question

Correct Coding Initiative (CCI)

answer

computerized Medicare system that prevents overpayment

question

CCI edits

answer

code combinations used by computers in the Medicare system to check claims

question

CCI column 1/ column 2 code pair edit

answer

Medicare code edit where CPT codes in colum 2 will not be paid if reproted in the same way as the column 1 code

question

CCI mutually exclusive code (MEC) edit

answer

both services represented by MEC codes that could not have been done during one encounter

question

CCI modifer indicator

answer

number showing if ht euse of a modifer can bypass a CCI edit

question

Medically unlikely edits (MUEs)

answer

units of servie edits used to lower the Medicare fee-for-service paid claims error rate

question

OIG Work Plan

answer

OIG annual list of planned projects-

question

Advisory opinion

answer

opinion issued by CMS or the OIG that becomes legal advise

question

Excluded parties

answer

individuals or companies not permitted to participate in federal healthcare programs

question

Claims are rejected or downcoded because of:

answer

-medical necessity errors -Coding errors -Errors relating to billing

question

Truncated coding

answer

diagnoses not coded at the highest lefel of specificity -using diagnosis codes that are not as specific as possible-mismatch between the gender or age of the patient and the selected code when the code involves selection for either criterion

question

Assumption coding

answer

reporting times or services that are not actually documented, but the coder assumes was performed -altering documentation after services are reported -coding without proper documentation -reporting services provided by unlicensed or unqualified clinical personnel -coding an unilateral service tice instead of choosing a bilateral code- -not satistisfying the conditions of coverage for a particular service, such as the physician's direct supervision of a a physician assistant's work

question

Errors related to billing cycle

answer

-billing noncovered services -billing overlimit services -unbundling -using an inappropriate modifer or no modifier when one is required -always assinging he same leel of E/M service -billing a consultantation instead of an office visit -billing invalid/ outdated code -billing without proper signatures on file

question

Upcoding

answer

using a procedure code that provides a higher reimbursement rate then the correct code--may lead to the payer downcoding

question

Downcoding

answer

using lower-level code

question

Strategies to ensure compiant billing

answer

-carefully bundled codes and global periods -benchmark the practice's E/M codes with national averages -used modifier appropriately -be clear on professional courtesy and discounts to unisured/low-income patients -maintain compliant job reference aids and doucumentation templates

question

Professional courtesy

answer

providing free services to other physicians

question

Job reference aid

answer

list of practice's frequently reported procedures and diagnosis

question

Computer-assisted coding(CAC)

answer

allows a software program to assist in assigning codes

question

Documentation template

answer

form used to prompt a physician to document a complete review of systems (ROS) and treatment's medical necessity

question

External audit

answer

audit conducted by an outside organization

question

Internal audit

answer

self-audit conducted b a staff member or consultant

question

prospective audit

answer

internal audit of claims conducted before transmission

question

Retrospective audit

answer

internal audit conducted after claims are processed and RAs have been received two benefits: -complete record is available so auditor knows which codes have been rejected or downcoded -explanation of the rejection or reduced charges making changes to the coding approachd if needed

question

Recovery Audit contractor (RAC)

answer

program designed to audit Medicare claims

question

Usual fee

answer

normal fee charged by a provider

question

selecting the correct E/M (evaluation and management) code

answer

-location(where on the body the symptom is occurring) -Quality(characteristics of the pain) -severity(the rank of the symptom or pain 1-10) -duration(how long has been present or how long when it occurs) -timing(when symptom or pain occurs) -context(the situation that is asssociated with the pain or symptom -modifing factors(things done to make the P or S change) -associated signs and symptoms

question

Charge-based fee structure

answer

fees based on typically charged amounts -fees that providers of similar training and experience have charged for similar services

question

resource-based fee structure

answer

fees structures built by comparing three factors (1) how difficult it is the the provider to do the procedure (2) how much office overhead the procedure involves (3) the relative risk the the procedure presnets to the patient and the provider

question

usual, customary, and reasonable (UCR)

answer

setting fees by comparing usual fees, and reasonable fees

question

relative value unit (RVU)

answer

factor assigned to a medical service based on the realative skill and required time

question

Conversion factor

answer

amount used to multiply a relative value unit to arrive at a charge

question

Resource-based relative value scale (RBRVS)

answer

relative value scal for establisihing Medicare charges

question

Geographic practice cost index (GPCI)

answer

Medicare factor used to adjust providers' fees in a particular geographic area

question

Medicare Physician Fee Schedule (MPFS)

answer

the RBRVS-base allowed fees

question

Steps used to calculate the RBRVS payments under the MPFS:

