AMPC Designation cheat sheet

ICD-10-CM codes are alphanumeric and up to seven characters; the 7th character is a required extension only for certain chapters such as injuries and obstetrics.

In ICD-10-CM the tabular list is the authoritative source: a code from the alphabetic index must be verified against the tabular list before assignment.

CPT codes are five digits and category I codes are numeric; category II are four digits plus F, and category III are four digits plus T.

E/M level selection under 2021+ outpatient rules uses either medical decision making or total time on the date of encounter, not both together.

Modifier 25 is appended to an E/M service when a significant, separately identifiable service is performed on the same day as a procedure.

Modifier 59 or the X{EPSU} subset indicates a distinct procedural service; payer preference determines which is accepted.

HCPCS Level II codes begin with a letter (or letter-number) and cover supplies, drugs, and equipment not described in CPT.

Laterality, encounter type, and external cause codes must be supported by provider documentation; coders may not infer clinical facts.

A surgical package includes the procedure, local anesthesia, and typical postoperative care; only documented, distinct services are separately billable.

Clean claim rate equals claims accepted first pass divided by total claims submitted, expressed as a percentage.

Days in accounts receivable equals total accounts receivable divided by average daily charges; lower values indicate faster payment.

The 1500 claim form is the standard paper format for professional claims; the UB-04 is used for institutional claims.

Coordination of benefits determines primary versus secondary payer; the birthday rule generally governs dependent children with dual coverage.

An ABN must be issued before a service likely to be denied as not medically necessary, so the patient can accept liability.

Timely filing limits are payer-specific; a claim denied for late filing is generally unrecoverable unless proof of timely submission exists.

Deductible, coinsurance, and copay are distinct: deductible is paid before benefits begin, coinsurance is a percentage share, copay is a fixed amount.

An EOB from the payer and an RA/835 remittance provide denial and adjustment data used for secondary billing and appeals.

Appeal levels typically move from first-level internal review to external or independent review, each with its own filing deadline.

No-show rate equals missed appointments divided by scheduled appointments; benchmark monitoring drives reminder and scheduling policy.

Provider utilization equals scheduled clinical hours divided by available clinical hours, expressed as a percentage.

A scheduling template defines appointment slot types and durations; overbooking policy should be documented and consistent.

OSHA requires an exposure control plan, hepatitis B vaccination offer, and post-exposure evaluation for at-risk staff.

HIPAA minimum necessary standard limits access to protected health information to what is needed for the task.

Retention schedules for medical records are set by state law and payer contracts; the longer applicable requirement controls.

A notice of privacy practices must be provided and documented, and good-faith breach documentation supports the risk assessment.

Staff credentialing and payer enrollment must be complete before claims can be billed under a provider's identifier.

The seven elements of an effective compliance program include written policies, a compliance officer, training, communication, monitoring, enforcement, and corrective action.

The False Claims Act imposes liability for knowingly submitting false claims; the qui tam provision allows private relators to sue on the government's behalf.

The Anti-Kickback Statute prohibits remuneration for referrals of items or services reimbursed by federal health care programs.

The Stark Law is a strict liability statute restricting physician self-referral for designated health services, with defined exceptions.

The OIG Work Plan and the Medicare fee schedule set audit targets and payment rules that compliance monitoring should track.

Exclusion screening against the OIG LEIE and SAM databases should occur at hire and periodically thereafter.

A compliance program should document internal audits, corrective action plans, and staff training completion.

The Civil Monetary Penalties Law and the Health Care Fraud Statute are additional enforcement tools used alongside the FCA and AKS.

An audit sample should be statistically valid or risk-based; small samples support internal education, not extrapolated repayment.

E/M audit tools compare documentation to the selected level using either MDM elements or total time, depending on the code set.

A documentation query to the provider must be non-leading and should not suggest a diagnosis or code.

Audit accuracy equals records without errors divided by records reviewed, expressed as a percentage.

Overcoding and undercoding both create compliance exposure; undercoding also reduces legitimate revenue.

Audit findings should be tracked through a corrective action plan with re-audit timelines to confirm improvement.

Medical necessity review compares documented signs, symptoms, and history against the code's definition and payer policy.

A modifier audit checks that modifiers such as 25, 59, and 26 are supported by the record, not just the claim.

The seven elements of an effective compliance program include written policies, a compliance officer, training, communication, monitoring, enforcement, and corrective action.

The False Claims Act imposes liability for knowingly submitting false claims; the qui tam provision allows private relators to sue on the government's behalf.

The Anti-Kickback Statute prohibits remuneration for referrals of items or services reimbursed by federal health care programs.

The Stark Law is a strict liability statute restricting physician self-referral for designated health services, with defined exceptions.

The OIG Work Plan and the Medicare fee schedule set audit targets and payment rules that compliance monitoring should track.

Exclusion screening against the OIG LEIE and SAM databases should occur at hire and periodically thereafter.

A compliance program should document internal audits, corrective action plans, and staff training completion.

The Civil Monetary Penalties Law and the Health Care Fraud Statute are additional enforcement tools used alongside the FCA and AKS.