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INSUR {CPC}
The Business of Medicine
| Question/Term | Answer/Definition |
|---|---|
| Code assignment | is determined both by the provider’s documentation and by the unique rules that govern each code set |
| Professional Coders | coders who specialize in coding for provider services, are referred to as professional coders or pro fee coders |
| Outpatient Facility Coders | outpatient coders use CPT®, HCPCS Level II, and ICD-10-CM codes |
| Outpatient Facility Coders | they work in facility outpatient departments and Ambulatory Surgical Centers (ASCs) and also use Ambulatory Payment Classifications (APCs) |
| Inpatient Facility Coders | specialize in coding inpatient hospital services reported by the facility are referred to as health information coders, medical record coders, coder/abstractors, or coding specialists |
| Risk Adjustment Coders | focuses on diagnosis coding using the ICD-10-CM code set |
| Risk Adjustment Coders | can work for health plans, providers, or other healthcare entities |
| Cancer Registrars | maintain facility, regional, and national databases of cancer patients |
| Medicare Part A | helps to cover inpatient hospital care, as well as care provided in skilled nursing facilities, hospice, and home health |
| Medicare Part B | covers medically necessary provider services needed to diagnose or treat a medical condition and that meet accepted standards of medical practice |
| Medicare Part B | covers preventive services to prevent illness or detect it at an early stage. Medicare Part B is an optional benefit for which the patient pays a monthly premium, an annual deductible, and generally has a 20 percent co-insurance, except for preventive services covered under healthcare law |
| Medicare Part C | also called Medicare Advantage, combines the benefits of Medicare Part A, Part B, and sometimes Part D |
| Medicare Part C | managed by private insurers approved by Medicare & may include PPO's, HMO's, and others |
| Medicare Part C | private insurer plans may charge different copayments, coinsurance, or deductibles for services |
| CMS hierarchical condition category (CMS-HCC) | risk adjustment model provides adjusted payments based on a patient’s diseases and demographics |
| Medicare Part D | is a prescription drug program available to all Medicare beneficiaries for a fee |
| Medicare fee schedule for providers(MFSDB) found on the CMS website | is released in the Medicare Physician Fee Schedule Database |
| When referring to Medicare | it may be referred to as “Part B", this refers to Medicare Part B which covers the professional fee services performed by providers |
| Medicaid | is a health insurance assistance program sponsored by federal and state governments for low-income people (especially children and pregnant women) |
| Medicaid | is administered on a state-by-state basis, although each state program adheres to certain federal guidelines |
| Children’s Medical Services, Children’s Indigent Disability Services, and Children with Special Healthcare Needs | state funded insurance programs that provide coverage for children up to 21 years of age |
| Children’s Medical Services, Children’s Indigent Disability Services, and Children with Special Healthcare Needs | these programs are designed for beneficiaries with specific chronic medical conditions |
| Par provider | a participating provider |
| Participating providers | are required to accept the allowed payment amount determined by the insurance carrier as the fee for payment and follow all other guidelines stipulated by the contract |
| Non-participating provider | (provider not contracted with the insurance carrier) is not required to make this adjustment |
| Limiting charge | set limits on what the patient can be charged |
| Medical record | is the provider’s documentation of pertinent facts and observations about a patient’s health history, including past and present illnesses, tests, treatments, and outcomes |
| Medical record | chronologically documents patient care to assist in continuity of care between providers, facilitate claims review and payment, and can serve as a legal document |
| Administrative data/Financial Records | should not be included in the medical record nor provided in response to a subpoena or request for medical records |
| Two types of Medical Records | Evaluation and Management (E/M) & Operative Reports |
| Evaluation and Management (E/M) visit | occurs when a provider sees a patient to evaluate the patient’s condition(s) and determine the management of care required to treat the patient |
| Evaluation and Management (E/M) visit | could take place in a provider’s office, hospital, nursing facility, etc. This service is then documented in the medical record |
| Evaluation and Management (E/M) services | are often documented in a standard format such as SOAP |
| S—Subjective | the patient’s statement about his or her health, including symptoms |
