ACA CCS key terms

A standardized code set maintained by the American Medical Association that describes medical, surgical, and diagnostic services and is used mainly to report physician and outpatient procedures for reimbursement.

A national code set maintained by CMS that identifies products, supplies, and services not represented in CPT, such as drugs, durable medical equipment, and ambulance transport.

The diagnosis classification system used in the United States to report diseases, injuries, and health conditions on claims and in medical records, organized by body system and chapters.

The inpatient procedure classification system used in the United States, built from seven-character alphanumeric codes that describe the body system, root operation, body part, approach, device, and qualifier.

In ICD-10-PCS, the third character of a procedure code that defines the objective of the procedure, such as excision, drainage, or repair, and determines how the code is built.

The condition established after study to be chiefly responsible for occasioning the patient's admission to the hospital for care, and the first-listed diagnosis on an inpatient claim.

The inpatient procedure performed for definitive treatment that is most closely related to the principal diagnosis, or the procedure most related to the reason for admission.

Any additional condition documented in the record that coexists at the time of admission, develops during the stay, or affects patient care and treatment during the encounter.

A flag reported on inpatient claims showing whether a diagnosis was present when the patient was admitted, used to distinguish hospital-acquired conditions from preexisting ones.

An instructional note in ICD-10-CM telling the coder that a condition is classified elsewhere or that two codes are required, guiding correct code selection and preventing misclassification.

An instructional note in ICD-10-CM that clarifies the conditions, synonyms, or sites covered by a particular code or category, helping the coder confirm that a code is appropriate.

A two-character code appended to a procedure code that provides additional information about the service, such as a distinct site, laterality, or reduced service, without changing the base code's definition.

A category of CPT codes used to report patient visits and consultations, selected based on factors such as medical decision making or time rather than the performance of a procedure.

The complexity of establishing a diagnosis and selecting a management option, judged by the number and complexity of problems, the amount of data reviewed, and the risk of complications.

The practice of combining services that are routinely performed together into a single payment, so that separate codes for the component services are not reimbursed individually.

Reporting components of a bundled service as separate codes to obtain higher payment, which is generally improper and may be treated as a compliance violation or fraud.

A CMS program that publishes edit pairs identifying code combinations that should not be billed together because they represent overlapping or redundant services.

The determination that a service is reasonable and required for the diagnosis or treatment of a condition, consistent with accepted standards of care and supported by documentation.

A written notice given to a Medicare beneficiary before a service that may not be covered, informing the patient of possible financial responsibility if the claim is denied.

A statement from an insurer to a patient and provider showing services billed, the amount allowed, the amount paid, and any patient responsibility such as coinsurance or deductible.

An electronic or paper document from a payer that explains payment decisions on submitted claims, including paid, denied, or adjusted amounts and associated reason codes.

An intermediary that receives claims from providers, checks them for formatting and data errors, and forwards them electronically to the appropriate payer.

An automated pre-submission review that checks a claim for missing data, invalid code combinations, and formatting problems before it is sent to the payer.

A payer's refusal to pay a claim, often because of missing authorization, incorrect coding, lack of medical necessity, or eligibility problems, requiring follow-up and possible appeal.

A formal request by a provider or patient asking a payer to reconsider a denied or underpaid claim, usually supported by clinical documentation and citing the specific denial reason.

The share of covered healthcare costs that a patient pays after meeting the deductible, typically expressed as a percentage of the allowed amount.

The amount a patient must pay out of pocket for covered services before an insurance plan begins to pay its share of the cost.

A fixed dollar amount a patient pays at the time of a covered service, such as a set fee for an office visit or prescription.

A numeric value assigned to a service under the Medicare fee schedule that reflects physician work, practice expense, and malpractice cost, used to calculate payment amounts.

A list of predetermined payment amounts that a payer will reimburse for specific services, often derived from relative value units and a geographic adjustment factor.

The maximum amount a payer will recognize as payable for a covered service under its contract, which serves as the basis for calculating payer and patient responsibility.

A medical condition or complication that develops during a hospital stay and was not present at admission, which may reduce or eliminate payment under federal programs.

The clinical record entries that describe the patient's history, findings, diagnoses, and services provided, which must support the codes reported on a claim.

The patient's stated reason for seeking care, usually recorded in the patient's own words and used to focus the history and examination.

A chronological record of system activity that tracks who accessed or changed health information and when, supporting accountability and data integrity.

A privacy rule requirement that covered entities limit the use, disclosure, and request of protected health information to the least amount needed to accomplish the purpose.

Individually identifiable health information held or transmitted by a covered entity or business associate, in any form, that relates to a person's health, care, or payment.

A federal law that protects the privacy and security of health information, sets standards for electronic transactions, and provides rules for handling breaches.

A federal law that imposes liability on individuals and organizations that knowingly submit false or fraudulent claims to government payers, with penalties and whistleblower provisions.

Reporting a service with a code that reflects a higher level or greater payment than the service actually performed, which is a form of fraudulent billing.