Lec 6: Language Of Payment/Coding/Billing Flashcards
Assignment of Benefits:
Payment of medical benefits DIRECTLY to the provider rather than the member/subscriber, requires written release
Authorization:
Gatekeeper/primary care provider approval for hospitalization or care
Balance Billing:
The administrative practice of holding the pt financially responsible for the remainder of medical service charges, beyond the insurer’s allowed amount.
Does not apply when a managed care contract contains a “hold harmless” clause
Cost sharing:
Patient responsible for portion or % of total charge
Methodology to reduce utilization
Denial:
Refusal by insurer to reimburse services that have been rendered
Can be for various reasons
Explanation of Benefits (EOB)
Insurer-provided description of provider services and explanation of those covered and denied
Policyholder:
Purchaser of an insurance policy
In group health insurance, this is usually the employer who purchases policy coverage for its employees
Pre-authorization:
Insurance company review of care before delivery to establish appropriateness of payment
Pre-existing condition:
Physical or mental condition of patient occurring before start of insurance coverage
Profiling:
Data collection by insurers on billing and utilization by providers
What is needed to get paid for professional services?
Professional license Business structure Services available Price list Business policies (registration and verification of info) Reimbursement contracts, arrangement Charge system Billing processes Accounting procedures Collection procedures Documentation system
PT relationship with payers: Cultivate a reputation for _________, appropriate documentation (payers track this information)
QUALITY care
Office staff relationship with payers:
Phone courtesy
Competence
Reliability
What does the client admissions process include?
Medical record
Business account
Authorizations/consents
Client Admissions Process: What is included in medical record ?
Demographics
Patient record
Client Admissions Process: What is included in business account?
Payment info
Client Admissions Process: What is included in authorizations/consents
Informed consent
Confidentiality/HIPAA
Assignment of benefits
AOB: A patient’s voluntary signed agreement to a provision such as “I hereby request assignment of payment of all insurance benefits to the ___________”
Provider of service
AOB: The provider then directly submits the claim to the ______
Payer
AOB: Provider must typically be __________
participating
AOB: Alternative- patient pays for service and submits for reimbursement from _______
Insurer
Billing for services: Bills submitted to patient or third party payer, or provided to __________ to prepare bills
Claims clearinghouse
Billing for services: most billing is now ______
Electronic
Billing for services: there is an importance of _______
CLEAN CLAIMS
Fee Determination: A provider must know their ______ in order to determine _____
Costs
Fees
Fee determination: Basing charges on ______ plus reasonable profit avoid ________________
COST
Anticompetitive pricing issues
Fee determination: A single fee schedule with fee discounts based on policy and arrangements with payers is more _________ than multiple fee schedules
Defensible
Claim submission: Must verify 4 things
Patient info
Person responsible for bill
Insurance info, including primary and secondary
Coordination of benefits
Coordination of benefits: Generic term for situations where the patient have have coverages under _________
More than one insurance plan
Coordination of benefits: Health Vs. Liability insurer:
Primary pay or may be decided by liability (workers comp or auto)
Coordination of benefits: Medicare patients with supplemental coverage – A medicare patient may have supplemental coverage, either ______ or _______
Medical insurance
Medicaid
Coordination of benefits: IF BOTH SPOUSES HAVE COVERAGE:
In adults, each spouse’s employee health insurance is the primary payer for his/her care; spouse’s family coverage is _______
Secondary
Coordination of benefits: IF BOTH SPOUSES HAVE COVERAGE: With children, if one parent has family coverage and the other only individual coverage, then the _________ is the only payer
Family coverage
Coordination of benefits: IF BOTH SPOUSES HAVE COVERAGE: If both have family coverage, most states use the ______
Birthday rule
The insurance of the parent with the bday earlier in the calendar year pays first
Coordination of benefits: Once the primary payer has processes the claim, the provider or patient must resend to _________, along with the primary insurer’s __________ or __________
Secondary insurer
Explanation of Benefits
Remittance Notice
Coordination of benefits: True or false, the secondary insurance will never pay more than the patient’s liability remaining after the primary payer has processed the claim
True
Copayments: May be collected when service is provided, or _____
Billed later
Copayments are the expectation that
Is the patient responsibility
Copayments are the same as balance billing, T/F?
False. They differ
Insurers expect that having the pt share the expense of the medical care will result in the patient having an ________ to limit their own care
Incentive
Medicare Advanced Beneficiary Notice is what?
For medicare providers, if the service is known to be non covered or not medically necessary, the provider have the the patient sign an ABN
What is an NPI?
National Provider Identifier
10 digit numeric ID that must be used on claim forms submitted to payors by individual and organization health care providers who meet the definition of a covered entity under HIPAA
What is the intent of an NPI?
