CPC CHAPTER 1 BUSINESS OF MEDICINE – Flashcards
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What is APC?
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Ambulatory Payment Classifications
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What is MS-DRG's?
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Medical Severity Disgnosis Related Groups
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Code updates and insurance policies may change as often as?
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Quarterly
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What are mid level providers?
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Physician extenders such as PA's, and NP's
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What are the two primary types of insurers?
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Private insurance plans and government insurance plans
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What is Medicare?
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A federal health insurance program administered by CMS that provides coverage for people over the age of 65, blind or disabled individuals, and people with permanent kidney failure or ESRD.
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What is CMS?
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Center for Medicare and Medicaid Services
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What is Medicare Part C, AKA Medicare Advantage?
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It combines the benefits of Medicare Part A and Medicare Part, and sometimes Medicare Part D. The plans are managed by private insurers approved by Medicare. The plans may charge different co-payments, coinsurance, or deductible services.
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What is Medicare Part D?
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A prescription coverage plan available to all Medicare beneficiaries. Private companies approved by Medicare provide coverage.
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What is RBRVS?
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resource-based relative value scale used to calculate medical payments for physician services
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What is PFS?
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Physician Fee Schedule annually published by CMS
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What is PE in relation to the RBRVS formula?
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Physician Expense
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What is MP in relation to the RBRVS formula?
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Malpractice
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What is GPCI in relation to the RBRVS formula?
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Geographic practive cost index, used to realize the varying cost based on geographic location
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What is CF in relation to the RBRVS formula?
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Conversion factor
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What is the conversion factor?
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a fixed dollar amount used to translate the RVUs into fees
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What is the formula for non-facility pricing amount?
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[(Work RVU * Work GPCI) + (Non facility PE RVU*PE GPCI)+(MP RVU*MP GPCI)] * CF
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What is the formula for facility pricing amount?
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[(Work RVU*Work GPCI)+(Facility PE RVU*PE GPCI)(MP RVU*Mp GPCI)] * CF
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What is medical necessity ?
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Refers to whether a procedure or service is considered appropiate in a given circumstance
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In general, a medically necessary service or procedure is what?
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The least radical service/procedure that allows for effective treatment of the patient's complaint or condition
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What is NCD?
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National Coverage Determinations
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What is MAC?
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Medicare Adminstrative Contractor
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What is LCD?
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Local Coverage Determinations
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What does NCD do?
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explain when Medicare will pay for items and services
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What is each MAC responsible for?
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interpreting national policies into regional policies
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What is purpose of LCD?
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regional policies, explain when a given service is indicated or necessary, give guidance on coverage limitations, describe the specific CPT codes to which the policy applies and list the ICD-9-CM codes that support the medical necessity for the given service or procedure
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If the NCD doesn't exist for a particular item, who determines coverage?
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MAC
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What doesn ABN stand for?
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Advance Benificary Notice
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What is an ABN?
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standardized form that explains to the patient why Medicare may deny the particular service or procedure, protects the providers financial interest by creating a paper trail that CMS requires before a provider can bill the patient for payment if Medicare denies coverage
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What is HIPAA?
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Health Insurance Portability and Accountability Act, provides federal protection for PHI when held by covered entities
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What is PHI?
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Protected Health Information
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What does HITECH stand for?
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Health Information Technology for Economic and Clinical Health Act
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What is HITECH?
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allows patients to request an audit trail showing all disclosures of their health information made through an electronic record, requires individuals to be notified if there is unauthorized disclosure or use of his/her health information
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What is definition of fraud?
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purposely bill for services that were never given or to bill for a service that has a higher reimbursement than the service provided
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What is compliance plan?
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written set of instructions outlining the process for coding and submitting accurate claims, and what to do if mistakes are found
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What does OIG stand for?
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Office of Inspector General
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What does OIG do?
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test efficiency and economy of government programs , mandated by public law
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What is AMA?
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American Medical Association
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What is ARRA?
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American Recovery and Reinvestment Act of 2009
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What is ASC?
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Ambulatory Surgical Centers
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What is CPT?
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Current Procedural Terminology
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What is EHR?
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Electronic Health Record
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What is HCPCS?
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Healthcare Common Procedure Coding System
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What is HHS?
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Department of Health and Human Services
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What is HMO?
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Health Maintenance Organization
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What is OCR?
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Office of Civil Rights
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What is PLI?
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Protected Liability Insurance
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What is RUC?
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Relative Value Update Committee
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What is RVU?
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Relative Value Unit
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What is a health care clearinghouse?
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entities that process non standard health information they recieve from another entity into a standard format or vice versa
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What OIG document should a provider review for potential problem areas that will receive special scrutiny in the upcoming year?
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OIG work plan
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The amount on an ABN should be within how much of the cost to the patient?
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$100 or 25% of the cost
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What is an NCD interpreted at the MAC level considered?
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LCD
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How are E/M services documented?
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SOAP
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What does SOAP stand for?
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Subjective, Objective, Assessment, and Plan
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What does the OCR do?
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enforces the HIPAA privacy rule
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What document was created to assit physicians with the development of compliance manuals?
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OIG Compliance Plan Guidance
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What document should be referred to when looking for potential problem areas identified by the government indicating scrutiny of the services within the coming year?
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OIG work plan
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What does TPO stand for?
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treatment, payment and healthcare operations
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What does CDT stand for?
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Current dental terminology
