Chapter 1 - The Business of Medicine Flashcards
What is Medical Coding?
The process of translating written or dictated medical records into a series of numeric/alphanumeric codes.
What 2 things are the focus of outpatient coding?
- Physician professional services
2. Outpatient facility coding
What code sets does outpatient coding focus on?
CPT, HCPCS Level II, and ICD-10-CM
What code sets does hospital inpatient coding focus on?
ICD-10-CM and ICD-10-PCS
What are NPPs?
Non-physician providers
What are 2 different kinds of NPP?
- Nurse Practitioner
2. Physician’s assistant
What are commercial payers?
Private payers that may offer both group and individual plans. Contracts may include differing levels of protection for basic, major, and hospitalization coverage.
What entity administers Medicare?
(CMS) Center for Medicare and Medicaid Services
Who qualifies for Medicare?
- 65/+
- Blind/Disabled
- Permanent kidney failure/(ESRD) End-stage renal disease
Whose regulations determine coding requirements for both Medicare and non-Medicare payers?
(CMS) Center for Medicare and Medicaid Services
What is Medicare Part A coverage?
Hospital inpatient, skilled nursing facility, hospice, and home healthcare coverage
What is Medicare Part B coverage?
Medically necessary physician’s services, outpatient care, some other services not included in Part A (Part B is optional and typically requires premium, deductible, and copayment)
What is Medicare Part C coverage?
(AKA Medicare Advantage) Combines Part A, Part B, and sometimes Part D coverage. Managed by private insurers approved by Medicare.
What is Medicare Part D Coverage?
A prescription drug program available to all Medicare beneficiaries. Coverage provided by private companies approved by Medicare.
What is Medicaid?
Medicaid is a health insurance assistance program for low-income (especially children and pregnant women) sponsored by federal and state governments.
How is Medicaid administered?
On a state-by-state basis that follow some federal guidelines.
How are Medicare physician payments regulated?
(RBRVS) Resource-based relative value scale
What 3 components are resource costs divided into?
- Physician Work
- Practice Expenses
- (PLI) Resource-based professional liability insurance
What percentage of resource costs are physician work expenses?
52%
What percentage of resource costs are practice/facility expenses?
44%
What percentage of resource costs is (PLI) resource-based professional liability insurance?
4%
How is physician work measured?
- time to perform service
- technical skill/physical effort required
- Mental effort and judgment required
- Stress due to potential risk to patient
What does medically necessary mean?
Whether a procedure/service is appropriate; the least radical service/procedure allowing for effective treatment of the patient’s complaint or condition.
Who has developed policies for medical necessity?
(CMS) Center for Medicare and Medicaid Services (title XVIII of the Social Security Act)
