Helpful Terms


CCI: Correct Coding Initiatives
See NCCI: National Correct Coding Initiative.

CPT®: Current Procedure Terminology
Code set that describes medical, surgical, and diagnostic services and is designed to communicate uniform information about medical services and procedures among physicians, coders, patients, accreditation organizations, and payers for administrative, financial, and analytical purposes.

EDI: Electronic Data Interchange
The structured transmission of data between organizations by electronic mean.

EHR: Electronic Health Record
A record, in digital format, of health information about individual patients or populations.

EMR: Electronic Medical Record
A computerized medical record created in an organization that delivers care, such as a hospital or physician’s office.

HCPCS: Healthcare Common Procedure Coding System
A coding system consisting of the Current Procedural Terminology and a standardized coding system that is used primarily to identify products, supplies, and services not included in the CPT codes.

ICD: International Classification of Diseases
The World Health Organization’s standard diagnostic tool for epidemiology, health management and clinical purposes..

LCD: Local Coverage Determinations
A determination by a fiscal intermediary or a carrier under part A or part B of the Social Security Act, respecting whether or not a particular item or service is covered on an intermediary- or carrier-wide basis.

LMRP: Local Medical Review Policies
Guidance to the public and medical community about when items and services will be eligible for payment under the Medicare statute. See also LCD: Local Coverage Determinations.

MUE: Medically Unlikely Edit
A Medicare unit of service claim edit applied to Medical claims against a procedure code for medical services rendered by one provider/supplier to one patient on one day.

NCCI: National Correct Coding Initiative
National program designed to prevent improper payment of medical procedures that should not be submitted together.

NCD: National Coverage Determinations
Nationwide determinations of whether Medicare will pay for an item or service.

NDC: National Drug Code
A unique, three-segment number that serves as a universal product identifier for human drugs. FDA publishes the listed NDC numbers and the information submitted as part of the listing information in the NDC Directory.

NPI: National Provider Identifier
A unique identification number for covered health care providers. Covered health care providers and all health plans and health care clearinghouses must use the NPIs in the administrative and financial transactions adopted under HIPAA.

OCE: Outpatient Code Editor
CMS software that performs a computerized review of outpatient claims.

PQRS: Physician Quality Reporting System (formerly PQRI: Physician Quality Reporting Initiative)
A voluntary reporting program that provides an incentive payment to practices with eligible professionals who satisfactorily report data on quality measures for covered Physician Fee Schedule (PFS) services furnished to Medicare Part B Fee-for-Service (FFS) beneficiaries.

RVU: Relative Value Unit
A measure of dollar value used in the Medicare reimbursement formula for physician services.

 Auditing & Consulting


CERT: Comprehensive Error Rate Testing
A CMS program for measuring improper payments in the Medicare fee-for-service (FFS) program.

CMIP: Comprehensive Medicaid Integrity Plan
A program established by CMS to combat fraud, waste and abuse in the Medicaid program.

MAC: Medicare Administrative Contractor
Medicare claims processing entities.

MIC: Medicaid Integrity Contract
Section 1936 of the Social Security Act obligates the Centers for Medicare & Medicaid Services (CMS) to procure contractors to audit Medicaid claims and identify overpayments. To fulfill this statutory requirement, the Medicaid Integrity Program (MIP) has procured Audit Medicaid Integrity Contractors (Audit MICs) to conduct provider audits throughout the country.

MIG: Medicaid Integrity Group
In July 2006, CMS announced the creation of the MIG within the Center for Medicaid and State Operations (CMSO). The CMS MIG is responsible for implementing the Medicaid Integrity Program.

PERM: Payment Error Rate Measurement
The PERM program measures improper payments in Medicaid and CHIP and produces error rates for each program. The error rates are based on reviews of the fee-for-service (FFS), managed care, and eligibility components of Medicaid and CHIP in the fiscal year (FY) under review.

RAC: Recovery Audit Contractors
The Recovery Audit Contractor, or RAC, program was created through the Medicare Modernization Act of 2003 (MMA) to identify and recover improper Medicare payments paid to healthcare providers under fee-for-service (FFS) Medicare plans.

ZPIC: Zone Program Integrity Contractors (formerly PSC: Program Safeguard Contractors)
The primary goal of the ZPIC benefit integrity (BI) unit is to identify cases of suspected fraud, develop them thoroughly and in a timely manner, and take immediate action to ensure that Medicare Trust Fund monies are not inappropriately paid out and that any mistaken payments are recouped.

Government Regulation


ACA: Affordable Care Act of 2010
The ACA creates a National Prevention, Health Promotion, and Public Health Council, composed of senior officials across the government, to elevate and coordinate prevention activities and design a focused strategy across Departments to promote the nation’s health.

CMS: Centers for Medicare & Medicaid Services
The federal agency that runs the Medicare programs and works with the States to run the Medicaid program. CMS works to make sure that the beneficiaries in these programs are able to get high quality health care.

DRA: Deficit Reduction Act of 2005
Federal law enacted in 2006 with the goal of saving almost $40 billion from 2006 through 2010 by slowing spending growth for Medicare and Medicaid and other strategies.

HIPAA: Health Insurance Portability and Accountability Act of 1996
Federal law designed to protect health insurance coverage for employees and their families when they face a job change or loss, to streamline electronic health care transactions, and to address security and privacy of health data.

IPERA: Improper Payments Elimination and Recovery Act
Federal law signed on July 22, 2010, requiring federal agencies to spend at least $1 million each year on audits to target government fraud and waste.