question

Medical Billing & Coding as a Career

answer

*Claims assistant professional or claims manager, *Coding Specialist, * Collection Manager, *Electronic Claims Processor, *Insurance Billing Specialist, * Insurance Coordinator, *Insurance Counselor, *Medical Biller, *Medical & Financial Records Manager, * Billing & Coding Specialist

question

What are Medical Ethics?

answer

Standards of conduct based on moral principle. They are generally accepted as a guide for behavior towards pt's, dr's, co-workers, the gov, and ins co's.

question

What does acting within ethical behavior boundaries mean?

answer

carrying out one's responsibilities w/ integrity, dignity, respect, honesty, competence, fairness, & trust.

question

Legal Aspects of of Medical Billing & Coding:

answer

...

question

Compliance regulations:

answer

Most billing-related cases are based on HIPPA and False Claims Act

question

Health Insurance Portability & Accountability Act (HIPPA)

answer

Enacted in 1996, created by the Health Care Fraud & Abuse Control Program-enacted to check for fraud and abuse in the Medicare/Medicaid Programs and private payers

question

What are the 2 provisions of HIPPA?

answer

Title I: Insurance Reform Title II: Administrative Simplification

question

What is Title I of HIPPA?

answer

Insurance Reform-primary purpose is to provide continuous ins coverage for worker & their dependents when they change or lose jobs. Also *Limits the use of preexisting conditions exclusions *Prohibits discrimination from past or present poor health *Guarantees certain employees/indv the right to purchase new health ins coverage after losing job *Allows renewal of health ins cov regardless of an indv's health cond. that is covered under the particular policy.

question

What is Title II of HIPPA?

answer

Administrative Simplification-goal is to focus on the health care practice setting to reduce administrative cost & burdens. Has 2 parts- 1) development and implementation of standardized health-related financial & administrative activities electronically 2) Implementation of privacy & security procedures to prevent the misuse of health info by ensuring confidentiality

question

What is the False Claims Act (FCA)?

answer

Federal law that prohibits submitting a fraudulent claim or making a false statement or representation in connection w/ a claim. Also protects & rewards whistle-blowers.

question

What is the National Correct Coding Initiative (NCCI)?

answer

Developed by CMS to promote the national correct coding methodologies & to control improper coding that lead to inappropriate payment of Part B health ins claims.

question

How many edits does NCCI include?

answer

2: 1)Column 1/Column 2 (prev called Comprehensive/Component) Edits 2) Mutually Exclusive Edits

question

Column 1/Column 2 edits (NCCI)

answer

Identifies code pairs that should not be billed together b/c 1 code (Column 1) includes all the services described by another code (Column 2)

question

Mutually Exclusive Edits (NCCI)

answer

ID's code pairs that, for clinical reasons, are unlikely to be performed on the same pt on the same day

question

What are the possible consequences of inaccurate coding and incorrect billing?

answer

*delayed processing & payment of claims *reduced payments, denied claims *fine and/or imprisonment *exclusion from payer's programs, loss of dr's license to practice med

question

Who has the task of investigate and prosecuting health care fraud & abuse?

answer

The Office of Inspector General (OIG)

question

Fraud

answer

knowingly & intentionally deceiving or misrepresenting info that may result in unauthorized benefits. It is a felony and can result in fines and/or prison.

question

Who audits claims?

answer

State & federal agencies as well as private ins co's

question

What are common forms of fraud?

answer

billing for services not furnished, unbundling, & misrepresenting diagnosis to justify payment

question

Abuse

answer

incidences or practices, not usually considered fraudulent, that are inconsistent w/ the accepted medical business or fiscal practices in the industry.

question

What are examples of Abuse?

answer

submitting a claim for services/procedures performed that is not medically necessary, and excessive charges for services, equipment or supplies.

question

What is a method use to minimize danger, hazards, & liabilities associated w/ abuse?

answer

Risk Management

question

Patient Confidentiality

answer

All pt's have right to privacy & all info should remain privileged. Only discuss pt info when necessary to do job. Obtain a signed consent form to release medical info to ins co or other individual.

question

When may providers use PHI (Protected Health Information) w/o specific authorization under the HIPPA Privacy Rule?

answer

When using for TPO, Treatment (primarily for the purpose of discussion of pt's case w/ other dr's) Payment (providers submit claims on behalf of pt's) & Operations (for purposes such as training staff & quality improvement)

question

What is Employer Liability?

answer

Means physicians are legally responsible for their own conduct and any actions of their employees (designee) performed w/in the context of their employment. Referred to as \"vicarious liability. A.K.A \"respondent superior\"-\"let the master answer\". Means employee can be sued & brought to trial

question

What is Employee Liability?

answer

\"Errors & Omissions Insurance\"-protection against loss of monies caused by failure through error or unintentional omission on the part of the indv or service submitting the claim. ****Some dr's contract w/ a billing service (clearinghouse) to handle claims submission, & some agreements contain a clause stating that the dr will hold the co harmless from \"liability resulting from claims submitted by the service for any account\", means dr is responsible for mistakes made by billing service, errors & omissions is not needed in the instance. ******However, if dr ever asks the ins biller to do the least bit questionable, such as write of pt's balances for certain pt's automatically, make sure you have a legal document or signed waiver of liability relieving you of responsibility for such actions.

question

What is a Medical Record & what is it comprised of?

answer

documentation of the pt's social & medical history, family history, physical exam findings, progress notes, radiology & lab results, consultation reports and correspondence to pt- Is the foremost tool of clinical care and communication.

question

What is a medical report?

answer

part of the medical record & is a permanent legal document that formally states the consequences of the pt's exam or treatment in letter or report form. IT IS THIS RECORD THAT PROVIDES INFO NEEDED TO COMPLETE THE INS CLAIM FORM.

question

Reasons for Documentation

answer

Important that every pt seen by dr has comprehensive legible documentation about pt's illness, treatment, & plans for following reasons: *Avoidance of denied or delayed payment by ins co investigating the medical necessity of services *Enforcement of medical record-keeping rules by ins co requiring accurate documentation that supports procedure & diagnosis codes. *Subpoena of medical records by state investigators or the court for review *Defense of professional liability claim

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Retention Of Medical Records

answer

Is governed by state & local laws & may vary from state-to-state. Most dr are required to retain records indefinitely, deceased pt records should be kept for @ least 5 years

question

Med Term

answer

...

question

Diagnosis suffixes:

answer

...

question

-algia

answer

pain

question

-emia

answer

blood condition

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-itis

answer

inflammation

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-megaly

answer

enlargement

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-meter

answer

measure

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-oma

answer

tumor, mass

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-osis

answer

abnormal condition

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-pathy

answer

disease condition

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-rrhagia

answer

bursting forth of blood

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-rrhea

answer

discharge, flow

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-sclerosis

answer

hardening

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-scopy

answer

to view

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Procedural Suffixes:

answer

...

question

-centesis

answer

surgical puncture

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-ectomy

answer

removal, resection, excision

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-gram

answer

record

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-graphy

answer

process of recording

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-lysis

answer

separation, breakdown, destruction

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-pexy

answer

surgical fixation

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-plasty

answer

surgical repair

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-rrhapy

answer

suture

question

-scopy

answer

visual examination

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-stomy

answer

opening

question

-therapy

answer

treatment

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-tomy

answer

incision, to cut into

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Common Prefixes:

answer

...

