Fitz professional issues Flashcards
Dual eligible
Receives Medicaid and Medicare
Medicaid definition
publicly financed health and long term care coverage for low-income people
Prospective payment system
-Pays the provider a set amount based on the applicable Diagnosis Related Group
Four elements of malpractice
duty of care
breach of standard of care
injury
proximal cause
Standard of care
care that a reasonable, similarly situated professional would have provided for an individual
CPT stands for
Current Procedural Terminology
ICD stands for
International Classification of Diseases
When billing Medicaid, NP’s authority to bill comes from
state and federal law
When billing commercial insurance, NP’s authority to bill comes from
state law and/or the commercial payers
Are capitated rates negotiable
yes
When billing Medicare, NP’s authority to bill comes from
state law
Components of evaluation and care
- taking history
- physical exam
- medical decision making
- counseling
- coordination of care
Fee-for-service
-every procedure performed has an associated payment
Capitated system of reimbursement
-agency recieves set amount per month for all services needed by the patient and covered under a contract between payer and practice company
What are capitation rates based on
-profit projections and actuarial data
T/F when payment is capitated, practices want to take care of as much as possible through calls, electornic, mailings, or visit with other staff other than MD, NP, PA
True
How many levels of evaluation in CPT
5
Most frequently billed level of visit for Medicare established patients
level 3
99213
What is composed of a level 3 visit
- need 2/3
- at least one element of HPI and at least one positive or negative response to ROS
- at least 6 elements of PE
- Low complexity
What is composed of a level 4 visit (99214)
- need 2/3
- at least 4 elements of HPI, positive or negative responses to at least 2 ROS and at least one notation about past history, FMH, or social history
- at least 12 elements on PE
- medical decision making of moderate complexity
What is “incident-to”
- an integral, although incidental, part of the physician’s personal professional services in the course of diagnosis or treatment of an injury or disease
- allow physician to bill for services provided by an assistant or delegate in the office
- Ex: return visit for BP check
- can bill Medicare for CPT 99211 (level 1)
- physician must be in the office a the time of visit, must have documented the plan of care, must employ the nurse, and must remain involved in the care of the patient.
What does HIPAA stand for
Health Insurance Portability and Accountability Act
Major purpose of privacy rule
-define and limit the circumstances in which an individual’s protected health information can be used or disclosed by covered entities
De-identified
-when specific identifiers have been removed from protected health information so that it no longer can be used to identify an individual
What is a covered entity
-every healthcare provider who electronically transmits health information in connection with certain transactions
