CMRE 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, necessary, and appropriate for the patient's condition, consistent with accepted standards, and no less costly adequate alternative exists.

National Coverage Determination

A Medicare policy issued nationally that specifies whether and under what conditions a particular item or service is covered for all beneficiaries across all jurisdictions.

Local Coverage Determination

A Medicare Administrative Contractor policy stating reasonable and necessary conditions for coverage within its jurisdiction; it cannot contradict a national coverage determination.

Two-midnight rule

An inpatient admission is generally appropriate when the physician expects the stay to span at least two midnights; stays under that benchmark require documented exception rationale.

Observation status

An outpatient designation for monitoring and short-term treatment; it does not create Part A inpatient coverage and affects cost sharing and skilled nursing facility eligibility.

Peer-to-peer review

A discussion between the treating or ordering physician and the reviewing plan physician before a final adverse determination, used to supply clinical context and challenge criteria application.

Principal diagnosis

The condition established after study to be chiefly responsible for the inpatient admission; it drives diagnosis related group assignment and payment.

Present on admission

An indicator on inpatient claims showing whether a condition existed at admission; hospital-acquired conditions marked not present can reduce payment.

Modifier 25

A code appended to an evaluation and management service indicating it was significant and separately identifiable from a procedure performed the same day.

NCCI edits

National Correct Coding Initiative code pair edits that identify services ordinarily not billed together; override modifiers apply only when clinical circumstances support separate services.

Global surgical package

A bundled payment covering preoperative, intraoperative, and postoperative care for a defined period, during which related routine follow-up is not separately payable.

Upcoding

Assigning a higher-paying code than the documentation supports, such as a higher evaluation and management level; it is a common audit finding and potential fraud indicator.

Unbundling

Billing components of a bundled service separately to increase payment; it violates correct coding rules and may constitute abuse or fraud depending on intent.

False Claims Act

A federal statute imposing liability for knowingly submitting or causing submission of false claims, with qui tam relator provisions allowing private suits and shared recoveries.

Anti-Kickback Statute

A criminal statute prohibiting remuneration intended to induce referrals of federally payable items or services; safe harbors protect qualifying arrangements.

Stark law

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

Sixty-day overpayment rule

An identified Medicare overpayment must be reported and returned within sixty days; retaining it after identification can create False Claims Act liability.

Qui tam relator

A private person who files a False Claims Act suit on behalf of the government and may receive a statutory share of any recovery.

Grievance versus appeal

A grievance expresses dissatisfaction with the plan or provider; an appeal requests reconsideration of an adverse benefit determination and follows distinct regulatory timeframes.

Redetermination

The first level of Medicare claim appeal, filed with the Medicare Administrative Contractor within 120 days of the initial determination.

Reconsideration

The second level of Medicare appeal, conducted by a qualified independent contractor and filed within 180 days of the redetermination decision.

Amount in controversy

The dollar threshold, adjusted annually, that a claim must meet to qualify for a Medicare Administrative Law Judge hearing.

Expedited appeal

A fast-track review available when the standard timeframe could seriously jeopardize life, health, or the ability to regain maximum function; decisions are due within 72 hours.

Adverse benefit determination

A denial, reduction, or termination of a requested service or payment, which triggers written notice, specific reasons, criteria cited, and appeal rights.

Sentinel event

An unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof, requiring immediate investigation and root cause analysis.

Root cause analysis

A structured method to identify underlying system failures contributing to an adverse event, focusing on process redesign rather than individual blame.

Never event

A serious, largely preventable patient safety incident such as wrong-site surgery or retained foreign body, which is reportable and often nonpayable.

Hospital-acquired condition

A condition not present at admission that meets specified criteria; affected discharges may receive reduced Medicare payment under the hospital-acquired condition program.

Cloned documentation

Identical or near-identical record entries copied across dates or patients; it undermines record credibility and is a frequent audit and integrity finding.

Late entry

A documentation addition made after the fact that must be dated, timed, signed, and labeled as late; backdating or altering original entries is prohibited.

Minimum necessary standard

A HIPAA requirement limiting uses and disclosures of protected health information to the least amount reasonably needed to accomplish the intended purpose.

Conflict of interest

A financial or personal relationship that could bias a review decision; it must be disclosed and typically requires recusal from the affected case.