Urology Coding Alert

Question: We have new staff in our office who are having a hard time maneuvering the “alphabet soup” of terms that our Medicare contractor sends our way. Do you have a short list of common Medicare acronyms and their definitions that we could use in our office?

Maine Subscriber

Answer: Here is a short list of reimbursement-related acronyms that your staff should know when dealing with the Part A/B Medicare Administrative Contractors (MACs).

• ABN: An advance beneficiary notice of noncoverage (ABN) is a document that you provide to a Medicare patient ahead of a service or procedure if you think that Medicare might not pay for part or all of the service. The ABN’s purpose is to offer the patient as much information as possible before deciding whether to proceed with a treatment.
• EOB: The explanation of benefits (EOB) is a form that insurers send patients after they process a medical claim. Patients often mistake the EOB for a bill, but it is not. Instead, it is a detailed explanation of the claim and services rendered.
• IOM: Centers for Medicare & Medicaid Services (CMS) defines internet-only manuals (IOMs) as “a replica of the agency’s official record copy.” IOMs cover the Medicare daily posts, rulings, policies, and updates to procedures and coverage — guidebooks for understanding CMS.
• LCD: A local coverage determination (LCD) relates to MAC limitations placed on particular items and services under its distinct jurisdiction.
• MSP: Medicare secondary payer (MSP) refers to the process of payment when Medicare is the second insurer after another entity who holds the primary payment responsibility.
• MUE: CMS established medically unlikely edits (MUE) as a unit-of-service edit for HCPCS Level II/ CPT® codes. An MUE is assigned to a specific code to represent the maximum number of units of the code that you should report — either on a specific claim or on a specific date. CMS developed the edits to reduce the paid claims error rate for Medicare claims.
• NCD: National coverage determinations (NCDs) pertain to the nationally recognized information on coverage for a service or item. CMS provides extensive laboratory NCDs.
• OCA: An overpayment claims adjustment (OCA) happens when Medicare determines that a provider has been overpaid for care given. The OCA is the process that occurs to rectify the overpayment by making a payment back to Medicare.
• RA/ERA: MACs send remittance advice (RA) or the electronic version (ERA) to providers after the provider has submitted a claim to the MAC. The RAs or ERAs are itemized and offer information about the payment and any adjustments made by Medicare.