INSURANCE CODING FINAL Flashcards
ICD-9-CM is updated how often?
every year on October
Worker’s compensation cases are kept open for how long from the last date of service?
2 years from the last date of treatment
Is the data bank that lists all active and retired military service members called Manage Care? Why?
No, it is called DEERS ( defense enrollment eligibility reporting system)
When parents are divorced or separated, whose insurance is usually considered the primary plan?
Whoever has legal custody
An insurance card proves that a patient has insurance coverage?
No, eligibility need to be verified through the automated system using point of service or online in California
The statute of limitations for minors is extended until what age?
Legal age in all states
A V-code describes what?
A condition other than illness
An E-code is used to identify what?
Identifies an accident
What volume of ICD-9-CM would you use to code inpatient services?
Volume 3
Medicare Part A is for inpatient services, would the patient have to pay premiums for this coverage?
Usually they do not pay a premium
What is indemnity insurance? Can patients chose their own doctors?
A fee-for-service with annual deductible and copay; yes patients can choose their own doctor and pay portion of the fees
Where would you find the rules and regulations governing health insurance and coding?
Federal register
Which claim form would be submitted to the insurance company using ICD and CPT codes?
CMS 1500
What are the methods for sending electronic claim to the insurance company or clearinghouse?
Dial up modem, over the internet, and direct data entry
The Department of Veterans Affairs manages which healthcare program?
CHAMP VA
What is an explanation of benefits?
a statement receive from the insurance check and explained how payment was made
give four examples of Medical fraud
Dispensing generic drugs and billing for brand name drugs, bribery, false cost reports, and giving or accepting something in return for medical services (kickback)
list four services a state must provide to receive federal matching funds for Medicaid.
inpatient care, outpatient care, hospital care, and physical therapy
what is COBRA?
it provides possible continuation of health insurance coverage’s through a previous employer when a worker leaves a job
what is commercial insurance?
any kind of insurance not paid by the government
what is a waiver?
form that the doctor has the patient sign to acknowledge financial responsibility when the patient insist on receive treatment not covered by their insurance
what federal act protects civil rights of disabled individuals?
Federal act of 1990 of ADA
who issues a NPI number for physicians?
center of medicare and Medicaid (CMS)
which agency handles the claims and payments for self-funded insurance plans?
third party administrator
which volume of ICD-9-CM contains the alphabetic index?
volume 2
Medicaid is insurance that covers what category of patients?
Medically needy
what do the OCR guidelines consist of?
Month, day, year, upper case, no punctuation, cannot send a copy of the claim
when using multiple modifiers in coding, which modifier would you use first?
-99
Which HMO model allows patient’s to go outside and see any provider they choose?
point of service
worker’s compensation benefits would include what type of coverage for patient’s?
Disability payments, medical cost, and vocational rehabilitation
after finding a code in the alphabetic index of the ICD-9-CM, you should cross-reference the coding by checking what?
tabular list
who pays the premiums for worker’s compensation?
the patients employer
which insurance is more expensive, individual or group insurance?
individual
can providers balance bill Medicaid patients for any cost of treatment after their insurance pays for services?
no
what is one of the advantages of having group insurance through your employer, union, etc?
everyone is eligible for coverage no matter what their health status is
does the date of service refer to the date the charges are posted to the patients account?
no the date of service is when the patient was provided the services
are the usual, customary and reasonable fees of physician the same or different from the healthcare provider’ actual charges?
they may be different from the health care providers charges
an allowable charge is the maximum that who will pay for the particular procedure or service?
third party payers
what does ICD-9-CM stand for?
international classification of diseases, ninth revision, clinical modification
what does HCPCS stand for?
health care common procedure coding system
what does CPT stand for?
current procedural terminology
how many sections are in the CPT?
6
the codes most frequently used in the CPT manual are?
evaluation and management
define outpatient:
not officially admitted, staying less than 24 hours
do you only need to code from the alphabetic index in the ICD-9? Why?
no, confirm your code in the tabular list
can V codes be used as the primary diagnosis?
yes
can E codes be used as the primary diagnosis?
no
how many digits are ICD-9 codes?
5th digit used whenever possible
how many digits are CPT codes?
5
when coding an unlisted procedure, what must be attached to the claim?
special report
managed care insurance plans usually require what before a patient can be referred to a specialist?
referral report
define deductible:
a specific amount of money that must be paid each year before the policy benefits begin
define crossover claim:
claim that automatically forwards from one plan to another
define an eligible patient:
a patient that has current coverage with an insurance claim
define a dependent under an insurance plan:
person covered under the subscribers plan
define pre-existing condition:
a condition test that existed and treated before the insurance policy is issued
define exclusion:
injury or illness that is excluded from the policy
is Medicare only for retired person age 65 and older? Why?
No, also for certain individuals who are disabled at any age with end stage renal disease, permanent kidney disorders, and required dialysis or transplant
when coding from the ICD-9-CM in a doctor’s office, which volumes should you use?
Volumes 1 & 2
what is another name for the CMS-1500 claim for?
universal claim form
what is the birthday rule?
when both parents have insurance, it determines that a parent whose bday falls first in the calendar year is the primary insurance
ICD-9 identifies:
diagnosis
CPT identifies:
procedures
which codes have a modifier?
CPT
why do we use standard coding systems to report diagnosis and procedures?
to facilitate payment from third party payers
is the secondary insurance billed first?
no, the primary is billed first
which claim form is used to bill medicare?
CMS-1500
