CMR flashcards

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

Medical necessity

A determination that a service is reasonable and necessary for the diagnosis or treatment of illness or injury, supported by the clinical record and applicable coverage criteria.

National Coverage Determination

A Medicare policy issued by CMS that establishes whether a service is covered nationwide and applies to all Medicare contractors regardless of jurisdiction.

Local Coverage Determination

A Medicare contractor policy that specifies coverage for a service within a MAC's jurisdiction and may not be less restrictive than an NCD.

Minimum necessary standard

The HIPAA requirement to limit protected health information used or disclosed to the least amount needed to accomplish the intended purpose, excluding treatment disclosures.

EMTALA

A federal law requiring hospitals with emergency departments to provide a medical screening examination and stabilizing treatment regardless of insurance status or ability to pay.

Conditions of Participation

Minimum health and safety standards that providers must meet to participate in Medicare and receive payment for services rendered.

Late entry

A documentation addition made after the original entry date, which must be clearly labeled with the actual date and time of the addition.

Authentication

The process of verifying that a medical record entry was made by the person identified, typically by a legible written or electronic signature.

Cloned documentation

Identical or near-identical text appearing across multiple patient records, indicating possible copying rather than individualized clinical documentation.

Principal diagnosis

The condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care.

Modifier 25

A CPT modifier indicating a significant, separately identifiable evaluation and management service was provided by the same physician on the same day as a procedure.

NCCI edits

National Correct Coding Initiative edits that define code pairs not separately payable together, with certain pairs bypassable by an appropriate modifier.

Clean claim rate

The percentage of claims accepted on first submission without edits, rejections, or requests for additional information.

Unbundling

Reporting components of a bundled service as separate codes to obtain higher payment, which is a billing compliance violation.

Two-midnight rule

A Medicare presumption that an inpatient admission is appropriate when the physician expects the patient to require hospital care spanning at least two midnights.

Condition code 44

A code used when a hospital changes a patient's status from inpatient to outpatient before discharge because inpatient criteria were not met.

Observation status

An outpatient status for monitoring and evaluation that does not qualify as an inpatient admission and does not count toward the three-day stay rule.

Interrater reliability

A measure of the degree of agreement among reviewers applying the same criteria to the same case, reflecting consistency of determinations.

Compliance program elements

Seven core elements including written policies, a designated compliance officer, training, communication, monitoring and auditing, enforcement, and corrective action.

Extrapolation

Projecting an error rate found in a statistically valid random sample onto the full population of claims to estimate total overpayment.

Root cause analysis

A structured method to identify the underlying system and process failures that contributed to an adverse event, rather than assigning individual blame.

OIG Work Plan

An annual publication listing the audit and enforcement priorities of the Office of Inspector General, signaling areas of heightened federal scrutiny.

Fraud

Intentional deception or misrepresentation that an individual knows to be false and uses to obtain unauthorized payment or benefit.

Anti-Kickback Statute

A federal law prohibiting the offer, payment, or receipt of remuneration to induce referrals for items or services payable by federal health care programs.

Stark Law

A strict liability statute prohibiting physician self-referral of designated health services to entities with which the physician has a financial relationship, absent an exception.

False Claims Act

A federal statute imposing liability on parties who knowingly submit false claims to the government, with treble damages and per-claim civil penalties.

Redetermination

The first level of Medicare appeal, filed with the MAC that issued the initial determination, generally within 120 days of the notice.

Qualified Independent Contractor

An independent entity that performs the second level of Medicare appeal, the reconsideration, and is not the contractor that issued the initial denial.

Amount in controversy

The minimum dollar threshold a claim must meet to proceed to Administrative Law Judge or judicial review, updated annually by CMS.

Peer review

Evaluation of a clinician's professional performance and quality of care by peers with comparable training, often protected under federal quality improvement law.

Conflict of interest

A situation where a reviewer's financial or personal interest could improperly influence a determination, requiring disclosure and recusal.

Informed consent

A patient's voluntary agreement to treatment after disclosure of the nature, risks, benefits, and reasonable alternatives of the proposed intervention.