Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

Medical Assistant Exam Review > Medical Insurance, Biling, Coding > Flashcards

Medical Insurance, Biling, Coding Flashcards

You may prefer our related Brainscape-certified flashcards:
USMLE® Step 1 flashcards
1
Q

Center for Medicare and Medicaid services

A

CMS

-administers funding

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

Evaluation and management

A

E&M

-CPT office visit procedure codes

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

Employer identification number

A

EIN

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

Explanation of benefits

A

EOB

  • sent by insurance carrier to provider
  • give breakdown of reimbursement for services billed
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

Explanation of Medicare benefits

A

EOMB

  • sent to provider
  • gives breakdown of reimbursement for services billed
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

Early and periodic screening, diagnosis and treatment

A

EPSDT

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

Internal revenue services

A

IRS

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

Length of stay

A

LOS

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

Term used for Medicare and Medicaid coverage

A

MEDI/MEDI

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

Nonsufficient funds

A

NSF

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

Problem focused

A

PF

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

Provider identification number

A

PIN

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

Remittance advice

A

RA

  • sent by Medicaid to provider
  • gives break down of reimbursement for services billed
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

Signature on file

A

SOF

-signed copy authorizing claim submission and direct payment to provider

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

Utilization review

A

UR

  • examination of services provided
  • performed by unaffiliated group to determine medical necessity
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

Allowed charges

A

Max dollar amount an insurance carrier will cover for provided services

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

Assignment of benefits

A

Patient authorizes insurance carrier to pay physician directly

  • patient signature required
  • assignment automatically in place in participating providers with insurance carrier
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

Beneficiary

A

Subscriber and eligible person named by subscriber to receive insurance benefits

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

Birthday rule

A

Determine which insurance company is billed 1st

-rule is enforced if covered individual is beneficiary of more than 1 health insurance policy

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

Capitation

A
  • Fixed dollar amount paid by insurance co to PAR providers
  • usually 1-2 times per month
  • for each enrolled patient
  • number and type of services provided to patient do not influence dollar amount paid
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
21
Q

Clearinghouse

A

Used to scrutinize claims for correctness after they been electronically transmitted from health care provider, but before insurance co receives them

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
22
Q

Coordination of benefits

A

Limits benefits 100% of cost of service when there is more than 1 insurance carrier used for coverage

  • primary ins pays required contractual amount
  • secondary ins pay remainder of allowable amount
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
23
Q

Diagnosis-retaliated group

A

Determine payment for hospital claims under Medicare part A

-using a system based on patient primary diagnosis, course of treatment, lengths of stay in hospital

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
24
Q

Direct billing

A

Electronic claims submission transmitted from provider to ins carrier for processing.
-no vendor use to examine claim for correctness

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
25
Q

Electronic claims

A

Preferred method of claim submission reduces time in mailing and processing claims.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
26
Q

Fee profile

A

Given physician usual charges for various procedures complied over time

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
27
Q

Fee schedule

A

Preset dollar amount an ins co allows for each service or procedure

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
28
Q

Fiscal agent

A

Company processes ins claims on behalf of health ins plan

-used by Medicare and Medicaid in each state

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
29
Q

Formulary

A

Listing of ins covered prescription medication

-purpose to lower cost with use of generic drugs

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
30
Q

Guarantor

A

Individual is financially responsible for payment for themself or family member

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
31
Q

Nonparticipating provider

A

NON-PAR

  • does not have an agreement with insurance carrier
  • provider expects full payment from patient for billed services
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
32
Q

Participating or member provider

A

PAR

  • has an agreement or contracted with ins co to accept company allowed charge as 100% payment
  • physician writes off difference between their fee and allowed charge
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
33
Q

Preauthorization

A

Approval given from ins co for services resulting from medical necessity

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
34
Q

Precertification

A

Process used by ins co to determine coverage for specific services

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
35
Q

Premium

A

Dollar amount paid for ins coverage

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
36
Q

Deductible

A

Out of pocket money before insurance makes payment

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
37
Q

Copayment

A

Set amount patient pays for each office visit

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
38
Q

Co-insurance

A

Percentage patient pays for each office visit (usually 20%)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
39
Q

Professional courtesy

A

Represent a reduced charge or free service to a professional associate

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
40
Q

Referral

A

A directive, executed by primary care physician for patient to see specialized care from a preferred provider

