AMPC Designation flashcards

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

ICD-10-CM seventh character

An extension character required for certain chapters such as injuries and obstetrics; it captures encounter type, laterality, or healing stage and must match the documentation.

CPT modifier 25

Appended to an evaluation and management service when a significant, separately identifiable service is performed on the same day as a procedure.

HCPCS Level II

A code set beginning with a letter, used for supplies, drugs, and equipment not described in CPT, such as durable medical equipment and injectable medications.

Surgical package

The global service bundle including the procedure, local anesthesia, and typical postoperative care; only documented distinct services are separately billable.

Clean claim rate

The percentage of claims accepted on first submission without rejection or denial, calculated as accepted claims divided by total claims submitted.

Days in accounts receivable

Total accounts receivable divided by average daily charges; a lower value generally indicates faster payment and more efficient revenue cycle performance.

Coordination of benefits

Rules that determine primary versus secondary payer when a patient has multiple coverages; the birthday rule commonly governs dependent children.

Advance beneficiary notice

A form issued before a service likely to be denied as not medically necessary, allowing the patient to accept financial liability if denied.

Explanation of benefits

A payer statement showing billed charges, allowed amount, adjustments, patient responsibility, and denial reasons used for secondary billing and appeals.

No-show rate

The number of missed appointments divided by scheduled appointments, expressed as a percentage and used to evaluate scheduling and reminder policies.

Exposure control plan

An OSHA-required written plan identifying at-risk staff, describing protective measures, and outlining post-exposure evaluation and hepatitis B vaccination offers.

Minimum necessary standard

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

Record retention schedule

The period medical records must be kept, set by state law and payer contracts; when requirements conflict, the longer period controls.

Notice of privacy practices

A HIPAA-required document describing how protected health information may be used and disclosed and explaining patient rights; provision should be documented.

Compliance program elements

The seven core elements: written policies, a compliance officer, training and education, communication lines, monitoring and auditing, enforcement, and corrective action.

False Claims Act

A federal statute imposing liability for knowingly submitting false claims; its qui tam provision lets private relators sue on the government's behalf.

Anti-Kickback Statute

A criminal statute prohibiting remuneration intended to induce referrals of items or services reimbursed by federal health care programs.

Stark Law

A strict liability statute restricting physician self-referral for designated health services, subject to defined exceptions and safe harbors.

OIG exclusion screening

Checking the OIG List of Excluded Individuals and Entities and the SAM database at hire and periodically to avoid billing for excluded providers.

Corrective action plan

A documented plan describing identified compliance deficiencies, remediation steps, responsible parties, and timelines for completion and verification.

Audit sampling

Selecting a subset of records for review; statistically valid or risk-based samples support extrapolation, while small samples support education only.

Provider query

A written request for clarification of documentation that is non-leading and does not suggest a diagnosis or code to the provider.

Audit accuracy rate

The number of records without coding or documentation errors divided by the total records reviewed, expressed as a percentage.

Medical necessity review

Comparing documented signs, symptoms, and history against the code definition and payer policy to confirm the service was reasonable and necessary.

Modifier audit

A review confirming that modifiers such as 25, 59, and 26 are supported by the medical record rather than applied only on the claim.

E/M level audit

A comparison of documentation to the selected evaluation and management level using either medical decision making elements or total time.

Overcoding vs undercoding

Overcoding selects a higher level than documentation supports; undercoding selects a lower level; both create compliance exposure and undercoding reduces revenue.

Re-audit timeline

A scheduled follow-up review after corrective action to confirm that identified documentation and coding errors have been resolved.

Civil Monetary Penalties Law

A statute authorizing civil penalties for violations such as false claims, kickbacks, and exclusion violations, used alongside the False Claims Act.

Total time for E/M

The cumulative time on the date of the encounter spent in face-to-face and non-face-to-face activities permitted for the code, used to select the level.

Distinct procedural service

A service separate from other procedures performed on the same day, reported with modifier 59 or an X{EPSU} modifier when documentation supports it.

UB-04 claim form

The standard paper claim format for institutional providers such as hospitals, distinct from the 1500 form used for professional claims.