CPT Study Guide: The Revenue Cycle and Regulatory Compliance

These flashcards cover key terms and concepts related to the revenue cycle, fraud, and regulatory compliance in billing and coding.

Clean Claim

A claim submitted without any errors or implications; necessary for timely payment.

Fraud

Intentional misrepresentation in billing and coding, including billing for services not performed or double billing.

Abuse

Excessive or unnecessary billing patterns that do not meet fraud criteria; penalties are educational.

National Correct Coding Initiative (NCCI)

A program to prevent coding errors that can lead to inappropriate reimbursement for Medicare claims.

Encounter Forms

Forms that bridge administrative and clinical information, including diagnoses and services for billing.

Claims Scrubbing

A process used to proofread claims for errors before submission to ensure accuracy and completeness.

False Claims Act (FCA)

A law that regulates providers’ conduct regarding false and fraudulent claim submissions.

Upcoding

Purposeful medical coding errors where services are coded at a higher level than justified.

ZPIC Audits

Targeted audits used in cases of suspected Medicare and Medicaid fraud, waste, and abuse.

Recovery Audit Contractor (RAC) Program

A program designed to identify and recover improper payments made to healthcare providers.

Adjudication

The process of determining financial responsibility among the stakeholders of a claim.

Medical Record Audit

A review aiming to ensure that documentation matches the codes billed for services.