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Medical Billing And Coding > CPC Complaince And Regulatory > Flashcards

CPC Complaince And Regulatory Flashcards

1
Q

Participating provider/in network provider (INN)

A

Is one contracted with the health insurance company to provide service to plan members for specific pre- negotiated rates

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2
Q

Non participating providers/Non-par/Out of network(oon)

A

Is one not contracted with the health insurance plan

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3
Q

2 primary types of insurers

A

Private insurance plans and government insurance plans

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4
Q

Commerical insurance/ non federal insurance

A

Are private payers that may offer both group and individual plans. Contracts they provide may include hospitalization, basic and major medical coverage.

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5
Q

Government insurance/federal insurance

A

The most significant insurance is medicare

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6
Q

Physician edits

A

These code pairs apply to physicians, non-physician practitioners, and ambulatory surgery centers

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7
Q

Hospital outpatient prospective payment system edits (outpatient edits)

A

These edits apply to the following types of bills: hospitals, skilled nursing facilities, home health agencies, outpatient physical therapy and speech language pathology providers and comprehensive outpatient rehabilitation facilities.

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8
Q

National coverage determination (ncd)

A

Is a US nationwide determination of whether Medicare will pay for an item or service

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9
Q

UCR

A

Amounts commonly charged for a service within a particular geographic region

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10
Q

Capitation

A

Pre-established payments to providers for enrollees over a period of time, whether the patient is seen or not by the provider

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11
Q

CMS 1500

A

Standard claim form used to submit physician office services to Medicare and other insurance payors

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12
Q

TPA

A

A company that provides health benefits claims administration, processes claims and other outsourcing services for self insured companies

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13
Q

Outpatient coding

A

Focuses on physician professional services and outpatient facility coding. Coders should learn icd-10-cm, cpt, and hcpcs level 2.

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14
Q

Hospital inpatient coding

A

focuses on a different subset of skills, where coders will work with ICD-10-CM and ICD-10-PCS. Coders assign medical severity diagnosis related groups(MS-DRGS).

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15
Q

Type of providers

A

primary care provider (pcp), physician extenders, participating providers, non participating providers

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16
Q

physician extenders

A

mid level provider, advance practice registered nurse (APRN), nurse practitioner(NP), physician assistant(PA), clinical nurse specialist(CNS)

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17
Q

practice expense

A

accounts for 44% of the total relative value for each service. is relative values are a source based and differ by site of service

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18
Q

Professional liability insurance(PLI)

A

accounts for 4% of the total relatie value for each service.

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19
Q

physician fee schedule(PFS)

A

cms annually published physician fee schedule information on its website

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20
Q

PE

A

physician expense

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21
Q

MP

A

malpractice

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22
Q

GPCI(geographic cost index)

A

used to realize the varying cost based on geographic location

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23
Q

Conversion factor(CF)

A

this is a fixed dollar amount used to translate the RVUs into fees

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24
Q

Medical Physician Fee Schedule(MPFS)

A

look up tool, provides information on each procedure code including the global surgery indicator