question

a, an

answer

without

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ante

answer

before

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anti

answer

against

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brady

answer

slow

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dys

answer

painful, difficult

question

endo

answer

inside, within

question

epi

answer

upon, above

question

ex

answer

out, out of

question

hemi

answer

half, partial

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hypo

answer

below, deficient

question

infra

answer

below

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inter

answer

between

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neo

answer

new

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oligo

answer

scanty, little

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pan

answer

all

question

para

answer

beside

question

per

answer

through

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poly

answer

many

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pre

answer

before, in front of

question

pseudo

answer

false

question

sub

answer

under

question

supra

answer

above, beyond

question

tetra

answer

four

question

Common Root Words

answer

...

question

arth

answer

cartilage

question

cephal

answer

head

question

cardi

answer

heart

question

cholecyst

answer

gall bladder

question

chondro

answer

cartilage

question

colp

answer

vagina

question

derm

answer

skim

question

enter

answer

intestine

question

episi

answer

vulva

question

gastro

answer

stomach

question

gloss

answer

tongue

question

hepato

answer

liver

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hyster

answer

uterus

question

lapar

answer

abdomen

question

lact

answer

milk

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lith

answer

stone

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mast

answer

breast

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myo

answer

muscle

question

nat

answer

birth

question

oophor

answer

ovary

question

oste

answer

bone

question

pneum

answer

lung

question

rhin

answer

nose

question

salping

answer

fallopian tubes

question

stomat

answer

mouth

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Directional Terms:

answer

...

question

Anterior, Ventral

answer

front surface of the body

question

Posterior, Dorsal

answer

back side of the body

question

Superior

answer

above another structure

question

Inferior

answer

below another structure

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Proximal

answer

near the point of attachment to the trunk

question

Distal

answer

far from the point of attachment to the trunk

question

Medial

answer

pertaining to the middle of the body

question

Lateral

answer

pertaining to the side

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Frontal, Coronal

answer

Vertical plane dividing the body into anterior & posterior portions

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Sagittal

answer

vertical plane dividing the body into right & left sides

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Transverse, Cross-sectional

answer

Horizontal plane dividing the body into upper & lower portions

question

Anatomy & Physiology

answer

A professional medical coder must have knowledge of anatomy & physiology so that coding assignment is quick & accurate.

question

What is the 1st body system for which medical procedures are described in the CPT manual?

answer

The Integumentary System (the skin and it's accessory organs) Integument means covering. It is a complex system of specialized tissues containing glands, nerves and blood vessels.

question

How much area does the skin cover?

answer

an area of 22 sq ft (an average adult). It is the largest organ of the body

question

What is the main function of the skin?

answer

To protect the deeper tissues from excessive loss of minerals, heat & water. It also provides protection form diseases by providing a barrier. It accomplishes its diverse functions w/ assistance from the hair, nails and glands.

question

SEBACEOUS (OIL) GLANDS & SUDDORIFERIOUS (SWEAT GLANDS)

answer

produce secretions that allow the body to be moisturized or cooled.

question

How many layers to the skin?

answer

3; 1) Epidermis (thin, cellular membrane layer that contains keratin) 2) Dermis (dense, fibrous, connective tissue that contains collagen) 3) Subcutaneous layer (thicker & fatter tissue)

question

Hair, Nail & Glands

answer

...

question

Hair

answer

composed of tightly fused meshwork of cells filled w/ hard protein called karatin. Has its roots in the dermis & together w/ their coverings, is called HAIR FOLLICES. Main function is to assist in regulating body temp. Holds heat when body is cold by standing on end & holding a layer of air as insulation.

question

Nails

answer

cover & protect the dorsal surface of the distal bones of the fingers & toes. Part that is visible is nail body, nail root is under skin @ the base of the nail and nail bed is the vascular tissue under the nail that appears pink when the blood is oxygenated or blue/purple when it is oxygen deficient.

question

What is the moon like white area of the nail called?

answer

lunula

question

What is the eponychium?

answer

the cuticle at the lower part of the nail sometime referred to as such

question

SEBACEOUS GLANDS

answer

located in the dermal layer of the skin over the entire body, expect for palm of hands and soles of feet. Secrete oily substance called SEBUM. SEBUM CONTAINS LIPIDS THAT HELP LUBRICATE THE SKIN & MINIMIZE WATER LOSS. It is the overproduction of sebum during puberty that contributes to acne in some people

question

SUDDORIFEROUS GLANDS

answer

sweat glands that are tiny, coiled gland found on almost all body surfaces. They are most numerous in the palms and soles of feet. Coiled sweat glands originate in the dermis and straighten out to extend up through the epidermis. Tiny opening at surface is called a PORE.

question

How many types of sweat glands?

answer

2; 1) eccrine sweat glands (most common) 2) apocrine sweat glands (secrete orderless sweat)

question

What organ secretes hormones?

answer

the adrenal glands, they secrete epinephrine & steriods

question

Integumentery Vocabulary

answer

...

question

Albino

answer

deficient in pigment (melanin)

question

Collagen

answer

structural protein found in the skin & connective tissue

question

Melanin

answer

major skin pigment

question

Lipocyte

answer

a fat cell

question

Macule

answer

discolored, flat lesion (freckles,, tattoo marks)

question

Polyp

answer

benign growth extending from the surface of the mucous membrane

question

Fissure-

answer

groove or crack like sore

question

Nodule

answer

solid, round or oval elevated lesion more than 1 cm in diameter

question

Ulcer

answer

open sore on the skin or mucous membrane

question

Vesicle

answer

small collection of clear fluid; blister

question

Wheal

answer

Smooth, slightly elevated, edematous (swollen) area that is redder or paler than the surrounding skin

question

Alopecia

answer

absence of hair form areas where it normally grows

question

Gangrene

answer

death of tissue associated w/ the loss of blood supply

question

Impetigo

answer

bacterial inflammatory skin disease characterized by lesion, pustules, and vesicles

question

Multigravida

answer

a pregnant woman who has had at least one previous pregnancy

question

The Musculoskeletal System

answer

includes bones, muscles & joints. Acts as a framework for the organs, protects many of those organs, and also provides the body w/ the ability to move

question

What are bones connected to one another by?

answer

by fibrous bands of tissues called LIGAMENTS

question

What are muscles attached to the bone by?

answer

tendons

question

What is the fibrous covering of muscles called?

answer

the fascia and the aricular cartilage, covers the end of many bones and serves as a protective function.

question

Bones

answer

complete organs made up of connective tissue called OSSEOUS. Inner core of bones is comprised of HEMATOPOIETIC tissue. This is where the red bone marrow manufactures blood cells. Other parts of the bones are storage areas for minerals necessary for growth, ie; calcium and phosphorous

question

How are bones categorized?

answer

as belonging to either the AXIAL SKELETON or the APPENDICULAR SKELETON.

question

Axial Skeleton

answer

consist of the skull, rib cage & spine

question

Appendicular Skeleton

answer

made up of the shoulder, collar, pelvic, arm & legs

question

Long Bones

answer

typically very strong, are broad at the ends and have large surfaces for muscle attachment. IE: HUMERUS & FEMUR.

question

Short Bones

answer

are small w/ irregular shapes, they are found in wrist and ankle

question

Flat Bones

answer

are found covering the soft body parts, IE; SHOULDER BLADES, RIBS AND PELVIC BONES

question

Sesamoid Bones

answer

small, rounded bones that resemble a sesame seed. they are found near joints and increase the efficiency of muscles near a joint. IE, KNEE CAP

question

The Axial Skeleton-Skull, Rib Cage, Spine

answer

...

