Acronyms & Abbreviations

Question 1

HIPAA

Answer 1

Health Insurance Portability and Accountability Act

This act was passed in 1996 to protect privacy and security in the exchange of electronic health records.

Question 2

NCCI

Answer 2

National Correct Coding Initiative

NCCI is the CMS development intended to promote national correct coding methodologies and discourage improper medical coding that may lead to incorrect payment for Medicare Part B claims. It involves two categories of edits: Physician Edits, which apply to physician and non‐physician providers in addition to ambulatory surgery centers; and Hospital Outpatient Prospective Payment System Edits (Outpatient Edits), which apply to other providers such as hospitals.

Both sets of edits are maintained to identify codes that bundle together and indicate when unbundling may be permissible with the proper use of a particular modifier. They also indicate when unbundling is never appropriate. NCCI edits are maintained and revised if necessary on a quarterly basis.

Question 3

EHR

Answer 3

Electronic Health Record

The EHR is a digital record that may be shared by providers from more than one practice or entity such as a hospital. It is a key provision of the American Recovery and Reinvestment Act of 2009, which went into effect January 1, 2014, and required all public and private healthcare providers to adopt the use of electronic health records in order to avoid penalties that affect reimbursement.

The EHR differs from the EMR (electronic medical record), which is simply a digital version of a paper chart and is not shared outside the practice.

Question 4

Medicare Part A

Answer 4

Part A covers hospital stays, although not doctors’ fees. Part A also covers some home health services, skilled nursing care after a hospital stay and hospice care. If one has paid medicare taxes for 40 quarters (10 years) during his or her working career there is no monthly premium for Part A.

Question 5

Medicare Part B

Answer 5

Part B covers doctor fees, some home health care, medical equipment, outpatient procedures, rehabilitation therapy, laboratory tests, X-rays, mental health services, ambulance services and blood. Part B coverage is optional and incurs a monthly premium.

Question 6

Medicare Part C

Answer 6

Part C plans are optional plans provided by private insurance companies rather than the Federal government. Parts A and B have deductibles which the patient is responsible for and then usually cover only 80% of the costs. Part C plans help the patient meet these costs; they usually work with PPOs or HMOs. Some Part C Medicare Advantge Plans also cover prescription drugs

Question 7

Medicare Part D

Answer 7

Part D plans are offered by private insurance companies and help cover the cost of prescription drugs.

Question 8

PPO

Answer 8

Preferred Provider Organization

A health management plan that allows patients to visit any providers contracted with their insurance companies. If the patient visits a non-contracted provider, the claim is considered out-of-network.

Question 9

HMO

Answer 9

Health Maintenance Organization

A health management plan that requires the patient use a primary care physician who acts as a “gatekeeper.” In HMOs, patients much seek treatment from the primary physician first, who, if she feels the situation warrants it, can refer the patient to a specialist within the network.

Question 10

CMS

Answer 10

Centers for Medicare and Medicaid Services

Part of HHS, CMS is the federal agency that develops the policies and procedures for paying Medicare and Medicaid claims. CMS is responsible for updating ICD-10-PCS procedure classifications.

Question 11

NCHS

Answer 11

National Center for Health Statistics

Part of the CDC, NCHS is the principal health statistics agency in the US. It provides a public resource of statistical health information.

Question 12

CDC

Answer 12

Centers for Disease Control and Prevention

Part of HHS, the main goal of the CDC is to protect public health and safety through the control and prevention of disease, injury, and disability.

Question 13

WHO

Answer 13

World Health Organization

WHO is an agency of the United Nations that is concerned with international public health

Question 14

CAC system

Answer 14

Computer Assisted Coding system

CAC systems scan an EHR, identify key terms, and suggest medical codes that match the terms. The term ‘cancer’ may appear in an EHR indicating that there is a family history, but current systems will assume it is a diagnosis of cancer. A medical coder must review the suggested codes and approve them for medical claims.

Question 15

DRG

Answer 15

Diagnosis-Related Group

A DRG is a system of classifying any inpatient stay into groups for the purposes of payment. The DRG classification system divides possible diagnoses into more than 20 major body systems and subdivides them into almost 500 groups for the purpose of Medicare reimbursement.

Question 16

APC

Answer 16

Ambulatory Payment Classification

APC codes are used by hospitals to bill Medicare for outpatient services.

Question 17

NCD

Answer 17

National Coverage Determination

Medicare coverage is limited to items and services that are considered ‘reasonable and necessary’ for the diagnosis or treatment of an illness or injury. A National Coverage Determination (NCD) is a nationwide determination that Medicare will pay for an item or service. In the absence of a NCD, an item or service is covered at the discretion of the Medicare contractors based on a Local Coverage Determination (LCD).

Question 18

LCD

Answer 18

Local Coverage Determination

Medicare coverage is limited to items and services that are considered ‘reasonable and necessary’ for the diagnosis or treatment of an illness or injury. A National Coverage Determination (NCD) is a nationwide determination that Medicare will pay for an item or service. In the absence of a NCD, an item or service is covered at the discretion of the Medicare contractors based on a Local Coverage Determination (LCD).

