CMRS (ACAC) flashcards

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

SOAP Note

A documentation format organizing clinical information into Subjective, Objective, Assessment, and Plan sections, used to structure patient encounters.

Late Entry

A documentation entry made after the time of the event, clearly labeled as late, dated with the actual entry date, and authenticated by the author.

Audit Trail

An electronic record that captures who accessed or modified a patient's health information and when, supporting accountability and security.

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 that a significant, separately identifiable evaluation and management service was performed by the same physician on the same day as a procedure.

NCCI Edits

National Correct Coding Initiative edits that identify code pairs that should not be billed together without an appropriate modifier.

Upcoding

Billing for a higher level of service or more complex diagnosis than is supported by the documentation, often to increase reimbursement.

Medical Necessity

The determination that a service or item is reasonable and necessary for the diagnosis or treatment of illness or injury, meeting accepted standards of care.

Physician Query

A communication from a CDI specialist or coder to a provider requesting clarification of documentation to support accurate code assignment and medical necessity.

Clinical Indicators

Objective data such as vital signs, laboratory results, and imaging findings that support the presence of a documented diagnosis.

CDI Program

A clinical documentation integrity program that reviews records to ensure documentation is complete, accurate, and reflective of the patient's clinical status.

False Claims Act

A federal law that prohibits knowingly submitting false or fraudulent claims to government payers and provides for penalties and whistleblower actions.

Anti-Kickback Statute

A federal law prohibiting offering or receiving remuneration to induce referrals for services reimbursed by federal healthcare programs.

Stark Law

A federal law restricting physician self-referrals for designated health services paid by Medicare, with certain exceptions.

HIPAA Privacy Rule

A federal regulation governing the use and disclosure of protected health information by covered entities and their business associates.

60-Day Overpayment Rule

A requirement that providers report and return identified overpayments to the payer within 60 days of identification.

Statistically Valid Sample

A sample drawn using probability methods so that results can be extrapolated to the population with a known confidence level.

Stratified Sampling

A sampling method that divides the population into subgroups and samples from each to ensure representation of high-risk areas.

Audit Universe

The total set of claims, records, or entities from which a sample is drawn for an audit.

Error Rate

The number of claims with errors divided by the total claims audited, multiplied by 100, expressed as a percentage.

Root Cause Analysis

A systematic process to identify the underlying reason for a compliance deficiency or audit finding.

Fraud

Intentional deception or misrepresentation that an individual knows to be false and that may result in unauthorized benefit.

Waste

The overutilization of services or practices that result in unnecessary costs, often due to inefficiency rather than intentional deception.

Abuse

Practices that are inconsistent with accepted medical or business practices and result in unnecessary cost, but without intent to deceive.

Qui Tam Action

A whistleblower lawsuit filed under the False Claims Act on behalf of the government, allowing the relator to share in recovered funds.

OIG Exclusion List

A list of individuals and entities excluded from participating in federal healthcare programs; providers must screen employees against it.

Corrective Action Plan

A plan that specifies the issue, corrective steps, responsible parties, timeline, and measurable outcomes to address audit findings.

Audit Report

A document that presents the scope, methodology, findings, and recommendations of an audit in a clear and objective manner.

Follow-up Audit

A review conducted after corrective actions are implemented to verify effectiveness and sustained compliance.

Minimum Necessary Standard

A HIPAA requirement to limit access and disclosure of protected health information to the amount needed to accomplish the intended purpose.

Conflict of Interest

A situation in which a reviewer has a personal or financial interest that could compromise objectivity in an audit or review.

Breach Notification

The requirement to notify affected individuals, authorities, and possibly the public when unsecured protected health information is impermissibly accessed or disclosed.