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Medical Ethics are Standards of conduct based on moral principals. Acting within ethical behavior boundries means carrying out one's responsibilities with integrity, decency, respect, honesty, competence, fairness and trust.
Compliance Regulations Most billing related cases are based on HIPAA and the False Claims Act
HIPAA is an acronym for Health Insurance Portability and Accountability Act of 1996.
Category 1 CPT codes Medical Procedures
Category 2 CPT codes Supplemental Codes for Performance Measures
Category 3 CPT codes Emerging Technologies
Add on Codes Used for procedures that are always performed during the same operative session, as another surgery in addition to the primary service/procedure and is never performed separately.
Anesthesia is found 00100-01999, 99100-99140
Evaluation and Management (E&M) codes Are listed first in the CPT manual because they are used by all the different specialties.
Brackets Used to enclose synonyms, alternative wording or and explanatory phrase
Bullets Represents a new procedure or service code added since the previous edition of the manual.
Chief Complaint (CC) The reason the patient came to see the physician.
Circle with a line through it exemption from modifier 51
CPT Used to report services and procedures by physicians
E&M Codes 99201-99499
Guidelines are Found? At the beginning of each section and used to provide specific coding rules for that section.
History (HX) The set of information the physician gathers from the patient concerning he past.
History of Present Illness (HPI) A chronological account of the development of the complaint from the first sign or symptom that the patient experienced to the present.
Indented Codes Listed under associate and stand alone codes
E Codes For durable medical equipment for use in home
Level 1 codes Codes found in the CPT manual
Level 2 codes National codes for physician and non-physician service not found in the CPT Level 1
Level 3 codes Used locally or regionally and have been eliminated by the CMS since the implementation of HIPAA
The List of Modifiers is found where in the CPT Appendix A and in the front of the book.
Modifier 50 bilateral procedure
Modifier 24 Attach to E/M service code when service is provided during postoperative period to indicate the the service is not part of postoperative care and not included in the Surgical Package
Modifier 26 Provider only provided the professional component
Modifier 51 Used more than on procedure during the same surgical episode
Modifier 57 Modifier 57 is used on E/M services the day before or day of major surgery when the initial decision to perform the surgery is identified.
Modifier 78 Physician must return to Operating Room to address complication stemming from initial procedure
Modifier 79 Procedure or service provided during postoperative period not associated with initial procedure.
Modifiers Reporting indicators that indicate that the procedure or service has been altered by specific circumstance but has not changed in it's definition of code.
Parentheses Used to enclose supplementary words, non-essential modifiers
Past, Family and Social History (PFSH) Consists of patients personal experiences with illnesses, surgeries, and injuries; Information of illnesses predominant in family; Patients educational background, occupation, marital status and other factors
Pathology and Laboratory 80048-89356
Plus sign indicates add on codes
Radiology 77010-79999
Review of Symptoms (ROS) Inventory of the constitutional symptoms regarding the various body systems
Stand Alone Codes Contain full description to the procedure for a code.
Sideways triangle means change in wording between triangles
Bullet means new procedure code
Circle with a line through it means modifier 51 exempt code
Six sections of CPT E&M, Anatomical Site, Condition or Disease, Synonym or Eponym, Abbreviation.
Three Components for E*M Codes 1.History 2.Physical Exam 3.Medical Decision-Making
Three Catagories for E*M Codes Category I: Procedures that are consistent with contemporary medical practice and are widely performed.Category II: Supplementary tracking used for performance measures.Category III: Temporary codes for emerging technology, services & procedures.
4 contributing factors for E&M Codes New or existing patient, History, Physical Exam, Medical Decision making, Time spent can be a 5th factor
Medicare part A Part A is hospital insurance provided by Medicare. Most people do not pay a premium for this coverage.
Medicare part B Part B is medical insurance to pay for medically necessary services and supplies provided by Medicare. (Doctors, outpatient care, Phys. and Occ. Therapists etc.)
Medicare part C Part C is the combination of Part A and Part B. The main difference in Part C is that it is provided through private insurance companies approved by Medicare.
Medicare part D Part D is stand-alone prescription drug coverage insurance.
Medicaid free or low-cost health insurance coverage through the state
Medicaid catagorically needy A distinction for individuals who fall into a specific category (or criteria)of mandatory Medicaid eligibility established by the federal government. These categories apply to every state Medicaid program.
Medicaid Medically Needy provide Medicaid to certain groups not otherwise eligible for Medicaid.must cover: •Pregnant women •Children under 18.: States have option to cover:•Children up to 21•Parents and other caretaker relatives•Elderly•Individuals with disabilities
Who is the Payer of Last Resort? Medicaid is always the payor of last resort.
TRICARE health care program for Uniformed Service members, retirees and their families
TRICARE STANDARD option that provides the most flexibility to TRICARE-eligible beneficiaries. It is the fee-for-service option that gives beneficiaries the opportunities to see any TRICARE-authorized provider.
