NCICS cheat sheet

Revenue cycle order: registration and eligibility verification, coding and charge capture, claim scrub and submission, payer adjudication, remittance posting, denial management, patient balance follow-up.

Coding credential split: CPC and CCS-P apply outpatient physician and facility coding; CCS and RHIT/RHIA apply hospital inpatient and health information management; CPC-A and CCS-Apprentice are pre-experience designations.

ICD-10-CM structure: 3–7 characters; character 1 is the chapter letter, characters 4–6 add etiology, site, and laterality, and character 7 is the encounter type (A initial, D subsequent, S sequela).

ICD-10-PCS has 7 alphanumeric characters with no decimals; each character position is a defined axis (section, body system, root operation, body part, approach, device, qualifier).

CPT Category I codes are 5 digits; Category II are 4 digits plus F (performance tracking); Category III are 4 digits plus T (emerging technology). Add-on codes are billed with a primary procedure and never alone.

E/M level selection under 2021+ office/outpatient guidelines uses either medical decision making or total time on the date of the encounter; history and exam are no longer level-driving elements for those codes.

Modifier 25 is appended to a significant, separately identifiable E/M service on the same day as a procedure; modifier 59 or XS/XE/XP/XU signals a distinct procedural service to override bundling.

National Correct Coding Initiative edits are column-one/column-two pairs; modifier indicator 0 means never unbundle, indicator 1 permits unbundling with an appropriate modifier.

Claim form mapping: CMS-1500 for noninstitutional providers; UB-04/CMS-1450 for institutional facility claims; NPI in items 24J and 33 (CMS-1500) and loop 2010AB for billing provider on 837P electronic claims.

Clean claim rate = claims accepted on first submission ÷ total claims submitted; denial rate = denied claims ÷ total claims submitted; both are tracked per payer and per provider.

Days in accounts receivable = (total AR ÷ total charges) × days in period; a lower figure indicates faster cash collection and is compared against payer fee schedules.

Timely filing limits are payer-specific and measured from date of service or, for secondary claims, from the primary payer's remittance date; missing the limit forfeits appeal rights.

Coordination of benefits: the birthday rule assigns primary coverage to the policyholder whose birthday falls earlier in the calendar year when a dependent child is covered by both parents.

Medicare Secondary Payer situations include age-based (employer group health plan with 20+ employees), disability-based (100+ employees), and ESRD-based (working aged or 30-month coordination period) rules.

Copay is a fixed patient amount collected at service; coinsurance is a percentage of the allowed amount; deductible is the patient balance before payer cost-sharing begins.

Allowed amount = contracted rate; payer payment = allowed amount − patient cost-sharing; write-off = billed charge − allowed amount when the provider is in network.

Appeal levels for Medicare Part B redetermination are redetermination, reconsideration, ALJ hearing, Medicare Appeals Council, and federal district court, each with dollar thresholds and filing windows.

EOB (Explanation of Benefits) is issued to the patient; ERA/835 remittance advice is the electronic transaction sent to the provider and is the source for automated posting.

HIPAA transactions and code sets: 837P/837I for claims, 835 for remittance, 270/271 for eligibility, 276/277 for claim status, 278 for prior authorization, 820 for premium payment.

HIPAA Privacy Rule permits treatment, payment, and health care operations uses without authorization; minimum necessary standard applies to most other disclosures.

Breach notification: individual notice without unreasonable delay and no later than 60 days after discovery; HHS notice annually for breaches under 500 individuals and within 60 days for 500 or more.

ICD-10-CM coding conventions: 'code first' signals an underlying etiology sequenced before the manifestation; 'use additional code' is a required secondary code; 'Excludes1' means the two conditions cannot be coded together.

CPT surgical package includes the procedure, local anesthesia, immediate postoperative care, and typical follow-up; modifier 57 applies to the decision for surgery on the day of a major procedure.

Global surgical periods: 0 days for minor procedures, 10 days for minor procedures with follow-up, 90 days for major procedures; modifier 24 unbundles an unrelated E/M during the global period.

Place of service codes affect payment: POS 11 (office) versus POS 22 (outpatient hospital) trigger different facility and non-facility rates and separate facility fees.

Advance Beneficiary Notice of Noncoverage (ABN) is required before providing items Medicare may deem not reasonable and necessary; without it, the provider may not bill the patient.

Medical necessity documentation must link the diagnosis to the service; ICD-10-CM codes must be supported by the clinical record, and unspecified codes are used only when documentation lacks specificity.