Medical Insurance, Biling, Coding Flashcards
Center for Medicare and Medicaid services
CMS
-administers funding
Evaluation and management
E&M
-CPT office visit procedure codes
Employer identification number
EIN
Explanation of benefits
EOB
- sent by insurance carrier to provider
- give breakdown of reimbursement for services billed
Explanation of Medicare benefits
EOMB
- sent to provider
- gives breakdown of reimbursement for services billed
Early and periodic screening, diagnosis and treatment
EPSDT
Internal revenue services
IRS
Length of stay
LOS
Term used for Medicare and Medicaid coverage
MEDI/MEDI
Nonsufficient funds
NSF
Problem focused
PF
Provider identification number
PIN
Remittance advice
RA
- sent by Medicaid to provider
- gives break down of reimbursement for services billed
Signature on file
SOF
-signed copy authorizing claim submission and direct payment to provider
Utilization review
UR
- examination of services provided
- performed by unaffiliated group to determine medical necessity
Allowed charges
Max dollar amount an insurance carrier will cover for provided services
Assignment of benefits
Patient authorizes insurance carrier to pay physician directly
- patient signature required
- assignment automatically in place in participating providers with insurance carrier
Beneficiary
Subscriber and eligible person named by subscriber to receive insurance benefits
Birthday rule
Determine which insurance company is billed 1st
-rule is enforced if covered individual is beneficiary of more than 1 health insurance policy
Capitation
- 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
Clearinghouse
Used to scrutinize claims for correctness after they been electronically transmitted from health care provider, but before insurance co receives them
Coordination of benefits
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
Diagnosis-retaliated group
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
Direct billing
Electronic claims submission transmitted from provider to ins carrier for processing.
-no vendor use to examine claim for correctness
Electronic claims
Preferred method of claim submission reduces time in mailing and processing claims.
Fee profile
Given physician usual charges for various procedures complied over time
Fee schedule
Preset dollar amount an ins co allows for each service or procedure
Fiscal agent
Company processes ins claims on behalf of health ins plan
-used by Medicare and Medicaid in each state
Formulary
Listing of ins covered prescription medication
-purpose to lower cost with use of generic drugs
Guarantor
Individual is financially responsible for payment for themself or family member
Nonparticipating provider
NON-PAR
- does not have an agreement with insurance carrier
- provider expects full payment from patient for billed services
Participating or member provider
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
Preauthorization
Approval given from ins co for services resulting from medical necessity
Precertification
Process used by ins co to determine coverage for specific services
Premium
Dollar amount paid for ins coverage
Deductible
Out of pocket money before insurance makes payment
Copayment
Set amount patient pays for each office visit
Co-insurance
Percentage patient pays for each office visit (usually 20%)
Professional courtesy
Represent a reduced charge or free service to a professional associate
Referral
A directive, executed by primary care physician for patient to see specialized care from a preferred provider
Resource-based relative value scale
Used by Medicare to determine fee schedule for Medicare part B
-dollar amount based on factors involving procedure performed and provider geographic location
Rider
An addition made to insurance policy
-stipulates exclusion for preexisting chronic condition, procedure for specific time
Risk withhold
Portion of capitation payment to provider is withheld until the end of year or defined fiscal year
Subscriber or policyholder
Primary person covered by insurance
Third party payer
Usually the paying insurance company
UCR
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
Major medical
Catastrophic insurance
- assist paying for unexpected medical expenses
- high deductible helps keep premium cost low
Worker’s compensation
- 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
Self-insured plan
- employer-provided staffed health facility on site to cover employee need
- drug test, physical exam, special job-related testing
Group
- 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
Health savings account
- 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
Individual
- 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
Indemnity
- specific dollar amount paid for each service
- patient pays any remaining amount due
- work on fee for serve basis
Managed care
- 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
Health maintenance organization
- 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
Preferred provider organization
- use service in and out of network
- MD rewarded for using in network service only
- patient pay deductible and co-insurance
Exclusive provider organization
- in network coverage only
- employer must contract only with EPO
- out of network coverage available for emergencies or travel outside of service area only
Independent practice association
- formally organized groups of MD working independently
- MD paid by subscriber funds
- partial payment of allowable risk withhold paid at end of fiscal year
Medicare
- 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
Medicare parts
- 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
Medicaid
- 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
Children’s health insurance program
CHIP
- federally and state funded
- managed by individual states
Tricare
-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
CHAMPVA
- federal funded
- cover disable veterans
- cover family of veterans with total, permanent service-related disabilities and those had died in line of duty
Liability insurance
- if injury occur on site, covers homeowners and/or business
- if injury result from vehicle accident, covers occupants
Life insurance
Pay beneficiaries set dollar amount in event of policyholder’s death
Coding
- 1 diagnostic code, 1 procedure code
- procedural coding manual (CPT)
- healthcare common procedure coding system (HCPCS)
- diagnostic coding manual (ICD)
- updated annually
Procedure coding
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
Current procedural terminology
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
Alphabetic index
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
Tabular index
Numeric
-led to those section from alphabetic section to finalize proper code use
Evaluation and management
99201-99499
- history HPI
- examination ROS: one or more body system
- decision making: straightforward or highly complex
- time, counseling, coordination of care
Anesthesiology
00100-01999, 99100-99140
Surgery
10040-69990
Radiology
70010-79999
Pathology and laboratory
80049-89399
Medicine
90281-99199
Unlisted procedure or service
Identified by “99” in last 2 character. When reporting service code, special report must accompany submission
Modifier
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
21
Modifier code, prolong evaluation and management
26
Modifier code, professional component
52
Modifier code, reduced service
54
Modifier code, surgical care only, another physician provided preoperative and postoperative services
56
Modifier code, preoperative management only
Bundling
One CPT code in place for multiple available code to identify a procedure fully
Consultation
Consist of advice, opinion of physician asked for by another physician
Down code
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
Establish patient
Who receives service within past 3 years from particular medical provider, that provider’s medical practice
New patient
Who has not received service in past 3 years from a particular physician or that physician medical practice
Referral
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
Up code
Insurance claim purposely coded to next highest reimbursable code, does not have proper document to support it
Health care common procedure coding system
- 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
International classification of disease
- 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
International classification of disease, 10th revision procedure coding system (ICD-10-PCS)
- 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
International classification of disease, 10th revision, clinical modification (ICD-10-CM)
- 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
ICD-10-CM
- 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
ICD-10-CM: tabular list chapters`````
- 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)
Punctuation marks
- () parentheses: enclosed supplementary words
- [] Brackets: enclose synonyms
- : colon: seen after a term that needs modifiers
Abbreviations
- NEC: not elsewhere classified - specified code not available
- NOS: not otherwise specified - unspecified
Instructional notes
- 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
Late effects
Residual condition produced after the acute phase of injury or illness has terminated. No time limit, requires 2 codes
Placeholders
- 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
Primary diagnosis code
Is chief condition for which services or procedures were provided in outpatient setting
Principal diagnosis code
Apply only to inpatient setting
-after study, condition responsible for patient admission to hospital
Cycle billing
- 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
Balance billing
- patient billed difference between charge and insurance payment
- done if provider is not participating with patient insurance plan
Type of payment
- at time of service
- bill with credit extension
- insurance
- outside collection agency
Credit policy of office
- payment due date
- payment due at time of service
- collection procedures, include use of agency
- participating ins co and accepting assignment
Collection agency
- 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
