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Medical Coding > Chapter 1: Business Medicine > Flashcards

Chapter 1: Business Medicine Flashcards

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USMLE® Step 1 flashcards
1
Q

What document is referenced when looking for potential problem areas identified by the government indicating scrutiny of the services?

A

OIG Work Plan

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2
Q

According to the example LCD from Novitas Solutions, which of the following conditions is considered a systemic condition that may result in the need for routine foot care?

A

Chronic venous insufficiency

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3
Q

When presenting a cost estimate on an ABN for a potentially non-covered service, the cost estimate should be within what range of the actual cost?

A

$100 or 25 percent

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4
Q

Which act was enacted as part of the American Recovery and Reinvestment Act of 2009 (ARRA) and affected privacy and security?

A

Health Information Technology for Economic and Clinical Health (HITECH)

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5
Q

What document assists provider offices with the development of Compliance Manuals?

A

OIG Compliance Program Guidance

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6
Q

Under HIPAA, what would be a policy requirement for “minimum necessary”?

A

Only individuals whose job requires it may have access to protected health information.

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7
Q

What form is provided to a patient to indicate a service may not be covered by Medicare and the patient may be responsible for the charges?

A

Advanced Beneficiary Notice (ABN)

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8
Q

Who would NOT be considered a covered entity under HIPAA?

A

Patients

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9
Q

Which statement describes a medically necessary service?

A

Using the least radical service/procedure that allows for effective treatment of the patient’s complaint or condition.

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10
Q

What type of profession, other than coding, might skilled coders enter?

A

Consultants, educators, medical auditors.

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11
Q

What is the difference between outpatient and inpatient coding?

A

Inpatient coders use ICD-10-CM and ICD-10-PCS. Outpatient coders use CPT or HCPCS.

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12
Q

What is a mid-level provider?

A

Mid-level providers include physician assistants (PA) and nurse practitioners (NP).

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13
Q

What are the different parts of Medicare?

A

Part A, B, C, D

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14
Q

Evaluation and management (E/M) services are often provided and documented in a standard format. One such format is SOAP notes. What does SOAP represent?

A

Subjective, Objective, Assessment, Plan

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15
Q

What are five tips for coding operative (op) reports?

A

Diagnosis code reporting, Start with the procedures listed, Look for key words, Highlight unfamiliar words, Read the body.

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16
Q

What is considered a medical necessity?

A

Relates to whether a procedure or service is considered appropriate in a given circumstance.

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17
Q

What is not a common reason Medicare may deny a procedure or service?

A

Covered service.

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18
Q

Under the Privacy Rule, the minimum necessary standard does NOT apply to what type of disclosures?

A

Disclosures to the individual who is the subject of the information.

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19
Q

Which is not one of the seven key components of an internal compliance plan?

A

Conduct training but not perform education on practice standards and procedures.

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20
Q

What is coding?

A

The process of translating a written medical record into a series of numeric or alpha-numeric codes.

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21
Q

Why is coding important?

A

It helps narrow down and clarify diagnoses to obtain additional information. It helps to improve patient care, helps better control costs, provide documentation for use in legal actions and research studies.

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22
Q

What codes are hospitals reported using?

A

IDC-10-CM for diagnoses; ICD-10-PCS for inpatient procedures; CPT or HCPCS for outpatient procedures.

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23
Q

What are the payment classification systems?

A

MS-DRGs; APCs for reimbursement.

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24
Q

What form do hospitals bill with?

A

UB-04

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25
Q

What is Medicare Part A?

A

Inpatient hospital care, skilled nursing facilities, hospice care, home health care.

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26
Q

What is Medicare Part B?

A

Medically necessary physician services, outpatient care and other medical services not covered by Part A.

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27
Q

What is Medicare Part C?

A

Managed by private insurers and may include a combination of Part A, Part B and sometimes Part D services.

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28
Q

What is Medicare Part D?

A

Prescription drug coverage program available to Medicare beneficiaries.

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29
Q

What is a medical record?

A

Documentation is the recording of an individual’s health history, including past and present illnesses, tests, treatments and outcomes.

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30
Q

National Coverage Determinations (NCD):

A

Describes whether medical items, services, treatment, procedures or technologies can be paid for under Medicare.

