Medicare & Coding Flashcards
As a coder you are to stay abreast of current and changing: (2)
Reimbursement policies
Coding guidelines
Medicare was originally established for those…
When was it implemented?
65 and older
In 1966
Persons who are covered are called…
“Beneficiaries”
Medicare Part A
Hospital and Institutional Care Coverage
Which Medicare Part will most inpatient coders work with?
Part A
Medicare Part B
Supplemental-Nonhospital
Which Medicare Part will most outpatient coders will work with?
Part B
Medicare Part C
Medicare Advantage Organizations plans-combine Parts A & B
Medicare Part D
Prescription Drug Plan (PDP)
Medicare Part A Pays:
All covered costs except deductible
Medicare Part B Pays:
80% of Medicare-allowed amount of covered services after deductible is met
Medicare also pays…
Preventive Services
What is covered in Medicare Part A In-Hospital Expenses? (3)
Semiprivate room
Meals and special diets in hospital
All medically necessary services
What is not covered In-Hospital Expenses? (2)
Personal convenience items
Any service or procedure determined to be “not medically necessary”
Medicare Part A Types of Covered Expenses (6)
Rehabilitation
Skilled nursing
Some personal convenience items for long-term illness or disabilities
Home health visits
Hospice care
Not automatically covered
Part B pays…
Services and supplies not covered under Part A
Types of Items Covered in Part B (5)
Physician services
Outpatient hospital services
Ambulatory surgical services
Home health care
Medically necessary supplies and equipment
Coding for Medicare Part B Services (3)
CPT (procedures and service)
HCPCS (drugs, supplies, equipment, and special services)
ICD-10-CM (diagnosis codes)
2 Types of QIOs
Beneficiary and Family Centered Care (BFCC)
Quality Innovation Network (QIN)
BFCC
Beneficiary and Family Centered Care
QIN
Quality Innovation Network
Beneficiary and Family Centered Care (BFCC) (3)
Assists beneficiaries directly
Quality of care reviews
Filing complaints or appeals
Quality Innovation Network (QIN) (3)
Organizes beneficiaries, providers, and community members for improvement initiatives
Data-driven approach
Focus on safety, health quality, and care coordination
Fraud
Intentional deception to benefit
Intentional deception to benefit
Fraud
Fraud can be…(6)
Billing for services not provided
Misrepresenting diagnosis or CPT/HCPCS codes
Kickbacks
Unbundling services
Falsifying medical necessity
Systematic waiver of copayment or deductible
