NIS chapter 5 - reimbursement Flashcards
What does CPT stand for?
Current procedural terminology
Who has full editorial control of CPT codes?
CPT Editorial panel
What does RVU stand for?
relative value unit
What are three things that an RVU encompasses
Work, practice expense, malpractice
denials based on medical necessity are usually the result of
mismatched ICD and CPT codes
Medicare uses which process as the basis for physician payment determination:
resource based relative value system. The Resource Based Relative Value System was implement by Medicare approximately 25 years ago as a national system to objectively and uniformly establish the fee schedule for physician payments. The Current Procedural Terminology and International Classification of Diseases Systems are both essential for claims submission, but are not themselves used as the basis for Medicare payments.
CPT codes are used to report:
what service was rendered.
Current Procedural Terminology codes are used by physicians to report what services they performed. Separate codes are used to report why a service was rendered (ICD), where a service was rendered (site of service codes), and who rendered a service (national provider identification codes).
ICD codes are used to report:
WHY a service was rendered
physician procedural services are valued by Medicare based on:
the typical physician time involved
how is medical necessity defined?
the concordance between ICD and CPT codes = medical necessity
CPT codes for radiography are based on:
number of views performed
CPT codes for CT and MRI are based on:
details of contrast administration
CPT codes for US are based on:
number of body regions assessed
The CPT code set is maintained by:
The AMA officially oversees all CPT codes……The American College of Radiology, like many other physician professional societies, participates in the CPT code development process through the CPT Advisory Committee.
What organization develops and maintains ICD codes
World Health Organization
For radiology services, which group or entity is the final arbitrator of CPT codes?
CPT editorial panel
optimize appropriate ICD code assignments for radiology services:
what, when, where
Medicare pays radiologists in teaching hospitals for their clinical professional services through which payment pathway:
physician fee schedule. ……Medicare pays radiologists in teaching hospitals—just like radiologists in non-teaching settings—for their professional services through the Part B Medicare Physician Fee Schedule. Direct graduate medical education and indirect medical education payments are made by Medicare to hospitals and health systems to support resident education. Medicare pays hospitals for inpatient hospitalizations through its inpatient prospective payment system.
If a resident interprets an imaging study and prepares a report, Medicare will only pay his/her attending radiologist for that interpretation if that attending physician:
personally reviewed those images and that interpretation and documented accordingly
In order to bill for a surgical, high-risk, or other complex procedure performed by a trainee, an attending interventional radiologist must:
be present during all key and critical portions of the procedure
process by which individual components of a complicated procedure are combined into one code for the purposes of billing is known as what
Bundling
What is the purpose of a CPT code
to document medical, surgical, or diagnostic services. It is a code set used to report medical surgical and diagnostic procedures and services to physicians, insurance companies, and accreditation organizations.
The total RVU has three components:
the work RVU, the practice expense RVU, and the malpractice RVU.
work RVU takes into account
work RVU takes into account encounter time, intensity, effort, and skill.
practice expense RVU accounts for
practice expense RVU accounts for the cost of maintaining a practice such as equipment, nonphysician staff, and supplies.
malpractice RVU encompasses
malpractice RVU encompasses professional liability expenses.
RVU that encompasses professional liability expenses.
malpractice RVU
RVU that accounts for the cost of maintaining a practice such as equipment, nonphysician staff, and supplies.
practice expense RVU
RVU that accounts for practice expense RVU, and the malpractice RVU.
practice expense RVU
