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MAA102 Week 1
| Question | Answer |
|---|---|
| International Classification of Diseases Coding System (ICD-9) is for what? | Diagnosis |
| What sources can the diagnosis for coding be taken from? | A variety of sources, such as clinical notes, laboratory tests, radiological results, and others. |
| What is the ICD-10? | International Classification of Diseases, Tenth edition, Clinical Modifications Coding System |
| Where can I find the most important information in the ICD-10-CM manual? | Part II-Alphabet Index, Index to Diseases and Injuries, and Neoplasm Table (Table of Drugs and Chemicals and External Causes of Injuries Index) |
| What is in the Tabular List (also known as Volume 1)? | List of codes arranged alphanumerically |
| What is a placeholder character? | A lowercase x within a code |
| What is a seventh character? | Some ICD-10-CM categories require an extension to provide further specificity about the condition being coded. |
| What are the two types of health insurance? | Indemnity (fee-for-service) and Managed care |
| Which type of insurance is traditional, patients can choose any provider or hospital and can change any time, Policyholder (the insured) pays periodic fee (higher premium), better coverage = higher premium, and Deductibles | Indemnity (Fee-for-Service) |
| How do we calculate UCR? | Historical data for charges for same/similar service, charge variance by providers for same service; same geographic area, whether procedure requires more time, skill, or experience than usual, and value of procedure compared to other services |
| What is RBRVS? | Resource-Based Relative Value Scale assigns a value to every medical procedure to calculate Medicare’s fee schedule allowance, and cost divided into three components: physician work, practice expense, and professional liability insurance |
| What are Out-of-Pocket Maximum and Lifetime Limits? | A specified amount the patient must pay out of pocket for covered services in a benefit period, includes deductibles, coinsurance, copayments, and any other expenditure that the individual must pay that is considered a qualified medical expense |
| What year did the first health insurance company (Blue Cross) form? | 1929 |
| What year was the ACA enacted? | 2010 |
| What were 3 major changes that went into effect immediately when the ACA was enacted? | Illegal for insurance to deny coverage because of preexisting conditions and cannot charge more than a healthy person, children allowed to remain on parents' insurance until age 26, Medicare recipients who fall into a coverage gap receive a $250 rebate |
| Why is the cost of healthcare increasing? | Americans are living longer, advances in medical technology, rise in chronic diseases, and more demand for healthcare |
| What is cost sharing? | Insured individuals pay a portion of the healthcare costs |
| What is an ACO? | Accountable Care Organization is a network of doctors and hospitals that share responsibility for providing care to patients and manage a minimum of 5,000 Medicare beneficiaries for at least 3 years. |
| What are the two basic types of health insurance? | fee-for-service (indemnity) and managed care |
| Name 2 payment systems | UCR (usual, reasonable, customer) and RBRVS (resource-based relative value scale) |
| What is a universal form created by the government for Medicare claims and since adopted by most insurances? | CMS-1500 |
| What is a preexisting condition? | A physical or mental condition of an insured person that existed before the issuance of a health insurance policy or that existed before issuance and for which treatment was received. |
| What is a market for health insurance called? | Health Insurance Exchange |
| What is COBRA? | Consolidated Omnibus Budget Reconciliation Act provides continuation of group health coverage that otherwise would be terminated when someone leaves their place of employment, premiums are expensive |
| How long can someone be insured under COBRA? | 18 months |
| What is the the informal procedure to determine the "primary" insurance of a dependent, usually for children, with more than health plan? | The birthday rule states that the health plan of the policy holder/parent whose birthday is first in the calendar year will be considered the primary plan |
| What is coordination of benefits? | Limits the total benefits someone can receive from multiple group plans to not exceed 100% of allowable expenses, this prevents policyholders from profiting from health insurance claims |
| What are the requirements for something that insurance considers to be medically necessary? | Proper and needed for diagnosis or treatment of medical condition; provided for diagnosis, direct care and treatment of a medical condition; meet standards of good medical practice in local area; not mainly for convenience of patient and provider. |
| What do Medicare patients sometimes need for a medical necessity? | Completion of a certificate of medical necessity |
| What is a PAR? | Participating provider contracts with insurance. They must accept insurance carriers fees as payment in full, they may be offered incentives, and insurance pays directly to provider |
| What is a copayment? | Patients pay a flat fee when they receive a medical service to share medical costs, usually associated with managed care |
| What is a PCP? | Primary care physician is the patients first contact for healthcare, some insurance may only pay for a specialist if referred by a PCP, usually is a family physician, internist, OBGYN, or pediatrician |
| What is another name for a health insurance company, managed care organization, or any federal program that fulfills the role of health insurance? | Third-party payer |
| What are the 2 basic claims submission methods? | electronic and paper |
| What is the essential info to identify on an insurance card? | Insurance name, member name, member number, office visit co-pay, phone numbers for insurance claims, and pharmacy/RX plan |
| What are the other names for an Encounter Form? | routing form, patient service slip, and superbill |
| Why would a CMS-1500 claim be rejected? | Missing and/or invalid patient, provider, code, dates, or insurance information; failure to include necessary documentation, filing after deadline date |
| Why should you submit a clean claim? | Clean claims can be processed for payment quickly without being returned |
| When should you proofread? | After you write a paper and/or electronic document, before you submit/send it - always proofread! |
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