Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

Professional Development IV > The Business of Medicine > Flashcards

The Business of Medicine Flashcards

1
Q

What are the 3 steps of provider reimbursement?

A
  1. Appropriate coding of diagnosis from associated encounter - ICD-10-CM codes or ICD-11 codes
  2. Appropriate coding of services from encounter - CPT codes (outpatient) or ICD-10PCS (inpatient), may use modifiers to indicate extra level of care
  3. Insurance determines appropriate fee based on codes
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

What is ICD-10?

A
  • International Statistical Classification of Diseases and Related Health Problems, 10th edition
  • Published by WHO for standardization of assessments/diagnosis of patients, assists with storage and retrieval of diagnostic info, helps with assembling data with certain diagnosis
  • ICD-10CM (clinical management): diagnosis codes
  • ICD-10PCS (procedure coding system): hospital inpatient procedures
  • HIPAA requires use of standardized coding system
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

What is CPT?

A

Current procedural technology published initially by american medical association in 1966
Standardizes and quantifies complexity of an encounter based on
* Types and number of diagnosis discussed/addressed
* Extensiveness of history and physical exam
* Extensiveness and complexity of decision-making process/care plan

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

What is the role of providers in medical billing and coding?

A
  • Many facilities require to select appropriate dx codes based on problems discussed with patient, typically listed in order of importance/time spent
  • Many require to select appropriate procedure codes based on what was carried out at visit
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

What is the role of providers in medical reimbursement?

A
  • Facility is reimbursed based on visit codes: higher-level = higher reimbursement
  • Different insurances = different reimbursements
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

What are the primary goals of a medical audit?

A
  • Improve efficiency and quality of delivery of care to patients
  • Avoid undercharging or overcharging for services rendered
  • Ensure adequate documentation of encounters
  • Eliminate use of outdated or inappropriate coding

May be done internally (by your facility) or externally
Can be fined for overcharging or undercharging

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

What codes are used for outpatient procedures? Inpatient?

A
  • CPT codes (outpatient)
  • ICD-10-PCS codes (inpatient)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

What are examples of diagnostic procedures that can be assigned codes? Therapeutic?

A

Diagnostic: imaging, UA, EKG, wet mount
Therapeutic: nebulizer treatment, injection, wound care

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

How do you decide which code to use?

A

Most facilities have reference database

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

What are examples of special circumstances that require modifiers?

A
  • Multiple visits on the same day
  • Repeat tests in a short period of time
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

What elements are required for a problem focused history?

A
  • CC
  • Brief HPI
  • No ROS
  • No PFSH
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

What elements are required for a expanded problem focused history?

A
  • CC
  • Brief HPI
  • Problem-pertinent ROS
  • No PFSH
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

What elements are required for a detailed history?

A
  • CC
  • Extended HPI
  • Extended ROS
  • Pertinent PFSH
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

What elements are required for a comprehensive HPI?

A
  • CC
  • Extended HPI
  • Complete ROS
  • Complete PFSH
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

How can a HPI be classified? How many elements need to be documented for each?

A
  • Brief: 1-3 HPI elements
  • Extended: 4+ HPI elements or status of 3+ chronic conditions
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

What are classifications of ROS?

A
  • Problem pertinent
  • Extended
  • Complete
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

What is considered a problem pertinent ROS?

A
  • Only system directly related to problem in HPI
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

What is considered extended ROS?

A
  • System directly related to CC plus 2-9 additional
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

What is considered complete ROS?

A
  • System directly related to CC plus 10+ additional
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

What are classifications of PFSH?

A

Pertinent or complete

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
21
Q

What is considered a pertinent PFSH?

A
  • Reviews at least one item from any of the 3 areas pertinent to the HPI
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
22
Q

What is considered a complete PFSH?

A

Review of 2 or all 3 areas
Two areas: for established or ER visits
Three areas: for new patients, hospital or consultation visits

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
23
Q

How can history be documented?

A

Separately as CC, HPI, ROS, PFSH with own headings
Congruently as one HPI paragraph

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
24
Q

Do you need to re-record each time you document a established patient?

A

It’s okay to update but be sure to review the history each time and document you did

25
Q

What qualifies as problem focused physical exam?

A
  • 1+ organ systems/body areas
  • 1-5 elements
26
Q

What qualifies as a expanded problem focused physical exam?

A
  • 1+ organ system/body area
  • 6+ elements
27
Q

What qualifies as a detailed physical exam?

A
  • 6+ organ systems/body areas
  • Each system/area-2+ elements
  • Alternative- 12+ elements over 2+ organ systems/body areas
28
Q

What qualifies as a comprehensive physical exam?

A

9+ organ systems/body areas
Each system/area 2+ elements

29
Q

How is a single system physical exam qualified as problem focused?

A
  • 1 to 5 elements
30
Q

What is included in a single-system expanded problem focused exam?

A

6+ elements

31
Q

What is a single system detailed exam?

A

12+ elements
If eye or psych 9+ elements

32
Q

What is a single system comprehensive exam?

A

All elements

33
Q

Is abnormal okay to document for the affected area?

A

NO always need to document abnormal findings

34
Q

Is normal okay to document for the affected system/area

A

Not really-should always spell out pertinent normal findings

35
Q

Is abnormal okay to document if it’s not the affected area?