| O—Objective | the provider’s examination and documentation of the patient’s illness using observation, palpation, auscultation, and percussion. Tests and other services performed may be documented here as well |
| A—Assessment | evaluation and conclusion made by the provider. This is usually where you find the diagnosis(es) that supports the services rendered |
| P—Plan | (course of action) the provider will list the next steps for the patient, whether it’s ordering additional tests, taking over-the-counter medications, etc |
| E/M documentation | is written in a clear SOAP format, but each chart must contain the required components of the visit associated with the code(s) billed |
| Operative reports | are used to document the details of a procedure performed on a patient |
| Operative note header includes: | 1. Date and time of the procedure - 2. Names of Surgeon, co-surgeon, assistant surgeon - 3. Type of Anesthesia/Anesthesia Provider - 4. Pre/Post Operative diagnoses - 5. Procedure performed - 6. Complications |
| Operative note body includes: | 1. Indication for surgery - 2. Details of the procedure(s) - 3. Findings |
| Operative Report Coding Tips | Highlight unfamiliar words - Diagnosis code reporting - Procedure reporting - Look for key words - Read the body |
| Medical Necessity | relates to whether a procedure or service is considered appropriate in each circumstance |
| Medically Necessary Service or Procedure | is the least radical service/procedure that allows for effective treatment of the patient’s complaint or condition |
| Title XVIII, §1862(a)(1) of the Social Security Act | a CMS developed policy regarding medical necessity based on regulations found in this act |
| National Coverage Determinations Manual | describes whether specific medical items, services, treatment procedures, or technologies can be paid for under Medicare |
| National Coverage Determinations (NCD) | explains CMS polices on when Medicare will pay for items or services |
| Medicare Administrative Contractor (MAC) | is responsible for interpreting national policies into regional policies |
| Medicare Administrative Contractor (MAC) | may also define what codes are needed for coverage in a related billing and coding article |
| Local Coverage Determinations (LCD) | further define when an item or service will be covered and have jurisdiction only within their region |
| 2016 21st Century Cures Act | made changes to the LCD process and requires MACs to place codes for coverage in billing and coding articles that are linked to the LCD |
| Codify | allows the user to search for LCD policies by Procedure, Title, or LCD/Article ID |
| Advance Beneficiary Notice | is a standardized form that explains to the patient why Medicare may deny the service or procedure |
| Advance Beneficiary Notice | protects the provider’s financial interest by creating a paper trail that CMS requires before a provider can bill the patient for payment if Medicare denies coverage for the service or procedure |
| Medicare Cost Estimate | should be within $100 or 25 percent of the actual costs, whichever is greater |
| Advance Beneficiary Notice | should not be used to bill the beneficiary for additional fees beyond what Medicare reimburses for a given procedure or service |
| Advance Beneficiary Notice | doesn’t allow the provider to shift liability to the beneficiary when Medicare payment for a particular procedure or service is bundled into payment for other covered procedures or services |
| Advance Beneficiary Notice | are never required in emergency or urgent care situation |
| Advance Beneficiary Notice | without this valid form, the Medicare beneficiary cannot be held responsible for denied charges |
| Advance Beneficiary Notice | non-Medicare payers may not recognize this form |
| Health Insurance Portability and Accountability Act of 1996 | (HIPAA), sometimes referred to as the Kennedy-Kassebaum Law or Kennedy-Kassebaum Act for sponsors Sen. Edward Kennedy and Sen. Nancy Kassebaum, is a five-part act |
| HIPAA Act of 1996 = Title II | Prevents Healthcare Fraud and Abuse, Administrative Simplification, and Medical Liability Reform |
| Title II—Administration Simplification | speaks to the increasing use of technology in the healthcare industry |
| Title II—Administration Simplification | National standards for electronic healthcare transactions and code sets |
| HCFAC {acronym stands for} | Healthcare Fraud and Abuse Control Program |
| Healthcare Fraud and Abuse Control Program (HCFAC) | designed to coordinate federal, state, and local law enforcement activities with respect to healthcare fraud and abuse |
| Transactions | are electronic exchanges involving the transfer of information between two parties for a specific purpose |
| HCPCS {acronym stands for} | Healthcare Common Procedure Coding System |
| CPT® {acronym stands for} | Current Procedural Terminology |
