Chapter 1 Flashcards
LCD (Local Coverage Determinations)
LCDs further define when an item or service will be covered. LCDs only have jurisdiction within their region
NCD (National Coverage Determations)
They explain when Medicare will pay for items or services. If there isn’t an NCD for something then MACs decide the coverage.
MAC (Medicare Administrative Contractor)
Are responsible for interpreting national policies. MACs may also define what codes are needed for coverage in a related billing and coding article.
ABN (Advanced Beneficiary Notice)
A form that explains to a Medicare beneficiary that the procedure they requested or agreed to may not be covered by Medicare
When presenting a cost estimate on an ABN for a potentially noncovered service, the cost estimate should be within what range of the actual cost?
$100 or 25 percent
HIPAA (Health Insurance Portability and Accountability Act of 1996)
- Prevents Healthcare Fraud and Abuse
- Administrative Simplification through the use of technology
- Medical Liability Reform
- Defines Covered Entities
- Defines Health Plans
HIPAA defined Healthcare Providers (7 total)
- Doctors
- Clinics
- Psychologists
- Dentists
- Chiropractors
- Nursing Homes
- Pharmacies
HIPAA defined Health Plans (4 total)
- Health Insurance companies
- HMOs
- Company Health Plans
- Government programs that pay for healthcare such as Medicare, Medicaid, the military and veterans’ healthcare programs
HIPAA’s “Minimum Necessary Requirement”
Only individuals whose job requires it may have access to protected health information
HITECH (Health Information Technology for Economic and Clinical Health Act)
A part of the American Recovery and Reinvestment Act of 2009. Empowers HIPAA rules by addressing privacy and security concerns related to electronic transmission of health info.
American Recovery and Reinvestment Act of 2009
Introduced HITECH
What document is referenced to when looking for potential problem areas identified by the government indicating scrutiny of the services?
OIG Work Plan
What document assists provider offices with the development of Compliance Manuals?
OIG Compliance Program Guidance
What would be defined as a medically necessary service?
Using the lead radical service/procedure that allows for effective treatment of the patient’s complain or condition.
Fraud
An intentional deception or misrepresentation that can result in unauthorized benefits or payment
Abuse
An unintentional misrepresentation that can result in unauthorized benefits or payment
What is used to report inpatient codes?
ICD-10-CM and ICD-10-PCS
What is used to report outpatient codes?
ICD-10-CM and CPT/HPCS Level II
S.O.A.P.
Subjective, Objective, Assessment, and Plan
Order of action used to evaluate and manage patients
What is the value of a remittance advice?
It states what will be paid and why any changes to charges were made.
Healthcare providers are responsible for developing ____ _____ and policies and procedures regarding privacy in other practices.
Notices of Privacy Practices
The Medicare program is made up of several parts. Which part is affected by the Centers for Medicare & Medicaid Services - Hierarchical Condition Categories (CMS - HCC)?
Part C. Accurate and thorough diagnosis coding is important for Medicare Advantage claims because reimbursement is impacted by the patient’s health status
Which part of Medicare covers provider fees without the use of a private insurer?
Part B. Covers medically necessary provider services, outpatient care and other medical services not covered under Medicare Part A
What is the definition of medical coding?
Translating documentation into numerical/alphanumerical codes used to obtain reimburshment
Which options below is NOT a covered entity under HIPAA?
Worker’s Compensation
In what year did HIPAA become law?
1996
What type of insurance is Medicare Part D?
Prescription drug coverage available to all Medicare beneficiaries.
The OIG releases a ____ outlining its priorities for the fiscal year ahead and beyond.
Work Plan
HITECH provides a _____ day window during which any violation not due to willful neglect may be corrected without penalty.
30 days
A covered entity may obtain consent from an individual to use or disclose protected health information to carry out all of the following except what?
Research
What form is used to submit a provider’s charge to the insurance carrier?
CMS-1500
AAPC Code of Ethics
- Integrity
- Respect
- Commitment
- Competence
- Fairness
- Responsibility
Who is responsible for enforcing the HIPAA security rule?
OCR, The Office of Civil Rights
