AMCA BCSC cheat sheet

ICD-10-CM diagnosis codes have 3–7 characters; the first character is alphabetic (except U codes used for special purposes), and the 7th character is a required encounter/extension character for many injury and obstetric codes.

CPT Category I codes are 5 digits; Category II are 4 digits followed by F (performance measurement); Category III are 4 digits followed by T (emerging technology).

E/M level selection under 2021+ office/outpatient guidelines is based on either medical decision making (straightforward, low, moderate, high) or total time on the date of the encounter, not both.

The ICD-10-CM Official Guidelines for Coding and Reporting govern code assignment, sequencing, and the rules for signs/symptoms, combination codes, and laterality.

HCPCS Level II codes begin with a letter (A–V) followed by 4 digits and cover supplies, drugs, and services not in CPT; J codes report injectable drugs.

Modifier 25 indicates a significant, separately identifiable E/M service by the same physician on the same day as a procedure or other service.

Modifier 59 (and X{EPSU} subsets) identifies distinct procedural services not normally reported together, supporting separate payment.

The alphabetic index is consulted first, then the tabular list is verified; the tabular list takes precedence when the two conflict.

The CMS-1500 claim form is used for professional (non-institutional) claims; the UB-04/CMS-1450 is used for institutional facility claims.

NCCI edits consist of Procedure-to-Procedure (PTP) edits and Medically Unlikely Edits (MUE); PTP pairs generally deny the column-two code unless a valid modifier applies.

The Medicare Physician Fee Schedule payment formula is (Work RVU × Work GPCI) + (PE RVU × PE GPCI) + (MP RVU × MP GPCI), multiplied by the conversion factor.

The allowed amount minus any patient responsibility (deductible, coinsurance, copay) equals the expected payer payment.

Timely filing limits are set by each payer contract; Medicare standard is 12 months from the date of service for most claims.

Coordination of benefits (COB) determines primary versus secondary payer; the birthday rule generally assigns primary coverage to the policyholder whose birthday falls earlier in the year for dependent children.

An EOB (Explanation of Benefits) or ERA (835) reports paid, denied, and adjusted amounts, including CARC and RARC reason codes.

A clean claim contains all required data elements and passes front-end edits; rejected claims are not adjudicated and must be corrected and resubmitted.

Directional terms: superior (toward head), inferior (toward feet), anterior (front), posterior (back), medial (toward midline), lateral (away from midline), proximal (near point of attachment), distal (away).

The four abdominal quadrants are RUQ, LUQ, RLQ, and LLQ; the appendix is typically in the RLQ.

Prefixes alter meaning (brady- slow, tachy- fast, hyper- above, hypo- below, dys- difficult), while suffixes denote condition or procedure (-itis inflammation, -ectomy removal, -otomy incision, -ostomy opening).

The skeletal system has 206 bones in the adult; the axial skeleton includes the skull, vertebral column, and rib cage, and the appendicular skeleton includes limbs and girdles.

The heart has four chambers: right atrium and ventricle handle pulmonary circulation; left atrium and ventricle handle systemic circulation.

The respiratory tract divides into upper (nose, pharynx, larynx) and lower (trachea, bronchi, bronchioles, alveoli), with gas exchange occurring in the alveoli.

The digestive tract runs mouth, esophagus, stomach, small intestine (duodenum, jejunum, ileum), large intestine, rectum, anus; the liver and pancreas are accessory organs.

The integumentary system layers are epidermis (outer), dermis (middle, containing nerves and vessels), and subcutaneous/hypodermis (fat and connective tissue).

HIPAA Privacy Rule permits disclosure of protected health information for treatment, payment, and healthcare operations without patient authorization; other uses require authorization.

The HIPAA Security Rule applies to electronic PHI and requires administrative, physical, and technical safeguards.

The Anti-Kickback Statute prohibits knowingly offering or receiving remuneration to induce referrals for items or services payable by federal healthcare programs.

The Stark Law restricts physician self-referral for designated health services payable by Medicare, unless an exception applies.

The False Claims Act imposes liability, including treble damages, for knowingly submitting false claims; qui tam provisions allow private relators to sue on the government's behalf.

Compliance program elements include written policies, a compliance officer, training, communication lines, internal monitoring/auditing, and enforcement/discipline.

The OIG Work Plan and Medicare Learning Network publications identify audit targets and coding/billing guidance for providers.

Advance Beneficiary Notice (ABN) is used to notify Medicare beneficiaries that a service may not be covered and to obtain financial responsibility acknowledgment.