question

Skull

answer

made up of 2 parts, the cranium and the facial bone

question

Cranium

answer

includes following bones *Frontal Bone- forms the anterior part of the skull & forehead *Parietal Bone- Forms the sides of the cranium *Occipital Bone- forms the back of the skull, there is a large hole at the ventral surface in this bone, called the foramen magnum, which allows the brain communication w/ the spinal cord *Temporal Bone- forms the 2 lower sides of the cranium *Ethmoid Bone- forms the roof of the nasal cavity *Sphenoid Bones- anterior to the temporal bones

question

Facial Bones

answer

...

question

Zygoma

answer

cheekbone

question

Lacrimal Bones

answer

paired bones at the corner of each eye that cradle the tear ducts

question

Maxilla

answer

upper jaw bone

question

Mandible

answer

lower jaw bone

question

Vomer

answer

bone that forms posterior/inferior part of the nasal septal wall between the nostrils

question

Palatine bones

answer

Make up part of the roof of the mouth

question

Spinal/Vertebral Column

answer

is divided into 5 regions from the neck to the tailbone. There are 26 bones in the spine & are referred to as the VERTABRAE

question

Cervical

answer

Neck Bones

question

Thoracle

answer

Upper Back

question

Lumbar

answer

Lower Back

question

Sacral

answer

Sacrum

question

Coccygeal

answer

Coccyx (tailbone)

question

Rib Cage

answer

There are 12 pairs of ribs. The 1st 7 pairs join the sternum anteriorly through the cartilaginous attachments called COSTAL CARTILAGE. The TRUE RIBS #'s 1-7 attach directly to the sternum in the front of the body. The FALSE RIBS, #'s 8-10 are attached to the sternum by cartilage. Ribs 11 & 12 are FLOATING RIBS, b/c they are not attached at all

question

The Appendicular Skeleton

answer

...

question

Upper Appendicular Skeleton

answer

includes the shoulder girdle which is made up of the SCAPULA, CLAVICLE, & UPPER EXTREMITIES

question

Scapula

answer

or shoulder blades are flat bones that help support the arms

question

Clavicle

answer

or collarbone, is curved horizontal bones that attach to the upper sternum at one end, these bones help stabilize the shoulder

question

Upper Extremities

answer

consist of the following:

question

Humerus

answer

upper arm bone

question

Ulna

answer

lower medial arm bone

question

Radius

answer

lateral lower arm bone (in line w/ the thumb)

question

Carpals

answer

Wrist bones, there are 2 rows of 4 bones in the wrist

question

Metacarpals

answer

the 5 radiating bones in the fingers. These are the bones in the palm of the hand.

question

Phalanges

answer

finger bones, each finger has 3 phalanges, except for the thumb. The 3 phalanges are the proximal, middle and a distal phalanx. The thumb has a proximal and distal

question

Lower Appendicular

answer

can be divided into the pelvis and the lower extremities

question

Pelvis

answer

superior & widest bone

question

Ischium

answer

lower portion of the pelvic bone

question

Pubic Bone

answer

lower anterior part of the bone

question

Lower Extremeties

answer

...

question

Femur

answer

thighbone

question

Patella

answer

kneecap

question

Tibia

answer

shin

question

Fibula

answer

smaller, lateral leg bone

question

Malleolus

answer

ankle

question

Tarsal

answer

hind foot bone

question

Metatarsal

answer

midfoot bone

question

Phalanx

answer

toe bones, 14 in all (2 in great toe, 3 in each of the other toes)

question

Joints

answer

parts of the body where 2 or more bones of the skeleton join. Different joints have different ROM (range of motion), ranging from no movement at all to full range of movement

question

No ROM

answer

most synarthroses are immovable joints held together by fibrous tissue

question

Limited ROM

answer

amphiathroses are joints joined together by cartilage that is slightly moveable, such as the vertebrae of the spine or the pubic bone

question

Full ROM

answer

diathroses are joints that have free movement, Ball-and-socket joints (hip) and hinge joints (knees) are common diathroses joints (synovial joints)

question

Synovial Joints

answer

free moving joints, are surrounded by joint capsules. Many of the synovial joints have BURSAE-SACS OF FLUID THAT ARE LOCATED BETWEEN THE BONES OF THE JOINT AND THE TENDONS THAT HOLD THE MUSCLES IN PLACE.

question

Muscles

answer

Muscle is tissue comprised of cells. Have the ability to contract & relax.

question

What are the 3 different functions of the human muscles?

answer

1) allow the skeleton to move 2) responsible for movement of organs 3) to pump blood to the circulatory cystem

question

How are muscles attached to bones?

answer

by strong, fibrous bands of connective tissues called tendons.

question

Muscle Actions

answer

...

question

Extension

answer

to increase the angle of the joint

question

Flexion

answer

to decrease the angle of the joint

question

Abduction

answer

movement away from the midline

question

Adduction

answer

movement towards the midline

question

Supination

answer

turning the palm or foot upward

question

Pronation

answer

turning the palm or foot downward

question

Dorsiflexion

answer

raising the foot, pulling the toes toward the shin

question

Plantar Flexion

answer

lowering the foot, pointing the toes away form the shin

question

Eversion

answer

turning outward

question

Inversion

answer

turning inward

question

Protraction

answer

moving a part of the body forward

question

Retraction

answer

Moving a part of the backward

question

Rotation

answer

revolving a bone around its axis

question

Fractures

answer

broken bone, most occur as a result of trama, however some disease such as cancer or osteoporosis can also cause spontaneous fractures. Can be classified as simple or compound. Simple fractures don't rupture the skin as compound fractures split open the skin allowing for an infection to occur.

question

Communicated Fracture

answer

the bone is crushed and/or shattered

question

Compression Fracture

answer

the fractured area of the bone collapses on itself

question

Colles Fracture

answer

the break of the distal end of the radius at the epiphysis often occurs when the pt has attempted to break his/her fall

question

Complicated Fracture

answer

the bone is broken and the ends are driven into each other

question

Hairline Fracture

answer

a minor fracture appears as a thin line on x-ray; and may not extend completely through the bone

question

Greenstick Fracture

answer

the bone is partially bent & partially broken, this is a common fracture in children b/c their bones are still soft

question

Pathologic Fracture

answer

any fracture occurring spontaneously as a result of disease

question

Salter-Harris Fracture

answer

a fracture of the epiphyseal plate in children

question

Sprains, strains and dislocation/subluxation

answer

SPRAIN is a traumatic injury to the joint involving the soft tissue, soft tissue includes the muscles, ligaments and tendons.

question

Strain

answer

lesser injury, usually this is a result of overuse or overstretching

question

Dislocation

answer

is when the bone is completely out of place

question

Subluxation

answer

bone is partially out of joint

question

Evaluations & Management Review

answer

The E&M section include codes that pertain to the nature of the physicians work. Codes depend on type of service, pt status, and place where service was rendured. The E&M section is divided into broad categories such as office visit, hospital visits, and consultations

question

Basic Format of the levels of E&M services

answer

1) a unique code # is listed 2) the place & type of service is specified 3) the content of the service is defined 4) the nature of the presenting problem(s) usually associated w/ a given level is (are) described 5) time is typically specified in the descriptor of the code

question

New Patient

answer

defined as one who has not received medical services w/in the last 3 years

question

Established Patient

answer

defined as someone who has recieved medical services w/in the last 3 years from the physician or another physician of the same specialty who belongs to the same group practice

question

Chief Complaint

answer

brief statement describing the symptom, problem, diagnosis, or condition that is the reason the pt seeks medical care

question

How many Volumes to ICD manual?