A

No, if you find something abnormal you need to explain

36
Q

Is normal okay to document if it’s not the affected area?

A

For billing, yes. For the same of other providers no

37
Q

What elements are required for a straightforward type of decision making?

A
  • Minimal number of diagnosis or management options
  • Minimal or none amount and/or complexity of data to be reviewed
  • Minimal risk of significant complications, morbidity, and/or mortality
38
Q

What elements are required for low complexity decision making?

A
  • Limited number of diagnosis or management options
  • Limited amount and/or complexity of data to be reviewed
  • Low risk of significant complications, morbidity, and/or mortality
39
Q

What elements are required for moderate complexity decision making?

A
  • Multiple diagnosis or management options
  • Moderate amount and/or complexity of data to be reviewed
  • Moderate risk of significant complications, morbidity, and/or mortality
40
Q

What elements are considered high complexity decision making?

A
  • Extensive number of diagnosis or management options
  • Extensive amount and/or complexity of data to be reviewed
  • High risk of significant complications, morbidity, and/or mortality
41
Q

How do you determine the number of diagnosis/management options?

A
  • How many distinct entities were addressed today?
  • Were there numerous treatment options to choose from, or only a few?
  • Improving/resolving problems are less complex than worsening/failing to change as expected problems
  • If you have to refer someone out, it’s probably a more complex issue
42
Q

What increases the amount/complexity of data to review?

A
  • Reviewing old medical records or other data sources
  • Discussing contradictory or unexpected test results with the performing/interpreting physician
  • Personally reviewing images/specimens rather than just relyinf on the report/interpretation
43
Q

How is the risk of complications, morbidity, mortality decided?

A
  • Based on risk associated with presenting problems/diagnosis, any diagnostic procedures ordered, and the possible management options
  • Highest level of risk in any one category determines the overall risk
  • Consider their comorbidities, the type of procedure, and the urgency of the procedure or treatment
44
Q

idk if we need to know all of the examples and everything or not

A
45
Q

What is the patients over paperwork initiative?

A

Attempt to reduce administrative burden and stop providers from trying to document to code rather than to the needs of the pt/visit

46
Q

What were 2019 medicare coding changes?

A
  • Optional documentation changes for E/M visits (evaluation and management)
  • Home visits no long require documented medical neccesity
  • H&P may focus on waht has changed for established patients (no need to re-record required elements if evidence the provider has reviewed and updated previous information as needed)
  • CC &HPI for new and established pts no need to re-document info already documented by the pt/staff
47
Q

What were 2021 Medicare Coding Changes?

A
  • Single rates: condensing rates for level 2-4 applied to both new and established patients
  • Add-on codes: to address additional resources for level 2-5 visits
  • Extended visit codes: to address additional time in level 2-4 visits
  • Options for documenting: may document charge based on current framework with levels or based on time
48
Q

What do you have to document if using time?

A

Medical necessity of visit and that the billing practitioner personally spent the required amount of time

49
Q

What do you have to document if using current framework?

A

Levels 2-4 visits must only meet criterion for level 2 visits
Primary emphasis on either time spent caring for encounter or level of medical decision-making, not H&P requirements

50
Q

What are 2023 medicare coding changes?

A
  • Facility-based (inpatient) E/M services are similar to office outpatient services
  • Primary emphasis on either time spent caring for encounter or level of medical decision-making and not H&P requirements
  • Eliminating codes: merged some codes for services like observation into existing hospital care codes
  • Prolonged service codes: to addresss additional time or resources used in visits
  • Virtual and AI care: new codes to reflect billing for use of technology like remote monitoing, AI applications
51
Q

Why did we stop using ICD-9?

A
  • Outdated
  • Nonspecific codes
  • Limited data collection
  • Insufficient to adequately descibe pts conditions and diagnoses
52
Q

What are major changes in ICD-10?

A
  • Increased number of codes from 13,000 to over 68,000
  • Increased specificity
  • Allows for clarification
  • Expandibility (room to add more diagnosis)
  • Combination codes (multiple diagnosis in one code)
53
Q

Why did we stop using ICD-10?

A
  • Already outdated
  • Areas of non-congruence with current medical science advances
  • New diagnostic categories and reported greater ease of use (searchable), codes like antimicrobial resistance
  • However, clinical implementation often lags behind formal approval
54
Q

Can you use a symptom/sign as a diagnosis code?

A
  • Where possible, a specific condition is preferred as a diagnosis
  • However, if a specific diagnosis has not been found by the end of the encounter it is appropriate to report codes for a s/s in lieu of a diagnosis
55
Q

How many digits should I go to for a diagnosis code?

A

Providers should choose a code with as many digits as are available- using an incomplete code may result in rejection of the claim

56
Q

What if there are 2 principal diagnoses for a given encounter

A

If there are 2 principal diagnoses, either may be listed first in the assessment

57
Q

There are practice questions you can get to from the slides! I don’t really understand this lecture so I’m going to come back to it

A
58
Q

What is the ICD-10 code format?

A
  • Alpha 1st digit
  • Numeric 2nd digit
  • Alpha or numeric 3rd digit

1st, 2nd, and 3rd are category

Characters 3-7 can be any combination of alpha or numeric and are etiology, anatomical site, and severity. 7th digit is a extension

Professional Development IV (4 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2024 Bold Learning Solutions. Terms and Conditions