To further streamline electronic claims processes already in place
Out of Network Model: Limited Insurance Contracts: Collect payment directly from patients at the time of service and provide an _________ for the to submit to their health insurer
Itemized bill
Out of Network Model: Limited Insurance Contracts: Collect from patients at the time of service and offer to send ________ to their insurer on their behalf
Courtesy bills
Out of Network Model: Limited Insurance Contracts: Accept __________, bill the _________, and bill the ________ for the balance once the insurer has paid.
Assignment
Insurer
Patient
Cash practice: No insurance contracts: Opt out of all _______ insurance contracts
Private
Cash practice: no insurance contracts: Patient pay in full at the __________ or insurer is billed directly and patient is billed for the ____________
Usually ______ patient cost sharing
Time of service
Balance not covered by the plan
HIGHER
Cash practice: Physical therapists are not permitted to opt out of _________ for covered services
Medicare
Cash practice: Noncovered services: Providing services that are _____ covered services under most insurance plans
NOT
Cash practice: Noncovered services: Practice determines the value of the service, establishes the fee, and in most cases, collects the fee at the ____________
Time the service is delivered
Code for Billing: Diagnoses: When billing for services provided by a PT, must specify the ______
Medical Diagnosis
ICD-10 as of 10/1/15
Codes for Billing: Interventions:
CPT-4
ICD-9 and ICD-10CM are the official system of assigning codes to diagnoses and procedures associated with _______ in the US
Hospital utilization
ICD-10 features about ________ codes
69,000
The new ICD-10 allows clinicians to be far more specific with IDing patient health conditions and will provide better data top measure and track health care utilization and quality of care, T/F?
True
ICD-10 has how many characters?
First 3 for?
Next 3 for?
7th for?
3-7 characters
First 3: Category of Dx
Next 3: Etiology, an anatomical site, severity, vital clinical details
7th: Type of patient encounter (initial, subsequent, sequela)
CPT: Listing of descriptive terms and IDing codes for ________
Reporting medical services and procedures
What is the purpose of CPT?
To provide a uniform language that accurately describes medical, surgical, and diagnostic services, and thereby serves as an effective means for reliable nationwide communication among physicians and other HCP, patients, and third parties
CPT is used for what?
Payment
Outcome assessments
Other data collection
Relationship of code to payment: Existence of code does not necessarily mean that ______
The provider will be paid for that code
Payment policy for coding is dependent on what?
Individual payors and their policies
Who first developed CPT?
AMA
There is a regulation for requiring the use of CPT for PT and OT services, T/F?
True
What are the most common codes utilized by PTs?
Category I codes: 5 digit code
Are Physical Medicine and Rehab Caterogry I codes exclusive to PT?
No
There are three different kinds of PT Evals, what are they?
Low, moderate, or high complexity
Is there a code for PT re-eval?
Yes, as of 1/1/2017
Therapeutic procedures include:
Therex Neuromuscular re-ed Gait training Manual therapy Therapeutic activities
Supervised modalities do not require what?
Do not require direct one-on-one contact by the provider
How many supervised modalities codes can you bill per visit?
Only one, regardless of the number of body parts treated
What is an example of a supervised modality?
Hot/cold packs
Diathemy
Unattended e-stim
Constant attendance modalities require what?
That a provider have direct one-on-one contact with the patient for all of the minutes represented in billing
What is an example of constant attendance modalities?
Iontophoresis
US
Contrast baths
What is the CMS 8-minute rule?
For any single, time CPT code in which one unit is defined as 15 minutes, a provider is required to bull one unit of care for greater than or equal to 8 minutes and less than 23 minutes
CMS 8 Minute Rule: Two units of care can be billed for a specific CPT code for greater than or equal to _____ minutes and less than _____ minutes
23 minutes
38 minutes
CMS 8 Minute Rule: 3 units of care can be billed for a specific CPT code for greater than or equal to _____ minutes and less than _____ minutes
38 minutes
53 minutes
CMS 8 Minute Rule: 4 units of care can be billed for a specific CPT code for greater than or equal to _____ minutes and less than _____ minutes
53 minutes
68 minutes
CMS 8 Minute Rule: 5 units of care can be billed for a specific CPT code for greater than or equal to _____ minutes and less than _____ minutes
68 minutes
83 minutes
Group Therapy Code: This is to be used when care is provided to more than one person during the same _____
Time interval
What are modifiers?
Increase the specificity of the CPT code
Example: can be used to describe that the service was provided on both of the patient’s legs or during a distinct time interval
What is the purpose of correct coding initiative?
To develop correct coding methodologies to curtail improper unbundling or services for Medicare Part B claims
A code pair edit is a combination of ________ that cannot be billed together because either the code pair represents services that are considered mutually exclusive or one code in the pair is considered a component of a more comprehensive procedure code
Two CPT codes
If the prohibited code combo is reported to the carrier, only ______ will be reimbursed
One code
Medicare will only pay for ____ 15 minute codes in an hour, unless you have a PTA, you can bill for more
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