question

ABN

answer

Advance Beneficiary Notice

question

AMA

answer

American Medical Association

question

APC

answer

Ambulatory Payment Classification

question

ARRA

answer

American Recovery and Reinvestment Act of 2009

question

ASC

answer

Ambulatory Surgical Center

question

CDT

answer

Current Dental Terminology

question

CMS

answer

Centers for Medicare & Medicaid Services

question

CMS-HCC

answer

Centers for Medicare & Medicaid Services - Hierarchical Condition Cetegory

question

CPC

answer

Certified Professional Coder

question

CPT

answer

Current Procedural Terminology

question

EHR

answer

Electronic health Record

question

EIN

answer

Employer Identification Number

question

E/M or E&M

answer

Evaluation and Management

question

HCPCS

answer

Healthcare Common Procedure Coding System

question

HHS

answer

Department of Health & Human Services

question

HIPAA

answer

Health Information Portability & Accountability Act of 1996

question

HITECH

answer

Health Information Technology for Economic & Clinical Health Act

question

HMO

answer

Health Maintenance Organization

question

ICD-9-CM

answer

International Classification of Disease, 9th Clinical Modification

question

LCD

answer

Local Coverage Determination

question

MAC

answer

Medicare Administrative Contractor

question

MS-DRG

answer

Medicare Severity Diagnostic Related Group

question

NCD

answer

National COverage Determination

question

NP

answer

Nurse Practitioner

question

NPI

answer

National Provider Identifier

question

OCR

answer

Office for Civil Rights

question

OIG

answer

Office of Inspector General

question

PA

answer

Physicians Assistant

question

PHI

answer

Protected Health Information

question

SOAP

answer

Standard format for E/m services Subjective Objective Assessment Plan

question

TPO

answer

Treatment, Payment and healthcare Operations

question

Technicians who specialize in coding are...

answer

Medical Coders or Coding specialists

question

Technicians who specialize in coding Inpatient Hospital Services...

answer

Health Information Coders, Medical Record Coders, Coder/Abstractors or Coding Specialists

question

Determines the amount a hospital will be reimbursed for if PT is covered by MCR

answer

MS-DRG

question

May Specialize in Cancer Registry

answer

Health Information Technicians and Medical Record Coders

question

Codes and updates are made as often as...

answer

Quarterly

question

Used for Outpatient coding

answer

CPT HCPCS Level II ICD (9 or 10) Volumes 1 & 2

question

Used for Inpatient coding

answer

CPT ICD (9 or 10) volumes 1, 2 & 3 HCPCS Level I

question

AKA Mid-Level Providers

answer

Physician Extenders such as Physician Assistant or Nurse Practitioner

question

Two types of payers

answer

Private and Gov't

question

Commercial Carriers offer..

answer

individual or group plans

question

Medicare is a _____ Health insurance Program

answer

Federal

question

Medicare is administerd by the ___

answer

CMS - Centers for Medicare & Medicaid

question

Medicare Provides Coverage for

answer

PPL Over 65 Blind Disabled Perm. Kidney Damage ESRD

question

Medicare Part A

answer

Inpatient Hospital Care SNF Hospice Home Health

question

Medicare Part B

answer

Medicall Necessary services Outpatient Care Some preventative services Other services not under Part A

question

Medicare Part B is a _____

answer

Optional benefit for which the PT must pay a premium as well as co-insurance

question

Medicare Part C

answer

AKA Medicare Advantage Combines Part A, B and sometimes D Managed by private insurers approved by medicare and may include PPOS/HMOs

question

CMS-Hierarchial Condition Category risk adjustment model

answer

Provides adjusted payments based on a patient's diseases and demographic factors

question

Medicare Part D

answer

Prescription drug coverage avaliable to all Medicare beneficiaries. Private Companies approved by medicare provide this coverage

question

Medicaid

answer

Insurance program for low income people sponserd by federal and state governments administered on a state by state basis

question

Medical Record

answer

Record of facts and observatons about an individuals health history, tests, treatments and outcomes. Chronoloically documents PTs care

question

What is the purpose of a Medical Record?

answer

To assist in continuity of care between provdiers, facilitate claims review and payment, as well as serve as legal documentation

question

What is SOAP?

answer

Standard format for E/M Service reporting

question

What is the S in SOAP?

answer

Subjective - The PTs statement ab their health including symptoms

question

What is the O in SOAP?

answer

Objective - The provider's exam including tests, and other services performed.

question

What is the A in SOAP?

answer

Assessment - Evaluation and conclusion made by the provider. This is where the diagnosis for the service is found

question

What is the P in SOAP?

