Medical Provider Fraud reference materials
The Medical Provider Fraud detection relies on industry standard reference materials for classifying and coding medical invoices and claims.
- CMS-1500 Medicare health insurance claim form
National Uniform Claim Committee (NUCC) approved claim form for Medicare. For a sample form, see https://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/Downloads/CMS1500.pdf.
- CMS-1500 Medicare Claims Processing Manual
Medicare claims must be submitted on the CMS-1500 form and submitted for processing. For more information on entering data and submitting claims, see https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c26.pdf.
- DEA (Drug Enforcement Administration) number
All healthcare providers who write prescriptions for controlled substances must apply for an ID. For more information, see https://en.wikipedia.org/wiki/DEA_number.
- Diagnosis-Related Group (DRG) and Ambulatory Payment Classification (APC)
DRG is a system that classifies hospital cases into groups that have similar hospital resource use. APC is a system that classifies hospital facility outpatient services into groups. Both systems are used by Medicare. For more information, see https://www.findacode.com/medical-code-sets/drgs-apcs.html.
- Episode-based payment
An episode payment is a single price for all of the services that are needed by a patient for an entire episode of care rather than separate billings for each visit and procedure. For more information, see http://www.chqpr.org/downloads/transitioningtoepisodes.pdf.
- Hospital Revenue Code
Revenue Codes are descriptions and dollar amounts that are charged for hospital services that were provided to a patient. For more information, see http://valuehealthcareservices.com/education/understanding-hospital-revenue-codes/.
- ICD, CPT, HCPCS codes
Providers use these code sets to report medical diagnoses and procedures on claims for services.
- IDC
International Classification of Diseases
- CPT
Current Procedural Terminology
- HCPCS
Healthcare Common Procedure Coding System
- Major Diagnostic Categories (MDC)
The Major Diagnostic Categories are formed by dividing all possible principal diagnoses into 25 mutually exclusive diagnosis areas. DRG codes also are mapped into MDC codes. For more information, see https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/MedicareFeeforSvcPartsAB/downloads/DRGdesc08.pdf.
- Medicare Part A versus Part B
Medicare coverage plans determine which services are eligible for payment. For more information, see https://www.medicareinteractive.org/get-answers/introduction-to-medicare/explaining-medicare/what-does-medicare-cover-parts-a-b-c-and-d.
- Medicare Provider/Supplier to Healthcare Provider taxonomy crosswalk
This publication links the types of providers and suppliers who are eligible to apply for enrollment in the Medicare program with the appropriate Healthcare Provider Taxonomy Codes. For more information, see https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/MedicareProviderSupEnroll/downloads/JSMTDL-08515MedicarProviderTypetoHCPTaxonomy.pdf.
- National Correct Coding Initiative (NCCI)
The CMS developed the National Correct Coding Initiative (NCCI) to promote national correct coding methodologies and to control improper coding that might lead to inappropriate payment in Part B claims. For more information, see https://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/index.html.
- Place of Service codes (POS)
POS codes are used on medical claims to specify the entity where the service was rendered. For more information, see https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/Downloads/Website-POS-database.pdf.
- Uniform Billing (UB-04) Implementation
Medicare implemented the UB-04 form in March 2007. For more information, see https://www.cms.gov/regulations-and-guidance/guidance/transmittals/downloads/r1104cp.pdf.