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Medical Coding and Billing

Study Guide/Coding and BillingAnswers
Medicaid Card A common method for verifying the patient's Medicaid eligibility is the ID card. This card provides important information regarding eligibility date and type shown on the face of the card.
Birthday Rule The birthday rule determines which plan is primary(usually children) are listed as dependents on more than one health plan. It states that the health plan of the parent whose birthday comes first in the calendar year will be considered the primary plan.
Group Health Plan Covers eligible employees and an employer or member. Employees employed full-time (or for a specific number of hours, 30 or 35 hours per week.
Diagnosis The detemination of the nature of a cause of disease or the art of distinguishing one disease from another.
ICD-9-CM International Classification of Disease 9th Revision, Clinical Modification
E-Codes The Supplementary Classification of External Causes of Injury and Poisoning (codes E800-E999).
V-Codes The Supplementary Classification of Factors Influencing Health Status and Contact with Health Services. V-Codes are used when circumstances other than a disease or injury are recorded as a diagnosis or problem.
Evaluation and Management Codes Found in the beginning of the CPT manual. The E&M section of the CPT is divided into broad catergories, including office visits, hospital visits, and consultations. Coded 99201 and 99499).
TRICARE Is the U.S. military's comprehensive healthcare program for active duty personnel and eligible family members, retirees and family members younger than age 65, and survivors of all uninformed services (i.e., Army, Air Force, Marines, Navy).
Referral/Authorization Provided by the PCP to visit any physician, hospital, or other healthcare provider who belongs to the network. Authorization is a procedure required by most managed healthcare and indemnity plans before a provider carries out specific procedure/treatment
Allowable Charge Are the fees Medicare permits for a particular service or supply.
Upcoding Billing for a more expensive service or procedure than what was provided.
Workers' Compensation Insurance that pays workers who are injured or disabled on the job or have job-related illnesses.
Federal Registry A daily publication that provides a uniform system for publishing federal regulations, legal notices, presidential proclamations, and executive orders.
Insurance Log Tracks the status of insurance claims.
Cafeteria Plan A plan falls under the cafeteria category when the cost of the plan (premium) is deducted from the employee's wages before withholding taxes are deducted.
OCR Means "Optical Charter Recognition". OCR is the recogntion of printed or written text charters by a computer.
POS Is a "hybrid" type of managed care (also referred to as an open ended HMO) that allows patients to use the HMO provider or go outside the plan and use any provider they choose.
NON Par A provider that has no contractual agreement with the insurance carrier; the provider does not have to accept insurane company's reimbursement as payment in full.
Examples of Medicaid Fraud (1). Billing for medical services not actually performed (2). Billing for a more expensive service than was rendered (3). Billing separately for several services that should be combined into one billing (4). Billing twice for the same medical service
Examples of Medicaid Fraud (5). Dispensing generic drugs and billing for brand name drugs (6). Giving or accepting something in return for medical services (kickbacks). (7). Bribery (8). Providing unnecessary services (9). False cost reports
Examples of Medicaid Fraud (10). Billing for ambulance runs when no medical service is provided (11). Transporting multiple passengers in an ambulance and billing a run for each passenger.
Preventive Services Covered by Medicare (1). Bone mass measurements (2). Colonrectal cancer screening (3). Diabetes services (4). Glaucoma testing (5). Pap tests, pelvic examinations, clinical breast examinations (6). prostate cancer screening (7). screening mammograms (8). certain vaccinations
Created by: MichaelAJ007