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

Medical Insurance, Biling, Coding Flashcards

1
Q

Center for Medicare and Medicaid services

A

CMS

-administers funding

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2
Q

Evaluation and management

A

E&M

-CPT office visit procedure codes

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3
Q

Employer identification number

A

EIN

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4
Q

Explanation of benefits

A

EOB

  • sent by insurance carrier to provider
  • give breakdown of reimbursement for services billed
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5
Q

Explanation of Medicare benefits

A

EOMB

  • sent to provider
  • gives breakdown of reimbursement for services billed
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6
Q

Early and periodic screening, diagnosis and treatment

A

EPSDT

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7
Q

Internal revenue services

A

IRS

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8
Q

Length of stay

A

LOS

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9
Q

Term used for Medicare and Medicaid coverage

A

MEDI/MEDI

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10
Q

Nonsufficient funds

A

NSF

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11
Q

Problem focused

A

PF

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12
Q

Provider identification number

A

PIN

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13
Q

Remittance advice

A

RA

  • sent by Medicaid to provider
  • gives break down of reimbursement for services billed
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14
Q

Signature on file

A

SOF

-signed copy authorizing claim submission and direct payment to provider

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15
Q

Utilization review

A

UR

  • examination of services provided
  • performed by unaffiliated group to determine medical necessity
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16
Q

Allowed charges

A

Max dollar amount an insurance carrier will cover for provided services

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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
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18
Q

Beneficiary

A

Subscriber and eligible person named by subscriber to receive insurance benefits

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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

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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
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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

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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
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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

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24
Q

Direct billing

A

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

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25
Q

Electronic claims

A

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

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26
Q

Fee profile

A

Given physician usual charges for various procedures complied over time

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27
Q

Fee schedule

A

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

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28
Q

Fiscal agent

A

Company processes ins claims on behalf of health ins plan

-used by Medicare and Medicaid in each state

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29
Q

Formulary

A

Listing of ins covered prescription medication

-purpose to lower cost with use of generic drugs

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30
Q

Guarantor

A

Individual is financially responsible for payment for themself or family member

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31
Q

Nonparticipating provider

A

NON-PAR

  • does not have an agreement with insurance carrier
  • provider expects full payment from patient for billed services
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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
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33
Q

Preauthorization

A

Approval given from ins co for services resulting from medical necessity

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34
Q

Precertification

A

Process used by ins co to determine coverage for specific services

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35
Q

Premium

A

Dollar amount paid for ins coverage

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36
Q

Deductible

A

Out of pocket money before insurance makes payment

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37
Q

Copayment

A

Set amount patient pays for each office visit

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38
Q

Co-insurance

A

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

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39
Q

Professional courtesy

A

Represent a reduced charge or free service to a professional associate

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40
Q

Referral

A

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

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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

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42
Q

Rider

A

An addition made to insurance policy

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

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43
Q

Risk withhold

A

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

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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)

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