Medical Insurance Ch 7

The connection between a service and a patient's condition or illness establishes the medical necessity of the procedure.

Computerized Medicare system to provent overpayment for procedures

Computerized screening system used to identify improperly or incorrectly reported codes.

A Medicare code edit under which CPT codes in column 2 will not be paid if re3ported for the same patient on the same day of service by the same provider as the column 1 code.

Under the CCI edits, both services represented by MEC codes could not have reasonably been done during a single patient encounter, so they will not both be paid by Medicare; only the lower-paid code is reimbursed.

A number that shows whether the use of a modifier can bypass a CCI edit.

CMS unit-of-service eddits that check for clerical or software-based coding or billing errors, such as anatomically related misakes.

The OIG's annual list of planned projects under the Medicare Fraud and Abuse Initiative.

An opinion issued by CMS or the OIG that becomes legal advice for the requesting party; a requesting party who acts according to the advice is immune from investigation on the matter; the advisory opinion provides guidance for other in similar matters.

Individuals or companies that, because of reasons bearing on professional competence, professional performance, or financial integrity, are not permitted by the OIG to participate in any federal health care programs.

Diagnoses that are not coded at the highest level of specificity availab.e.

Reporting items or services that are3 not actually documented, but that the coder assumes were performed

Using a procedure that provides a higher reimbursement rate than the correct code.

Using a lower level code. some physicians downcode to be "safe"

Providing free medical services to other physicians