answer

-Determine the procedure code for the service -Use the MPFS to find three RVUs--work, practice expense, and malpractice--for the procedure -use the Medicare GPCI list to find the three geographic practice cost indices -Multipy each RVU by its GPCI to calculate the adjusted value -Add the three adjusted totals, and multiply ;the sum by the annual conversion factor to determine the payment

question

Payer use one of three methods to pay providers

answer

-Allowed charge--maximum charge a plan pays for a service or pocedure -Bundled payment--method by which an entire episode of care is paid for by a predetermined single payment -Balance billing--collecting the difference between a provider's usual fee and a payer's lower allowed charge -Write off--to deduct an amount from a patient's account

question

Capitation rate (or cap rate)

answer

is the periodic prepayment to a provider for spcified services to each plan member -Health plan sets a capitation rate that pays for all contracted services to enrolled members for a given period

question

HIPAA X12 837 Health Care Claim or equivalent Encounter Information

answer

used to send a claim to primary and secondary payers the electronic HIPAA claim is based on the CMS1500, which is a paper claim form

question

Nationa Uniform Claim Committee(NUCC)

answer

organization responsible for claim content -CMS-1500 (08/05) current paper claim approved by the NUCC 5010 version-new format for the EDI transactions

question

Completing CMS 1500 Claim- Patient info section

answer

Carrier block- data entry area in the upper right of the form CMS-1500 Condition code- two-digit numeric or alphanumeric codes used to report a special condition or unique circumstance #1-13 list demographic information about the patient and specific info about the patients insurance information is entered based on the patien info form, insurance card, and payer verification data

question

Types of providers

answer

-Pay to provider- person or organizatio that will be paid for services on a HIPAA claim -Rendering provider--term used to identify an alternative physician or professional who provides the procedure on a claim -Billing provider--person or organizaiton sending a HIPAA claim -Referring provider

question

Completing the CMS-1500 Claim: Physician/Supplier Info Section

answer

identifies the provider , describes services performed, gives the payer additonal info to process the claim -Other ID number-additional provider identification number -Qualifier- two digit code for a type of provider id # other thatn the NPI -Outside lab-purchased lab services -Service line info-info about services being reported -Place of service(POS) admin code indicating where medical service were provided -Taxonomy code-- administrative code set used to report a physician's specialty -Admin code set-- required codes for various data elements -The lower portion of the CMS-1500 claim form- # 14-33- contains information about the provider or supplier and the patient's condition, including diagnoses, procedures and charges. info is entered based on the encounter form

question

Data Element

answer

smallest unit of information in a HIPAA transaction ex. a patient 's name -required data element -info that must be supplied on a an electronic claim -situational data element-info that must be on a claim in conjunction with cerain other data elements

question

Completing the HIPAA 837

answer

five sections -provider info -suscriber info -payer info -claim info -service line info

question

responsible party-

answer

other person or entity who will pay a patient's charges

question

claim filing indicator code

answer

adminstrative code that idenitifies thetype of health plan

question

individual relationship code

answer

administrative code specifying the patient's relationship to the subscriber

question

destination payer

answer

health plan receiving a HIPAA claim

question

claim control #

answer

unique number assigned to a claim that itdentifies the claim as orginal, replacment or void/cancel action

question

line item control number

answer

unique number assigned to each service line item reported

question

claim attachment

answer

additional data in printed or electronic form sent to support a claim- i.e. lab results, specialty consultation notes and discharge notes

question

Clean Claim

answer

claim accepted by a health plan for adjudication properly completed and contains all the necessary info

question

HIPAA X12 276/277 Health Care Claim Status Inquiry/Response

answer

electronic format used to ask payer about claims

question

Clearinghouse and claim transmission

answer

three methods of handling electronic claims: 1. direct transmission approach, providers and payers exchange transactions directly 2. majority of providers use clearinghouses to send and receive data in correct EDI format 3. some payers offer online direct data entry (DDE) to providers , which involves using an Internet-based service into which employees key the standard data elements

question

Claim Scrubber

answer

software that checks claims to permit error correction

question

Employer sponsored medical insurance

answer

-Group health plan (GHP)- plan of an employer or employees organization to provide health care to employees, former employees, or their families -Rider-document modifing an insurance contract -Carve out- part of a standard health plan changed under an employer sponsered plan -open enrollment period- time when a policyholder select from offered benefits

question

Federal Emplyees Health Benefits Program(FEHBP)

answer

covers employees of the federal program self-funded health plans Employee Retirement Income Security Act of 1874 (ERISA)- law providing incentives and protection for companies with employee health an dpension plans

question

Summary Plan Description (SPD)

