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Ch. 16

Coding and Insurance

beneficiary recipient of insurance coverage
benefit year 12-month period starting with the date of initial insurance coverage
birthday rule insurance regulation that uses the subscribers' dates of birth to determine primary and secondary coverage for dependents
capitation system of payment in which physicians are paid a flat rate per patient
coordination of benefits insurance carrier;s explanation of how it will pay benefits if a patient has more than one insurance plan
copayment patients share of the cost of an office visit
Current Procedural Terminology 4th edition coding manual used to identify the procedures performed by physicians and their staff; also called CPT-4
demographics personal information used to identify a patient
fee-for-service payment method based on each item billed to the insurance company
modifier two-digit number added to the end of a procedure code that changes and further defines the procedure
policyholder person who purchases an insurance policy
preferred provider organization managed care plan that contracts with physicians to furnish services to its members
premium money paid to an insurer to obtain insurance
referral request by a physician to have another physician examine a patient
registration process of collecting patient demographic and insurance information when the patient begins care
superbill document used in a medical office to indicate the services provided by a physician to a patient during an office visit
upcode illegal practice of using a procedure code that yields a higher reimbursement than the procedure that is actually performed
utilization review determination by a managed care organization of medical necessity of a procedure or service
verification process of confirming insurance benefits with the patients insurance carrier
write-off difference in the amount charged for a service and the amount contractually allowed by an insurance company
what are the two broad categories of coding procedural coding and diagnostic coding
what is the source book for procedural coding cpt-4
what is the source book for diagnostic coding icd-9
what are the 4 types of cpt codes category I, II, III, and modifiers
what are the 6 sections in the cpt manual evaluation and management, anesthesia, surgery, radiology, pathology and lab, and medicine
what are the 3 main factors to describe physician services in evaluation and management place of service, type of service, pt status
what are category II codes used for they are a set of supplemental tracking codes used for performance measurement
when do you use category 3 codes when it pertains to new technology
what is the purpose of a modifier the addition of a modifier indicates that the service or procedure has changed
when are hcpcs codes used they are used to translate medical equipment and transport services provided to a patient
describe the introduction of ICD9 the introduction offers instructions to the reader on how to code diseases and disorders. It includes the latest updates to coding
describe Vol. I of ICD9 tabbed in numerical order, and divided into chapters
describe Vol. II of ICD 9 tabbed in alphabetical order also contains a table of drugs and chemicals and an index
describe Vol. III of ICD 9 tabbed in alphabetical order of hospital procedures
what are the different types of V codes problem- orientated, service-oriented, and fact-oriented
what is the use of a problem orientated V code identifies risk factors that may effect a pt but are not an injury or illness ex: V02 which indicates a carrier or suspected carrier of an infectious disease or V69.0 which indicates lack of physical exercise
what is the use of a service orientated V code identify services for a pt that is not currently sick but are seeking medical treatment for other reasons such as injury after care or routine exams. ex: V67.4 which indicates a follow up visit for a healed fracture after treatment, and V20.2 for a WCC
what is the purpose of a fact oriented V code identify the patient's condition. ex: V27.0 indicates the outcome of a the delivery of a single newborn, and V09.0 indicates infection w/ a microorganism that is resistant to penicillin
what is the purpose and use of E codes used to establish medical necessity. identify cause of injury and poisoning, and to identify medications
what is the first rule of E codes they can never be a primary code
what is the 2nd rule of E codes they will not effect the amount of reimbursement
what is the 3rd rule of E codes they can speed up the reimbursement by providing additional info to the insurance company
what is the order of priority of E codes Child abuse, cataclysmic events, and transportation accident
Created by: rewebb
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