| CDT® {acronym stands for} | Common Dental Terminology |
| ICD-10-CM {acronym stands for} | International Classification of Diseases, Tenth Revision, Clinical Modification |
| NDC {acronym stands for} | National Drug Codes |
| NPI {acronym stands for} | National Provider Identifier |
| EIN {acronym stands for} | Employer Identification Number |
| PHI {acronym stands for} | Protected Health Information |
| Office for Civil Rights (OCR) | enforces the HIPAA Privacy Rule, which protects the privacy of individually identifiable health information |
| HIPAA Security Rule | sets national standards for the security of electronic protected health information (ePHI); and the confidentiality provisions of the Patient Safety Rule, which protect identifiable information being used to analyze patient safety events and improve patient safety |
| TPO {acronym stands for} | Treatment, Payment, and Healthcare Operations |
| Notices of Privacy Practices and policies | Healthcare providers are responsible for developing procedures regarding privacy in their practices |
| Minimum Necessary Requirement | a key provision of HIPAA |
| Minimum Necessary Requirement | only the minimum necessary protected health information should be shared to satisfy a particular purpose |
| HITECH {acronym stands for} | Health Information Technology for Economic and Clinical Health Act |
| Health Information Technology for Economic and Clinical Health Act (HITECH) | was enacted as part of the American Recovery and Reinvestment Act of 2009 (ARRA) “to promote the adoption and meaningful use of health information technology.” |
| Health Information Technology for Economic and Clinical Health Act (HITECH) | portions of this Act strengthen HIPAA rules by addressing privacy and security concerns associated with the electronic transmission of health information |
| Health Information Technology for Economic and Clinical Health Act (HITECH) | establishes four categories of violations — depending on the covered entity’s level of culpability for releasing protected information — and minimum and maximum penalties |
| Health Information Technology for Economic and Clinical Health Act (HITECH) | lowers the bar for what constitutes a violation but provides a 30-day window during which any violation not due to willful neglect may be corrected without penalty |
| ARRA {acronym stands for} | American Recovery and Reinvestment Act of 2009 |
| Health Information Technology for Economic and Clinical Health Act (HITECH) | allows patients to request an audit trail showing all disclosures of their health information made through an electronic record |
| Health Information Technology for Economic and Clinical Health Act (HITECH) | requires an individual to be notified if there is an unauthorized disclosure or use of his or her health information |
| Medicare Access and CHIP Reauthorization Act (MACRA) | which provided significant changes to the healthcare delivery system |
| SGR {acronym stands for} | sustainable growth rate |
| QPP {acronym stands for} | Quality Payment Program |
| Quality Payment Program (QPP) | launched in 2017, provides two tracks in which eligible clinicians can participate |
| MIPS {acronym stands for} | Merit-Based Incentive Payment System |
| APMs {acronym stands for} | Advanced Alternative Payment Models |
| Merit-Based Incentive Payment System (MIPS) | is a combination of three former quality initiative programs |
| Merit-Based Incentive Payment System (MIPS) | the goal is to provide a single quality reporting system with a single payment adjustment factor based on individual or group performance in Medicare Part B |
| Merit-Based Incentive Payment System (MIPS) | is a budget neutral program, meaning successful reporters of measured data earn positive payment adjustments funded by unsuccessful reporters who receive negative payment adjustments |
| Traditional MIPS | the provider selects the quality measures and improvement activities to collect and report on. The provider also reports the complete Promoting Interoperability measure set |
| Alternative Payment Model (APM) Performance Pathway | the provider participates in a MIPS APM and reports on a specified measure set of quality measures in addition to the complete Promoting Interoperability measure set |
| MIPS Value Pathways (MVPs) | the provider selects, collects, and reports on a reduced number of quality measures and improvement activities, as well as the complete Promoting Interoperability measure set |
| QCDR {acronym stands for} | Qualified Clinical Data Registry |
| Collection types | Quality measure sets with comparable specifications and data completeness criteria; such as: eCQMs, MIPS CQMs, QCDR measures |
| CEHRT {acronym stands for} | Certified Electronic Health Record Technology |
| APM {acronym stands for} | Advanced Alternative Payment Models |
