ACA CCS flashcards

33 cards. Read the term and the definition here. The deck at the top of this page is optional.

ICD-10-CM code structure

Codes are 3-7 characters; the first character is alphabetic, the second numeric, and later characters may be letters or digits. A 7th character may indicate encounter type or laterality.

Placeholder X

Used in ICD-10-CM when a 7th character is required but the 6th character is not otherwise used, allowing the code to reach the required length.

7th character A

In ICD-10-CM injury and fracture codes, the 7th character A indicates the initial encounter for the condition being actively treated.

External cause code

An ICD-10-CM code from categories V, W, X, or Y describing how and where an injury or event occurred. It is never sequenced as the principal diagnosis.

Combination code

A single ICD-10-CM code that represents two diagnoses, or a diagnosis with an associated secondary condition, complication, or manifestation.

Code first note

An ICD-10-CM instruction indicating the underlying etiology or cause must be sequenced before the manifestation or secondary condition code.

ICD-10-PCS structure

Seven alphanumeric characters with no decimal: Section, Body System, Root Operation, Body Part, Approach, Device, and Qualifier.

Root operation

The third character of an ICD-10-PCS code that defines the objective of the procedure, such as Excision, Resection, Reposition, or Insertion.

Excision versus resection

In ICD-10-PCS, excision removes a portion of a body part while resection removes the entire body part; documentation of extent determines which root operation is coded.

PCS approach character

The fifth character of an ICD-10-PCS code describing how the procedure was performed, such as 0 Open, 3 Percutaneous, or 4 Percutaneous Endoscopic.

PCS device character

The sixth character of an ICD-10-PCS code identifying whether a device was used or left in place, such as Z for no device.

CPT Category III

Temporary CPT codes ending in 'T' used for emerging technology, services, or procedures that do not yet meet Category I criteria.

Modifier 25

CPT modifier appended to an E/M service indicating a significant, separately identifiable evaluation and management service was performed on the same day as another procedure.

Modifier 59

CPT modifier indicating a distinct procedural service, used to identify procedures not normally reported together but appropriate under the circumstances.

Modifier 57

CPT modifier appended to an E/M service indicating the encounter resulted in the decision for surgery, including the preoperative workup.

Global surgical period

The number of postoperative days included in a surgical code's payment: 0 days for minor or endoscopic, 10 days for minor, 90 days for major procedures.

HCPCS J codes

HCPCS Level II codes beginning with J used to report drugs and biologicals, including their dosage and method of administration.

Medical decision making

An E/M level selection method based on number and complexity of problems, amount and complexity of data reviewed, and risk of complications or mortality.

Add-on code

A CPT code describing a service always performed with a primary procedure; it is never reported alone and is exempt from modifier 51.

MS-DRG

Medicare Severity Diagnosis Related Group used for inpatient payment, determined by principal diagnosis, secondary diagnoses, procedures, and discharge disposition.

APC payment

Ambulatory Payment Classification groups outpatient services under the Medicare OPPS; status indicators determine whether and how a code is paid.

RVU

Relative value unit used by the Medicare Physician Fee Schedule, composed of work, practice expense, and malpractice components multiplied by a conversion factor.

Days in A/R

A revenue cycle metric calculated as total accounts receivable divided by total charges, multiplied by the number of days in the period.

Coordination of benefits

The process determining which payer is primary and which is secondary when a patient has coverage under more than one health plan.

CARC and RARC

Claim Adjustment Reason Codes and Remittance Advice Remark Codes appear on remittance advice and explain why a claim or line was denied or adjusted.

False Claims Act

Federal law imposing treble damages and civil penalties on entities that knowingly submit false or fraudulent claims to government health care programs.

Anti-Kickback Statute

Federal law prohibiting knowingly offering or receiving remuneration to induce referrals for items or services payable by federal health care programs.

Stark Law

Federal physician self-referral law prohibiting referrals of designated health services to entities with which the physician has a financial relationship, absent an exception.

HIPAA minimum necessary

A Privacy Rule standard requiring covered entities to limit uses and disclosures of protected health information to the minimum needed to accomplish the purpose.

Unbundling

Billing individual components of a procedure or service separately to increase payment, a compliance risk area subject to CCI edits and audits.

Master Patient Index

An HIM database that uniquely identifies each patient across encounters; duplicate or overlapped records represent a significant data integrity risk.

Legal health record

The official business record of the healthcare organization designated for disclosure, which may differ from the complete medical record.

Leading query

A physician query that suggests or directs a specific diagnosis rather than seeking clarification from clinical indicators; discouraged in compliant query practice.