Document published by the Office of the Inspector General (OIG) to enable hospitals, home health care, nursing homes, third-party billing companies, and physician medical practices to establish compliance programs.

Under the Health Insurance Portability and Accountability Act (HIPAA), to check provider and insurance company responsibilities in regard to the accuracy of procedure codes and verification of medical services provided to patients to prevent fraud and abuse.

Individual overseeing a facility’s or medical practice’s compliance program who plans, implements, and monitors the program with a staff trained to perform activities that comply with the Health Insurance Portability and Accountability Act (HIPAA) rules.

Auditing, monitoring, and staff training implemented to get rid of errors in coding, billing, and transmission of electronic claims for compliance with HIPAA guidelines.

A management plan adopted by a medical practice or facility that is composed of policies and procedures to accomplish uniformity, consistency, and conformity in medical recordkeeping that fulfills official HIPAA requirements. It fosters prevention of fraudulent activities by the development of internal controls.

Disease or condition arising during the course of, or as a result of, another disease, modifying medical care requirements; for diagnosis-related groups (DRGs), a condition that arises during the hospital stay that prolongs the length of stay by at least 1 day in approximately 75% of cases. Also known as substantial complication.

Key factors in establishing a diagnosis-related group (DRG). See complication and comorbidity.

1. The portion of a service described before the semicolon (;) of a CPT comprehensive code, together with the portion of a service described by the indented (component) code. 2. Under the Correct Coding Initiative (CCI), a CCI file known as component edits lists pairs of codes considered an integral part of the main surgical service provided or a component of a more comprehensive procedure. When billing a Medicare case, a component code that follows a comprehensive code cannot be charged to Medicare if the comprehensive code is billed.

In the Correct Coding Initiative (CCI) edits, the code that follows the column I code, which cannot be billed when the more comprehensive code is billed.

Standardizing method that allows a physician to list a code, regardless of specialty, that specifically identifies whether the procedural component, the radiological component, or both aspects of the service was provided.