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L002 Chapter 1
The Bussiness of Medicine
| Question | Answer |
|---|---|
| Outpatient coding pertains to... | provider services |
| This type of hospital coding requires use of ICD-10-CM and ICD-10-PCS codes.These coders also use MS-DRGs for reimbursement. | In patient |
| This type of coders use CPT®, HCPCS Level II, and ICD-10-CM codes | Outpatient |
| The charges are billed to the payer using the ----- claim form, which is available in both paper and digital formats. physician srvices | CMS-1500 |
| The payer’s determination is sent to the provider in the form of a _____ or explanation of benefits (EOB) | remittance advice (RA) |
| federal health insurance program, administered by CMS, that provides coverage for people 65 and older, blind, or disabled, and people with permanent kidney failure or end-stage renal disease (ESRD | Medicare |
| Medicare program that helps to cover inpatient hospital care, as well as care provided in skilled nursing facilities, hospice, and home health. | Medicare Part A |
| covers two types of services: 1) Medically necessary provider services needed to diagnose or treat a medical condition 2) Preventive services to prevent illness or detect it at an early stage. It is an optional benefit. | Medicare Part B |
| Also called Medicare Advantage, combines the benefits of Medicare Part A, Part B, and sometimes Part D. | Medicare Part C |
| is a prescription drug program available to all Medicare beneficiaries for a fee. Private companies approved by Medicare provide the coverage. | Medicare Part D |
| a health insurance assistance program sponsored by federal and state governments for low-income people (especially children and pregnant women) | Medicaid |
| Evaluation and management (E/M) services are often provided in a standard format such as SOAP notes. What does each letter in SOAP stand for? | Subjuctive, Objective, Assesment and Plan. |
| explains when Medicare will pay for items or services. | National Coverage Determinations (NCD) |
| Each MAC is responsible for interpreting national policies into regional policies. What does MAC stand for? | Medicare Administrative Contractor |
| LCDs further define what codes are needed and when an item or service will be covered. LCDs have jurisdiction only within their region. What does LCD stand for? | Local Coverage Determinations (LCD) |
| Common reasons Medicare may deny a procedure or service include: | Medicare doesn’t pay for the procedure/service for the patient’s condition l Medicare doesn’t pay for the procedure/service as frequently as proposed l Medicare doesn’t pay for experimental procedures/ services |
| Providers should use this when a Medicare beneficiary requests or agrees to receive a procedure or service that Medicare may not cover. The ABN is a standardized form that explains to the patient why Medicare may deny the service or procedure. | Advance Beneficiary Notice (ABN) |
| This includes entities that process nonstandard health information they receive from another entity into a standard format; defind by HIPPA as a convered entity | A healthcare clearinghouse |
| The(OCR) enforces the HIPAA Privacy Rule, what does ocr stand for | Office for Civil Rights |
| hospitals typicals bill on which form? | UB-04 |
| used “to promote the adoption and meaningful use of health information technology.” what does HITECH stand for? | The Health Information Technology for Economic and Clinical Health Act |
| The four Merit-Based Incentive Payment System (MIPS) performance categories are: | Quality (replaces PQRS) Promoting Interoperability (PI), Improvement Activities Cost (replaces the VM) |
| APC | Ambulatory Payment Classification |
| ARRA | American Recovery and Reinvestment Act of 2009 |
| ASC | Ambulatory Surgical Centers |
| HHS | Department of Health & Human Services |
| MAC | Medicare Administrative Contractor |
| MS-DRG | Medicare Severity-Diagnostic Related Group |
| OIG | Office of Inspector General |
| PPACA | patient Protection and Affordable Care Act |
| TPO | treatment, payment, and healthcare operations |
| ABN “Notifiers must make a good faith effort to insert a reasonable estimate… the estimate should be within ? of the actual costs, whichever is greater.” | $100 or 25 percent |
| identifies potentially noncompliant areas the OIG intends to scrutinize, such as the audit of the department’s financial statements, which is mandated by the Government Management Reform | The OIG Work Plan |
| APM is the second track under the Quality Payment Program. An APM is a group of clinicians who have voluntarily come together in an organized way to deliver coordinated highquality care to Medicare patients. What does apm stand for? | Alternative Payment Models (APM) |
| To calculate the final CPS, add up the overall scores for each category and multiply by 100. those with a score of 4-69 points will receive a modest positive adjustment; 0 recieves negative. What does CPS stand for? | The Composite Performance Score |
| Which act was enacted as part of the American Recovery and Reinvestment Act of 2009 (ARRA) and affected privacy and security? | HITECH |
| What document assists provider offices with the development of Compliance Manuals? | OIG Compliance Plan Guidance |
| What document is referenced to when looking for potential problem areas identified by the government indicating scrutiny of the services? | .OIG Work Plan |
| What is not a common reason Medicare may deny a procedure or service? | Covered service |
| Under the Privacy Rule, the minimum necessary standard does NOT apply to what type of disclosures? | Disclosures to the individual who is the subject of the information. |
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marrufotheresa