NCICS flashcards

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

Clean claim rate

The percentage of claims accepted by a payer on first submission without rejection or denial. Calculated as accepted first-pass claims divided by total claims submitted.

Days in accounts receivable

A liquidity metric computed as total accounts receivable divided by total charges, multiplied by days in the period. Lower values indicate faster collection.

Denial rate

The proportion of submitted claims that payers deny. Computed as denied claims divided by total claims submitted and tracked by payer and provider.

Allowed amount

The contracted reimbursement rate a payer recognizes for a service. Patient cost-sharing is subtracted from it to determine the payer payment.

Coinsurance

The patient's percentage share of the allowed amount after the deductible is satisfied, such as 20 percent. It differs from a copay, which is a fixed dollar amount.

Copay

A fixed dollar amount the patient pays at the time of service, set by the health plan. It is collected regardless of whether the deductible is met.

Deductible

The amount a patient must pay out of pocket for covered services before the health plan begins paying its share of the allowed amount.

Explanation of Benefits

A payer statement to the patient summarizing services, allowed amounts, payments, and patient responsibility. Providers receive the electronic equivalent, the 835 remittance.

ERA 835 transaction

The HIPAA electronic remittance advice that reports claim adjudication results to the provider. It supports automated posting of payments, adjustments, and denials.

CMS-1500 claim form

The standard paper claim form for noninstitutional providers such as physicians. It carries NPI, diagnosis codes, procedure codes, and place of service.

UB-04 claim form

The standard institutional claim form, also called CMS-1450, used by hospitals and facilities. It reports revenue codes, type of bill, and facility charges.

NPI

The National Provider Identifier, a 10-digit HIPAA identifier assigned to individual and organizational providers. It appears on claims for billing and rendering providers.

Modifier 25

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

Modifier 59

Indicates a distinct procedural service to override bundling edits. XS, XE, XP, and XU are more specific alternatives describing the reason for separation.

NCCI edit pairs

National Correct Coding Initiative edits list column-one and column-two code combinations that should not be billed together. Modifier indicator 0 prohibits unbundling.

Global surgical period

The postoperative window included in a surgical code: 0 days for minor, 10 days for minor with follow-up, and 90 days for major procedures.

Modifier 24

Used to report an unrelated evaluation and management service during a postoperative global period. The service must be for a condition unrelated to the surgery.

Modifier 57

Appended to an E/M service that results in the decision to perform a major surgery, typically on the day before or day of the procedure.

Place of service code

A two-digit code identifying where a service was rendered, such as 11 for office or 22 for outpatient hospital. It affects facility and non-facility payment rates.

Advance Beneficiary Notice

A form given to a Medicare beneficiary before a service that may be denied as not reasonable and necessary. It transfers financial liability if denial occurs.

Medical necessity

The requirement that services be reasonable and necessary for diagnosing or treating a condition. Diagnosis codes must be supported by clinical documentation.

ICD-10-CM seventh character

The final character of certain diagnosis codes indicating encounter type: A for initial, D for subsequent, and S for sequela of a prior condition.

Excludes1 note

An ICD-10-CM instruction stating that two conditions cannot be coded together because they are mutually exclusive. The excluded code is never reported with the primary code.

Code first convention

An ICD-10-CM instruction requiring the underlying etiology code to be sequenced before the manifestation code, which is typically listed as an additional diagnosis.

CPT Category II codes

Four-digit codes followed by the letter F, used for performance measurement and tracking. They are optional and not used for reimbursement.

CPT Category III codes

Four-digit codes followed by the letter T, assigned to emerging technology and services. They support data collection but are not guaranteed payer coverage.

Add-on code

A CPT code describing a service performed in addition to a primary procedure. It is never billed alone and must accompany the base procedure code.

Birthday rule

A coordination of benefits rule for dependent children covered by both parents' plans. The policyholder with the earlier birthday in the calendar year is primary.

Medicare Secondary Payer

Rules determining when Medicare pays after another plan, based on age, disability, or ESRD status and employer group health plan size thresholds.

Timely filing limit

The payer-defined deadline for submitting a claim, counted from the date of service or the primary payer's remittance date for secondary claims.

Redetermination

The first level of Medicare Part B appeal, filed with the Medicare Administrative Contractor within 120 days of the initial determination notice.

HIPAA minimum necessary

A Privacy Rule standard requiring that uses and disclosures of protected health information be limited to the least amount needed for the purpose.

Breach notification window

The HIPAA requirement to notify affected individuals without unreasonable delay and no later than 60 days after discovery of a breach of unsecured protected health information.