answer

3; *Volume 1- Disease: Tabular List *Volume 2- Disease: Alphabetic Index *Volume 3- Procedures: Tabular list and Alphabetic Index

question

Volume 1-Index to Diseases, Tabular List

answer

contains the disease and condition codes and the descriptions, also contains the V codes and E codes

question

Volume 2-Index to Diseases, Alphabetic Index

answer

the is the alphabetic index of Volume 1; use this first then volume 1 to confirm codes

question

Volume 3-Procedures

answer

contains codes for surgical, therapeutic, and diagnosis procedures, used primarily in hospitals

question

Which volume(s) are used in the inpatient and outpatient settings (physician office)?

answer

Volume's 1 & 2

question

How to ensure you have chosen the correct code?

answer

First locate the code in the alphabetic index (Volume 2) then cross-reference this code in the Tabular List (Volume 1)

question

Supplementary Classification Codes

answer

...

question

What are V codes?

answer

Supplementary Classification of Factors Influencing Health Status and Contact of Health Services-supplementary classification code used to identify health care encounters that occur for reasons other that illness or injury or to indentify pt's whose illness is influenced by special circumstances or problems. Can be found in both Volume 1 & Volume 2

question

What are circumstances when V codes are used?

answer

*When a person who is not currently sick encounters health services for some specific reason such as to act as an organ donor or receive a vaccination. (IE; V59.3 is the code for donor of bone marrow) *When a person w/ a resolving disease or chronic condition presents for specific treatment of that disease or condition. (IE; V56.0 is used for extracorporeal dialysis) *When a circumstance may influence the pt's health status but is not a current illness (IE; V16.3 is used for family history of coronary artery disease) *To indicate the birth status of a newborn (IE; V30.0 is uused for a newborn male born in the hospital by c-section)

question

What are E codes?

answer

Supplementary Classification of External Causes of Injury and Poisoning-supplementary classification codes used to describe the reason of EXTERNAL CAUSE of injury, poisoning and other adverse effects. Can be found in both Volumes ! & 2.

question

What codes are used to classify environmental events, circumstances, and conditions as the cause of injury, poisoning & other adverse effects and capture how the injury or poisoning happened, the intent and the place where the event happened?

answer

E codes

question

/When is the ICD manual updated

answer

Annually, Usually in October

question

How many chapters does the Tabular List(Volume 1) contain?

answer

17; based on either body system or cause or type of disease

question

What do the codes range from? (ICD-Volume 1)

answer

001-999

question

Chapters

answer

are the main division on the ICS-9-CM, they are divided into secctions

question

Sections

answer

composed of a group of 3 digit categories representing a group of conditions or related conditions, they are divided into categories

question

Categories

answer

are composed of 3 digit codes representing a single disease or condition. the 3 digit code is used only if it is not further subdivided. There are about 100 category codes and most requires a 4th digit (subcategory code) Ex; 242

question

Subcategories

answer

provide a 4th digit code (one digit after the decimal point) which is more specific that category code (3 digit) in terms of causes, site, manifestation of the condition. This must be used in available. Ex; 242.0

question

Subclassification

answer

provides a 5th digit code which gives the highest specificity of description to a condition. Use of it is mandatory when available. A code not reported to the full # of digits required is invalid ex; 242.01

question

Level of detail in coding

answer

a category code is used only if it is not further subdivided. Where subcategory and subclassifaction codes are provided, their assignment is mandatory. A code is invalid if it has not been coded to the level of specificity required for that code.

question

Sequencing the diagnosis

answer

the diagnosis, condition, or other reason for the encounter or visit shown in the medical record to be chiefly responsible for the services provided is listed first. Coexisting conditions that were treated or medically managed or influenced by the pt during the encounter are listed as additional codes. (Conditions that were previously treated and no longer exist are not coded.) If personal history or family history has an impact on current care or influence treatment, history code may be assigned as a secondary code

question

Alphabetic Index (Volume 2)

answer

Everything in the Index is listed by condition-that is, diagnosis, signs, symptoms, and conditions such as pregnancy or admission

question

Nonessential Modifers

answer

the main term may be followed by these in paranthesis, their presence or absences does not have an effect on the the selection of the code listed for the main term

question

Essential Modifiers

answer

Terms indented two spaces to the right below the main term called subterms. Are essential modifiers b/c they have bearing on the right selection of the code.

question

Hypertension table

answer

found in the Index under the main term \"Hypertension\" and it contains a list of conditions that are due to or associated with hypertension. The Table classifies the conditions as: -Malignant; an accelerated sever form of hypertension w/ vascular damage and a diastolic pressure of 130mmHg> -Benign; Mild or controlled hypertension & no damage to the vascular system or organs -Unspecified; This is not specified as benign or malignant in the diagnosis or medical record

question

Neoplasm Table

answer

this is located in the Index under the main term \"Neoplasm\" and is organized by anatomic site. Each site has 6 columns w/ 6 possible codes determined by whether the neoplasm is malignant, benign, of uncertain behavior or of unspecified nature

question

Describe the 6 columns of the neoplasm table

answer

...

question

Malignant

answer

further classified as to primary, secondary or carcinoma in situ

question

Primary Malignancy

answer

the original cancer site. Malignant tumors are considered primary unless documented as secondary or mastastic

question

Secondary Malignancy

answer

cancer that has metastasized (spread) to a secondary site either adjacent or remote region of the body

question

Carcinoma (Ca) in Situ

answer

cancer that is localized and has not spread to adjacent tissues or distant parts of the body

question

Benign

answer

noninvasive, non-spreading, nonmalignant

question

Uncertain Behavior

answer

uncertain whether benign or malignant, borderline malignancy

question

Unspecified Nature

answer

a neoplasm is identified; however, no nature of the tumor is documented in the diagnosis of the medical record

question

Choose the code that represents the current status of the neoplasm

answer

a neoplasm code is assigned if the tumor has been removed and pt is still receiving chemotherapy tx or radiation. A V code is assigned if the tumor is no longer present or if the patient is not receiving treatment, but is returning for follow-up care

question

3 sections to Alphabetic Index

answer

Section 1) Index to diseases Section 2) Table of drugs and chemical Section 3) Index to External Cause of Injury (E Codes)

question

Section 1: Index to diseases

answer

each term is followed by the code or codes that apply to that term

question

Section 2: Table of Drugs and Chemicals

answer

contains a list of drugs & chemicals w/ the corresponding poisoning code and E codes. The E codes are used to explain the circumstances surrounding the poisoning which may be: -Accident: Poisoning was due to accidental overdose, wrong substance taken, accidents in use of drugs and biologicals, external causes of poisoning classifiable to 980-989 -Therapeutic Use: instances when a correct substance properly taken is the cause of an adverse effect -Suicide Attempt: the poisoning was self-inflicted -Assault: poisoning was inflicted by another person w/ intent to kill or injury -Understand: poisoning cannot be determined whether intentional or accidental

question

Section 3: Index to External Cause of Injury (E codes)

answer

this is the index for the E codes. It classifies in alphabetical order, environment events and other conditions as the cause of injury and other adverse effects.

question

Health Care Financing Administration Common Procedure Coding System

answer

HCPCS Reference Manual

question

Who assigns NPI#'s & what are they?

