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Ch. 16
Coding and Insurance
| Question | Answer |
|---|---|
| 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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