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MBC
Medical coding and billing
| Question | Answer |
|---|---|
| Coinsurance | The portion of charges that an insured person must pay for healthcare services after payment of the deductible amount; usually stated as a percentage |
| Conversion Factor | The dollar amount used to multiply a relative value unit to arrive at a charge |
| Usual, Customary, and Reasonable (UCR) | Setting fees by comparing the usual fee the provider charges for the service, the customary fee charged by most providers in the community, and the fee that is reasonable considering the circumstances |
| Audit | A methodical review; in medical insurance, a formal examination of a physician's accounting or medical records |
| Condition Code | Two digit numeric or alphanumeric code used to report a special condition or unique circumstance about a claim; report in item number 10D on the CMS-1500 claim form |
| Qualifier | Two digit code for a type of provider identification number other than the National Provider Identifier (NPI) |
| Electronic Health Record (EHR) | A computerized lifelong healthcare record for an individual that incorporates data from all sources that provide treatment for the individual |
| Consolidated Omnibus Budget Reconciliation Act (COBRA) | Federal law requiring employers with more than 20 employees who have been terminated for reasons other than gross misconduct to pay for coverage under the employer's group health plan for 18 months after termination |
| Advance Beneficiary Notice (ABN) | A waiver of liability or Medicare waiver, is issued by medical providers to Medicare recipients warning that services might not be covered |
| Clearinghouse | A company (billing service, repricing company, or network) that converts nonstandard transactions into standard transactions and transmits the data to health plans; also handles the reverse process |
| Managed Care Organization (MCO) | Organization offering some type of managed healthcare plan |
| Per member, per month (PMPM) | Periodic capitated prospective payments to a provider who covers only services listed on the schedule of benefits |
| Practice Management Program (PMP) | Business software designed to organize and store a medical practice's financial information; often includes scheduling, billing, and electronic medical record features |
| Preferred Provider Organization (PPO) | Managed care organization structured as a network of healthcare providers who agree to perform services for plan members at discounted fees; usually, plan members can receive services from non-network providers for a higher charge |
| Health Insurance Portability and Accountability Act of 1996 (HIPAA) | Federal act that set forth guidelines for standardizing the electronic data interchange of administrative and financial transactions, exposing fraud and abuse in government programs, and protecting the security and privacy of health information |
| Health Information Technology for Economic and Clinical Health Act (HITECH) | Law that guides that uses federal stimulus money to promote the adoption and meaningful use of health information technology, mainly using electronic health records |
| Coordination of Benefits | A clause in an insurance policy that explains how the policy will pay if more than one insurance policy applies to the claim |
| Real-Time Adjudication | Electronic health insurance claim processed at patient check-out; allows practice to know what the patient will owe for the visit |
| Capitation | Payment method in which a fixed prepayment covers the provider's services to a plan member for a specified period of time |
| Capitation Rate (Cap Rate) | The contractually set periodic prepayment to a provider for specified services to each enrolled plan member |
| CMS | Means Centers for Medicare and Medicaid Services |
| Healthcare Provider Taxonomy Code (HPTC) | Administrative code set used to report a physician's specialty |
| Resourced-Based Relative Value Scale (RBRVS) | Federally mandated relative value scale for establishing Medicare charges |
| Clean Claim | A claim that is accepted by a health plan for adjudication |
| HIPAA X12 837 Heath Care Claim: Professional (837P) | The form used to send a claim for physician services to both primary and secondary payers |
| National Uniform Claim Committee (NUCC) | Organization responsible for the content of healthcare claims |
| Recovery Audit Contractor (RAC) | The type of contractor hired by CMS to validate claims that have been paid to providers and to collect a payback of any incorrect payments that are identified |
| Health Maintenance Organization (HMO) | A managed healthcare system in which providers agree to offer healthcare to the organization's members for fixed periodic payments from the plan; usually members receive medical services only from the plan's providers |
| Accounts Receivable (AR) | The money owed to a medical practice by its patients and 3rd party members |
| Correct Coding Initiative (CCI) | Computerized Medicare system that controls improper coding which would lead to inappropriate payments for Medicare claims |
| Accountable Care Organization (ACO) | A network of doctors and hospitals that shares responsibility for managing the quality and cost of care provided to a group of patients |
| Consumer-Driven Health Plan (CDHP) | Type of medical insurance that combines a high-deductible health plan with a medical savings plan that covers some out-of-pocket expenses |
| Remittance Advice (RA) | Health plan document describing a payment resulting from a claim adjudication; the copy sent to the insured is called an explanation of benefits (EOB) |
| Accounts Payable (AP) | The practice's operating expenses, such as for overhead, salaries, supplies, and insurance |
| Medicare Part A | The part of the Medicare program that pays for hospitalization, care in a skilled nursing facility, home health care, and hospice care. Also known as hospital insurance |
| Medicare Part B | The part of the Medicare program that pays for physician services, outpatient hospital services, durable medical equipment, and other services and supplies. Also known as Supplementary Medical Insurance (SMI) |
| Medicare Part C | Managed care health plans offered to Medicare beneficiaries under the Medicare Advantage Program |
