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MED112 Chapters 3&4
| Question | Answer |
|---|---|
| When a patient is new to the practice, 1st type of information are important: | Preregistration and scheduling information |
| When a patient is new to the practice, 2nd type of information are important: | Medical history. |
| When a patient is new to the practice, 3rd type of information are important: | Patient/guarantor and insurance data |
| When a patient is new to the practice, 4th type of information are important: | Assignment of benefits |
| When a patient is new to the practice, 5th type of information are important: | Acknowledgment of Receipt of Notice of Privacy Practices |
| Referring physician | physician who transfers care of a patient to another physician |
| Participating provider (PAR) | provider who agrees to provide medical services to a payer’s policyholders according to a contract. |
| Nonparticipating provider (nonPAR) | provider who does not join a particular health plan. |
| Chart number/MRN/Patient Number(ID), Medical Record Number | unique number that identifies a patient. |
| Three Steps to Establish Financial Responsibility for insured patients | Verify patient’s eligibility for benefits, Determine preauthorization and referral requirements, Determine the primary payer if more than one insurance plan is in effect. |
| Verify patient’s eligibility for benefits from the patient information form (PIF) and insurance card. | Patient’s eligibility, Required copayment or coinsurance amount , Covered service considered medically necessary |
| Factors Affecting General Eligibility | Premiums paid on time, Changes monthly for government-sponsored plans, Employment status |
| Other Considerations | Check out-of-network benefits, Verify amounts for copayment and coinsurance, Inform the patient of his or her financial responsibility in advance, if service is not covered. |
| Electronic Eligibility Verification | x12-270/271 |
| Trace Number | Number assigned to Electronic Eligibility Verification(270) |
| Preauthorization | requested before a patient is given certain types of medical care. |
| Preauthorization are assigned | Prior authorization number/certification number |
| Primary insurance | First to be billed |
| Secondary insurance | Remaining charges received after primary is billed |
| Tertiary insurance | Possible Third insurance charged if anything remains |
| Supplemental insurance | Additional assistance |
| Birthday Rule | Which ever parent is born first in the year the child's primary insurance is their policy |
| Gender Rule | States that father's insurance is primary for the child |
| Joint custody | Birthday rule applies |
| No joint Custody | Primary guardian responsible for primary insurance of the child |
| Database of payers | Database and list of insurance companies |
| Database of payers Contains | Contains payers name and contact information |
| Database of payers are | Kept up-to-date to assist with information on secondary payers, policy numbers, effective dates, and referral numbers |
| Communication with Payers | Checking on eligibility., Receiving referral certification., Resolving billing disputes. |
| Communication with Payers should always be | Documented |
| An encounter form (electronic or paper) | is completed by a provider to summarize billing information for a patient’s visit |
| Charge Capture | procedures that ensure billable services are recorded and reported for payment. |
| NPI | National Providers/ Physician Identifier |
| Collections at Time of Service | Previous balances, Copayments, Coinsurance, Noncovered or overlimit fees. |
| Other Collections at Time of Service | Charges of nonPAR providers, Charges for self-pay patients, Deductibles for patients with consumer-driven health plans (CDHPs), Charges for supplies and copies of medical records. |
| Unassigned claims | Provider's Who don't accept Medicare payments in full |
| Assigned claims | Medicare payment that providers accept as full payment |
| RTA | Real Time Adjudication |
| Adjudication | Judging the claim, Process used to determine the amount insurance is willing to pay and how much the patient will have to pay |
| Alphabetic Index | part of ICD-10-CM listing diseases and injuries alphabetically with corresponding suggested diagnosis codes |
| Tabular List | part of ICD-10-CM listing diagnosis codes in chapters alphanumerically |
| Step 1: process of assigning ICD-10-C M diagnosis codes | In the medical documentation, find the main reason the patient is receiving care |
| Step 2: process of assigning ICD-10-C M diagnosis codes | n the Alphabetic Index, find the description of the condition and proposed (suggested) code. |
| Step 3: process of assigning ICD-10-C M diagnosis codes | In the Tabular List, look up the proposed code, and study any conventions (notations/rules) to guide you in selecting the right code |
| Step 1: process of assigning ICD-10-C M diagnosis codes | In the medical documentation, find the main reason the patient is receiving care. |
