Final Review Flashcards
charging for a higher procedure than what was provided
upcode
individuals covered under Medicare
beneficiaries
who is responsible for the administration of the Federal Medicare program
DHHS
who is responsible for collecting and handling funds
Social Security Administration
largest third party payer
government through Medicare
Part A
Hospital insurance
Part B
Supplemental Insurance
coinsurance
20% medicare does not pay
computerized health record limited to one practice
EMR
the entire health record compiled from multiple sources
EHR
Where are national changes posted?
Federal Register
November/December Federal Register
Outpatient
October Federal Register
Hospital
Parts of RVU
Work
Overhead
Malpractice
practice expense
overhead
Amount of time, intensity, and technical expertise
work
total RVUs of a service is
sum of the units established for each component of the service
national dollar amount that is applied to all services paid on the basis of the Medicare Fee Schedule
conversion factor
limiting charge does not apply when
a nonphysician provider performs a technical component of a service that is on the fee schedule
percentage over the allowable
limiting charge
when do the general multiple-procedures not apply
when a CPT code description states “additional”
medicare set s the payment level for assistants-at-surgery at
16% of the fee schedule amount
how much of the global fee does medicare pay
125%
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
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
- Index to Diseases and Injuries
- Table of Drugs and Chemicals
- 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
A
appendix that contains a complete list of the additions to, deletions from, and revisions of the CPT manual
B
appendix that contains clinic examples of many of the Evaluation and Management
C
appendix that lists all add-on codes (+)
D
lightning bolt symbol
identifies codes that are being tracked by the AMA
complete list of modifier -51 exempt codes
E
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)
- history
- examination
- medical decision making complexity
contributory factors (4)
- counseling
- coordination of care
- nature of presenting problem
- time
