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.
coding for “impending” or “threatened” conditions
–if the condition actually occurred and is a final diagnosis, then use the diagnosis for the condition.
–If the condition did not actually occur, refer to alphabetical index to see if the condition has a sub-entry term for impending or threatened
–Also check reference the main term for impending and/or threatened
explained the anatomy of an ICD 10 code
–first digit is always alpha (never “U”)
–First 3 digits define “category”
–Digit #4,5,6 code 4 etiology, anatomic site and severity
–Digit #7 is called “extension”
when should a 3 digit code be used?
3 digit codes should only be used if it is not further subdivided, i.e. no further information available
Do all codes have 7 digits?
no.
The seventh character is only use in certain chapters to provide data about the characteristics of the encounter
what are the extension digits used in injuries and external causes?
A = initial encounter D = subsequent encounter S = sequela
what is an “X” extension and when isn’t used?
“X” is a place holder
It is use in certain codes to fill empty characters when a code contains fewer than 6 characters and a seventh character applies
what are the extension digits use with fractures?
A = initial encounter for close fractures B = initial encounter for open fracture D = subsequent encounter for fracture with routine healing G = subsequent encounter for fracture with delayed healing K = subsequent encounter for fracture with nonunion P = subsequent encounter for fracture with malunion S = sequela
(you don’t have to remember these if you don’t want to)
what are “R” codes?
Symptoms, signs, and abnormal clinical and laboratory findings, not elsewhere classified
what are “S” codes?
Injury, placing, and certain other consequences of external causes
what are “T” codes?
Injury, poisoning, and certain other consequences of external causes
what are codes “V00–Y99”?
External causes or morbidity
what are “Z” codes
factors influencing health status and contact with health services
explain “NEC” code
Not Elsewhere Classified
“I know what is going on, however, there is not a code I can choose to properly explain the condition”
explain “NOS” code
Not Otherwise Specified
“I do not have sufficient information to code more specifically than this”.
What does the word “and” mean in the context of ICD 10?
“And” used in ICD 10 can mean either “and” or “or”.
What this a word “with” mean in the context of ICD 10
“with” means that both conditions must exist simultaneously
explain and discuss “excludes 1”
“excludes 1” indicate that the condition you looked up is actually in a different location in ICD 10.
Diseases and conditions with “excludes 1” can never be coded together because they cannot exist at the same time
explain and discuss “excludes 2”
“excludes 2” list conditions that are not the same as a major heading
explain and discuss “includes”
“includes” means that for the purposes of ICD 10, both codes are the same
explain and discuss “code first”
“code first” means that you should use the other code listed before the code you just looked up
explain and discuss “use additional”
“use additional” gives U codes to use after the primary code. The “use additional” code goals after the primary code.
What are brackets “[ ]”use for
brackets are used to include synonyms, alternate wordings, or explanatory phrases
what are parenthesis “( )”use for
used to close supplementary words that may be present or absence in the statement of the disease. The presence or absence does not affect the code number to which it is assigned.
Sometimes referred to as “nonessential modifiers”
does “confirmation” of HIV require documentation of positive laboratory tests of HIV?
No, practitioners diagnostic statement that patient has HIV is sufficient to label it as “confirmed
how to code for patient admitted with an HIV related condition
–principal diagnoses = B 20 (HIV)
–Then code additional diagnoses for all reported HIV related conditions
how to code for patient with HIV admitted for an unrelated condition
–cold the unrelated condition first
–Then code B 20
–Then code HIV related conditions
how to code for asymptomatic HIV
Z 21 = asymptomatic HIV = HIV positive = known HIV = HIV test positive = etc.
when not to use code Z 21
do not use Z 21 if:
–Patient has ever had an HIV opportunistic illness
What to HIV codes should never be used together
B 20 and Z 21
how to code 4 inconclusive HIV serology, e.g., without definitive diagnosis or manifestations of HIV
R 75
if the patient had an HIV related opportunistic illness for which she is fully recovered, what code to use
if the patient has ever had any opportunistic or other HIV related disease, B 20 is always used
how to code for HIV in pregnancy childbirth and puerperium
–code O 98.7 is a principal code in pregnancy, childbirth, And puerperium.
–Then code B 20 or Z 21
how to code for an encounter for testing for HIV
Z 11.4 = “encounter for screening for human immunodeficiency virus”
–Use additional colds for associated high-risk behavior
–Also code for signs and symptoms related to the encounter
how to code for HIV counseling
Z 71.7 = use for HIV counseling during encounter
how to code positive or negative HIV result reporting encounter
if HIV testing is negative, report Z 71.7
–If HIV testing is positive, report B 20 or Z 21
how to cold for suspected exposure to HIV person
Z 20.6 = contact with and (suspected) exposure to HIV
define sepsis
presence of both infection and systemic inflammatory response
how to code for sepsis
code for the underlying systemic infection first.
How to code for sepsis without known organism or systemic condition
A 41.9 = sepsis, unspecified organism
what is SIRS
Systemic Inflammatory Response
when to use R 65.2 (severe sepsis)
use R 65.2 only if there is diagnosis of severe sepsis or an associated acute organ dysfunction
defining urosepsis
the term urosepsis is no longer used. Use only the word “sepsis”
how to code for an acute organ dysfunction in the presence of sepsis, but not specifically stated as being a result of the sepsis
–query the practitioner
Do not use R 65.2
how to code for severe sepsis
to Cozaar necessary for severe sepsis
–Code the underlying systemic infection
–Code from subcategory R 65.2 = severe sepsis
how to code for sepsis if causal organism is not documented
A 41.9 = sepsis, unspecified organism
define septic shock
circulatory failure associated with severe sepsis (is therefore a type of organ dysfunction)
how to code for septic shock
–R 65.21 = severe sepsis with septic shock
Or
–T 81.12 = postprocedural septic shock
–10 code additional codes for other acute organ dysfunctions
sequencing of severe sepsis
is severe sepsis is present on admission and meets definition of principal diagnosis, underlying systemic infection is the principal diagnosis, followed by cold from subcategory R 65.2
when should subcategory R 65.2 codes be used as the principal diagnosis
never!
Code for sepsis and severe sepsis with a localized infection
if patient admitted with post sepsis and localize infection such as pneumonia, cold for the pneumonia first and the localize infection second
