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HCAN Quiz 4 > Quiz 4 > Flashcards

Quiz 4 Flashcards

1
Q

What is the billing function in health care

A

process of quantifying health care services to insurance carriers, 3rd party payors, and patients for reimbursement.

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2
Q

ICD-10

A

diagnosis, 3-7 digit alphanumeric code

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3
Q

ICD-10-CM

A

Clinical diagnosis

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4
Q

ICD-10-PCS

A

Hospital diagnosis

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5
Q

CPT

A

procedure

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6
Q

HCPCS

A

CPT for Medicare

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7
Q

What does NPI stand for

A

National Provider Identifier

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8
Q

When did NPI start

A

HIPAA 1996

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9
Q

What is NPI

A

10 digit unique alphanumeric number that is similar to a SSN, but it is given out to other providers

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10
Q

Who has to have an NPI

A

physicians, non physician extenders, CRNA

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11
Q

What is credentialing

A

verification of health care practitioners education, training, and work

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12
Q

What is UPD

A

Universal Provider Database, uniform application that any provider can complete for credentialing.

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13
Q

What are some payors additional requirements for credentialing?

A

Every 2 years

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14
Q

What are the different levels of an established patient office visit?

A

Level 1: 99211, patient gets blood pressure checked, less documentation Level 2: 99212 Level 3: 99213 Level 4: 99214 Level 5: 99215, 15-20 minutes of face time with doctor, more documentation

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15
Q

How much reimbursement does Medicare allow for a 99211?

A

$18

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16
Q

How much reimbursement does Medicare allow for a 99215?

A

$134

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17
Q

Why is documentation important

A

it is linked directly to reimbursement, the more specific and complex

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18
Q

Bellcurve

A

there is a normal distribution between 99211 and 99215

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19
Q

Skewed left

A

not using rescouces properly, not documenting appropriately, administration might be conservative

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20
Q

Skewed right

A

might have more severe cases, but still need good documentation, red flag for CMS, coders might not be trained properly

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21
Q

What does coding and reimbursement depend on?

A

Medical necessity= CPT+ICD-10

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22
Q

ABN

A

Advanced beneficiary notice, form that patient signs saying that they will pay out of pocket what Medicare doesn’t pay

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23
Q

Claim

A

itemized statement of services and costs from a health care provider submitted to payers for payment

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24
Q

UB04 (CMS 1450)

A

Hospital inpatient

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25
Q

CMS 1500

A

Physician/ outpatient

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26
Q

“clean” claim

A

complete documentation that has no special circumstances and no defects

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27
Q

Chargemaster

A

list of facility charges for every service provided

103% above market level

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28
Q

How are Part A services paid

A

contract, per diem, percent of charges, DRG’s

29
Q

How are Part B services paid

A

based on fee schedule

30
Q

fee schedule

A

set price that payers say are allowed and they they will pay. Can be negotiable in some states

31
Q

priviledges

A

have to be credentialed in order to gain priviledges

32
Q

What are the key components of billing

A

charge

allowable

deductible/copay

actual payment

contractual allowance

bed debt

33
Q

When does a claim begin

A

when a patient schedules an appointment or enters the clinic/hospital

34
Q

What must be collected at the beginning of a revenu cycle for a claim

A

demographics

medical history

insurance carrier

ABN

HIPAA privacy form

divers license and insurance

PHI release form

35
Q

Dx

A

Diagnosis

36
Q

Charge capture

A

documentation recorded by a provider of service provided

37
Q

scrub

A

check to ensure that claim is clean

38
Q

where are claims sent after they are batched

A

clearinghouse or to payer

39
Q

clearinghouse

A

3rd party organization contracted by a provider to scrub, transmit, and bill services to payers

40
Q

What do clearinghouses generate?

A

audit trails, summary detailing all claims that were sent to the carrier along with upfront denials and rejections

41
Q

claims adjudication process

A

clean claims that meet medical necessity are generally reimbursed

42
Q

electronic remittance advice

A

electronic payment files, used to post payments from carriers back to billing system

43
Q

EOB

A

explanation of benefits, statement sent to beneficiary explaining what was reimbursed

44
Q

MACs

A

Medicare Administration Contracts

45
Q

What MAC is Alabama under

A

Palmetto

46
Q

How many MACs are with Part A and B

A

12

47
Q

How many MACs are with DME

A

4

48
Q

What do MACs do?

A

process Medicare claims

make and account for Medicare payments

enroll providers in Medicare programs

49
Q

What are LCDs

A

local coverage determination, determining what is medically necessary

50
Q

RACs

A

Recovery Audit Contractors

51
Q

What is the purpose of RACs

A

identify and correct Medicare improper payments by both Part A and B, detection and collection of overpayments

52
Q

What RAC does Alabama fall under

A

Cotiviti

53
Q

What are the 2 types of reviews

A

automated- medical records not required

complex- medical records required

54
Q

ACO

A

Accountable Care Organizations

55
Q

What does an ACO do

A

encourage providers to form new type of health care entity that improves quality of care, reduces cost, and improves transparency

56
Q

Who is responsible in an ACO

A

physicians and hospitals share responsibilty for the patient

57
Q

How many ACO’s are there?

A

41

58
Q

What do you need to qualify for ACO

A

minimum of 5000 Medicare beneficiaries for at least 3 years

providers are jointly accountable for patient

59
Q

MedPAC

A

independent body that advises congress on all things Medicare and Medicaid

Has 17 members that have a background in healthcare

60
Q

How can ACOs participate

A

it is voluntary

61
Q

Who is eligible to form ACOs

A

hospitals

group practice

networks of individual practices

partnerships/joint venture arrangements between hospitals and health professionals

62
Q

Who is limited to one ACO?

A

primary care physicians: internal medicine, geriatric medicine, family practice

63
Q

Who is allowed to participate in more than one ACO

A

acute care hospitals, surgical and medical specialites, rural health clinics, and qualified health centers

64
Q

What are the 5 aspects to meeting proposed requirements

A

measures to assess the quality of care provided

requirements for data submission

quality performance standards

reporting requirements

public reporting

65
Q

What are the 5 domains that are part of the quality performance measures

A

patient/caregiver experience

care coordination

patient safety

prevention health

at risk population: elderly, heart failure, hypertension

66
Q

MACRA

A

Medicare Access and CHIP Reauthorization Act

67
Q

What did MACRA create

A

repealed sustainable growth rate

changed the way medicare rewards clinicians for value over volume

streamlined multiple quality programs under the new merit based incentive system (MIPS)

Gives bonus payments for participation in eligible alternative payemtn models

Required removal of all SSN from Medicare cards by April 2019

68
Q
A

HCAN Quiz 4 (2 decks)

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