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31
Q

Medicare Administrative Contractors:

A

Responsible for interpreting national policies into regional policies.

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32
Q

Local Coverage Determinations (LCD):

A

The LCD includes information about the national coverage policy that the LCD is attached to, when the service is indicated or when the service is considered medically necessary. A third section details coverage limitations; it describes the specific CPT codes to which the policy applies.

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33
Q

What is fraud?

A

Making false statements or misrepresenting facts to obtain an undeserved benefit or payment from a federal healthcare program.

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34
Q

Examples of fraud:

A

Billing for services and/or supplies that you know were not provided.
Altering claim forms and/or receipts to receive a higher payment amount.
Billing a Medicare patient above the allowed amount for their service.
Billing for services at a higher level than provided or necessary.
Misrepresenting the diagnosis to justify payment.

35
Q

What is abuse?

A

An action that results in unnecessary costs to a federal healthcare program, either directly or indirectly.

36
Q

Examples of abuse:

A

Misusing codes on a claim.
Charging excessively for services or supplies.
Billing for services that were not medically necessary.
Failure to maintain adequate medical or financial records.
Improper billing practices.
Billing Medicare patients a higher fee schedule than non-Medicare patients.

37
Q

What is the most important title medical coders must pay attention to in terms of HIPAA?

A

Title II Administration Simplifications.

38
Q

What are Title II Administration Simplifications?

A

Addresses national standards for electronic healthcare transactions and code sets.
Establishes national unique identifiers for providers, health plans and employers.
Provides federal protection for the privacy and security of personal health information.

39
Q

What are the Code Sets for HIPAA?

A

HCPCS: Healthcare Common Procedure Coding System
CPT: Current Procedural Terminology
CDT: Dental Procedures and Nomenclature
ICD-10-CM: International Classification of Diseases, 10th Revision, Clinical Modification
NDC: National Drug Codes

40
Q

What is HITECH?

A

HITECH was enacted as part of the American Recovery and Reinvestment Act (ARRA) in 2009, to promote the adoption and meaningful use of health information technology.

41
Q

What is the purpose of HITECH?:

A

Subtitle D of the HITECH Act addresses the privacy and security concerns associated with the electronic transmission of health information, in part, through several provisions that strengthen the civil and criminal enforcement of the HIPAA rules.
HITECH strengthened HIPAA rules and established more responsibility for business associates complying with HIPAA.
HITECH allows patients to request an audit trail of health information made through an electronic record.

42
Q

What is QPP?

A

The Quality Payment Program (QPP) is a payment incentive model mandated by the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA).

43
Q

The QPP rewards value and outcomes in one of two ways:

A

Merit-based Incentive Payment System (MIPS)

Advanced Alternative Payment Models (APMs)

44
Q

What do Collection Types do?:

A

Measures and activities dictate submission mechanisms.
Coding and billing staff should be knowledgeable on which a physician group or virtual group is reporting, as well as the submission mechanisms being used.

45
Q

Collection types are:

A 
eCQMs 
MIPS Clinical Quality Measures (MIPS CQMs)
QCDR measures
Medicare Part B claims measures
CMS Web Interface measures
CAHPS for MIPS survey
Administrative claims measures
46
Q

Which coding manuals do outpatient coders focus on learning?

A

CPT®, HCPCS Level II and ICD-10-CM

47
Q

LCDs only have jurisdiction in their ____.

A

Region

48
Q

The minimum necessary rule applies to

A

Covered entities taking reasonable steps to limit use or disclosure of PHI

49
Q

What will the scope of a compliance program depend on?

A

The size and resources of the provider’s practice.

50
Q

How many components are included in an effective compliance plan?

A

7

51
Q

A covered entity does NOT include

A

Patients

52
Q

AAPC credentialed coders have proven mastery of what information?

A

All of the above; AAPC credentialed coders have proven mastery of all code sets, evaluation and management principles, and documentation guidelines.

53
Q

Evaluation and management services are often provided in a standard format such as SOAP notes. What does the acronym SOAP stand for?

A

Subjective, Objective, Assessment, Plan

54
Q

What is the definition of medical coding?

A

Translating documentation into numerical/alphanumerical codes used to obtain reimbursement.

55
Q

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)?

