Medical Coding Flashcards
healthcare systems
-expenditure
-quality
-availability
-populations health
-upfront costs
types of insurance
-employer-provided (private)
-medicare (federal)
-medicaid (state)
choosing insurance plans (private)
-deductibles- paid before insurance plan contributes to service/cost
-copayments- paid to every medical visit
-coinsurance- percentages of cost paid
-premiums- paid regardless of use/claim
employer provided
-affordable health care act 2010- lower healthcare costs- pre-tax cash to buy choice of insurance
-expand coverage- maximize time of short-term insurance plans
-network must be used
no insurance
-emergency medical treatment and labor act (EMTALA) 1986- ensure public access to emergency services regardless of ability to pay
-hippocratic oath- medical oath of ethics
-large medical bills- bankruptcy
US department of health and human services
-enhance the health and well-being of all Americans by promoting and providing:
-medical services
-public health services
-social services
-centers for medicare and medicaid services
medicare (federal)
-age >65 no matter income
or
-severe disabilities- ie- end stage renal disease, transplant no matter income
-funds:
-taxes- 2.9% split between employee and employer
-individual premiums
-tax deductible programs
medicaid (jointly operated by state and federal)
-low cost or free health insurance for - low income, disabilities, pregnant women
-service coverage is state-dependent- dental, vision, hearing
-cost vary from state to state
-may be full vs. supplemental coverage (after medicare or supplemental insurance)
-outcomes affect state reimbursement
federal vs state
-federal oversees all states- establish mandatory requirements for each state to receive federal funds
-states determine specific eligibility- duration, amount, type of service, scope of practice
-states “fee for service” to providers
high healthcare costs
-administrative
-drugs
-wages
-new technologies
-diverse charges (medical institution dependent)
-liability insurance
history of coding and classification
-ICD-10
-wordwide comparison
-london bills of mortality- classification of causes of death created ICDs -> documentation
who you should care about reimbursement and coverage issues
-knowledge of billing and coding rules is a marketable skill
-influences your scope of practice
-assists you when discussing practice compensation models and your work contract
-knowledge of rules helps to avoid allegation of fraud and abuse
documentation: old and new rules
-the old rule- if it wasnt written in the chart, it didnt happen
-new rule
-even if it is written in the chart, if it isnt medically necessary it wont be reimbursed
-outweigh costs and benefit
overview of the coding process
-you have a new pt who requires evaluation for a symptom
-diagnostic studies may be required
-a prescription for treatment (medication of physical therapy) based on your diagnosis is generated
EMR
-an interview (history) and diagnostic evaluation (physical examination) are performed
-check templates before signing a note
medical coding
-a numeric expression of a pts diagnosis and any service performed on that pt
-Prior to the advent of diagnosis related groups, coding was used primarily for research and public health planning.
-Coding allow for the study of disease patterns, treatment modalities and causes of mortality.
-Translates diagnoses and procedures into numbers for the purpose of statistically capturing data.
your documented examination is translated into codes
-ICD- international classification of diseases
-CPT- current procedural terminology
ICD
-international classification of diseases
-describes the pts symptoms, condition, complaint or problem
-justifies medical necessity
-16,000 increased to 70,000
-modernization of health care- recognizing advances in medicine
-reduce coding errors
-tracks public health and risk, increased data
-greater achievement of the benefits of an EHR
CPT codes
-Every service or procedure provided is characterized with a five-digit code.
-Continuous update – over 8,000 codes currently available.
-Provides a common language to describe and document medical and surgical services provided.
-Creates an accurate record of services performed for continuity of care as part of the patient’s medical record.
-PAs are critical in this process.
CPT utilization
-medicare, medicaid, private payers
-provides payers with a summary of patient care
-used for billing purposes
-E & M coding- evaluation and medical management
-the process of a provider assigning a CPT code to for billing
ICD codes are linked to procedure codes (CPT)
-requires the proper coupling of ICD and CPT codes
3 components determine the cost of a typical patient visit/encounter
-history component- CC- required & cannot be inferred , HPI cannot be documented by staff, ROS & PFSH can be documented by staff, PFSH (past, family, social history)
-physical exam- number of organ systems examined
-medical decisions making: assessment and plan- # dx or management options, amount of data/complexity, risk level to the pt
