CPB Medical Billing flashcards

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

Modifier 25

Appended to an E/M service when a significant, separately identifiable evaluation and management service is performed by the same provider on the same day as a procedure or other service.

Modifier 59

Indicates a distinct procedural service to override bundling edits when services are not normally reported together but are appropriate under the circumstances.

NCCI PTP edits

Procedure-to-procedure edits published by CMS that identify code pairs that should not be billed together; a modifier indicator of 0 means no modifier can bypass the edit.

Global surgical package

The bundled preoperative, intraoperative, and postoperative care associated with a surgical procedure; major surgery carries a 90-day global period and minor surgery 0 or 10 days.

CMS-1500 form

The standard paper claim form used for professional (non-institutional) services. Institutional claims use the UB-04 instead.

Allowed amount

The maximum amount a payer will reimburse for a covered service under its fee schedule or contract; the patient may owe cost-sharing on this amount.

Birthday rule

A coordination of benefits rule making the plan of the parent whose birthday falls earlier in the calendar year primary for dependent children.

Place of service code

A two-digit code on the claim identifying where the service was rendered, such as office, hospital outpatient, or telehealth; it affects payment rules.

Clean claim rate

The percentage of claims accepted on first submission without rejection or denial; a key front-end billing performance metric.

Eligibility verification

The process of confirming a patient's active coverage, benefits, cost-sharing, and authorization requirements before the date of service.

Prior authorization

A payer requirement that specific services be approved before they are rendered; failure to obtain it commonly results in a denial.

Advance Beneficiary Notice

Form CMS-R-131 used for Medicare when a service may not be covered; when properly executed it shifts financial responsibility to the patient.

Medicare Part B

The Medicare component covering outpatient and professional services, durable medical equipment, and certain preventive services, with monthly premiums and cost-sharing.

Medicare Advantage

A Medicare Part C plan offered by a private insurer that provides at least the same benefits as Original Medicare under the plan's own network and rules.

Medicaid managed care

A state Medicaid delivery model in which contracted managed care organizations cover benefits and impose their own billing and authorization requirements.

Timely filing limit

The maximum period after the date of service within which a claim must be submitted; it is set by payer contract or state regulation.

270/271 transaction

The ANSI X12 electronic data interchange pair used for eligibility inquiry (270) and eligibility response (271).

835 remittance advice

The electronic remittance transaction that reports claim payment, adjustment, and denial information from a payer to a provider.

CO-197 denial

A claim adjustment reason code indicating the service was denied because prior authorization was not obtained.

CO-50 denial

A claim adjustment reason code stating the service was denied as not medically necessary; it is typically appealed with clinical documentation.

CO vs PR adjustment

CO (contractual obligation) amounts are written off per contract and not billed to the patient; PR (patient responsibility) amounts may be billed to the patient.

Denial vs rejection

A denial is a payer decision on a processed claim; a rejection is a front-end edit that prevents the claim from reaching the payer and requires correction and resubmission.

Redetermination

The first level of the Medicare appeals process, filed with the Medicare Administrative Contractor, generally within 120 days of the initial determination.

ALJ hearing

A later level of Medicare appeal heard by an Administrative Law Judge, available only when the amount in controversy meets the threshold.

Days in A/R

A financial metric calculated as total accounts receivable divided by average daily charges; it estimates how long receivables take to collect.

Overpayment refund

The obligation to return funds when a payer or patient pays more than is owed; the refund must occur within the timeframe the payer contract specifies.

HIPAA Privacy Rule

The federal rule governing the use and disclosure of protected health information and establishing patient rights such as access and accounting of disclosures.

Anti-Kickback Statute

A federal law prohibiting knowingly offering or receiving remuneration to induce referrals of items or services payable by federal health care programs, subject to defined safe harbors.

Stark Law

The Physician Self-Referral Law prohibiting physician referrals of designated health services to entities with which the physician has a financial relationship, absent an applicable exception.

False Claims Act

A federal statute imposing liability for knowingly submitting false or fraudulent claims to the government, including through qui tam whistleblower actions.

No Surprises Act

Federal law limiting balance billing for emergency and out-of-network services and requiring good-faith cost estimates for uninsured or self-pay patients.

Two-Midnight Rule

A Medicare rule holding that an inpatient admission is generally appropriate when the physician expects the stay to span two midnights, otherwise outpatient or observation status applies.