answer

The CMS assigns a standard unique identifier known as National Provider Identifier (NPI).

question

Who developed HCPCS & What is it?

answer

The CMS developed Healthcare Common Procedure Coding System (HCPCS) which is a collection of codes for procedures, supplies, products, and services that may be provided to Medicare/Medicaid beneficiaries and also to those enrolled in a private health ins program. Codes are divided into 2 levels:

question

Level I Codes

answer

Consist of codes found in the CPT manual. They have five position numeric codes used to report physicians services rendered to patients.

question

Level II Codes (National Codes)

answer

codes formulated thru the joint efforts of the CMS, the health insurance association of america, and the bcbs association.they are five position alpha-numeric codes for physician and non-physician services not found in the cpt(level 1), start w/ a letter followed by 4 #'s and make up more than 2,400 5 digit alphanumeric codes divided into 22 sections, each covering a related group of items. Most of these items are supplies, materials or injections that are covered by medicare. Some codes are for physicians & non-physician services not found in the CPT (Level I) Ex; E section is for the Durable Medical Equipment category which covers reusable medical equipment ordered by the physician for use in the home, such as wheelchairs or portable oxygen tanks.

question

Level III Codes

answer

codes that were used locally or regionally have been eliminated by the CMS since the implementation of the HIPPA. Some of the codes are now in the Level II

question

CPT

answer

Current Procedural Terminology- codes from CPT code book used to report services and procedures by dr's. The CPT coding system uses a 5 digit numeric system for coding services rendered by dr's. Some codes use a 2 digit modifier to five a more accurate description of the services rendered

question

Who publishes CPT and updates it?

answer

The American Medical Association (AMA) and they update it annually withe a new one coming out each November & becoming effective on January 1st of the following calender year

question

Category I Codes

answer

represents services and procedures widely used by many health care prof in clinical practice in multiple locations and have been approved by the FDA

question

Category II Codes

answer

supplemental codes used for performance measures. Although these codes are intended to facilitate data collection about the quality of care, their use is optional. Cat II codes are published twice a yr, Jan 1st and July 1st

question

Category III Codes

answer

temp codes for emerging technology, services and procedures. If a Cat III code is available, it is reported instead of Cat I unlisted code

question

How many sections to the CPT Manual?

answer

8; each section begins w/ guidelines that provide specific coding rules for that section. Guidelines at the beginning of the section are applicable to all codes in the section, while notes that pertain to specific codes appear before or after such codes. Guidelines usually contain definitions of terms, applicable modifiers, subsection info, unlisted services, special reports of info, or clinical samples. The 8 sections are 1)Evaluation & Management (E&M) 2)Anesthesia 3)Surgery 4)Radiology 5)Pathology and Laboratory 6) Medicine 7) Category I codes 8)Category III codes

question

What format does CPT coding system use and why?

answer

Indented format, to save space

question

2 types of CPT Codes

answer

*Stand Alone Codes; contain the full description of the procedure for the code *Indented Codes- these are codes listed under associated stand-alone codes. To complete the the description for indented codes, one must refer to the portion of the stand alone code description before the semi-colon

question

Other CPT Codes

answer

*Add-on codes- used for procedures that is always performed during the same operative session as another surgery in addition to the primary service/procedure and is never performed separately *Modifiers-provide the means by which the reporting physician can indicate that a service or procedure that has been performed has been altered by some specific circumstance but not changed by the definition of the code

question

How do you know if an update has been made to the CPT manual?

answer

**A triangle- represents a change in the code description since the last edition. The change may be minor or significant and it could be an addition, deletion, or revision **2 triangle symbols-represent changes in the text or definition between the triangles **A bullet-represents a new procedure or service code added since the previous addition of the manual **A plus sign-indicates add-on codes **A circle w/ a line through it- represents exemption from use of modifier

question

How many parts to CPT Manual?

answer

t3; the main text, the appendices and the alphabetic index and is divided into 6 sections; these sections are subdivided into

question

Evaluation & Management

answer

99201-99499 (going to dr feeling 99% leave getting high 5)

question

Anesthesia

answer

00100-01999, 99100-99140 (knocked out=0)

question

Surgery

answer

10021-69990 (Surgery always want to feel 100%)

question

Radiology (including nuclear medicine and diagnostic ultrasound)

answer

77010-79999 (RPM-789)

question

Pathology and Laboratory

answer

80048-89356 (RPM-789; P=8)

question

Medicine (except anesthesiology)

answer

90281-99199, 99500-99602 (RPM-789, M=9)

question

Add-on codes

answer

some procedures are carried out in addition to the primary procedure performed. Designated as \"add-on\" codes w/ a \"+\" sign and they apply only to procedures performed by same dr to describe additional intra-service work provided. Are never used alone, rather they are always reported in addition to the primary procedure code. All add-on codes are modifier -51 (multiple procedures) exempt

question

Location Methods

answer

The CPT Index is arranged in alphabetic order by main terms which are further divided by subterms. There are 5 location methods; 1)Service or Procedure 2)Anatomic Site 3)Condition or Disease 4)Synonym/Eponym 5)Abbreviation

question

CPT Modifiers

answer

these are 2 digit add-ons attached to regular codes to tell 3rd party payers of circumstances in which the services or procedures were altered. All modifiers are listed in CPT appendix A. Modifiers relevant to each of the CPT sections are also found in the section guidelines. One must use the modifier that depicts the circumstances most accurately.

question

-24 Unrelated E/M Service by the same physician during a postoperative period

answer

this is attached to the code of the E/M service provided to a pt during the postop period to indicate that the service is not part of the postoperative care which is usually part of the package of services of the surgery performed. Major surgical procedures will usually have a postop period of 90 days, minor, 10 days. Used only w/ E/M codes

question

-26 Professional Component

answer

Most procedures have both professional (physician) and technical components. This modifier is attached to the procedure to indicate that the dr provided only the professional componenet

question

-32 Mandated Services

answer

used to indicate that the service provided was required by 3rd party payer, gov, legislative or regulatory body. this does not include second opinion requested by a pt, family member, or another physician

question

-50 Bilateral Procedure

answer

used when the same procedure is performed on a mirror-image part of the body

question

-51 Mulitple Procedure

answer

used when -more than 1 procedure is performed in the same surgical episode -one code does not describe all of the procedures performed -the secondary procedure is not minor or incidental to the major procedure Ex; *same operation, different site, *multiple operations, same operative session, *procedure performed multiple times

question

-58 Staged or Related Procedure or Service by the same Physician during the Postoperative Period

answer

used to explain that the procedure or service done during a postop period was planned at the time of the original procedure. also used if a therapeutic procedure is performed b/c of the findings from a diagnostic procedure

question

-78 Return to Operating Room for a Related Procedure During the Postoperative Period

answer

to report a circumstance in which the dr returns to the operating room to address a complication stemming from the initial procedure (third party payers usually pay the surgery portion of the complications surgical package b/c the pt remains in the postop period of the initial procedure. documentation must clearly indicate the reason for the return to the operating room)

question

79 Unrelated Procedure or Service by the same physician during the postoperative period

answer

used to indicate that the procedure or service provided during the postop period was not associated w/ the period. payment for the full fee of the subsequent procedure is requested and a new global period starts

question

-90 reference (outside) laboratory

answer

used to indicate that the procedure was done by outside lab and not by reporting facililty

question

-99 Multiple Modifiers

answer

used to report a procedure or service that has more than one modifier but the payer does not allow the addition of multiple modifiers to the code. is attached to the procedure code and the multiple modifier are listed in block 19 of claim form

question

Evaluation and Management (E/M Codes)

answer

these are listed 1st in the CPT manual b/c they are used by all different specialties. they cover physician services that are performed to determine the best course for pt care.