| Medicare Part D | Prescription drug reimbursement plans offered to Medicare beneficiaries |
| Adjudication | The process followed by health care plans to examine claims and determine benefits |
| National Coverage Determination (NCD) | Medicare policy stating whether and under what circumstances a service is covered by the Medicare program |
| Premium | The money the insured pays to a health plan for a healthcare policy. Periodic payment the insured is required to make to keep the policy in effect |
| Deductible | An amount that an insured person must pay, usually on an annual basis, for healthcare services before a health plan's payment begins |
| Health Plan Payment Formula | Charge - Payment Amount -Adjustment Amount = Patient Responsibility |
| How many steps are in the revenue cycle process? | 10 |
| What number step is "preregister patients" in the revenue cycle process? | 1 |
| What number step is "establish financial responsibility" in the revenue cycle process? | 2 |
| What number step is "check-in patients" in the revenue cycle process? | 3 |
| What number step is "review coding compliance" in the revenue cycle process? | 4 |
| What number step is "review billing compliance" in the revenue cycle process? | 5 |
| What number step is "check-out patients" in the revenue cycle process? | 6 |
| What number step is "prepare and transmit claims" in the revenue cycle process? | 7 |
| What number step is "monitor payer adjudication" in the revenue cycle process? | 8 |
| What number step is "generate patient statements" in the revenue cycle process? | 9 |
| What number step is "follow-up payments and collections" in the revenue cycle process? | 10 |
| How many steps are in the Medicare appeal process? | 5 |
| What number step is "redetermination" in the Medicare appeal process? | 1 |
| What number step is "reconsideration" in the Medicare appeal process? | 2 |
| What number step is "administrative law judge" in the Medicare appeal process? | 3 |
| What number step is "Medicare appeals council" in the Medicare appeal process? | 4 |
| What number step is "federal court (judicial) review" in the Medicare appeal process? | 5 |
| Z-codes | Codes that are the reason for encounters with health services, such as examinations, genetic tests, blood donation, etc. They are not diseases or injuries, but may influence health status or required specific care |
| NOS | Means "not otherwise specified" and is the equivalent of unspecified |
| NEC | Means "other specified" |
| How many chapters are in the ICD-10-CM? | 22 |
| What does Level 1 HCPCS include? | CPT codes |
| What does Level 2 HCPCS include? | Includes National codes that have physician and nonphysician services, products, and supplies that are not in the other level (such as ambulance products, durable medical equipment, drugs, prosthetics, and orthotics) |
| HCPCS | Means Healthcare Common Procedure Coding System |
| CPT | Means Current Procedural Terminology |
| ICD-10-CM | Means International Classification of Diseases, 10th Revision, Clinical Modification |
| UB-04 | A paper form used to submit hospital and facility claims for reimbursement with various payer groups *for inpatient claims* |
| 837I | The electronic UB-04 claim format (also known as the ANSI ASC X12N 837I) used to submit claims for facility services rendered by inpatient organizations *for inpatient claims* |
| CMS-1500 | A paper form used to submit professional claims for reimbursement with various payer groups *for outpatient claims* |
| 837P | The electronic CMS-1500 claim format (also known as the ANSI ASC X12N 837P) used to submit claims for professional services rendered by health care providers *for outpatient claims* |
| What are the 3 main categories of fraud? | Billing for services that have not been performed, reporting of fraudulent diagnosis for the patient's care, and purposeful medical coding errors (e.g. upcoding) |
| Add-on codes | Describes procedures or services that are always provided "in addition to" other, related services or procedures and cannot stand alone as a separate reportable service |
| Abuse | Billing patterns and practices that are excessive or unnecessary but not fraudulent |
| What is the largest and most commonly used CPT category code set? | Category Ⅰ and it is divided into 6 sections |
| How many sections are CPT code sets divided into? | 3 |
| Claim Cycle | Claim submission, claim process, adjudication and then payment |
| How are multiple CPT codes on the same day of service sequenced? | From highest to lowest value |
| *CPT code symbol* ⚡(black) | Means FDA approval pending |
| *CPT code symbol* ＃ | Means resequenced code |
| *CPT code symbol* ★ | Means telemedicine |
| *CPT code symbol* )( | Means duplicate PLA (proprietary laboratory analyses) test |
| *CPT code symbol* ⬤ (red) | Means new code |
| *CPT code symbol* ▲ (blue) | Means revised code |
| *CPT code symbol* ▶ ◀ (yellow) | Means contains new or revised text |
| *CPT code symbol* + | Means add-on code |
| *CPT code symbol* ⊘ | Means modifier 51 exempt |
| *ICD-10-CM code symbol* ◗ (yellow) | Means manifestation code |
| *ICD-10-CM code symbol* 🛑 | Means use additional character(s) |
| *ICD-10-CM code symbol* 𝓧 (red) | Means assign placeholder "x" |
| *ICD-10-CM code symbol* d̶e̶l̶e̶t̶e̶d̶ | Means deleted code |
| *ICD-10-CM code symbol* ➠ (blue) | Means revised code |
| *ICD-10-CM code symbol* ▶ (green) | Means new code |
| What is the place of service code for an Ambulatory Surgical Center (ASC)? | 24 |
| What is the place of service code for an Urgent Care Facility (UCF)? | 20 |
| What is the place of service code for an Inpatient Hospital? | 21 |
| What is the place of service code for an Emergency Room (ER)? | 23 |
| What is the place of service code for an Off Campus-Outpatient Hospital? | 19 |
| What is the place of service code for an On Campus-Outpatient Hospital? | 22 |
| What is another term for when a physician performs a reduction on a displaced fracture? | Manipulation |
| What is the difference between inpatient and outpatient care? | Inpatient care is the care of patients whose condition requires admission to a hospital which is typically for patients who are extremely ill or have severe physical trauma. |
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