coding and billing Flashcards
payment of medical benefits directly to the provider rather than the member/subscriber, requires written release
assignment of benefits
gatekeeper/primary care provider approval for hospitalization or care
authorization
he administrative practice of holding the patient financially responsible for the remainder of medical service charges, beyond the insurer’s allowed amount.
when does it not apply?
Balance billing
“Hold harmless” clause
Patient responsible for portion of total charge. what is this method used for?
Cost sharing
to reduce utilization.
Refusal by insurer to reimburse services that have been rendered.
denial
insurer-provided description of provider services and explanation of those covered and denied
Explanation of benefits (EOB)
purchaser of an insurance policy; in group health insurance, this is usually the employer who purchases policy coverage for its employees
Policy holder.
insurance company review of care before delivery to establish appropriateness of payment.
pre-authorization
Physical or mental condition of patient occurring before start of insurance coverage
Pre-existing condition
data collection by insurers on billing and utilization by providers
profiling
What is PT’s relationship with payers?
cultivate rep for quality of care, appropriate documentation.
Office staff relationship with payers?
phone
competence
reliability.
What is the admission process for clients?
Medical records
Business account
authorizations.
Pt signs agreement of insurance to pay provider for service?
what is alternative
assignment of benefits.
patient pays and is reimbursed by insurance.
What is more defensible? a single fee schedule with discounts based on policy or multiple fee schedules?
single.
A claim must verify
patient info
person responsible for bill
insurance info
coordination of benefits.
Term for situations where patient may have coverage under more than 1 insurance plane?
coordination of benefits
primary payor to be decided by liability?
example?
health vs. liability insurer
worker’s comp or auto.
Type of supplemental coverage medicare patients have?
medicaid or private medigap.
If both spouses have coverage then what?
the others is the secondary and their self is primary.
Process of coordination of benefits?
primary pays first and secondary pays liability or remaining costs.
whats reasoning for copay?
reduce utilizations.
For medicare providers, if service is known to be non-covered the provider may have the patient sign what?
advanced beneficiary notice.
a 10 digit numeric identifier that must be used on claim forms submitted to payers by individual and organization HCP who mean definition of covered entity under HIPPA
the national provider identifier (NPI)
What is the intent of the NPI?
National provider identifier
to streamline electronic claims already in place.
What is the out of network model?
The insurance contracts are ___
collecting payment from pt and provide bill to give to insurance or just do it for the patient .
limited.
Opt out of all private insurance contracts?
are PTs aloud to opt-out of medicare covered services?
cash practice.
payer takes responsibility.
naw.
When billing for services provided by PT, must specify
medical Diagnosis (ICD-10)
Interventions: (CPT-4)
official system of assigning codes to Dx associated with hospital utilization in the US
ICD-9 (14k Dx)
10-CM (69k Dx)
ICD-9 has how many characters?
how about 10?
no more than 5
3,4,5,6,7
Listing of descriptive terms and identifying for reportage medical services
common procedural terminology
CPT 1966
What is CPT used for?
where is it mandated?
payment
outcome assessment
Data collection
medicare B
payment policy for coding dependent on
payers and their policies.
When did legal requirement to use CPT come into play?
1996
final rule in 2000
What is CPT owned by?
AMA
Most common codes used by PTS are
Category 1 codes.
do supervised modalities require one-on-one contact by provider?
what does require it?
naw..
contant attendance.
minutes for 1 unit
2???
1: 8-23 mins
2: 23-38
keep adding 15
to be used when care is provided to more than one person during the same time interval?
group therapy code 97150
modifiers increase specificity of
CPT codes.
CMS policy implemented to promote correct coding by providers to ensure appropriate payment
correct coding initiative. CCI
What is the purpose of CCI?
to curtail improper unbundling of services for medicare part B claims.
