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Review Linkage Protocol Appropriateness of codes, payers rules about linkage, documentation to support codes. Compliance with regulation and guidelines.
Plus Sign indicates add on codes
Life Cycle of a Claim Submission, Processing, Adjudication, Non-Covered, Unauthorized, Medical Necessity Checks, Payment/RA/ERA
CMS 1500 Universal Claim Forms Claim developed by the AMA and the Centers for MCR and Medicaid services used by physicians and other professionals to bill outpatient services and supplies to Tricare MCR and some Medicaid programs and some private insurance and managed care plans.
PPO PPO is similar to an HMO, but care is paid for a received instead of in advance in form of a schedule PPO may offer more flexibility by allowing for visits to out-of-network require only the payment of a small fee
Modifier 50 bilateral procedure
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.
Pathology and Laboratory 80048-89356
HIPAA is and acronym for Health Insurance Portability and Accountability Act of 1996
Six Section of CPT E&M, Anatomical Site, Condition or Disease, Synonym or Eponym, Abbreviation
Health Maintenance Organization, a form of health insurance combining a range of coverage 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. HMO
Heath 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 Indmity Insurance
Patient Information, Verify Insurance, Prepare encounter form, Code DX and CPT, Review Linkage Protocol, Calculate Physicians charges, Prepare Claim Transmit Claim, Follow up on Reimbursement Basic Billing Reimbursement Steps
Any Medicare Claim that contains complete necessary information but is illogical or incorrect (e.g. listing an incorrect provider number for referring physician) Invalid Claims re identified to the provider and maybe resubmitted Invalid Claim
Private individuals are responsible for securing their own Health Insurance coverage, Commercial Government Employer, Group Health Insurance coverage Private payer vs Commercial
77010-79999 Radiology
Category I: Procedures that are consistent with contemporary medical practice and are widely performed. Category II: Supplementary tracking used for performance measure, Category III: Temporary codes for emerging technology, service and procedures. Three Categories for E'M codes
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 ABN/Advanced Beneficiary Notice
A rejected claim is any electronically submitted claim that is un processable due to missing or invalid information required by the payer. Rejected Claim
Change in wording Triangle means
Used to enclose synonyms alternative wording or and explanatory phrase brackets
Level 2 Codes National Codes for physicians and non-physicians service not found in the CPT Level 1
Basic Billing Reimbursement Steps Patient information, Verify Insurance Prepare encounter form, Code DX and CPT, Review Linkage Protocol, Calculate physicians charges. Prepare claim, transmit claim, follow up on reimbursements
BULLETS Represents a new procedures or service code added since the previous edition of the manual
Circle with a line through it means modifier 51 exempt codes
Elecontric 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
Insurance policy that pays benefits in the event that the policy holder becomes incapable of working Disability Insurance
free or low-cost health insurance coverage through the state Medicaid
New procedure Code bullet means
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 Usual Customary and reasonable
Listed under associate and stand alone codes Indented codes
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 care takers relatives, Elderly, Individuals with disabilities Medicaid Medially Needy
A distinction for individuals who fall into a specific category (or criteria) or mandatory Medicaid Eligibility established by the federal government. These categories apply to every state Medicaid program Medicaid Catagorically needy
Worker's Compensation is a job benefit that provides money and services to employees that are injured or become sick on the job. Worker's Compensation helps injured and sick workers to survive financially as they recover form health problems Workman's Comp
Health Care Programs for Uniformed Service members, retirees, and their families TRICARE