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MAA102 Week 1

QuestionAnswer
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!
Created by: FindSugar