Billing - Coordination of Benefits, HIPAA's Impact, and Payment Methodologies Flashcards
Describe Coordination of Benefits
According to the CMS website coordination of benefits is, “A program that determines which plan or insurance policy will pay first if two health plans or insurance policies cover the same benefits. If one of the plans is a Medicare health plan, Federal law may decide who pays first.”
When is Medicare the secondary payer (8)?
The working aged:
* 1. >65, working, and covered through EGHP (>20 employees)
* 2. Covered through an employed spouse (of any age) (>20 employees)
- Under 65, disabled, covered by large group health plan due to own or family member’s employment status (>100 employees)
When services are covered under:
* 4. Worker’s comp
* 5. Black lung benefits act
* 6. Auto, no-fault, liability plans
* 7. U.S. Dept of Veterans Affairs
- Any other determination of primary coverage other than Medicare
What does the acronym “EGHP” stand for
Employer Group Health Plan
How many employees must an employer have to be included in the definition of the working aged?
- if over 65 and working or through working spouse: 20
- If under 65, disabled, and covered by self or through family member: 100
Describe COB (coordination of benefits) with respect to medicaid
- Medicaid is always the “payer of last resort,” meaning no other payer is secondary to it (with the exception of Indian Health Service).
Describe COB (coordination of benefits) with respect to TRICARE
Federal law requires that TRICARE be the last payer after other health plans, except for Medicaid, TRICARE supplements, the Indian Health Service, and other programs or plans as identified by the TRICARE Management Activity.
When a person is covered by two commercial payers, what factors determine which one is primary
Almost all payers are secondary to any liability or property and casualty insurance.
A person’s own coverage is primary to that of a spouse.
When children are covered by both parents:
* If married, the plan of the parent with first birthday in the calendar year
* If same birthday, plan of the parent who has been covered the longest
* If divorced/separated, plan of parent with custody (plan of new spouse pays second, and plan of parent without custody pays last) - unless otherwise specified by court-ordered divorce decree
Describe conditional payment
When another payer is responsible, but the claim is not expected to be paid promptly (usually within 120 days from receipt of the claim), Medicare will make a conditional payment to prevent the beneficiary from having to pay out of pocket.
These conditional payments often apply to workers’ compensation, automobile, no-fault, or liability claims. Medicare then has the right to recover any payments that should have been made by another payer.
Providers must indicate they are requesting conditional payment from Medicare by using the correct value code on the claim.
What does the acronym “ICD” stand for
International Classification of Diseases (ICD)
What are ICD codes used for?
Diagnoses and inpatient procedures
What does the acronym “CPT” stand for
Current Procedural Terminology (CPT)
What are CPT codes used for?
Outpatient procedures (part of Healthcare Common Procedure Coding System - Level I)
What does the acronym “HCPCS” stand for
Healthcare Common Procedure Coding System
What are HCPCS codes used for?
Outpatient procedures
What are the rules for assigning ICD-10 codes
- Code the primary diagnosis first, followed by the secondary, tertiary, and so on.
- Code any coexisting conditions that affect the visit or procedure as supplemental information.
- Code the principal diagnosis and discharge diagnosis to the highest level of specificity.
- Code any coexisting diagnosis to the lowest level of specificity.
Describe Present on Admission (POA) Indicators
CMS mandated the use of POA indicators for most inpatient claims. The indicator is paired with each diagnosis code in the medical record. The POA will be used to help identify non-payable complications, such as hospital acquired conditions (HACs, for example, infections acquired in the hospital, sponges left in patients, etc.).
Describe CPT codes
Contained within Level I of the HCPCS.
The CPT is a system of descriptive terms and five-digit, numeric codes that are used primarily to identify medical services and procedures furnished by physicians and other healthcare professionals.
Level I does not include codes for items or services that are regularly billed by suppliers other than physicians.
What does the acronym “DMEPOS” stand for?
Durable Medical Equipment, Prosthetics, Orthotics, and Supplies
Describe Level II of the HCPCS
System of five-digit numeric codes with alphabetic prefixes A through V, assigned by CMS to identify products, supplies, and services not included in the CPT codes, such as ambulance services and durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) when used outside a physician’s office
Describe Level III of the HCPCS
Level III HCPCS codes were used at the state level by Medicaid and other payers to designate additional services. They are often referred to as “local codes” and are prohibited under HIPAA, but still required by some state programs.
Describe Evaluation and Management (E&M) Levels
A range of CPT codes that applies to evaluation and management (E&M). E&M refers to both the process of and the charge for examining a patient and formulating a treatment plan.
What are the 7 components of E&M
The provider performs the evaluation and management, and assigns a level based on seven components described below:
* History
* Examination
* Medical decision-making
* Counseling
* Coordination of care
* Nature of presenting problem
* Time spent
Usually history, examination, and medical decision-making are considered the three key components. An exception is the case of visits that consist predominantly (more than 50% of the visit time) of counseling or coordination of care. For these services, time spent is the key or controlling factor to qualify for a particular level of E&M service.
Describe the National Provider Identification number
10-digit identifier issued to health providers in the United States as dictated by CMS’s Administrative Simplification Identifier Standards
Describe Taxonomy Codes
Taxonomy codes are administrative codes to identify practitioner type and specialty for healthcare practitioners. The taxonomy code set is a hierarchical code that consists of codes, descriptions, and definitions.