question

What are the key components of E/M?

answer

a; history -chief complaint -History of present illness (HPI) -review of systems (ROS) -Past, family and social history (PFSH) b;physical examination c;medical decision making complexity

question

Unlisted Procedures

answer

Procedures considered experimental, newly approved, or seldom used may not be listed in the CPT manual. Can be coded as unlisted procedures. they are located at the end of the subsections or subheadings. when unlisted procedure code is reported must be described in the accompanying documentation

question

Surgical Package

answer

also called \"global surgery\" includes a variety of services rendered by a surgeon which includes the following: -surgical procedure performed -local infiltratration, metacarpal/metatarsal/digital block or topical anesthesia -Preoperative E/M services; on day immediately prior to the day of the procedure -immediate postoperative care -Normal, uncomplicated postop care

question

What is Health Insurance?

answer

A contract between a policyholder (one who purchases the contract) and an insurance carrier to reimburse the policyholder of all or most medical expenses

question

What 3 ways can an individual obtain health insurance?

answer

1)Group Ins-when a group of employees & their dependents are insured under 1 group policy issued to the employer. Generally the employer pays the premium or portion of premium and the employee pays the difference. 2)Personal Insurance- an insurance plan issued to an individual. premium rates are usually higher than group rates and service availability is lessened w/ this type of coverage 3)Pre-paid health plan- pre-determined set of benefits covered under one set annual fee

question

Indemnity Insurance

answer

also known as a fee-for-service. under this plan, the services that are paid for are listed in the policy and payments are based on the physicians charge for the service. there are no restrictions as to the physicians or hospital the beneficiaries may use and pre-approval of medical visits are not required. Each yr the beneficiary must meet a deductible, after which the benefit may cover for all or part of the charge. Usually a co-insurance for each service applies

question

HMO

answer

Health Maintenance Organization- managed care plan that provides wide range of services to individuals that are enrolled. Generally least costly but most restrictive. Uses a gatekeeper (primary care physician) whom the pt is required to visit initially for any case. If the pt goes to another physician w/o prior approval pcp pt will be responsible for all costs. Physician-Hospital Organization is when physicians, hospitals, and other health care providers contract w/ one or more HMO's or directly w/ employers to provide care.

question

PPO

answer

Preferred Provider Organization- basically same as HMO however PPO's charge a higher premium than HMO's in exchange for more flexibility & more options for beneficiaries, No gatekeeper and pt choose dr they want to see as long as they are in network, if pt chooses to see dr not in network they will shoulder all costs.

question

POS

answer

Point-of-service- managed care plan that gives beneficiaries the option whom to see for service. If the beneficiary see provider w/in network they will receive benefits similar to HMO but if they choose to see a provider not in the network, the POS will still pay for the services but at a rate significantly lower than the in-network dr and difference will be billed to pt

question

Preferred Provider Plan

answer

the type of plan a patient may have where they can see providers outside their plan, the pt is responsible for higher portion of the fee

question

How is a fee schedule determined?

answer

UCR method, the usual, customary, and reasonable- the carrier compare *the dr's most frequent charge for a given service (the usual) *the average charge of all providers of similar training/experience in a given geographical area (the customary) *the actual charge submitted on a claim (must be reasonable to the provider) *****the lowest amount is used as the basis for payment (the allowed charge)

question

Relative Value Payment Schedule Method

answer

involves the use of relative value scales which assign a relative weight to individual services according to the basis for the scale. Services that are more difficult, time consuming, or resource intensive to perform typically have higher relative values than other services

question

Medicare's Resource Based Relative Vale Scale (RBRVS) Payment Schedule

answer

under this schedule a procedure's relative value is the sum total of 3 elements 1) Work; represents the amount of time, intensity of effort, and medical skill required of the dr 2) Overhead; practice costs related to the performing of the service 3) Malpractice: cost of medical malpractice insurance -medical malpractice insurance that covers the insured only for those claims made while the policy is in force is called claims-made coverage

question

How are payments determined under Medicare's RBRVS?

answer

by multiplying a code's relative value by constant dollar amount called the conversion factor (multiplier). The conversion factors are determined annually by the CMS in cooperation with congress. The conversion factor varies according to the type of service provided such as medical, surgical, non-surgical

question

A geographic practice cost index is applied to account for the economic variation across the different area of the country

answer

true

question

What % does Medicare pay?

answer

80%

question

What portion of services do the beneficiary pay?

answer

20%, deductible, premiums, and for non-covered services

question

The St. Anthony Relative Value for Physicians (RVP)

answer

unlike the RBRVS the RVP has no geographical adjustment factor or individual RVU component to calculate. However, for each category of procedures, a separate conversion factor must be developed

question

Contracted Rates w/ MCO's

answer

physicians agree to provide services at a discount of their usual fee in return for a pool of existing pt's

question

Capitated Rates

answer

the dr provides a full range of contracted services to covered pt's for a fixed amount on a periodic basis. While guaranteed a fixed amount the dr assumes the risk that the cost of providing the care the pt's may exceed the payment amount. the only additional charge may be a co-payment and a deductible co-insurance

question

Medicare

answer

is the federall gov's health ins program created by Social Security Act of 1965 titled \"Health Insurance for the Aged & Disabled\" It is administered by the CMS, formally known as Health Care Financing Administration (HFCA)

question

Who is Medicare available to?

answer

-persons aged 65 or older, retired on Social Security Benefits -spouses of a person paying into the Social Security System -those who received social security disability payments for 24 months -those diagnosed w/ end stage renal disease (ERSD) -kidney donors to ERSD pt's (all expenses related to kidney transplant are covered) -retired federal employees of the Civil Service Retirement System (CSRS)

question

What are Medicare Health Insurance Claim Numbers (HCIN'a)?

answer

issued by CMS and are usually SS #'s with letter (alpha) or letter/number (alphanumeric) suffixes.

question

Common Suffixes used by Medicare:

answer

A-Wage earner (upon retirement) B-Spouse of wage earner C-Disabled Child D-Widow HaD- Disabled Adult M- Part B benefits only T- Uninsured and entitled only to health ins benefits

question

Medicare Part A

answer

aslo called the Hospital Insurance for the Aged and Disabled. It covers institutional providers for inpatient, hospice, and home health services, such as the following -a bed pt in a hospital -pt's in a pysch hospital -bed pt's in a nursing facility -pt's receiving home health care services -terminally ill pt who has <6 to live and needs hospice care -terminally ill pt who needs respite care

question

How do individuals that are not eligible for Social Security Obtain Medicare Part A?

answer

By paying a premium and they must enroll in Part B this is however limited to applicants 65+ and US resident. A deductible is req for each episode of illness and a co-insurance applies for hospitalizations of more than 60 days

question

Medicare Part B

answer

referred to as Supplementary Medical Insurance (SMI). coverage is a supplement of Part A, which covers medical expenses, clinical lab services, home health care, outpatient hospital treatment, blood, and ambulatory surgical services.

question

What out of pocket costs for beneficiaries are associated w/ Medicare part B?

answer

Contains an annual deductible that must be met b4 benefits begin, beneficiaries pay 20% of the Medicare-approved amount for services after the deductible has been met. Premiums are usually deducted from the monthly SS check.