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
41
Q

Resource-based relative value scale

A

Used by Medicare to determine fee schedule for Medicare part B
-dollar amount based on factors involving procedure performed and provider geographic location

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
42
Q

Rider

A

An addition made to insurance policy

-stipulates exclusion for preexisting chronic condition, procedure for specific time

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
43
Q

Risk withhold

A

Portion of capitation payment to provider is withheld until the end of year or defined fiscal year

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
44
Q

Subscriber or policyholder

A

Primary person covered by insurance

45
Q

Third party payer

A

Usually the paying insurance company

46
Q

UCR

A

Used to determine payable insurance benefits for performed procedures

  • U: usual fee physician charge for most frequent used procedure.
  • C: customary fee charge by physician in same geographic area and speciality
  • R: reasonable fee are justifiable when usual procedure is more complicated
47
Q

Major medical

A

Catastrophic insurance

  • assist paying for unexpected medical expenses
  • high deductible helps keep premium cost low
48
Q

Worker’s compensation

A
  • employer medical and disability insurance for employee death, injury, illness on job or related to job
  • physician send “first report of occupational injury” within 72 hours of patient first visit
  • patient not billed
49
Q

Self-insured plan

A
  • employer-provided staffed health facility on site to cover employee need
  • drug test, physical exam, special job-related testing
50
Q

Group

A
  • offered by employers to employee groups
  • low premium
  • all employees may join in lieu of physical exam
  • typically use managed care plan, HMO
  • usually no physical exam required
51
Q

Health savings account

A
  • use saving account where deductible is paid
  • preventative care at no cost, no deduction applied
  • high deductible health ins plan
  • monthly premium based on age, geographic area, and deductible
  • no tax on withdrawals if used for medical expenses
52
Q

Individual

A
  • coverage purchased by individual
  • usually require physical exam to qualify
  • high premium
  • medigap, crossover: supplemental policy purchase by individual more than 65 to pay Medicare deductible and 20% co-insurance
53
Q

Indemnity

A
  • specific dollar amount paid for each service
  • patient pays any remaining amount due
  • work on fee for serve basis
54
Q

Managed care

A
  • Patient choice of physician is limited to PAR providers
  • access is limited to PAR facility
  • patient select PCP
  • utilization review by plan evaluate purpose or current patient treatment
  • may require use of referral for specialist
  • include prevent it ave health care medicine
55
Q

Health maintenance organization

A
  • staff model: salaried MD work only for plan
  • network model: MD group are contracted, MD also contract with other health ins co
  • MD refer patient to PAR providers only
  • pay copayment
  • patient restricted using PCP belonging to network
56
Q

Preferred provider organization

A
  • use service in and out of network
  • MD rewarded for using in network service only
  • patient pay deductible and co-insurance
57
Q

Exclusive provider organization

A
  • in network coverage only
  • employer must contract only with EPO
  • out of network coverage available for emergencies or travel outside of service area only
58
Q

Independent practice association

A
  • formally organized groups of MD working independently
  • MD paid by subscriber funds
  • partial payment of allowable risk withhold paid at end of fiscal year
59
Q

Medicare

A
  • federally funded
  • for over 65 years old with minimum of 10 years of medicare-approved employment, disabled, end stage kidney disease, kidney donors, retired railway employees
60
Q

Medicare parts

A
  • part A: automatic enrolled, inpatient coverage, new deductible to meet for each hospital admission
  • part B: voluntary enrollment, add outpatient coverage, yearly deductible, monthly premium due
  • part C: medicare managed care plans, replace Part A and B
  • part D: prescription plans
61
Q

Medicaid

A
  • federally and state funded
  • low come individual and families
  • last healthcare coverage to bill if there is other coverage
  • if patient is treated, assignment is automatic, allowed payment is considered payment in full
  • cannot bill patient for covered services
62
Q

Children’s health insurance program

A

CHIP

  • federally and state funded
  • managed by individual states
63
Q

Tricare

A

-federally funded
-covers family of military active personnel and retirees
-3 choices:
—prime: HMO optional participation, preventative services
—extra: managed care network, use of network providers only
—standard: fee for service plan

64
Q

CHAMPVA

A
  • federal funded
  • cover disable veterans
  • cover family of veterans with total, permanent service-related disabilities and those had died in line of duty
65
Q