A

Part C; Accurate and thorough diagnosis coding is important for Medicare Advantage (Part C) claims because reimbursement is impacted by the patient’s health status. The Centers for Medicare & Medicaid Services-hierarchical condition category (CMS-HCC) risk adjustment model provides adjusted payments based on a patient’s diseases and demographic factors. If a coder does not include all pertinent diagnoses and comorbidities, there may be loss of additional reimbursement to which the provider is entitled.

56
Q

Which provider is NOT a mid-level provider?

A

Anesthesiologist

57
Q

Professionals who specialize in coding are called:

A

Coding specialists

58
Q

ABN stands for _____.

A

Advance Beneficiary Notice

59
Q

Who is responsible for enforcing the HIPAA security rule?

A

OCR

60
Q

What is the purpose of National Coverage Determinations?

A

To explain CMS policies on when Medicare will pay for items or services

61
Q

EHR stands for:

A

Electronic health record

62
Q

The OIG recommends that provider practices enforce disciplinary actions through well publicized compliance guidelines to ensure actions that are ______.

A

Consistent and appropriate

63
Q

The Medicare program is made up of several parts. Which part covers provider fees without the use of a private insurer?

A

Part B

64
Q

What form is used to submit a provider’s charge to the insurance carrier?

A

CMS-1500

65
Q

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?

A

Research

66
Q

The OIG releases a ____ outlining its priorities for the fiscal year ahead and beyond.

A

Work Plan

67
Q

According to AAPC’s Code of Ethics, an AAPC member shall use only ____ and ____ means in all professional dealings.

A

legal and ethical

68
Q

Which type of information is NOT maintained in a medical record?

A

Financial records

69
Q

What is PHI?

A

Protected health information

70
Q

What does the abbreviation MAC stand for?

A

Medicare Administrative Contractor

71
Q

The minimum necessary rule applies to

A

Covered entities taking reasonable steps to limit use or disclosure of PHI

72
Q

In what year was the AAPC founded?

A

1988

73
Q

Healthcare providers are responsible for developing ____ ____ and policies and procedures regarding privacy in their practices.

A

Notices of Privacy Practices; Healthcare providers are responsible for developing Notices of Privacy Practices and policies and procedures regarding privacy in their practices.

74
Q

According to the AAPC Code of Ethics, which term is NOT listed as an ethical principle of professional conduct?

A 
Efficiency; It shall be the responsibility of every AAPC member, as a condition of continued membership, to conduct themselves in all professional activities in a manner consistent with ALL of the following ethical principles of professional conduct:
·      Integrity
·      Respect
·      Commitment
·      Competence
·      Fairness
·      Responsibility
75
Q

When are providers responsible for obtaining an ABN for a service NOT considered medically necessary?

A

Prior to providing a service or item to a beneficiary.

76
Q

The OIG releases a ____ outlining its priorities for the fiscal year ahead and beyond.

A

Work Plan

77
Q

Local Coverage Determinations are administered by whom?

A

Each regional MAC

78
Q

If an NCD does not exist for a particular service/procedure performed on a Medicare patient, who determines coverage?

A

Medicare Administrative Contractor (MAC)

79
Q

Which CMS product describes whether specific medical items, services, treatment procedures or technologies are considered medically necessary under Medicare?

A

National Coverage Determinations Manual

80
Q

The minimum necessary rule is based on sound current practice that protected health information should NOT be used or disclosed when it is not necessary to satisfy a particular purpose or carry out a function. What does this mean?

A

Providers should develop safeguards to prevent unauthorized access to protected health information.

81
Q

Which of the following choices is NOT a benefit of an active compliance plan?

A

Eliminates risk of an audit.

82
Q

What does CMS-HCC stand for?

A

Centers for Medicare & Medicaid Services – Hierarchal Condition Category

83
Q

According to the OIG, internal monitoring and auditing should be performed by what means?

A

Periodic audits; A key component of an effective compliance program includes internal monitoring and auditing through the performance of periodic audits. This ongoing evaluation includes not only whether the provider practice’s standards and procedures are in fact current and accurate, but also whether the compliance program is working, (for example, whether individuals are properly carrying out their responsibilities and claims are submitted appropriately).

84
Q

Which option below is NOT a covered entity under HIPAA?

A

Workers’ Compensation

Medical Coding (5 decks)

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