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25
resource based relative value scale(rbrvs)
to determine how much money medical provider should be paid, assigns procedures performed by a physician and other medical provider a relative value which is adjusted by geographic region
26
resource costs are divided into 3 components
physician work, practice expense, professional liability insurance(PLI)
27
physician work
accounts for just over half(52%) of a procedure/service total relative value. is measured by the time it takes to perform the service
28
DRG
diagnosis related group
29
DSM V
Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition
30
advanced billing contract codes
codes are alphanumeric representatives of alternative medicine, nursing, and other integrative health care interventions established by foundation for integrative healthcare and an information product and consulting service firm called alternative link
31
MACs of FIs
cms delegates the daily operation of the medicare program to
32
Medicare Part A
cover inpatient hospital care, as well as care provided in skilled nursing facilities, hospice care, and home healthcare
33
Medicare Part B
covers medically necessary physician services, outpatient care and other medical services(including some preventative services). Medicare Part B is an optional benefit for which the patient must pay a premium and which generally requires a yearly deductible and coinsurance.
34
Medicare Part C (Medicare Advantage)
combines benefits of Part A and Part B and sometimes Part D. Plans are managed by private insurers approved by Medicare. The plans may charge different copayments, coinsurance, or deductibles for services.
35
Medicare Part D (Prescription drug coverage program)
available to all medicare beneficiaries. private company approved by medicare provide coverage.
36
Medicaid
is a health insurance assistance program for some low income people, children, and pregnant women sponsored by federal and state government.
37
state-funded insurance programs
providing coverage for children up to 21 years of age may include crippled children's services, children's indigent disability services, and children with special healthcare needs.
38
CHAMPUS or TRICARE
civilian health and medical program of the uniformed services, insurance linked to military services also known as Tricare, benefit program for active duty
39
types of paper claims
HCFA, UB04, CMS 1500
40
Healthcare Financing Administration (HCFA)
also called CMS-1500, standard medical claim form used for submitting Medicare Part B( outpatient billing)
41
Uniformed Bill (UB04)
also called CMS 1450, paper claim for Medicare Part A (inpatient billing)
42
types of electronic claims
NSF, ANSI
43
NSF
national standard format- limited byte carrying capacity
44
ANSI
american national standard institute- flexible format
45
patient
would not be considered a covered entity under HIPAA
46
under hipaa, what would be a policy requirement for "minimum necessary"
only individuals whose job requires it may have access to protected health information
47
ARRA
American Recovery and Reinvestment Act
48
Hitech
Health Information Technology Economic and Clinical Health Act
49
OIG work plan
a document to be referred to when looking for potential problem areas identified by government indicating scrutiny of the services within the coming year
50
OIG compliance plan guidance
a document that is created to assist physician offices with the development of compliance manuals
51
definition of MCO
a healthcare provider or a group of organizations of medical service providers who offer manager care health plans
52
claim adjudication
claim is reviewed by the insurance company to make sure it is correct for demographics, codes, payor rules have been followed and are covered benefits under the patients insurance contract
53
utilization review organization
the insurance companies will hire companies to review the appropriateness and medical necessity of procedures, surgeries, and other services. This takes the burden off the insurance company of not authorizing a service due to cost
54
who funds and administers medicaid benefits
federally funded program and administered by each state
55
two hipaa standards code sets
codes for dental procedures and nomenclature (CDT), healthcare common procedure coding system (HCPCS)
56
NPI( national provider identifier)
name of the identifier physicians and other healthcare providers must use when claiming medicare reimbursement
57
prospective audit
refers to auditing patients against proposed billing information
58
qui tam
a lawsuit initiated by a private citizen on the government s behalf
59
CHAMPVA (civilian health and medical program of the department of veterans affairs)
is a healthcare benefits program for permanently disabled veterans and their dependents
60
MEDIGAP insurance
privately purchased individual or group health insurance policies designed to supplement medicare coverage. benefits may include payment of medicare deductibles, coinsurance, and balance bills ads well as payment for service not covered by medicare
61
workers compensation
insurance provided by employers to cover employees injured on the job
62
managed care organiztion
includes hmo, ppo, and pos plans
63
AMA
CPT is published by
64
ICD-10-CM
the manual used to diagnose is
65
HCPCS
__________ is published by CMS
66
COBRA
consolidated omnibus budget reconsideration act. it is a law it is an act passed in 1985
67
Medicare
is a federal health insurance program administered by the Centers for Medicare and Medicaid Services (CMS)
68
Centers for Medicare and Medicaid Services (CMS)
provides coverage for people over the age of 65, blind or disabled individuals, and people with permanent kidney failure or esrd
69
CMS regulations
determine the coding requirements for Medicare and non-Medicare payers alike
70
Medicare program is made up of several parts
Medicare parts A,B,C,D

Medical Billing And Coding (7 decks)

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