| Step 2: process of assigning ICD-10-C M diagnosis codes | In the Alphabetic Index, find the description of the condition and proposed (suggested) code. |
| Step 3: process of assigning ICD-10-C M diagnosis codes | In the Tabular List, look up the proposed code, and study any conventions (notations/rules) to guide you in selecting the right code. |
| Main term | word that identifies a disease or condition in the Alphabetic Index |
| Default code | ICD-10-CM code listed next to the main term in the Alphabetic Index that is most often associated with a particular disease or condition. |
| Subterm | word or phrase that describes a main term in the Alphabetic Index |
| Etiology | cause or origin of disease or condition (or a description of a particular type or body site for the main term) |
| Nonessential modifier | supplementary word or phrase that helps to define a code in ICD-10-C M. |
| Common terms | are similar names for the same condition |
| Eponym | A name or phrase formed from or based on a person’s name |
| Not elsewhere classifiable (NEC) | abbreviation indicating the code to use when a disease or condition cannot be placed in any other |
| Not otherwise specified (NOS) | Term that indicates the code to use when no information is available for assigning the disease or condition a more specified code |
| Manifestation | characteristic sign or symptom of a disease. |
| First-listed code | code for diagnosis that is the patient’s main condition. |
| Combination code | single code describing both the etiology and manifestation(s) of a particular condition. |
| The Tabular List is divided into: | Category, Subcategory, Code |
| Code | three, four, five, six, or seven alphanumeric characters (always starting with a letter). |
| Subcategory | four- or five-character alphanumeric code. |
| Category | three-character code for classifying a disease or condition |
| Inclusion notes | Tabular List entries addressing the applicability of certain codes to specified conditions (indicated by the word “includes” |
| Exclusion notes | Tabular List entries limiting applicability of particular codes to specified conditions (indicated by the word “excludes”). |
| Colon(:) | Indicates an incomplete term. |
| Parentheses() | used around descriptions that do not affect the code typically used when two codes are listed |
| Brackets [] | used around synonyms, alternative wordings, or explanations. Can't be first listed |
| Abbreviations NEC and NOS are used in | the Tabular List with the same meanings as in the Alphabetic Index. |
| Etiology/manifestation coding | notes may include instructions on required use of additional code |
| Computerized database that is set up about the practice's income and expense accounting is called | Practice management program |
| Step 1 to establish financial responsibility | Verify the patients Eligibility for insurance benefits |
| Step 2 to establish financial responsibility | Determine preauthorization and referral requirements |
| Step 3 to establish financial responsibility | Determine the primary payer if more than one insurance plans is in effect |
| The financial agreement form given to notify patients of their obligation to pay the bill before the services are given | Advanced beneficiary notice |
| Another term used for the prior authorization number | Certification Number |
| Explains how an insurance policy will pay if more than one policy applies | Coordination of benefits (COB) |
| Form that list the patient diagnoses, procedures, and charges for a visit | Encounter form |
| Information listed on the encounter form | Payer's Coverage, Procedure codes, Diagnosis codes |
| Items Lusted on the encounter form | Payments made by the patient, Previous balance, Patient's Name |
| Up-front collection is money collected | Before the patient leaves the office |
| Updated in the PMP payer database | New Participation agreements or a new payer representative's contact information |
| other related PMP facts to update | Policy numbers, effective dates, and referral numbers, are entered for each patient |
| Information to document in the patient financial record | Outcome, Communication, Representative Name |
| Practice's rules governing payment for payments for patients | Financial Policy |
| Who ensures databases related to diagnosis and procedure codes listed on the encounter forms are updated | The medical insurance specialist |
| Charges routinely collected at time of service | Previous Balances, Copayments & Coinsurance |
| 1st step after the routine up-front collections are handled | A claim is created and sent to the payer |
| 2nd step after the routine up-front collections are handled | The practice waits to receive insurance payment |
| 3rd step after the routine up-front collections are handled | Post the amount of payment in the patient's account in the PMP |
| 4th step after the routine up-front collections are handled | The patient is billed for the balance |
| Named from the language of statistics, means to count, record, list systematically | Tabular list |
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