answer

Plan - Course of action. The provider lists the steps for the patient including odering additional tests or taking over the counter meds

question

Operative Repot

answer

Used to document the detail of a procedure performed on a patient

question

Operative reports are made of 2 parts the ____ and the ____

answer

Header and body

question

The OP header contains

answer

Date and time of the procedure Names of the providers Types of anesthsia used Pre-op and post-op DX Procedure performed Complications

question

The OP Body Includes

answer

Indication for surgery (reason) Details of the procedures Peocedure type (Closed, open, simple, complicated) Findings

question

What is Medical Necessity?

answer

The least radical service/procedure that allows for effective treatment of the patients complaint or condition

question

What are Local Coverage Determinations?

answer

Regional policies that explain when medicare will pay for items or services

question

Who is responsible for creating LCDs?

answer

Medicare Administrative Contractors (MAC) - responsible for interpreting national policies into regional policies.

question

Explains when Medicare Will pay for Items or Services....

answer

National Coverage Determinations (NCDs)

question

When should an ABN be used?

answer

When a Medicare beneficiary requests or agrees to recieve a procedure or service that Medicare may not cover

question

When creating an ABN the cost estimate must be within _____ of the actual costs

answer

$100 or 25% whichever is greater

question

Assigned claim

answer

Claim submitted by and paid to a physician on behalf of the beneficiary

question

Unassigned Claim

answer

Claim submitted by the provider but payment is sent to the patient who then pays the provider

question

Without a valid ABN providers cannot____

answer

Bill the MCR MM for denied charges

question

ABNs are ____required in an ______

answer

Never Emergency situation

question

When _____ and ____ care is denied by MCR for Medical Necessity physicians ____seek payment

answer

screening stabilizing cannot

question

HIPAA stands for

answer

Health Information Portability & Accountability Act

question

When was HIPAA enacted?

answer

1996

question

HIPAA is a _____ act

answer

5 Part

question

Title II of HIPAA is known as ______

answer

Administration Simplification

question

Title II of HIPAA adresses the need for

answer

-Nat'l Standards 4 Elect. Healthcare Transactions & code sets - Nat'l unique ID for provider's plans and employers - Privacy & security of health data

question

HIPAA covers Providers such as:

answer

Doctors, Clinics, Psychologists, Dentists, Chiropractors, Nursing Homes, Pharmacies

question

HIPAA Covers plans such as:

answer

Health Insurance Companies HMO plans Company Health Plan Gov't Plans Clearing Houses

question

Define Transactions

answer

Electronic exchanges involving transfer of information between two parties for a specific purpose

question

Name the types of transactions

answer

Health Claims, Enrollment and Disenrollment, Eligibility, Healthcare payments, RAs, Premium payments, Claim status, Referral certifications and authorizations, Coordination of benefits

question

HIPAA provides federal protections for personal health information when held by_____

answer

Covered Entities

question

Define Minimum Necessary requirement

answer

Only the minimum necessary protected health information should be shared to satisfy a particular purpose

question

HITECH was enacted to ___ and ___

answer

- promote the adoption and meaningful use of health information technology -Establishes four categories of violations as well as minimum and maximum penalties

question

HITECH allows PTs to...

answer

request an audit trail showing all disclosures of their PHI made through electronic record

question

HITECH requires an...

answer

individual to be notified if there is unquthorized disclosure or use of their PHI

question

Define Compliance Plan

answer

a written set of instructions outlining the process for coding and submitting accurate claims and what to do if mistakes are found

question

Compliance plans are...

answer

voluntary

question

The Office of Inspector General (OIG) is tasked to...

answer

Protect the integrity of the Department of Health & Human Services (HHS) programs as well as the health and welfare of the beneficiaries of those programs

question

The OIG Compliance Program Guidance was pluished in the ______ on____

answer

Federal Register on October 5th, 2000Guidance

question

Outlines key actions of a compliance program

answer

OIG Compliance Program Guidance

question

Name the 7 Key actions of the OIG Compliance Program Guidance

answer

Conduct internal monitoring and auditing, implement compliance and practice standards, designate a compliance officer or contacts, conduct appropriate training and education on practice standards and procedures, respond appropriately to detected violations, develope open lines of communication, enforce disciplinary standards throgh well publicized guidelines

question

The OIG releases a work plan each year in

answer

October

question

The work plan outlines

answer

priorities for the fiscal year ahead as well as announces potential problem areas with claim submissions that will be target for special scrutiny in the coming year

question

Which act was enacted as part of the American Recovery & Reinvestment Act of 2009?

answer

HITECH

question

What document was created to assist physician offices with the development of compliance manuals?

answer

OIG Compliance Plan Guidance

question

What document should be referred to when looking for potential problem areas identified bythe government indicating scrutiny of the services within the coming year?

answer

OIG Work Plan

question

When was AAPC Founded?

answer

1988

question

What does AAPC stand for?

answer

American Academy of Professional Coders

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