AMCA BCSC flashcards

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

ICD-10-CM code structure

Diagnosis codes are 3–7 characters: the first character is alphabetic, the second is numeric, and later characters may be alphabetic or numeric. The seventh character often specifies encounter type.

CPT Category III codes

Temporary five-character codes ending in T that report emerging technology, services, and procedures. They are used until a permanent Category I code is established.

Modifier 25

Appended to an E/M service to indicate that it was significant and separately identifiable from a procedure or other service performed on the same day by the same provider.

Modifier 59

Indicates a distinct procedural service, used to identify procedures that are not normally reported together but are appropriate under the circumstances, such as different sites or separate encounters.

Medical decision making levels

E/M office visits may be leveled by MDM using three elements: number and complexity of problems, amount of data reviewed, and risk of complications. Levels are straightforward, low, moderate, and high.

HCPCS Level II J codes

Alphabetic J-prefixed codes that report injectable drugs and biologicals, including their dosage, route, and units, for services not described by CPT codes.

Alphabetic index vs tabular list

Coders locate a term in the ICD-10-CM alphabetic index first, then verify the code in the tabular list. The tabular list governs when conflicts exist.

Laterality in coding

Many ICD-10-CM and CPT codes require specifying right, left, or bilateral. Missing laterality can cause claim denial or require documentation clarification before coding.

CMS-1500 form

The standard paper or electronic claim form used by non-institutional providers to bill Medicare, Medicaid, and commercial payers for professional services.

UB-04 claim form

The institutional claim form (CMS-1450) used by hospitals and facilities. It reports revenue codes, type of bill, and facility charges rather than individual professional services.

NCCI PTP edits

Procedure-to-Procedure edits identify code pairs that should not be billed together. The column-two code is denied unless a modifier establishes that the services were distinct.

Medically Unlikely Edits

MUEs set the maximum number of units of a single code that a provider would reasonably report for one beneficiary on one date of service.

Conversion factor

A dollar amount set annually by CMS and multiplied by the total geographically adjusted RVUs to calculate the Medicare allowed amount for a service.

Coordination of benefits

Rules that determine which insurance plan pays first when a patient has multiple coverages. The primary payer adjudicates first and the secondary payer considers the remainder.

Explanation of Benefits

A statement from the payer summarizing how a claim was processed, including allowed amounts, paid amounts, patient responsibility, and denial or adjustment reason codes.

Timely filing limit

The deadline set by payer contract or regulation for submitting a claim after the date of service. Claims received after the limit are typically denied.

Clean claim

A claim that contains all required data elements and passes front-end edits so it can be adjudicated without additional information from the provider.

Anatomical position

The standard reference posture: standing upright, face forward, arms at the sides with palms facing forward. Directional terms like medial and lateral assume this position.

Proximal versus distal

Proximal means closer to the point of attachment or trunk of the body; distal means farther from it. These terms describe limb structures relative to the body center.

Suffix -ectomy

A suffix meaning surgical removal or excision of a structure, as in appendectomy (removal of the appendix) or cholecystectomy (removal of the gallbladder).

Suffix -ostomy

A suffix meaning a surgical opening or stoma created between two structures, such as a colostomy connecting the colon to the abdominal surface.

Abdominal quadrants

Four regions formed by vertical and horizontal lines through the umbilicus: right upper, left upper, right lower, and left lower. The appendix lies in the right lower quadrant.

Pulmonary versus systemic circulation

Pulmonary circulation moves blood from the right ventricle to the lungs for oxygenation. Systemic circulation moves oxygenated blood from the left ventricle to the body.

Alveoli function

Tiny air sacs at the end of bronchioles where oxygen and carbon dioxide are exchanged between the lungs and pulmonary capillaries.

Layers of the skin

The epidermis is the outer avascular layer; the dermis contains nerves, vessels, and glands; the subcutaneous layer holds fat and connective tissue.

HIPAA Privacy Rule

Regulates use and disclosure of protected health information, permitting treatment, payment, and operations without authorization while requiring authorization for other uses.

HIPAA Security Rule

Establishes administrative, physical, and technical safeguards to protect the confidentiality, integrity, and availability of electronic protected health information.

Anti-Kickback Statute

A federal law making it illegal to knowingly offer, pay, solicit, or receive remuneration to induce referrals for items or services covered by federal healthcare programs.

Stark Law

A physician self-referral prohibition that bars physicians from referring Medicare patients for designated health services to entities with which they have a financial relationship, absent an exception.

False Claims Act

A federal statute imposing civil liability, including treble damages and penalties, on parties that knowingly submit false or fraudulent claims to government programs.

Advance Beneficiary Notice

A written notice given to a Medicare beneficiary before a service that may not be covered, allowing the patient to accept financial responsibility if coverage is denied.

Compliance program elements

Core components include written standards, a designated compliance officer, effective training, communication lines, internal monitoring and auditing, and consistent enforcement and discipline.