IAMI CPMA key terms

The process of choosing the correct E/M code by applying current guidelines on medical decision making or time, rather than by matching documentation volume to a code.

A guideline component that grades E/M complexity using the number and complexity of problems addressed, amount of data reviewed, and risk of complications or morbidity.

The condition in which the medical record supports every element required for the code billed, including the reason, assessment, and plan, without relying on inference or later clarification.

Copying or carrying forward text from a prior encounter so that it appears to describe the current visit, which can inflate the level of service supported.

A two-digit modifier appended to an E/M service to show that a significant, separately identifiable evaluation and management service was performed on the same day as another procedure or service.

The bundle of services a surgeon is paid for around an operation, typically including the procedure itself plus preoperative and postoperative care for a defined period.

Billing components of a procedure or service separately when they are integral to a single code, which can increase payment improperly.

Automated coding pairs that identify services generally not reported together, used to prevent improper payment when claims are processed.

The defined boundary of an audit, stating which providers, dates of service, codes, payers, and objectives are included and which are excluded.

A written document describing audit objectives, scope, methodology, sampling approach, timeline, resources, and reporting expectations before fieldwork begins.

The complete population of claims or encounters from which an auditor draws a sample and to which findings may be projected.

The documented approach used to select records for review, such as random, stratified, systematic, or judgmental selection, chosen to support the audit objective.

Selecting records using probability methods so that results can be projected to the population with a measurable confidence level and margin of error.

The probability, usually expressed as a percentage, that a statistical estimate falls within its stated margin of error if the sampling process were repeated.

Projecting findings from a statistically valid sample to the full population to estimate an overall error rate or overpayment amount.

A structured evaluation of likelihood and impact of compliance or coding failures, used to prioritize audit topics, providers, and frequency of review.

A federal statute imposing liability on persons who knowingly submit, or cause to be submitted, false or fraudulent claims to government payers.

A lawsuit brought by a private person on behalf of the government under the False Claims Act, with the relator potentially sharing in any recovery.

A federal law prohibiting knowingly offering, paying, soliciting, or receiving remuneration to induce referrals of items or services covered by federal health care programs.

A federal physician self-referral law that prohibits physicians from referring certain designated health services to entities with which they or immediate family members have a financial relationship, absent an exception.

A regulatory provision that protects specified payment or business arrangements from being treated as a violation of the Anti-Kickback Statute when all conditions are met.

A payment received by a provider that exceeds the amount properly payable, which generally must be identified, reported, and returned within a defined period.

The duty to return identified overpayments by a deadline, commonly 60 days after identification, supported by a documented investigation and repayment process.

An organization's structured set of policies, training, monitoring, and auditing activities designed to prevent and detect violations of law and program requirements.

A structured examination of clinical documentation to determine whether services reported are supported, accurate, complete, and consistent with payer requirements.

Comparing reported or system-stored values against source documents to confirm accuracy, completeness, and consistency before the data are used for reporting or payment.

The reliability and consistency of data across systems and over time, ensuring that values are not altered, duplicated, or lost between capture and reporting.

A chronological record of system or user activity that shows who created, changed, or accessed a record and when, supporting reconstruction of events.

A documented conclusion supported by evidence that a requirement was met or not met, including the condition, criteria, cause, and effect.

A structured method for identifying the underlying process or system reasons a deficiency occurred, rather than only describing the symptom.

A written plan assigning specific steps, owners, and deadlines to address an audit finding and prevent recurrence, with a method for verifying effectiveness.

A formal document presenting objectives, scope, methodology, findings, and recommendations, written so that both clinical and nonclinical readers can act on it.

The audited party's documented reply to findings and recommendations, including agreement or disagreement, planned actions, and target completion dates.

A closing meeting with audited leadership to review preliminary findings, confirm factual accuracy, and agree on next steps before the final report is issued.

Reporting a service at a higher level or with a more complex code than the documentation supports in order to obtain greater payment.

Inefficient or improper practices that may increase costs or misuse program resources without necessarily meeting the legal elements of fraud.

Intentional deception or misrepresentation that the person knows could result in an unauthorized benefit to themselves or another party.

The state of being free from relationships or pressures that could compromise objectivity, including auditing one's own work or reporting to a party with a conflicting interest.

An unbiased mental attitude that allows an auditor to reach conclusions based on evidence rather than preference, prior work, or organizational pressure.

A situation in which a personal, financial, or professional interest could improperly influence judgment, requiring disclosure and often recusal or reassignment.