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Medical Billing And Coding > CPC Complaince And Regulatory > Flashcards

CPC Complaince And Regulatory Flashcards

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USMLE® Step 1 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
Q

resource based relative value scale(rbrvs)

A

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

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26
Q

resource costs are divided into 3 components

A

physician work, practice expense, professional liability insurance(PLI)

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27
Q

physician work

A

accounts for just over half(52%) of a procedure/service total relative value. is measured by the time it takes to perform the service

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28
Q

DRG

A

diagnosis related group

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29
Q

DSM V

A

Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition

30
Q

advanced billing contract codes

A

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
Q

MACs of FIs

A

cms delegates the daily operation of the medicare program to

32
Q

Medicare Part A

A

cover inpatient hospital care, as well as care provided in skilled nursing facilities, hospice care, and home healthcare

33
Q

Medicare Part B

A

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
Q

Medicare Part C (Medicare Advantage)

A

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
Q

Medicare Part D (Prescription drug coverage program)

A

available to all medicare beneficiaries. private company approved by medicare provide coverage.

36
Q

Medicaid

A

is a health insurance assistance program for some low income people, children, and pregnant women sponsored by federal and state government.

37
Q

state-funded insurance programs

A

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
Q

CHAMPUS or TRICARE

A

civilian health and medical program of the uniformed services, insurance linked to military services also known as Tricare, benefit program for active duty

39
Q

types of paper claims

A

HCFA, UB04, CMS 1500

40
Q

Healthcare Financing Administration (HCFA)

A

also called CMS-1500, standard medical claim form used for submitting Medicare Part B( outpatient billing)

41
Q

Uniformed Bill (UB04)

A

also called CMS 1450, paper claim for Medicare Part A (inpatient billing)

42
Q

types of electronic claims

A

NSF, ANSI

43
Q

NSF

A

national standard format- limited byte carrying capacity

44
Q

ANSI

A

american national standard institute- flexible format

45
Q

patient

A

would not be considered a covered entity under HIPAA

46
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

47
Q

ARRA

A

American Recovery and Reinvestment Act

48
Q

Hitech

A

Health Information Technology Economic and Clinical Health Act

49
Q

OIG work plan

A

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
Q

OIG compliance plan guidance

A

a document that is created to assist physician offices with the development of compliance manuals

51
Q

definition of MCO

A

a healthcare provider or a group of organizations of medical service providers who offer manager care health plans

52
Q

claim adjudication

A

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
Q

utilization review organization

A

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
Q

who funds and administers medicaid benefits

A

federally funded program and administered by each state

55
Q

two hipaa standards code sets

A

codes for dental procedures and nomenclature (CDT), healthcare common procedure coding system (HCPCS)

56
Q

NPI( national provider identifier)

A

name of the identifier physicians and other healthcare providers must use when claiming medicare reimbursement

57
Q

prospective audit

A

refers to auditing patients against proposed billing information

58
Q

qui tam

A

a lawsuit initiated by a private citizen on the government
s behalf

59
Q

CHAMPVA (civilian health and medical program of the department of veterans affairs)

A

is a healthcare benefits program for permanently disabled veterans and their dependents

60
Q

MEDIGAP insurance

A

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
Q

workers compensation

A

insurance provided by employers to cover employees injured on the job

62
Q

managed care organiztion

A

includes hmo, ppo, and pos plans

63
Q

AMA

A

CPT is published by

64
Q

ICD-10-CM

A

the manual used to diagnose is

65
Q

HCPCS

A

__________ is published by CMS

66
Q

COBRA

A

consolidated omnibus budget reconsideration act.

it is a law
it is an act passed in 1985

67
Q

Medicare

A

is a federal health insurance program administered by the Centers for Medicare and Medicaid Services (CMS)

68
Q

Centers for Medicare and Medicaid Services (CMS)

A

provides coverage for people over the age of 65, blind or disabled individuals, and people with permanent kidney failure or esrd

69
Q

CMS regulations

A

determine the coding requirements for Medicare and non-Medicare payers alike

70
Q

Medicare program is made up of several parts

A

Medicare parts A,B,C,D

Medical Billing And Coding (7 decks)

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