question

How are services paid to physicians associated w/ Medicare Part B?

answer

services are paid according to a fee schedule which is based on the relative value multiplied by the geographical adjustment and conversion factors. All dr's in a given area are paid the same for same service regardless of specialization. However, non par's are paid 5% less for assigned claims. Non PAR's, not accepting assignment, can charge no more than 115% of the participating allowance w/o facing possible Medicare fines and penalties.

question

Medicare Part C

answer

Medicare Managed Care Plans (formally Medicare Plus (+) Choice Plan) was created to offer a # of healthcare services in addition to those available under Part A & Part B. The CMS contracts w/ managed care plans or PPO's to provide Medicare benefits. A premium similar to Part B may be required for coverage to take affect

question

Medicare Part D

answer

Prescription Drugs- enacted by the Medicare Prescription Drug, Improvement and Modernization Act in Dec 2003 and began implementation in Jan 2006 where Medicare beneficiaries can enroll in the Medicare Prescription drug plan. the beneficiaries have the choice of among several plans that offer drug coverage for which they pay a monthly premium

question

Claim Status

answer

Various terms are used to describe the state of submitted forms.

question

Clean Claim

answer

has all required fields accurately filled out, contains no deficiencies and passes all edits, the carrier does not require investigation outside of the carrier's operation before paying the claim

question

Dirty Claim

answer

contains errors and omissions, usually these claims do not pass front end edits they are either processed manually for resolving problems or rejected for payment

question

Invalid Claim

answer

contains complete necessary information but is incorrect or illogical in some way

question

Rejected Claim

answer

requires investigation and needs further clarification

question

What is an Advance Beneficiary Notice?

answer

a document provided to a Medicare beneficiary by a provider prior to a service being rendered letting the beneficiary know of his/her responsibility to pay if Medicare denies the claim

question

What is Medigap?

answer

Medicare Supplemental Insurance-to pay for medical services and items not covered by Medicare and Medicare's coinsurance and deductible. Medigap is a private insurance designed to help pay for those amounts that are typically the pt's responsibility under Medicare. there are several standard Medigap policies established by the federal gov w/ the ins industry

question

Medicaid

answer

a federal program administrated by state gov to provide medical assistance to the needy, each state sets its own guidelines for eligibility and services, therefore benefits and coverage may very widely from state to state

question

How is eligibility for Medicaid classified?

answer

divided into 2 classifications A) Categorically Needy: 1) families, pregnant women & children 2) Aged and disabled persons 3) Persons receiving institutional or other long-term care in nursing facilities (NF's) and intermediate care facilities (ICF's) B) Medically Needy: 1) medically indigent low-income and families 2)low-income persons losing employer health ins coverage (Medicaid purchase of COBRA purchase)

question

Medicaid is the payer of last resort

answer

True

question

Medicaid and Medicare (dual coverage)

answer

if pt has Medicare and Medicaid, medicaid usually pays for the Medicare Part B deductible, coinsurance, and monthly premium amounts.

question

Some of the Services covered by Medicaid

answer

-inpatient hospital services -outpatient hospital services -Physician services -emergency service -prenatal care -vaccines for children -cosmetics procedures necessitated by an injury (elective cosmetic procedures are not included) -family planning and supplies

question

Workers Compensation

answer

is a state required ins plan, the coverage of which provides benefits to employees and their dependents for work related injury, illness or death. Each state has established minimum # of employees required before this laws comes into effect. Further, not all states offer WC plans

question

Who covers cost of Workers Compensations?

answer

employers pay for premiums, the amount of which will depend on the specific job, occupational category, and level of risks

question

What are the 5 types of benefits offered?

answer

1) Medical treatment 2) Temporary disability 3) Permanent disability 4) Vocational rehabilitation 5) Death benefits for survivors

question

Disability Insurance

answer

defined as reimbursement for income and lost as a result of of a temporary or permanent illness or injury. When pt's are treated for disability diagnosis and other medical problems, separate pt records must be maintained. Disability ins does not pay for healthcare services, but provides the disabled person w/ financial insurance

question

Liability Insurance

answer

a policy that covers losses to a 3rd party caused by the insured, by an object owned by the insured, or on premises owned by insured. Liability ins claims are made to cover the cost of medical care for traumatic injuries, lost wages, and in many cases, remuneration for the \"pain and suffering\" of the insured party. Most health ins contracts state that health ins benefits are secondary to liability ins.

question

TRICARE

answer

regionally managed health care program for active duty and retired members of the armed forces, their families and survivors. It is a service benefit and contains no premium. TRICARE is the new title for CHAMPUS program (Civilian Health and Medical Program of the Uniformed Services)

question

What are the 3 types of plans covered under TRICARE?

answer

1) Standard- fee-for service, cost-sharing plan 2) Extra- preferred provider organization 3) Prime- health maintenance organization plan w/ a point of service option ***All have annual deductibles, w/ the exception of PRIME

question

How are co-payments determined with TRICARE?

answer

according to 2 programs a) active duty family members b) retirees, their families members and survivors of deceased personnel

question

CHAMPVA

answer

(Civilian Health and Medical Program of the Veteran Affairs)- was created to provide medical benefits to spouses and children of veterans w/ total, permanent service related disabilities or for surviving spouses and children of a veteran who died as a result of service related disability. It is a service benefit therefore no premiums. Members who receive TRICARE do not qualify for CHAMPVA

question

Commercial Carriers

answer

-are for profit organizations that operate in the private sector selling different health ins benefits plans to groups or individuals. Most have predefined pt yearly deductibles and coinsurance generally based on the 80/20 split. EX; Aetna, Cigna, Travelers, and Prudential -most have coordination of benefits (COB) clauses to identify the primary and secondary payer responsibility status for dependent children

question

Gender rule

answer

male of household is primary payer

question

Birthday rule

answer

the plan of the parent whose birthday falls earlier in the year (month and date, not year) is primary to that whose b-day falls later in the calender year. If both parents have same birthday, then the plan of the parent who has had the longest coverage is primary. **In case of divorce, the plan of the parent w/ custody of the children is the primary payer unless the divorce settlement states otherwise

question

Blue Cross/Blue Shield Plans

answer

group of independently licensed local companies, usually nonprofit that contracts w/ dr's and other health entities to provide services to their insured companies and individuals. Most BC/BS plans offer HMO's, PPO's and POS plans

question

Blue Cross

answer

covers hospital services, outpatient care, some institutional services and home care

question

Blue Shield

answer

covers physician services, and in some cases, dental, outpatient services and vision care

question

What are BC/BS plans reimbursement methodologies?

answer

physician reimbursement had been based on the UCR method but more plans have adapted the RBRVS method while some are using capitated rates.

question

Paper Claim

answer

traditional method used by providers for submission of charges to ins co's. The most commonly used form is the CMS-1500. Few plans will still accept the physicians encounter forms or superbill and Medicare will only accept claims onthe CMS-1500

question

Electronic Claim

answer

alternative to paper claim, submitted to payer directly by physician or clearinghouse. Are usually paid faster. Most electronic claims software have self-editing features that detect and report entries that may cause to be rejected, such as invalid codes or incomplete claims

question

What is a clearinghouse?

answer

an entity that receives transmission of claims for dr's offices, separate the claims by carriers and performs software edits on each claim to check for errors. One this process is complete, the claim is then sent to proper ins carrier. The dr pays the clearinghouse a fee for their services. A result of the review is sent back to the claims preparer using and audit/edit report

question

What are the 2 major sections of a claims form?

