B&C Chapter 10: Coding Compliance Programs, Clinical Documentation Improvement, and Coding for Medical Necessity Flashcards
assessment
contains the diagnostic statement and may include the provider’s rationale for the diagnosis.
auditing process
review of patient records and CMS-1500 (or UB-40) claims to assess coding accuracy and whether documentation is complete.
clinical documentation improvement (CDI)
ensures accurate and thorough documentation in patient records through the identification of discrepancies between provider documentation and codes to be assigned
clinical documentation integrity (CDI)
ensures accurate and thorough documentation in patient records through the identification of discrepancies between provider documentation and codes to be assigned
coding compliance
conformity to established coding guidelines and regulations
coding compliance program
developed by health information management departments and similar areas, such as the coding and billing section of a physician’s practice, to ensure coding accuracy and conformance with guidelines and regulations; includes written policies and procedures, routine coding audits and monitoring (internal and external), and compliance-based education and training.
coding for medical necessity
involves assigning ICD-10-CM codes to diagnoses and CPT/HCPCS level II codes to procedures/services, and then matching an appropriate ICD-10-CM code with each CPT or HCPCS level II code
compliance program guidance
documents published by the DHHS OIG to encourage the development and use of internal controls by health care organizations (e.g., hospitals) for the purpose of monitoring adherence to applicable statutes, regulations, and program requirements.
local coverage determination (LCD)
formerly called local medical review policy (LMRP); Medicare administrative contractors create edits for national coverage determination rules that are called LCDs.
medically managed
a particular diagnosis (e.g., hypertension) may not receive direct treatment during an office visit, but the provider had to consider that diagnosis when considering treatment for other conditions
medically unlikely edit (MUE)
used to compare units of service (UOS) with CPT and HCPCS level II codes reported on claims; indicates the maximum number of UOS allowable by the same provider for the same beneficiary on the same date of service under most circumstances; the MUE project was implemented to improve the accuracy of Medicare payments by detecting and denying unlikely Medicare claims on a prepayment basis. On the CMS-1500, Block 24G (units of service) is compared with Block 24D (code number) on the same line. On the UB-04, Form Locator 46 (service units) is compared with Form Locator 44.
Medicare coverage database (MCD)
used by Medicare administrative contractors, providers, and other health care industry professionals to determine whether a procedure or service is reasonable and necessary for the diagnosis or treatment of an illness or injury; contains national coverage determinations (NCDs), including draft policies and proposed decisions; local coverage determinations (LCDs), including policy articles; and national coverage analyses (NCAs), coding analyses for labs (CALs), Medicare Evidence Development & Coverage Advisory Committee (MedCAC) proceedings, and Medicare coverage guidance documents.
Medicare code editor (MCE)
software program used to detect and report errors in ICD-10-CM/PCS coded data during processing of inpatient hospital Medicare claims.
narrative clinic note
using paragraph format to document health care
national coverage determination (NCD)
rules developed by CMS that specify under what clinical circumstances a service or procedure is covered (including clinical circumstances considered reasonable and necessary) and correctly coded; Medicare administrative contractors create edits for NCD rules, called local coverage determinations (LCDs).
