study for CBCS Test
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| private payer vs commercial payer | private is responsible in securing own health coverage.
Commercial - government employer, group health coverage
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| compliance regulations | most billing related cases are based on HIPAA & the False Claims Act
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| Medical Ethics are: | Standards of conduct based on moral principals.
Acting w/n ethical behavior boundaries means carrying out ones responsibilities w/ integrity, decency, respect, honesty, competence, fairness and trust
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| PPO | care is paid for as recieved instead of in advance in form of a schedule
more flixibility-out of network
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| cirlcle with a line through it means | modifier 51 exempt
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| plus sign + indicates | add on codes
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| Past Family and Social History (PFSH) | consists of pts personal experiences w/ illnesses, surgeries, and injuries.
Info of illness predominant in family
pts educational background occupation
marital status
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| Disability Ins | policy that pays benefits in the event policyholder becomes incapable of working.
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| HIPAA is an Acronym for | Health Information Portability Accountability Act (1996)
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| Chief Complaint CC | the reason the pt came to see the doctor
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| CPT | used to report services and procedures by drs
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| modifier -57 | used on E/M services
the day before or day of major surgery when the initial decision to perform the surgery is identified.
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| modifier -78 | physician must return to operating RM to address complication stemming fr initial procedure.
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| modifier -79 | procedure or service provide during post-operative period - not associated w/initial procedure.
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| Category 2 CPT Codes | Supplemental Codes for Performance Measures
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| Level 3 Codes | used locally or regionally and have been eliminated by CMS since the Implementation of HIPAA
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| Add on codes | used for procedures that are always performed during the same operative session; as another surgery in addition to the primary service/ procedure and is never performed separately
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| sideways triangle means | change in wording between traingles
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| Brackets [ ] | used to enclose synonyms, alternative wording or/ and explanatory phase
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| TRICARE | uniformed services members retirees and their families
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| modifier -26 | Provider only provided the professional component
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| modifier - 51 | multiple procedures
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| CHAMPVA | Healthcare program which the VA shares the cost of covered health care services and supplies w/ eligible beneficiaries
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| The list of modifiers is found where in the CPT | Appendix A and the front of the book
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| Level 1 Codes | Codes found in CPT Manual
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| Level 2 Codes | National codes for physicians and non physician service not found in the CPT level 1
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| Stand Alone codes | contain full description to the procedure for a code
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| modifier - 50 | bilateral
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| modifier - 24 | E/M
service is provided during postoperative period to indicate that the service is not part of postoperative care and not included in the surgical package.
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| 3 Components for E/M codes | History
Physical Exam
Medical Decision Making
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| Medicare Part D | Stand alone
prescription drug coverage
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| Who is the payor of last resort | Medicaid
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| History (HX) | The set of info the dr gathers fr pt concerning the past
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| Medicaid | free or low cost health insurance through the state
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| Medicare Part B | Medical Insurance
Medically necessary services and supplies.
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| Medicare Part A | Hospital Insurance
Most $0 premium
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| category 1 CPT codes | Medical Procedures
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| Bullet means | New Procedure Code
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| Category 3 CPT codes | Emerging Technologies
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| Relative Value Payment Method | The Payment amount for each service pd under the physician fee schedule is the product of 3 factors; a nationally uniform relative value for service; geographic adjustment factor(GAF)
a nationally uniform conversion factor for the service.
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| Workman's Comp | job benefit that provides $ & services to employees that are injured or become sick on the job
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| Usual Customary and Reasonable | refers to the base amount that is treated as a standard or most common charge for a particular medical service when rendered in a particular geographic area.
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| Parentheses ( ) | used to enclose
Supplementary words, non-essential modifiers
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| Bullets | Represents a new procedure or service code added since the previous edition of the manual.
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| Group Health Plans | Provides healthcare coverage to a select group of people
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| Indemnity Insurance | fee for service plan that is sometimes used when a person is in between health plans
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| POS Point of Service | pt chooses in or out of network care- convenience-
cost varies
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| HMO | Health Maintenance Organization
combining a range of coverage in a group basis. a group of Doctors or other medical professionals offer care through HMO for a flat monthly rate w/no deductibles.
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| E Codes | For durable medical equipment for use in home
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| Evaluation and Management (E&M codes) | Are listed in the CPT manual because they are used by all different specialties
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| Guidelines are found | At the beginning of each section and used to provide specific coding rules for that section.
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| Review of Symptoms ROS | Inventory of the constitutional symptoms regarding the various body systems
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| History of present Illness (HPI) | A chronological account of the development of the complaint from first sign/symptom that pt experiences to the present
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| Indented Codes | Listed under associate and stand alone codes
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| Modifiers | Reporting indicators that indicate the procedure or service has been altered by specific circumstance but has not changed in it's definition of code
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