TRICARE EXTRA (PP0) A preferred provider option, rather than an annual fee, a yearly deductible is charged. Health care is delivered through a network of civilian health care providers who accept payments from CHAMPUS and provide services at negotiated, discounted rates
TRICARE PRIME (HMO) An HMO type plan in which enrollees receive health care through a Military Treatment Facilities PCM or a supporting network of civilian providers
CHAMPVA comprehensive health care program in which the VA shares the cost of covered health care services and supplies with eligible beneficiaries.
Private payer vs Commercial payer Private individuals are responsible for securing their own health insurance coverage. Commercial Government, Employer, Group health insurance coverage
Group Health Plans An insurance plan that provides healthcare coverage to a select group of people. Group health insurance plans are one of the benefits offered by many employers. These are generally uniform in nature, offering the same benefits to all members of group.
Indemnity insurance Health indemnity insurance is a fee for service insurance that is sometimes used when a person is in between health plans, and will cover some (but not all) expenses
HMO Health Maintenance Organization. A form of health insurance combining a range of coverages in a group basis. A group of doctors and other medical professionals offer care through the HMO for a flat monthly rate with no deductibles.
PPO PPO is similar to an HMO, but care is paid for as received instead of in advance in form of a schedule. PPOs may offer more flexibility by allowing for visits to out-of-network professionals. Visits within network require only the payment of a small fee.
POINT OF SERVICE feature of an insurance plan that allows a patient to choose between in-network care and out-of-network care every time he or she sees a doctor. The patient is allowed the freedom to go to whichever doctor is most convenient, although the cost will vary
Disability Insurance Insurance policy that pays benefits in the event that the policyholder becomes incapable of working.
Workman's Comp Workman's compensation is a job benefit that provides money and services to employees that are injured or become sick on the job. Worker's comp helps injured and sick workers to survive financially as they recover from health problems.
Usual Customary and Reasonable refer to the base amount that is treated as the standard or most common charge for a particular medical service when rendered in a particular geographic area.
Relative Value Payment Method The payment amount for each service paid under the physician fee schedule is the product of three factors; a nationally uniform relative value for service; a geographic adjustment factor (GAF); a nationally uniform conversion factor for the service.
Medicare Resource Based Relative Value Unit (RVU) Payments/Components The schedule assigns certain values to procedures/costs based upon Total RVUs. The total consists of three components; work, practice expense, and malpractice. Medicare adjusts payment by geographic price cost index (GPCI) and pays depending on locale.
Clean Claim A completed insurance claim form submitted with the program time limit that contains all the necessary information without deficiencies so it can be processed and paid promptly.
Dirty Claim A claim submitted with errors or one that requires manual processing to resolve problems or is rejected for payment.
Invalid Claim Any Medicare claim that contains complete, necessary information but is illogical or incorrect (e.g., listing an incorrect provider number for a referring physician). Invalid claims re identified to the provider and may be resubmitted
Rejected Claim A rejected claim is an electronically submitted claim that is unprocessable due to missing or invalid information required by the payer.
ABN / Advance Beneficiary Notice a notice that a doctor, supplier, or provider gives a Medicare beneficiary before furnishing an item or service if the doctor, supplier, or provider believes that Medicare may deny payment.
Paper Claims /CMS 1500 An insurance claim submitted on paper, including those opticaly scanned and converted to an electronic form by the insurance carrier
Electronic Claim An insurance claim submitted to the insurance carrier via a central processing unit (CPU), tape, diskette, direct data entry, direct wire, dial-in telephone, digital fax, or personal computer download or upload
CMS 1500 Universal Claim Form Developed by the AMA and the Centers for Medicare and Medicaid Services (CMS). Used by physicians and other professionals to bill outpatient services and supplies to Tricare, Medicare, some Medicaid programs, and some private insurance/managed care plans
Basic Billing Reimbursement Steps Patient Info, Verify Ins. Prepare encounter form, Code DX & CPT, Review Linkage Protocol, Calculate physicians charges, Prepare claim, Transmit claim, Follow up on Reimbursement.