Liability insurance

A
  • if injury occur on site, covers homeowners and/or business

- if injury result from vehicle accident, covers occupants

66
Q

Life insurance

A

Pay beneficiaries set dollar amount in event of policyholder’s death

67
Q

Coding

A
  • 1 diagnostic code, 1 procedure code
  • procedural coding manual (CPT)
  • healthcare common procedure coding system (HCPCS)
  • diagnostic coding manual (ICD)
  • updated annually
68
Q

Procedure coding

A

HCPCS
-based on American Medical Association’s CPT
-procedures, service performed in medical office translated into numbers/alphanumeric codes
-two levels
—Level I-known as CPT code (numeric)
—Level II-known as national codes (alphanumeric

69
Q

Current procedural terminology

A

Level I divided into 3 categories:

  • category I: procedure consistent with current medical practice, widely performed. Main body of CPT manual. Consist of 5 digits
  • category II: supplementary track code use for performance measure. Use optional. Consist 4 digit follow by F
  • category III: temp code for emerging tech or services. Retire within 5 years if not adopted as category I. Payment for service based on policies of payer, not a yearly fee schedule. Consist of 5 character, by 4 digit follow by letter T
70
Q

Alphabetic index

A

Where you begin to search for procedure codes
-6 helpful to begin search for code:
—procedure or service performed, an atomic site or organ, condition, synonym, eponym: proper name of inventor or discoverer, abbreviation

71
Q

Tabular index

A

Numeric

-led to those section from alphabetic section to finalize proper code use

72
Q

Evaluation and management

A

99201-99499

  • history HPI
  • examination ROS: one or more body system
  • decision making: straightforward or highly complex
  • time, counseling, coordination of care
73
Q

Anesthesiology

A

00100-01999, 99100-99140

74
Q

Surgery

A

10040-69990

75
Q

Radiology

A

70010-79999

76
Q

Pathology and laboratory

A

80049-89399

77
Q

Medicine

A

90281-99199

78
Q

Unlisted procedure or service

A

Identified by “99” in last 2 character. When reporting service code, special report must accompany submission

79
Q

Modifier

A

Made up of 2 characters provide additional info for procedure code identified. Does not change code meaning, identifies special circumstance should be considered by claim recipient

80
Q

21

A

Modifier code, prolong evaluation and management

81
Q

26

A

Modifier code, professional component

82
Q

52

A

Modifier code, reduced service

83
Q

54

A

Modifier code, surgical care only, another physician provided preoperative and postoperative services

84
Q

56

A

Modifier code, preoperative management only

85
Q

Bundling

A

One CPT code in place for multiple available code to identify a procedure fully

86
Q

Consultation

A

Consist of advice, opinion of physician asked for by another physician

87
Q

Down code

A

Less complicated, simpler management code substitute more complicated or complex code when irregularly found within submitted claim
-result is lower financial reimbursement by ins carrier to provider

88
Q

Establish patient

A

Who receives service within past 3 years from particular medical provider, that provider’s medical practice

89
Q

New patient

A

Who has not received service in past 3 years from a particular physician or that physician medical practice

90
Q

Referral

A

Written form, verbal notification by phone or other communication need to send patient from one physician to another
-form in which referral is accomplished depends on insurance carrier

91
Q

Up code

A

Insurance claim purposely coded to next highest reimbursable code, does not have proper document to support it

92
Q

Health care common procedure coding system

A
  • level II codes
  • developed by Health Care Financing Administration
  • now Centers for Medicare and Medicaid services
  • use is required for Medicare and Medicaid patient
  • used by provider to describe specific items and service provided in health care delivery that not covered in level I codes
  • alphanumeric: each code begins with a letter
93
Q

International classification of disease

A
  • world health organization develop and use ICD code system to compile data on morbidity and mortality
  • codes made up of characters.
  • 3 character made up coding category, may be further subdivided or used if it cannot be further subdivided
  • subcategories made up of 4, 5, 6, or 7 character for greater detail
  • to be valid: must be coded to full number of character required for that code
94
Q

International classification of disease, 10th revision procedure coding system (ICD-10-PCS)

A
  • comprehensive Manuel use for inpatient procedural codes
  • cms agency responsible for maintaining inpatient procedure code set
  • manual developed as replacement for volume III of ICD-9-CM
95
Q