Question 19

SNOMED CT

Answer 19

Systematic Nomenclature of Medicine - Clinical Terms

SNOMED CT is a computer accessible collection of medical terms, synonyms and definitions used in clinical documentation and reporting. Considered to be the most comprehensive, multilingual clinical healthcare terminology in the world SNOMED CT provides the core terminology for electronic health records (EHR).

Question 20

CPT

Answer 20

Current Procedural Terminology

CPT is a medical code set that is used to report medical, surgical, and diagnostic procedures and services. Its name reflects that it was developed by the American Medical Association (AMA) for standardizing the terminology used to describe medical services and procedures, but the term is now the copyrighted name for the AMA owned coding system.

Question 21

HCPCS

Answer 21

Healthcare Common Procedure Coding System

HCPCS “hicks-pics” is the coding system providers use to report medical procedures and professional services furnished in ambulatory / outpatient settings, including physician visits to inpatients. Level I of HCPCS is identical to the PCS codes developed and copyrighted by the AMA.

Question 22

ICD-10-CM

Answer 22

International Classification of Diseases, Tenth Revision, Clinical Modification

ICD-10-CM is a system for classifying diagnoses and reason for visits by patients in all American health care settings. The ICD-10-CM is based on classification of disease published by the World Health Organization (WHO).

Question 23

ICD-10-PCS

Answer 23

International Classification of Diseases, Tenth Revision, Procedure Coding System

The ICD-10-PCS is a system approved by the American Hospital Association (AHA), the American Health Information Management Association (AHIMA), the Centers for Medicare and Medicade Services (CMS), and the National Center for Health Statistics (NCHS) for classifying procedures performed in hospital inpatient health care settings.

Question 24

UHDDS

Answer 24

Uniform Hospital Discharge Data Set

UHDDS is used for reporting inpatient data in acute care, short-term care, and long-term care hospitals. It is required for reporting Medicare and Medicaid patients, but many other health care payers also use most of the UHDDS for the uniform billing system.

Question 25

POA

Answer 25

Present on Admission

In order to assign the proper Diagnosis-Related Group (DRG), conditions present on admission must be differentiated from conditions developed during treatment.

Question 26

MS-DRG

Answer 26

Medicare Severity Diagnosis Related Group

MS-DRG expands the number of DRGs to facilitate potential increases in diagnosable services and provide better recognition of the severity of illness than the traditional DRG system.

Question 27

OPPS

Answer 27

Hospital Outpatient Prospective Payment System

OPPS enables CMS to better predict and manage program expenditures by assigning fixed payment amounts to groups of services similarly to the inpatient prospective payment system (based on DRGs). The Outpatient Code Editor (OCE) is a software tool that combines editing logic with the new APC assignment program designed to meet the mandated OPPS implementation.

Question 28

OCE

Answer 28

Outpatient Code Editor

The Outpatient Code Editor (OCE) is a software tool that combines editing logic with the new APC assignment program designed to meet the OPPS requirement for hospital outpatient services.

Question 29

OIG

Answer 29

Office of Inspector General

The OIG is the section of the U.S. Department of Health & Human Services (HHS) at the forefront of the Nation’s efforts to fight waste, fraud, and abuse in Medicare, Medicaid and more than 100 other HHS programs.

Question 30

MAC

Answer 30

Medicare Administrative Contractor

Originally Medicare claims were processed by private health care insurers known as Fiscal Intermediaries (FI). Since 2003 this role has been transferred to regional Medicare Administrative Contractors (MAC)

Question 31

EDMS

Answer 31

Electronic Document Management System

Hospitals that have not adopted full Electronic Health Records (EHR) sometimes use EDMSs to scan all paper records making them available online.

Question 32

NLP

Answer 32

Natural Language Processing

NLP is an artificial intelligence field which can convert natural language into computer understandable code. “Seri” and “Echo” use NLP to understand spoken commands. NLP can be used in medical coding to read written records and suggest proper codes.

Question 33

Grouper

Answer 33

A software program called a ‘grouper’ can take ICD-10-CM/CPS and/or CPT/HCPCS codes and assign the proper DRG for billing.

Question 34

DEEDS

Answer 34

Data Elements for Emergency Departments Systems

Data set originally compiled by the CDC to smooth integration between emergency response systems

Question 35

EMEDS

Answer 35

Expeditionary Medical Support Systems

The Expeditionary Medical Support System (EMEDS) is a modular field hospital system developed by the U.S. military for mobile deployment of medical treatment facilities in any location.

Question 36

UACDS

Answer 36

Uniform Ambulatory Care Data Set

Standardized record similar to the Uniform Hospital Discharge Data Set (UHDDS) but for ambulatory care facilities (physician offices, medical clinics, same-day surgery centers, outpatient hospital clinics and diagnostic departments, emergency treatment centers, and hospital emergency departments)

Question 37

UHDDS

Answer 37

Uniform Hospital Discharge Data Set

Hospitals that provide medical services for those covered by Medicare and Medicaid must compile these records but it is standard practice for all insurance companies to gather information similar to the UHDDS because of the recognized value of having comparable data. The data set includes:

1. Hospital or facility identification number or code
2. Expected insurance payer number or code
3. Sex, age, and race of the patient
4. Significant medical procedures performed
5. Principal diagnosis
6. Additional significant diagnoses