| Compliance Plan | is a written process for coding and submitting accurate claims - all provider offices and healthcare facilities should have, and actively use one |
| OIG {acronym stands for} | Office of Inspector General |
| ACA or Obamacare {acronym stands for} | (Patient Protection) Affordable Care Act |
| The Office of Inspector General (OIG) | a government agency tasked “to protect the integrity of HHS programs, as well as the health and welfare of the beneficiaries of those programs |
| The Office of Inspector General (OIG) | offers compliance program guidance to form the basis of a voluntary compliance program for a provider practice |
| The OIG Compliance Program Guidance (CPG) for Individual and Small Group Physician Practices | was published in the Federal Register on October 5, 2000 |
| General Compliance Program Guidance (GCPG) | published on November 6, 2023 - applies to all individuals and entities involved in the health care industry - designed to modernize OIG’s guidance |
| OIG Work Plan | sets forth a plan outlining its priorities for the fiscal year and beyond |
| The American Academy of Professional Coders (AAPC) | was founded in 1988 to provide education and professional certification to physician-based medical coders, and to elevate the standards of medical coding by providing student training, certification, and ongoing education, networking, and job opportunities |
| CMS {acronym stands for} | Centers for Medicare & Medicaid Services |
| HCC {acronym stands for} | Hierarchical Condition Category |
| EHR {acronym stands for} | Electronic Health Record |
| MS-DRG {acronym stands for} | Medicare Severity-Diagnostic Related Group |
| PPACA {acronym stands for} | Patient Protection and Affordable Care Act |
| SOAP (Standard format for E/M Services) {acronym stands for} | Subjective, Objective, Assessment, Plan |
| Code assignment | is determined both by the provider’s documentation and by the unique rules that govern each code set |
| Number of key components necessary for an Internal Compliance Plan | Seven |
| Internal Compliance Plan Component: #1 | Written Policies and Procedures |
| Internal Compliance Plan Component: #2 | Compliance Leadership and Oversight |
| Internal Compliance Plan Component: #3 | Training and Education |
| Internal Compliance Plan Component: #4 | Effective Lines of Communication with Compliance Officer & Disclosure Program |
| Internal Compliance Plan Component: #5 | Enforcing Standards: Consequences & Incentives |
| Internal Compliance Plan Component: #6 | Risk Assessment , Auditing, & Monitoring (internal periodic audits) |
| Internal Compliance Plan Component: #7 | Responding to Detected Offenses and Developing Corrective Action Initiatives |
| Types of Mid-Level Providers | Physician Assistants (PA) & Nurse Practitioners (NP) |
| Mid-Level Providers | are also known as Physician Extenders that work within the same office as the Physician |
| Physician Assistants (PA) | are licensed to practice medicine with physician supervision |
| Nurse Practitioners (NP) | have a Master's degree in nursing |
| Physician Assistants (PA) Program | takes approximately 26.5 months to complete after receiving a Bachelor's degree |
| Covered Entities: Healthcare provider examples | Doctors / Clinics / Psychologists / Dentists / Chiropractors / Nursing Homes / Pharmacies |
| Title II—Administration Simplification | National unique identifiers for providers, health plans, and employers |
| Title II—Administration Simplification | Privacy and security of health data |
| Under the Privacy Rule, the minimum necessary standard doesn't apply to: | Disclosures to or requests by a healthcare provider for treatment purposes |
| Under the Privacy Rule, the minimum necessary standard doesn't apply to: | Disclosures to the individual who is the subject of the information |
| Under the Privacy Rule, the minimum necessary standard doesn't apply to: | Uses or disclosures made pursuant to an individual's authorization |
| Under the Privacy Rule, the minimum necessary standard doesn't apply to: | Uses or disclosures required for compliance with the HIPAA Administrative Simplification Rules |
| Under the Privacy Rule, the minimum necessary standard doesn't apply to: | Disclosures to the US Dept or Health & Human Services(HHS) when disclosure of information is required under Privacy Rule for enforcement purposes |
| Under the Privacy Rule, the minimum necessary standard doesn't apply to: | Uses or disclosures required by other law |
| Covered Entity Responsibility | To develop & implement policies best suited to its circumstances to meet HIPAA requirements |
| Medical Necessity | is using the least radical services/procedure that allows for effective treatment of the patient's complaint or condition |
| Chronic Venous Insufficiency | a systemic condition that may result in the need for routine foot care |
| Advanced Beneficiary Notice (ABN) | is used when a Medicare beneficiary request or agrees to receive a procedure or service that Medicare may not cover |
