Textbook Review Flashcards
define NCD
National Coverage Determination
Explains when Medicare will pay for procedure
define MAC
Medicare Administrative Contractor
Interprets national policies intraregional policies
define LCD
Local Coverage Determinations
Created by Medicare Administrative Contractor (MAC) to further define conditions needed and when an item will be covered.
Determination valid only in their region
define and discuss ABN
Advanced Beneficiary Notice
Form signed by patient to agree to pay practitioner if Medicare refuses payment.
Used when Medicare might not pay for procedure.
Creates paper trail that will assist practitioner in billing if Medicare rejects procedure payment
reasons why ABN might be necessary
- Medicare does not pay for this service for patients condition
- Medicare does not pay for procedure this frequently
- Medicare determines this is experimental procedure
what is required on ABN cost estimate
“notify her must make a good faith effort to insert a reasonable estimate… The estimate should be within $100 or 25% of the actual cause which ever is greater”
when should ABN be signed?
Medicare requires ABN to be signed “far enough in advance that the beneficiary has time to consider the options and make an informed choice”
what are beneficiaries options after signing ABN?
- Reject or proceed with procedure
- May request that charge be submitted to Medicare for consideration
- Should receive copy of form
when is ABN not allowed?
CMS prohibits giving ABN to patient who is “under duress” which includes everyone in emergency room.
Practitioner cannot bill patient for screening and stabilization in emergency room if if payment is denied
do all insurers recognize ABN?
non-Medicare health plans may or may not recognize ABN.
Many insurance companies have “hold harmless” clause that prohibits billing patient for anything other than deductible or co-pay
list “covered entities” under federal guidelines
health care provider
Health insurance plan
Healthcare clearinghouse
list “noncovered entities” under federal guidelines
Workmen's Compensation Auto insurance Disability insurance Liability insurance Credited only insurance Coverage for on-site medical clinics Other similar insurance coverage under which benefits for medical care are secondary or incidental to other insurance benefits
who is required to follow HIPAA rules?
Only covered entities are required to follow H IPAA rules.
Noncovered entities may or may not choose to follow them
define “transactions” according to CMS
“transactions are electronic exchanges involving transfer of information between 2 parties for specific purposes”
list types of “transactions” according to CMS
Health Claims Status Referral Certification and Authorization Coordination of Benefits health claims and equivalent encounter information Enrollment or disenrollment in a health plan Eligibility for health plan Healthcare payment and remittance advice Health plan premium payments Health claims status Referral certification and authorization Coordination of benefits
define CPT
Current Procedural Terminology
Coding for procedures performed
define ICD
International Classification of Diseases
codes various diseases and conditions
define HCPCS
Healthcare Common Procedure Coding System
Use in hospital coding
define NDC
National Drug Codes
Used to report drug administration
define CDT
Dental Terminology Dental Terminology
the key provision of HIPAA is__?
The “minimum necessary requirement” that is, only the minimal necessary protected health information should be shared to satisfy a particular purpose. If information is not required to satisfy a particular purpose it must be withheld.
list disclosures not covered by HIPAA minimum necessary role
to a healthcare provider for treatment purposes
2 the individual was the subject
Pursuant to an individuals authorization
When required for compliance with HIPAA administrative simplification rules
2 US Department of Health and human services when disclosure of information is required under the privacy rule for enforcement purposes
When required by other law
define HITECH
Health Information Technology for Economic and Clinical Health Act of 2009
lists the 4 major provisions of HITECH
- all business associates must sign contracts agreeing to abide by HIPAA
- Covered entities must provide copies of any covered health information to patient’s on demand, charging only the cost of providing them.
- There are potentially severe financial penalties for “willful neglect” of HIPAA provisions.
- Individuals must be notified if there is a breech of HIPAA provisions concerning their healthcare. Health and Human Services must be notified if the breech involves more than 500 patients
where can I find the “OIG Compliance Program Guidance for Individual and Small Group Physician Practices”?
Federal register, October 5, 2000
key provisions of OIG compliance program
– conduct internal monitoring and audits
–Implement compliance and practice standards that are written
–Designate compliance officer
–Conduct appropriate training and education
–Respond appropriately to detected violations with investigations of allegations
–Develop open lines of communication’s such as staph meanings and/or bulletin boards
–Enforced disciplinary standards through well published guidelines
OIG work plan
the OIG work plan is released each year in October outlying priorities for the fiscal year ahead including potential problem areas with Claim submissions that it will target for special scrutiny
when was ICD 10 first activated?
October 1, 2015
name the 2 sections of the ICD 10–CM book
Alphabetical Index
Tabular List
when should signs and symptoms be coded?
signs and/or symptoms should be coded only when a definitive diagnosis is not available
define default code
when is it used
is a code that is most often used with the condition.
It is located directly behind the bold face maintain term as use only when the provider’s documentation provides no additional detail.
defined sequela
a late effect.
Chronic residual condition that is a complication of an acute condition that occurs after the acute phase of the disease injury or illness. A can because indirectly by the treatment for the disease or condition. There is no time-limited I’m when the late effect can occur.