International classification of disease, 10th revision, clinical modification (ICD-10-CM)

A
  • used for outpatient diagnostic care
  • used by physician and other healthcare providers to classify and code all diagnoses, symptoms, procedure recorded in conjunction with hospital care
  • unique alphanumeric code to identify health related conditions, disease, sign/symptoms, injury and their causes
  • national center for health statistic responsible for maintaining manual
  • include more than 68,000 codes
96
Q

ICD-10-CM

A
  • divided into 2 sections: alphabetic index and tabular list (alphanumeric)
  • tabular list divided into 21 chapters, code ranges based on body system, section is final step for code confirmation
  • use alphabetic index first: disease/injury, external cause of injury, neoplasm table, drug / chemical table
97
Q

ICD-10-CM: tabular list chapters`````

A
  • 1: certain infectious and parasitic disease (A00-B99)
  • 2: Neoplasm (C00-D49)
  • 3: disease of blood / blood forming organs / certain disorders involving immune mechanism (D50-D89)
  • 4: Endocrine, Nutritional, metabolic disease (E00-E90)
  • 5: mental / behavioral disorders (F01-F99)
  • 6: disease of nervous system (G00-G99)
  • 7: disease of eye / adnexa (H00-H59)
  • 8: disease of ear / mastoid process (H60-H95)
  • 9: Disease of circulatory system (I00-I99)
  • 10: disease of respiratory system (J00-J99)
  • 11: disease of digestive system (K00-K94)
  • 12: disease of skin / subcutaneous tissue (L00-L99)
  • 13: disease of musculoskeletal system / connective tissue (M00-M99)
  • 14: Disease of genitourinary system (N00-N99)
  • 15: pregnancy, childbirth, puerperium ( O00-O9A)
  • 16: certain condition originating in perinatal period (P00-P96)
  • 17: congenital malformation deformation and chromosomal abnormalities (Q00-Q99)
  • 18: symptoms, signs, abnormal clinical and laboratory findings (R00-R99)
  • 19: injury, poisoning and certain other consequences of external cause (S00-T98)
  • 20: eternal cause of morbidity (V01-Y99)
  • 21: factor influencing health status, contact with health services (Z00-Z99)
98
Q

Punctuation marks

A
  • () parentheses: enclosed supplementary words
  • [] Brackets: enclose synonyms
  • : colon: seen after a term that needs modifiers
99
Q

Abbreviations

A
  • NEC: not elsewhere classified - specified code not available
  • NOS: not otherwise specified - unspecified
100
Q

Instructional notes

A
  • includes: seen after category. Defines or gives example
  • excludes: term used when 2 condition is not part of the condition represented by code
  • see/see also: indicates another term should be referenced within alphabetic index
  • code also: two codes may be required
  • code 1st: sequence underlying condition 1st, follows by manifestation
101
Q

Late effects

A

Residual condition produced after the acute phase of injury or illness has terminated. No time limit, requires 2 codes

102
Q

Placeholders

A
  • X character
  • used within certain codes allow for future expansion
  • maybe used a 5th character placeholder for certain 6 character code
  • used on 6th character placeholder for code requiring 7 characters
103
Q

Primary diagnosis code

A

Is chief condition for which services or procedures were provided in outpatient setting

104
Q

Principal diagnosis code

A

Apply only to inpatient setting

-after study, condition responsible for patient admission to hospital

105
Q

Cycle billing

A
  • developed to bill a set of patient at same time each month according to 1st letter of last name, or some other method
  • billing workload reduced by spreading task throughout month
  • ensure cash flow throughout month
106
Q

Balance billing

A
  • patient billed difference between charge and insurance payment
  • done if provider is not participating with patient insurance plan
107
Q

Type of payment

A
  • at time of service
  • bill with credit extension
  • insurance
  • outside collection agency
108
Q

Credit policy of office

A
  • payment due date
  • payment due at time of service
  • collection procedures, include use of agency
  • participating ins co and accepting assignment
109
Q

Collection agency

A
  • billing of last resort
  • agency keeps 40%-60% of collected amount
  • do not send bill or discuss account with patient after submitting the account to an agency

Medical Assistant Exam Review (10 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2024 Bold Learning Solutions. Terms and Conditions