CMRS (Court Reporting Certifications) flashcards

33 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 diagnosis and treatment of the patient's condition and consistent with accepted standards of care.

Peer-to-peer review

A discussion between the reviewing clinician and the treating provider about a proposed denial, allowing clinical clarification before a formal adverse determination is issued.

Minimum necessary standard

HIPAA requirement that uses and disclosures of protected health information be limited to the least amount reasonably needed to accomplish the intended purpose.

Late entry

A record addition made after the original documentation date; it must be labeled as late and include the actual date and time of entry plus author authentication.

Addendum

A correction or clarification appended to an existing medical record entry that preserves the original text and is authenticated, dated, and linked to the prior note.

HPI elements

Eight components scored in the history of present illness: location, quality, severity, duration, timing, context, modifying factors, and associated signs and symptoms.

Medical decision making

E/M scoring element composed of number and complexity of problems, amount and complexity of data reviewed, and risk of complications, morbidity, or mortality.

Modifier 25

A CPT modifier indicating a significant, separately identifiable evaluation and management service was performed on the same day as a procedure by the same provider.

NCCI edit

A National Correct Coding Initiative code pair that cannot be reported together unless a qualifying modifier demonstrates the services were distinct and separately reportable.

Two-midnight rule

CMS standard under which inpatient admission is generally appropriate when the physician expects the beneficiary to require hospital care spanning at least two midnights.

Observation status

An outpatient hospital status used for short-term monitoring and assessment; it does not require an inpatient order but must meet observation criteria and payer rules.

Sentinel event

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

Root cause analysis

A structured retrospective method that identifies system failures and contributing factors behind an adverse event rather than assigning individual blame.

FMEA

Failure mode and effects analysis is a prospective risk assessment that identifies where a process could fail and prioritizes mitigation before harm occurs.

Fraud

An intentional act of deception or misrepresentation that the person knows or should know could result in unauthorized benefit or payment.

Waste

Overutilization of services or inefficiency in care delivery that results in unnecessary cost without intent to deceive or misrepresent.

Anti-Kickback Statute

Federal law prohibiting knowingly offering, paying, soliciting, or receiving remuneration to induce referrals for items or services payable by federal health care programs.

Stark Law

Physician self-referral prohibition barring referrals of designated health services to entities with which the physician has a financial relationship, absent an exception.

False Claims Act

Federal statute imposing liability for knowingly submitting false or fraudulent claims, with qui tam provisions allowing private relators to sue and share recoveries.

Qui tam

A provision allowing a private person with knowledge of fraud to bring suit on behalf of the government and receive a share of any recovery.

Breach notification

HIPAA requirement to notify affected individuals without unreasonable delay and no later than sixty days after discovery of an impermissible disclosure of unsecured PHI.

De-identification

Removal of the eighteen HIPAA identifiers or application of an expert statistical method so the remaining data cannot identify an individual.

Security Rule

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

NCD and LCD

National Coverage Determinations apply nationwide; Local Coverage Determinations apply within a contractor's jurisdiction. Both define when Medicare will pay for a service.

Advance Beneficiary Notice

A written notice given to a Medicare beneficiary stating that a service may not be covered and that the patient may bear financial liability.

DRG

Diagnosis-related group, an inpatient payment classification based on principal diagnosis, secondary diagnoses, procedures, and complications or comorbidities.

Expedited appeal

A fast-tracked review available when the standard timeframe could seriously jeopardize the patient's life, health, or ability to regain maximum function.

External review

Independent review by an outside organization after internal appeals are exhausted, used to challenge adverse determinations on medical necessity or coverage.

Physician query

A non-leading written request asking the provider to clarify or add documentation supported by clinical indicators, with clinically reasonable response options.

Complication or comorbidity

A secondary condition present at admission or developing during the stay that increases resource use and can raise the inpatient DRG payment weight.

Inter-rater reliability

The degree to which independent reviewers reach the same determination on the same case, measured through audits and used to validate review consistency.

Upcoding

Billing a service at a higher level or intensity than documented or supported, a common fraud scheme identified through code distribution analysis.

Unbundling

Billing components of a single procedure or service separately to increase payment, contrary to correct coding and NCCI edit rules.