answer

-Blocks 1-13, refers to pt info -Blocks 14-33, refers to physician info

question

What should be done in absences of payer provided instructions for completing claim form?

answer

Instructions on the claim form

question

Basic Billing & Reimbursement Steps:

answer

-collect pt info -verify insurances -prepare encounter form (should reflect the diagnosis and services provided to pt, this is used as the basis for billing) -code diagnosis and procedures -review linkage and compliance, review should include the following *appropriateness of the codes *link between the diagnosis and the procedure *payers rules about the diag and proc *documentation of the procedure *compliance w/ regulations -calculate physician charges -prepare claims -transmit claims -payer adjudication, claims received by the payers go through a series of steps to determine whether it should be paid -follow up reimbursement/record retention

question

Life cycle of Insurance Claims

answer

I. Claims submission-transmission of claims data either electronically or manually to payers or clearinghouses for processing II. Claims Processing-payers and clearinghouses verify the info found in the submitted claims about the pt and provider III. Claims Adjudication-process by which the claim is compared to payer edits and the pt's health plan benefits to verify that: -required info is available to process claim -claim is not a duplicate -payer rules and procedures have been followed -procedures performed or services provided are covered benefits

question

Non-covered benefit

answer

any procedure or service reported on the ins claims that is not listed in the payer's master benefit list. This will result in the denial of the claim. Providers may be able to recover the charges from the pt

question

Unauthorized Benefit

answer

procedure or service provided w/o proper authorization or was not covered by a current authorization. The claim is denied and the provider cannot bill the pt for the charges

question

What does Medical Necessity edit check for?

answer

-procedure codes match the diagnosis code -procedure are not elective -procedures are not experimental -procedures are essential for treatment -procedures are furnished at an appropriate level

question

VI. Payment

answer

once the claim is approved for payment, a remittance advice (RA) is sent to the provider and an explanation of benefits (EOB) is mailed to the policyholder

question

Assignment of Benefits

answer

reimbursement is sent directly from payer to provider

question

Accept Assignment

answer

mean the provider agrees to accept what the ins co approves as payment in full for the claim

question

New Patient

answer

Individual who has not received any professional services from the physician or another physician of the same specialty who belongs to the same group practice within the past 3 years.

question

Established Patient

answer

Individual who has received any professional services from the physician or another physician of the same specialty who belongs to the same group practice within the past 3 years.

question

Inpatient

answer

term used when a patient is admitted to the hospital w/ the expectation that the pt will stay for a period of 24 hrs or more

question

Outpatient

answer

pt who receives treatment in any of the following settings: -physicians office -hospital clinic, emergency department, hospital same day surgery unit, ambulatory surgical center (pt is released w/in 23 hrs) -hospital admission for observation

question

Consultation

answer

service performed by a physician whose opinion or advice is requested by another physician in the evaluation or treatment of a pt's illness or suspected problem. The consultation does not assume any responsibility for the pt's care and must send a written report back to the requesting physician

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Fee-for-service

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fee that is charged for each procedure or service performed by the physician. This fee is obtained from a FEE SCHEDULE, which is a list of charges or allowances that have accepted for specific medical services. The system in which fee schedules are determined is referred to a USUAL, CUSTOMARY, AND REASONABLE, (UCR)

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Fiscal Intermediary

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an ins co that bids for a contract w/ CMS to handle the medicare program in a specific area

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Explanation of Benefits (EOB)

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describes the services billed and includes a breakdown of how the payment is determined (sent to pt)

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Premium

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the cost of ins coverage paid annually, semi-annually or monthly to keep a policy in effect

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Deductible

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a cumulative out-of-pocket amount that must be paid annually by the policyholder before benefits will be paid by the ins co

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co-payment

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cost-sharing requirement for the insured to pay at the time of service. This amount is usually a specific dollar amount

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Coinsurance

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percentage of the cost of covered services that a policyholder or a secondary ins pays. A common payment % for coinsurance is 80/20 which indicates that 20% is the coinsurance for the beneficiary or secondary ins is responsible

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Coding

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process of converting diagnosis, procedures, and services into numeric and alphanumeric characters

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Medical Neccessity

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defined by Medicare as \"the determination that a service or procedure rendered is reasonable and necessary for the diagnosis or treatment of an illness or injury\"

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Exclusion and Limitations

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conditions, situations, and services not covered by the ins carrier

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Pre-certification

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to determine coverage for a specific treatment such as surgery, hospitalization or tests, under the insured's policy

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Pre-determination

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to determine the pt's benefits and the maximum dollar amount that the ins company will pay. Often the 1st step of the ins verification process, it is completed prior to the first visit

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Pre-authorization

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requirement for some health ins plans to obtain permission for a service or procedure before it is done. It indicates that a specific procedure or service is deemed \"medical necessary\"

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Qualified diagnosis

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working diagnosis which is not yet established

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Eligibility

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the qualify factor or factors that must be met before a pt receives benefits

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Coordination of benefits (COB)

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when 2 ins co work together to coordinate payment of the benefits

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encounter form

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also called the superbill; it is a listing of the diagnosis, procedures, and charges for a pt's visit

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Itemized statement

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statement of the pt's account history, showing dates of service, detailed charges, payment (deductibles, co-pays), the date the ins claim was submitted, applicable adjustments and account balance

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Peer Review Organization (PRO)

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a state based group of physicians working under gov guidelines to review the cases and determine their appropriateness and quality of professional care

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Health Insurance Portability And Accountability Act (HIPPA)

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deals w/ the prevention of healthcare fraud and abuse of patients on Medicare/Medicaid

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Civil Monetary Penalties Law (CMPL)

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law passed by the fed gov to prosecute cases of medicaid fraud

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The Good Samaritan Act

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was developed to protect healthcare professionals from liability of any civil damages as a result of rendering emergency care

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Remittance Advice

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an electronic or paper-based report of payment sent by the payer to the provider

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The Patient Care Partnership (Patients Bill of Rights)

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was developed to promote the interests and well being of the pt's and residents of the healthcare facility. This bill has still not become law

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Physician

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a doctor of medicine or osteopathy, dental medicine, dental surgery, podiatric medicine, optometry, or chiropactic medicine legally authorized to practice by the state in which he/she performs

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Health Practitioner

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includes, but is not limited to, physician assistant, certified nurse-midwife, qualified psychologist, nurse practitioner, clinical social worker, physical therapist, occupational therapist,, respiratory therapist, certified registered nurse anesthetist, or any other practitioner as may be specified

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Group Practice

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group of 2 or more physicians and non-physician practitioners legally organized by a partnership, professional corporation, foundation, not-for-profit corporation, faculty practice plan, or similar association

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Physician's Identification Numbers

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-State license #, dr must obtain this # in order to practice w/in a state -Employer Identification # (EIN), also known as federal tax identification #, used by IRS -SS#, typically not used on claim form unless provider does not have (EIN) -Provider Identification # (PIN), # assigned by ins co to a physician who renders services to pt's -Unique Provider Identification # (UPIN), # assigned to the physician by medicare -performing Provider Identification provider # (PPIN), dr has a separate PPIN for each group office/clinic in which he/she practices. In the medicare program, in addition to a group #, each member of a group is issued a 8-character PPIN -Group Provider Number, # is used instead of the individual dr's # for the performing provider who is a member of a group practice that sub,its claims to ins co under the group name

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