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chapter 11
| Question | Answer |
|---|---|
| the three entites covered by HIPAA are: | health plans health care clearninghouses health care providers |
| identical procedures or services can be reported on the same line if two of the following four circumstances apply: | procedure performed on consecutive days in the same month same code assigned to procedure/service reported identical charges apply to assigned code block 24G (days or units) is completed |
| When a doctor refers a patient to the hospital for observation and bypasses the clinic or E.R. this is called | direct admission |
| when someone is admitted as a medical case but after testing they require surgery.. is called | medical/surgical case |
| secondary claims are processed after when? | when the R.A is generated on the first claim |
| claims with no processing errors and payments in full are marked what? | closed and moved to the closed assigned claims file |
| HIPAA privacy standars require what? | providers to notify patients about their right to privacy |
| The Medicare Conditions of Participation (CoP) requires | a provider to keep copies of government insurance claims and copies of all attachments filed by the provider |
| observation services are reimbursed under the Outpatient Prospective Payment System using the UB-04 as an? | alternative to inpatient admission |
| supplemental plans usually cover ? | the deductible and copay or coinsurance of a primary health insurance policy |
| the surgeon's charges for inpatient and outpatient surgery are billed according? | to a global surgical package |
| typewritten and handwritten claim have | higher error rates |
| the legal business name of a practice is its | billing entity |
| to report more than 6 procedures or services for the same date of service you must | it is necessary to generate a new claim |
| chronic conditions such as diabetes or hypertension always require medical management there for | should always be reported on the claim form |
| it is important to NOT enter... | commas periods or tother punctuation in the address on a claim form |
| the first listed code reported is | the major reason the patient was treated by the health care provider |
| block 13 of the CMS-1500 claim | authorizes payment of medical benefits to physicians or suppliers |
| the national provider identifier (NPI) | unique 10 digit number issued to individual providers and health care organizations |
| only 4 diagnosis codes | can be listed on a single claim form |
| backend recovery | a vendor who specializes in pursing funds fron the appropriate payer |
| the development of an insurance claims begins when the patient | contacts the health care providers office for an appointment |
| optical scanning of paper claims uses a scanner to convert printed or handwritten characters into text can viewed by | an optical character reader |
| provider services for inpatient care are billed | on a fee-for-services basis |
| a claims attachment should be used when: | a patients stay in the hospital is prolonged an outpatient/office procedure is performed as an inpatient a procedure is submitted with an unlisted procedure code |
| medicare coverage for observation services is limited to | no more than 48 hrs |
| to improve the accuracy of Medicare payments by detecting and denying unlikely Medicare claims on a payment basis, | Cms implemented the Medically Unlikely Edits project |
| when entering the patients name in Block 2 | separete the last name, first name, and middle name with commas |
| never code diagnoses that begin with the words | probable, suspicious for, rule out |
| a nonphysician practitoner provides services to patients under direct supervison of a physician | the billing is considered incident to |
| in block 21 of the CMS-1500 claim | a maximum of four ICD-9-CM codes may be entered |
| by May 2008 submission of the NPI was required on the CMS-1500 claim for | large health plans health care clearinghouses Small health plans |
| patients sign block 13 of the CMS-1500 form to instruct the payer to directly reimburse the provider | this is an assignment of benefits |
| Federal privacy act of 1974 | prohibits a payer from notifying the provider about payment or rejection of unassigned claims or payments sent directly to the patient/policyholder |
| medical management | deals with chronic conditions affecting patient care |
| national provider identifier | a ten digit number issued to providers |
| observation services | when a patient is monitered in order to decide if they should be admitted or dischared to/from the hospitals |
| assignment of benefits | the payer directly reimburses the provider |
| observastion services | when a patient is monitered in order to decide if they should be admitted or discharged to/from the hospital |
| first listed code | the major reasonthe patient was treated by the provider |
| unlisted code | a claim attachment is required |
| accept assignment | means that the provider accepts payment in full from the payer |
| unit of service | number of encounters |
Created by:
brocksobe