Insurance Claims Management Flashcards
Co-payment
Refers to making a small amount at the time of visit.
Premium
Is a monthly payment to keep a policy in force.
Exclusion
Is a peril that is not covered by the policy.
Capitation
A fixed, prepaid fee per person enrolled in a managed cafe program.
Maternity Leave
Can qualify as FMLA or short term disability.
Beneficiary
The person or party designated by the policyholder to receive the value of a policy.
Preadimission Certification
Determining medical necessity before a hospital admission is approved.
Preauthorization
Determines whether a service will reimbursed before its delivery.
Concurrent Review
Determines medical necessity before hospital admission.
Discharging Planning
Refers to arranging appropriate following patient release.
Medicare
Is title 18 of the Social Security Act.
Medicare Part B covers
Out-patient care.
Insurance Claims Management
A medical coding system enables the translation of verbal description of diseases, injuries, illness, and procedures into numerical.
CPT coding conventions, terms after a semicolon (;)
Is to clarify a main term.
Tracking
Systematic method of monitoring progress of disease condition.
Classification
Allows for grouping related diagnosis and procedures.
Research
Provides comparable data for compiling research information.
Evaluation
Permits analysis of medical utilization.
Standardization
Simplifies reimbursement functions.
Types of coding systems
ICD-9-CM: International Classification of Diseases 9th Edition
CPT: Current Procedural Terminology
HCCPCS: Healthcare Common Procedural Coding System
RBRVS: Resource-Base Relative Value System
DRG: Diagnosis Related Group
MS-DRG: Medical Severity
RVS: Relative Value Study
ICD-9-CM
International Classification of Diseases 9th Revision, Clinical Modification
- Used to code diagnosis or disease condition. - Assigns numeric codes to diseases, illnesses, injuries and health-related conditions.
CPT
Current Procedural Terminology
- Used to code medical services and procedures provided by physician.
HCCPCS
Healthcare Common Procedural Coding System
- A national coding system for reporting medical services to the Medicare program.
RBRVS
Resource-Based Relative Value System
- Medical Fee Schedule (MFS) for services based on the level or resources needed to provide a service.
DRG
Diagnosis Related Group
- A prospective fixed Medicare fee structure for hospital billing of inpatient services based on principle diagnosis.
RVS
Relative Value Study
- A point value is assigned to the service performed based on the time, knowledge, and skilled required of the provider. This point value is multiplied by a standard dollar factor to arrive at a final fee amount.
MS-DRG
Medical Severity
- Weighted by the severity of diagnosis, paying more for sicker patients.
ICD-9-CM coding system organized in three volumes
- Volume I (Tabular List of Diseases): numerical arrangement of conditions:
- Volume II (Alphabetical Index of Diseases): diseases and conditions arranged alphabetically.
- Volume III (Tabular List and Alphabetical Index of Procedures): medical procedures arranged both numerically and
alphabetically. Commonly used by hospitals to code inpatient procedures.
ICD-9 Volume I
Numerical arrangement
- 001 to 799: codes referring to specific health conditions by body systems.
ICD-9 Volume II
Numerical arrangement
- 800 to 959, 990 to 999: codes referring to injuries.
ICD-9 Volume III
Numerical arrangements
- 960 to 989: codes referring to poisoning.
ICD-9 V Codes (V01 to V89)
Codes referring to factors that influence health status. A definitive diagnosis can’t be stated; however, there’s a valid reason for seeking medical care.
- Preoperative evaluation - Annual physical exams - Well-baby check
ICD-9 E Codes
External causes of injuries and poisoning (associated with 800 + level codes.)
ICD-9 M Codes
- On Appendix A.
- Morphology of neoplasms.
ICD-9 Glossary of Mental Disorders
- Appendix B.
- Alphabetical list of terms and definitions associated with mental disorders.
- Code 290 to 319
ICD-9 Classification of Drugs by (AHFS) American Hospital Formulary Services
- Appendix C.
- Organizes in AHFS numerical order along with its ICD-9-CM equivalent.
ICD-9 Classification of Industrial Accident According to Agency
Appendix D
ICD-9 List of Three-Digit Categories
- Appendix E
- Identifies the three-digit category codes organized by section headings.
ICD-9 Volume II- Three-part index to Volume I
Section 1
- Alphabetical index of diseases and injuries.
- Hypertension chart
- Neoplasm chart
ICD-9 Volume II Section 2
Table of Adverse Effect to Drugs and Chemicals.
- Accidental poisoning - Assault - Misadventure in therapeutic use - Suicide attempts - Undetermined
ICD-9 Section 3
- The Index to External Causes (E codes).
- Codes the circumstances surrounding an accident or act of violence that resulted in an injury.
ICD-9 Coding conventions Volume I
- Colon :
- Brace }
- Section mark §
- Excludes (enclosed with a rectangle)
- Includes
ICD-9 Coding conventions Volume I
Colon :
Each modifier after the colon completes the main statement before the colon.