| Advanced Beneficiary Notice (ABN) | this form notifies the patient of potential out of pocket costs for the patient |
| Advanced Beneficiary Notice (ABN) | may not be recognized by non-Medicare payers |
| Advanced Beneficiary Notice (ABN): Actual Cost Estimate Range | $100.00 or 25% |
| Healthcare Clearinghouse | includes entities that process nonstandard health information they receive from another entity into a standard format |
| National Standards for Electronic Healthcare Transactions & Code Sets | are designed to improve the efficiency & effectiveness of the healthcare system by standardizing the format used for electronic transactions |
| Electronic Healthcare Transactions | examples include: Health claims/Encounter Info & Health claim status |
| Electronic Healthcare Transactions | examples include: Eligibility for a Health Plan & Enrollment/Disenrollment in a health plan |
| Electronic Healthcare Transactions | examples include: Healthcare payment & Remittance Advice (RA) |
| Electronic Healthcare Transactions | examples include: Health plan premium payments & Coordination of Benefits |
| Electronic Healthcare Transactions | examples include: Referral certification & Authorization |
| Prior to October 1, 2015, this was ICD-9-CM | ICD-10-CM {International Classification of Diseases, Tenth Revision, Clinical Modification} |
| MIPS Eligible Clinicians | examples include: Physicians, Nurse Practitioners, & Clinical Social Workers |
| Three aspects of Covered Professional Services | Allowed Charges - Number of Medicare patients - Number of Medicare services provided |
| MIPS performance year {when data is collected} | January 1st through December 31st |
| Collection Types | are delineated by Four MIPS performance categories |
| Four MIPS performance categories | 1. Quality - 2. Promoting Interoperability - 3. Improvement Activities - 4. Cost |
| Promoting Interoperability (PI) | formerly known as Advancing Care Information |
| Promoting Interoperability (PI) Performance Category | it's goal is to promote the secure exchange of health information & the use of Certified Electronic Health Record Technology (CEHRT) for coordination of care |
| Four Objectives & Measures of Promoting Interoperability (PI) | 1. ePrescribing - 2. Health Information Exchange - 3. Provider to Patient Exchange - 4. Public Health & Clinical Data Exchange |
| MVPs {acronym stands for} | MIPS Value Pathways |
| Proposed 6 new MVPs: | 1. Complete Ophthalmologic Care - 2. Dermatological Care - 3. Gastroenterology Care - 4. Optimal Care for Patients w/ Urologic Conditions - 5. Pulmonology Care - 6. Surgical Care |
| Advanced Alternative Payment Models (APMs) | a group of Clinicians who have voluntarily come together in an organized way to deliver coordinated high-quality care to Medicare patients |
| The Office of Inspector General (OIG) | posts its continuing work planning efforts and projects on its website monthly |
| "Patients" WOULD NOT be considered "one of these" under HIPAA | Covered Entity |
| Under HIPAA, what would be a policy requirement for MINIMUM NECESSARY? | Only individuals whose job requires it, may have access to PHI |
| What document assists provider offices with the development of Compliance Manuals? | OIG (General) Compliance Program Guidance (GCPG) |
| What document is referenced when looking for potential problem areas identified by the government indicating scrutiny of the services? | OIG Work Plan |
| AAPC {acronym stands for} | The American Academy of Professional Coders |
| ABN {acronym stands for} | Advance Beneficiary Notice |
| AMA {acronym stands for} | American Medical Association |
| APC {acronym stands for} | Ambulatory Payment Classification |
| ARRA {acronym stands for} | American Recovery & Reinvestment Act of 2009 |
| ASC {acronym stands for} | Ambulatory Surgical Centers |
| CPC® {acronym stands for} | Certified Professional Coder |
| E/M {acronym stands for} | Evaluation & Management |
| HHS {acronym stands for} | Department of Health & Human Services |
| HIPAA {acronym stands for} | Health Insurance Portability and Accountability Act of 1996 |
| HITECH {acronym stands for} | Health Information Technology for Economic and Clinical Health Act |
| HMO {acronym stands for} | Health Maintenance Organization |
| LCD {acronym stands for} | Local Coverage Determination |
| MAC {acronym stands for} | Medicare Administrative Contractor |
| MACRA {acronym stands for} | Medicare Access and CHIP Reauthorization Act |
| NCD {acronym stands for} | National Coverage Determination |
| NP {acronym stands for} | Nurse Practitioner |
| OCR {acronym stands for} | Office for Civil Rights |
| PA {acronym stands for} | Physician Assistant |
| Examples of APMs {Advanced Alternative Payment Model} | 1. Bundled Payments for Care Improvement Advanced - 2. Comprehensive ESRD Care - 3. Comprehensive Primary Care Plus |
Created by:
VA_MedCod3r