CIMO Chapter 1

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What is the billing cycle
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the step that leads to timely payment for medical service
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Medical Insurance
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An agreement between policyholder and health plan
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Tricare
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provides coverage for dependents of active duty service
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Medicaid
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for people with low income
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Preferred Provider Organization
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Common type of managed care, members pay higher fee if a provider outside the network is chosen
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Capitation
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payment to a provider , covers each members plan for certain amount of time
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Co-payment
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fixed fee paid for service at time of service
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What must all new patients complete
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Information form
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What is some important info needed on information form
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*personal,employment, and medical insurance info
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What does the information form require
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signature
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When patient info changes what does the information form do
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Update
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What are 8 requirements for checking in patients
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*Verify identity *copy or scan patient insurance card *copy or scan photo *collect time of service payments *take payment by check credit or debit card *always give patient receipt *collect co-pay during check in *give new patients financial policy info
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Diagnosis
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physicians opinion of the nature of the patients illness or injury
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Procedure
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service performed
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3 facts about procedure(service performed)
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*Each procedure is assigned a code that stands for a particular service or treatment *codes come from CPT book *book is updated by the AMA
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What is a diagnosis communicated to a health plan as
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ICD-9 code
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what is an encounter form referred to as
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Superbill
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An encounter form can be what
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Can be paper or electronic
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EHR
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A lifelong computerized health care record for an individual that incorporates data from providers who have treated the individual
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(PMP) Practice management System
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Software program that automates the administrative and financial tasks required to run a medical practice
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The diagnosis and the medical services documented should be what
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Logically connected so that the medical necessity of the charges is clear to the insurance company
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Adjudication
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A series of steps designed to judge whether claim should be paid
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How are results of adjudication sent
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Via EOB or remittance advice (RA)
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3 facts about sending adjudication results
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*Usually sent electronically *Sent with payment and compared with claim *If there are descrepancies, a request for view is file with insurance company
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Statements
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list of all services performed, along with the charges for each service
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Accounting cycle
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The flow of financial transactions in a business
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Accounts receivable
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monies flowing into a business
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Day sheet
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lists all charges , payments and adjustments that occurred during the day
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Health Insurance Portability Act of 1996 (HIPAA)
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*Ensures portability of insurance coverage when employees move from job to job *Increases accountability and decreases fraud and abuse in healthcare *Improves the efficiency of health care transactions and mandates health info *Ensures security and priva cy of health info
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Title I (HIPAA) is what, describe
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Health insurance reform, The continuous coverage for workers and their insured dependents when they change or lose their jobs
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Title II (HIPAA) is what describe
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Administrative Simplification, the uniform sets of standards that protect and place limits on how confidentially health info used
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what is IIHI
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Patient-Identifiable Health Related Information or Individually Identifiable Health Information (IIHI) Patient name DOB Demographics Past/present/future medical or mental condition Coding and claim information
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describe HIPAA Administrative safeguard
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Verify identification for individual trying to obtain info or records
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describe HIPAA Technical safeguard
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Computer passwords, log in access
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describe physical safeguard
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lock cabinets, limit access in the office
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PMP (Practice management systems) functions
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patient scheduling recording patient info creating and transmitting electronic claims billing patients creating financial reports receiving payments electronically collecting overdue accounts
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what is audit trail
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keeps track of data on computer and can be reviewed if any issues arise,,, can report when and who has accessed info
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where can a claim be sent (2)
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health plan clearing house
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what is a clearing house
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a company that collects electronic insurance claims from medical practices and forwards claims to the appropriate health plan
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3 steps a clearing house will take
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Clearing house also translates claim data to fit the standard format required for physician claims Clearinghouse performs an edit to see that all necessary information is included to file claim Then, an audit/edit report is sent to practice. This lists problems that need to be corrected before claim can be sent to the health plan.
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(the automated entry of information from a RA)
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Payments from insurance companies are auto posted
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EMRs—
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computerized records of one physician’s encounters with a patient over time
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PHRs
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private, secure electronic files that are created, maintained and owned by the patient
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advantages of EHR
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safety: Helps reduce medical errors by Medication and physician errors due to illegible handwriting Instant alerts for patient allergies and drug interactions Alerts when medications deemed unsafe have been pulled off the market Records are not lost due to natural disasters or intentional attacks Information is communicated timely
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advantages of EHR
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Quality Providers get a complete picture of the patient’s past and present condition Other ways EHRs enhance quality Patients are contacted with reminders about physicals Patients suffering from chronic diseases are able to monitor their conditions and report via the internet Patients can review data on quality for particular providers and facilities
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advantages of EHR
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Efficiency Information retrieval is immediate Saves time Other ways EHRs improve efficiency Speed of delivery of test results Two or more people can work with a patient record at the same time Eliminates the need to search for a misplaced chart Permits physicians to review a summary of the patient’s health information at a glance Eliminates the need to manually enter diagnosis and procedure codes from a paper encounter form Reduces the time it takes to refill a prescription Organizes all information in one place Enables physician to receive payment for services more quickly
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e commerce
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med practices participate in this to purchase supplies over the Internet
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the entity that criminal issues or complaints or non compliance of HIPAA regulations are referred
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Office of Inspector General
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people in this field work with administrative and clinical computer systems
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HIM Health Information Management
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insurance carrier that can be private or public
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third party payer
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three types of PHI that patient does NOT have the right to access
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psychotherapy notes, records of legal proceedings, CLIA protected info
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clearinghouses format electronic claims into this format
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HIPAA compliant
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HIPAA meaning
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Health Insurance Portability and Accountability Act
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you can find diagnoses in this book
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ICD-9
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standardized code specifies services the physicians provided
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CPT (Current procedural Terminology
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similar to EOB (explanation of benefits)
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RA (remittance advice)
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THE 10 steps in The Billing Cycle
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#1 PRE-REGISTER PATIENTS #2 ESTABLISHED FINANCIAL RESPONSIBILITY #3 CHECK IN PATIENTS #4 CHECK OUT PATIENTS #5 REVIEW CODING COMPLIANCE #6 CHECK BILLING COMPLIANCE #7 PREPARE AND TRANSMIT CLAIMS #8 MONITOR PAYER ADJUDICATION #9 GENERATE PATIENT STATEMENTS #10 FOLLOW UP PATIENT CLAIMS/COLLECTIONS
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FORM GIVEN TO PATIENT AT FIRST APPOINTMENT OUTLINES RIGHTS COVERED BY LEGAL DUTIES IN REGARDS TO PHI
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Notice of Privacy practice
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CPT was developed by
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AMA American Medical Assosiation
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three examples of PHI
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EHR,EMR,lab results x rAy
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THREE EXAMPLES OF IIHI
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patient name, demographics, med or mental conditions. coding and claim info
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Auto posting
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automated entry of info from remittance advice into PMP practice management system
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-billing in medical offices depends on these two types of services posting
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patient data transaction data
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a practice must have this if using an outside billing service
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contract
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a portion of charges that are a patients responsibility
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co -insurance
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medical insurance represents a contract between this and health plan
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policyholder
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this type of health plan has a high deductible but a small premium
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CDHP consumer driven health plan
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electronic claim format used to bill physician service
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837P form in paper
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these can be accessed in several locations at the same time
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EMR
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used to record clinical data
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EMR
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unlike paper form these do not use up space in the office
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EMR
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eliminates medication errors that result from illegible handwriting prescription forms
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Electronic prescribing
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refers to computer hardware and software that medical practices use to accomplish daily tasks
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IT information technology
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these billing programs eliminate data entry errors
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computerized

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