Review Linkage Protocol Appropriateness of Codes, Payers rules about linkage, Documentation to support codes, Compliance with regulation and guidelines
Life Cycle of a Claim Submission, Processing, Adjudication, Non-covered, Unauthorized, Medical Necessity Checks, Payment / RA / ERA
What does MAC stand for? Medicare Administrative Contractor
"A condition that develops after, the outpatient care has been provided or during an inpatient admission." Complication
"A concurrent condition that coexists with the first-listed diagnosis or principal diagnosis, has potential to affect treatment of the aforementioned diagnosis and is an active condition for which the patient is treated and/or monitored." Comorbidity
The process by which the provider contacts the insurance carrier to see if the proposed procedure is covered by a specific patients insurance policy. Preauthorization
Monies or Funds that are owed to the practice for services provided Accounts Receivable (A/R)
Monies being paid from the medical practice, for instance to pay for supplies, rent, utilities, payroll, etc. Accounts Payable (A/P)
What are the names of the three tables that appear in the Index to Diseases? Hypertension Neoplasm Table of Drugs and Chemicals
The explanation of payments received from the insurance company is often referred to or called the _____________. Remittance Advice
Billing a patient for the difference between a higher usual fee and a lower allowed charge is called _____________. Balance Billing
___________ is the national health insurance program for Americans aged 65 and older. Medicare
A health-benefit program designed for low-income, blind, or disabled patients; needy families; foster children; and children born with birth defects. Medicaid "payer of last resort"
What is the single largest healthcare program in the United States? Medicare
Signed into law in 2010, an act that resulted in improved access to affordable healthcare coverage and protection from abusive practices by healthcare insurance companies is what? Affordable Care Act (ACA)
Person who is responsible for a patients debt is called? Guarantor
Medicare beneficiaries can also obtain supplemental insurance called what? Medigap
What does Medigap do? Helps cover costs not reimbursed by the original Medicare plan.
A writ requiring the appearance of a person at a trial or other proceeding is a ___________. subpoena
When does the tertiary insurance pay? After the primary and secondary insurers.
Healthcare Common Procedure Coding System (HCPCS) A numeric and alphabetic coding system used for billing/pricing of procedures, medical supplies, medications, and durable medical equipment (DME).
A managed care organization that establishes a network of providers who care for their patients is called a/an _________. Preferred Provider Organization (PPO)
A group that takes nonstandard medical billing software formats and translates them into the standard Electronic Data Interchange (EDI) formats is called a/an? Clearinghouse
The out-of-pocket payment amount that a policyholder must meet before insurance covers the service(s) is called? Deductible
National Provider Identifier (NPI) number A unique 10-digit number assigned to providers in the U.S. to identify themselves in all HIPAA transactions.
What is a capitation? A payment structure in which a health maintenance organization prepays an annual set fee per patient to a physician.
A fixed fee collected at the time of the patients visit. Copayment
A fixed percentage of covered charges applied to the patients bill after the deductible has been met. Coinsurance
The charge for keeping the insurance policy in effect. Premium
Coding and billing that is inconsistent with typical coding and billing practices. Abuse
How does HIPAA define fraud? An intentional deception of misrepresentation.
"The difference between fraud and abuse is _______." Intent
Current Procedural Terminology (CPT) codes Numeric codes developed by the American Medical Association (AMA) to standardize medical services and procedures.
Is Abuse intentional? No
What simplified process was developed to enable Medicare beneficiaries to participate in mass pneumococcal pneumonia virus (PPV) and influenza virus vaccination programs offered by public health clinics? Roster Billing
A person filing an appeal is called? Claimant
Covers injuries caused by insured that occurred on the insured's property. Liability Insurance
A detailed accounting of the claims for which payment is being made by an insurance company. The __________ accompanies the payment from the insurance company. Remittance Advice (RA)
Authorization by a policyholder that allows a payer to pay benefits directly to a provider is called? Assignment of Benefits
A/An ___________ is a person admitted to a hospital or long-term care facility(LTCF) for treatment with the expectation that the patient will remain in the hospital for a period of 24 hours or more. Inpatient
What is confidentiality? Involves restricting patient information access to those with proper authorization and maintaining the security of patient information.
The first listed diagnosis can also be referred to as ______________. Principal diagnosis
Physicians who enroll in managed care plans are called ______________. They have contracts with Managed Care Organizations (MCO)s that stipulate their fees. Participating Providers
A formal, written document that describes how the hospital or physician's practice ensures rules, regulations, and standards that are being followed is known as a/an _______________. Compliance Plan
What act mandated the reporting of ICD-9-CM diagnosis codes? The Medicare Catastrophic Coverage Act of 1988
Transmitting electronic medical insurance claims from providers to payers using the necessary information systems is called ______________. Electronic Data interchange (EDI)
"A severe form of hypertension with vascular damage and a diastolic pressure reading of 130 mm hg or greater." Malignant
"Mild and/or controlled hypertension, with no damage to the patient's vascular system or organs." Benign
"No notation of benign or malignant status is found in the diagnosis or in the patient's chart." Unspecified
For Inpatient coding, the initials CC mean? Comorbidities and Complications
What does policy mean? Insurance
A person who receives a check in payment is the _________. Payee
Insurer/Insured, Subscriber, Member, Recipient are all terms that apply to the? Policyholder
True or False, Preferred Provider Organizations (PPO)s never allow members to receive care from physicians outside the network. False, Policyholders may choose to go out of network, but the may have to pay greater expenses.
Everything a medical claims specialist learns about a patient's condition must remain _____________. Confidential
Created by: Steven Cummings Steven Cummings