answer

required document for self-funded plans stating beneficiaries benefits and legal rights

question

Third party claims administrators (TPAs)

answer

business associates of health plans

question

Administrative services only (ASO)

answer

contract where a third-party administrator or insure provides administrative servis to an employer for a fixed fee per employee

question

Individual Health plan (IHP)

answer

medial insurance plan purchased by an individual

question

Section 125 cafeteria plan

answer

employers' health plans structured to permit funding of premiums with pretax payroll deductions Eligibility for benefits: -GPH specifies the rules for eligibility and the process of enrolling and disenrolling members -Waiting period- amount of time tha tmust pass before an employee/depedant may enroll in a health plan -Late enrollee-category of enrollment that may have different eligibility requirements

question

Individual deductible

answer

fixed amount that must be met periodically by each individual of an insured/dependent group

question

family deductible

answer

fixed, periodic amount that mus be met by the combinded paymets of an insured/dependent group before benefits begin

question

Maximum benefit limit

answer

amount an insurer agrees to pay for the lifetime covered expenses

question

Tiered network

answer

network system that reimburss more for quality, cost-effective providers

question

Consolidated Omnibus Budget Reconciliation Act (COBRA)

answer

law requiring employers with twenty or more employees to allow terminated employees to pay for coverage for eighteen months

question

Creditable coverage

answer

history of coverage for calculation of COBRA benefits

question

Parity

answer

equality for coverage of other treatments or services with medical/surgical benefits

question

subcaitiation

answer

arrangement where a caitated provider prepays an ancillary provider

question

Episode -of-care (EOC) option

answer

flat payment by a health plan to a provider for a defined set of services

question

Independent practice association(IPA)

answer

HMO in whch physicians are self-employed and provide services to mebers and nonmembers

question

Medical home model

answer

plan that seeks to imporve patient care by rewarding primary care physicians for coordinating patients' treatments

question

Consumer-Driven Health Plans (CDHP)

answer

two components 1. a high-deductible health plan (HDHP)-health plan that combines high-deductable insurance and a funding option to pay patients' out-of-pocket expenses up to the deductable 2. one or more tax-preferrred savings accounts that the patient directs

question

Three types of CDHP funding options that may be combined with HDHPs

answer

1. Health reimbursement account (HRA) employer sets aside an annual amount for healthcare cost 2. Health Savings account (HSA)- funding option uder which funds are set aside to pay for certain healthcare costs 3. Flexible savings account (FSA) funding option that has emplyer and employee contributions

question

Major Private Payers and the BCBS Association

answer

WellPoint, Inc. UnitedHealth Group Aetna CIGNA Health Care Kiaser Permanent Health Net Humana, Inc Coventry

question

Credentialing

answer

periodic verification that a provider or facility meets professional standards

question

The BlueCross BlueSheild Association(BCBS)

answer

national organization of independent copanies founded in the 1930's to provie low-cost medical insurance pay-for-performance (P4P) health plan finacial icnentives program based on proficer perfomance BlueCard- program that provides benefits for subscribers who are away from their local areas

question

BCBS plans

answer

Host plan- participating providers local BCBS plan Home plan- BCBS plan in the subscriber's community Flexible Blue- BCBS consumer driven health plan

question

Utilization review

answer

Payer's processfor determining medical necessity

question

Stop-loss provision

answer

protection against large losses or severely adverse claims experience

question

Silent PPO

answer

MCO that purchaces a list of participating providers and pays there enrollees' claims according to the contract's fee schedule despite the lac of a contract

question

Elective surgery

answer

nonemergency surgical procedure

question

Utilization Review organization (URO)

answer

organization hired by a payer to evaluate medical necessity

question

Plan Summary Grid

answer

quick- reference table for health plan -summarizes key items -list key information, provides shortcut references -includes info about collting payments at time of service and completing claims

question

Steps of medical billing cycle

answer

1. preregister patients 2. establish financial responsibility 3. check in patients-copayment collected before encounter 4. review coding compliance 5. check billing compliance 6. check out patient 7. prepare and transmit claims

question

repricer

answer

vendor that process a payer's out-of-network claims

question

Capitation Management

answer

medial insurance specialist verify patient eligibility with the plan because enrollment data are not always up-to-date Encounter info must accurately reflect the necessity for the provider's services

question

Monthly enrollment list

answer

document of eligible members of a capitated plan for a monthly period

question

Five parts of participation contracts

answer

introductory section contract purpose and covered expenses physician's responsibilities managed care plan obligations compensaton and billing guidelines

MO202 ch 6,7,8

Unlock all answers in this set

Haven't found what you were looking for?

Search for samples, answers to your questions and flashcards