Final Review Flashcards by Alexa Raley

charging for a higher procedure than what was provided

upcode

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individuals covered under Medicare

beneficiaries

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who is responsible for the administration of the Federal Medicare program

DHHS

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who is responsible for collecting and handling funds

Social Security Administration

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largest third party payer

government through Medicare

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Part A

Hospital insurance

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Part B

Supplemental Insurance

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coinsurance

20% medicare does not pay

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computerized health record limited to one practice

EMR

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the entire health record compiled from multiple sources

EHR

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Where are national changes posted?

Federal Register

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November/December Federal Register

Outpatient

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October Federal Register

Hospital

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Parts of RVU

Work
Overhead
Malpractice

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practice expense

overhead

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Amount of time, intensity, and technical expertise

work

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total RVUs of a service is

sum of the units established for each component of the service

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national dollar amount that is applied to all services paid on the basis of the Medicare Fee Schedule

conversion factor

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limiting charge does not apply when

a nonphysician provider performs a technical component of a service that is on the fee schedule

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percentage over the allowable

limiting charge

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when do the general multiple-procedures not apply

when a CPT code description states “additional”

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medicare set s the payment level for assistants-at-surgery at

16% of the fee schedule amount

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how much of the global fee does medicare pay

125%

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manages claims payment, oversees fiscal audit and/or overpayment prevention and recovery, and develops and monitors the payment safeguards necessary to detect and respond to payment errors or abusive patterns of service delivery

CMS

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responsible for developing a work plan that outlines the ways in which the Medicare program is monitored to identify fraud and abuse

DHHS

oversees Medicare's payment safeguard program related to fraud, audit, medical review, collection of overpayments, imposition of civil monetary penalties for certain violations of medicare law (CMPS)

OBI

establishes the specific regulations in the Internet-Only Manuals for the providers and carriers to follow

CMS

group that is responsible for the health care services offered to an enrolled group or person, coordinates or manages the care of the enroller

MCO

primary care physician of the patient

gatekeeper

providers who form a network and provide services at a discounted rate

PPO

which HMO are enrollees usually responsible for paying a portion of the costs when using a (___) provider, pay additional cost for healthcare outside this HMO

PPO

which HMO does not use a gatekeeper

PPO

what is the "total package" approach to healthcare organizations

HMO

enrollee is assigned a PCP and is the gatekeeper

HMO

services are prepaid by

HMO

benefits allow enrollees to receive services outside of the HMOs health care network, but at increased cost in copayments, in coinsurance, or in a deductible

POS

three sections of the alphabetic index

1. Index to Diseases and Injuries 2. Table of Drugs and Chemicals 3. External Cause of Injuries Index

provide greater specificity for proper code assignment

essential modifier

used for alle xclusion notes and to identify those codes that are not usually sequenced as the first-listed diagnosis

italicized type

equivalent of "unspecified", information at hand does not permit a more specific code assignment

NOS

"other specified", used when ICD-10 does not have any codes that provide greater specificity

NEC

enclose synonyms, alternative wording, explanatory phrases

brackets

enclose supplementary words

parenthesis

located in the Tabular List after an incomplete terms that needs one or more of the modifiers that follow in order to make the condition assignable

colon

"NOT CODED HERE", code excluded should not be assigned at the same time as the code

Excludes1

"Not included here", condition excluded is not part of the condition it is excluded from and a patient may have both conditions at the same time

Excludes2

"use additional code" note at the

etiology code

"Code first" note at the

manifestation code

"In diseases classified elsewhere" codes are never

first-listed diagnosis

two codes may be required to fully describe a condition

"Code also"

T/F A corresponding procedure code must accompany a Z code to describe any procedure performed

True

Encounter for screening for intestinal Infectious diseases

Z11.0

encounters for inoculations and vaccinations

Z23

lingering effect

sequelae

Z codes are most often assigned in the ______ settigns

outpatient

two categories of Z codes that report observation are

Z03 and Z04

when are uncertain diagnoses reported

in an inpatient setting

Z34

Encounter for supervision of normal pregnancy

O09

Supervision of high-risk pregnancy

not specifically manifestation codes but may be due to an underlying case

"code first"

indicate that this code may be assigned as a principal diagnosis when the casual condition is unknown or not applicable

"Code, if applicable, any casual condition first"

codes identified with a bullet

new codes

codes identified with a triangle

changed or modified

codes identified with a left and right triangle

beginning and end of the text changes

appendix that lists all modifiers that are used to alter or modify codes

appendix that contains a complete list of the additions to, deletions from, and revisions of the CPT manual

appendix that contains clinic examples of many of the Evaluation and Management

appendix that lists all add-on codes (+)

lightning bolt symbol

identifies codes that are being tracked by the AMA

complete list of modifier -51 exempt codes

circle with a line through it

modifier -51 exempt

codes with a bullseye

Moderate Sedation codes

codes with full description

stand-alone

codes listed under associated stand-alone codes

indented

the use of a _____ between code numbers indicates the presence of only those numbers displayed

comma

range is indicated by a

hyphen

list of key components (3)

1. history 2. examination 3. medical decision making complexity

contributory factors (4)

1. counseling 2. coordination of care 3. nature of presenting problem 4. time