civil War to penalize federal contractors who knowingly filed false or fraudulent claims, used false records or statements, or conspired to defraud the US government. | The False Claims Act |
| This act allows for fines up to $10,000 per violation for Medicare fraud or abuse. | The Medicare and Medicaid Patient and Program Protection Act of 1987 |
| OIG stands for | Office of Inspector General |
| Written policies and procedures, designation of a compliance officer, education and training, communication, auditing and monitoring, disciplinary action, and corrective action are 7 elements of _________ | an effective corporate compliance plan |
| Operation Restore Trust was released in 1995 to | target Medicare and Medicaid fraud and abuse among healthcare providers and was a major push for accurate coding and billing |
| The Medicare Integrity Program (1996) was created by | HIPAA |
| One provision of this act was that medicare beneficiaries would be educated about their role in preventing and reporting fraud. | The Balanced Budget Act of 1997 |
| Medicare Summary Notices (MSNs) were formerly known as this | Explanations of Medicare Benefits (EOMBs) |
| This act requires all federal agencies to provide an estimate of improper payments and describe how they are combating this. | The Improper Payments Information Act (2002) |
| IPERA stands for | Improper Payments Elimination and Recovery Act (2013) |
| This act strengthened efforts to identify, prevent and recover improper payments | IPERIA (Improper Payments Elimination and Recovery Improvement Act) |
| Medical reviews completed by Medicare contractors to identify improper payments are also known as | improper payment reviews |
| Claims in CERT and PERM reviews are ____________ (targeted/randomly selected) | randomly selected |
| The purpose of CERT is to measure | improper payments |
| RACs stands for | Recovery audit contractors |
| Recovery audit contractors carry out provisions of the _______________ Act | National Recovery Audit Program |
| RACs are reimbursed via | a contingency fee based on the amount of improper payments |
| A vulnerability is a | type of claim that is vulnerable to improper payments, which is a financial risk to the Medicare program |
| RVC stands for | Recovery audit validation contractor |
| CMS uses this type of contractor to ensure accuracy of RACs | RVCs (recovery audit validation contractors) |
| MACs and QICs are | parties who receive and decide on appeals about claims |
| benchmarking is the process of | comparing performance with preestablished standards of another facility or group |
| internal benchmarking allows the manager to | examine reporting rates over time |
| external benchmarking allows the manager to | know how his/her team performs in comparison to other teams |
| internal benchmarking is also known as | trending |
| external benchmarking is also known as | peer comparison |
