23 terms, one card each.
Revenue cycle management is the work of getting a medical practice paid for a visit, from checking the patient's coverage when the visit is booked to collecting the last dollar owed after the payer responds. It covers eligibility verification, prior authorization, coding, claim submission, denial management and payment follow-up.
Eligibility verification confirms that a patient's insurance is active on the date of service, what it covers, and what the patient will owe. Done before the visit, it prevents denials for inactive coverage or the wrong payer.
Coordination of benefits decides which plan pays first when a patient has more than one. Billing the secondary plan first, or omitting the primary, is a common cause of denials.
Prior authorization is a health plan's approval, obtained before a service is performed, that the service will be covered. Services that need one and are performed without it are usually denied.
Medical necessity is a payer's test of whether a service was reasonable and necessary for the patient's condition. For Medicare it is usually decided by matching the diagnosis on the claim to the diagnoses a coverage policy accepts for the procedure.
A local coverage determination is a Medicare coverage policy published by a regional Medicare Administrative Contractor. It lists when a service is covered in that contractor's states, often including the diagnoses that support it and how often it can be repeated.
A national coverage determination is a Medicare coverage policy issued by CMS that applies in every state. Where an NCD exists, local contractors cannot contradict it.
A Medicare Administrative Contractor processes Medicare Part A and Part B claims for a group of states and publishes local coverage policies for them. There are 12 A/B contractor jurisdictions, so the same claim can be judged differently in different states.
The National Correct Coding Initiative procedure-to-procedure edits are CMS's list of code pairs that should not be billed together for the same patient on the same day, either at all or without a modifier showing the services were distinct.
Medically Unlikely Edits are CMS's maximum units of a code that a provider would report for one patient on one day. Units above the limit are denied, usually with reason code CO-151.
Modifier 25 is added to an evaluation and management visit to show it was significant and separately identifiable from a procedure or preventive service performed on the same day. The note has to document the separate problem.
Modifier 26 bills only the professional component of a test, the interpretation. Modifier TC bills only the technical component, the equipment and staff. A test performed and read by the same practice is billed globally, without either.
Modifier 50 reports a procedure performed on both sides of the body in the same session. Whether it is allowed, and how many units go with it, depends on the code.
The KX modifier on outpatient therapy claims attests that services above Medicare's yearly therapy threshold are medically necessary and documented. Without it, therapy above the threshold is denied.
An Advance Beneficiary Notice is a form given to a Medicare patient before a service Medicare may not cover, so the patient can choose to receive it and pay. Without a valid ABN, the practice usually cannot bill the patient for a denied service.
The annual wellness visit is a Medicare preventive visit to create or update a prevention plan. The initial visit (G0438) is covered once per lifetime and subsequent visits (G0439) once every 12 months.
A screening test looks for disease in a patient without symptoms; a diagnostic test investigates a symptom or finding. Payers cover and cost-share them differently, so a screening that becomes diagnostic, such as a colonoscopy with polyp removal, needs its own coding.
Claim scrubbing is checking a claim for errors and rule conflicts before it is sent, so the payer does not reject or deny it. Clearinghouse scrubbers usually check format, code pairs and unit limits; medical necessity against coverage policies is checked less often.
A claim adjustment reason code is the standard code a payer uses to explain why a claim or line was paid differently from what was billed, such as CO-50 (not medically necessary) or CO-97 (bundled). The prefix CO means the practice, not the patient, is responsible for the difference.
An electronic remittance advice, the 835 file, is the payer's line-by-line explanation of what it paid on each claim and why. It is where denials and underpayments are found.
Denial management is finding denied and underpaid claims, working out why each was denied, and correcting, resubmitting or appealing it before the payer's deadline.
A timely filing limit is the deadline for submitting a claim after the date of service. Medicare's is 12 months; commercial plans set their own, often shorter. Claims sent after the limit are denied and usually cannot be billed to the patient.
A clean claim rate is the share of claims accepted and paid on first submission without correction. Vendors calculate it differently, so a published rate means little without its definition.
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