The Business of Medicine

Question 1

MS-DRG stands for:

Answer 1

Medicare Severity-Diagnosis Related Groups

Question 2

EHR stands for:

Answer 2

Electronic health record

Question 3

APCs stands for:

Answer 3

Ambulatory Payment Classifications

Question 4

What is a PA

Answer 4

Physician Assistant. PA’s are mid-level providers also known as “physician extenders”. PA’s are licensed to practice medicine with physician supervision. A PA’s program takes approximately 26 1/2 months to complete

Question 5

What is an NP

Answer 5

Nurse Practitioner. NP is a mid-level provider or “physician extender”. NP’s have a Master’s Degree in Nursing.

Question 6

CMS stands for:

Answer 6

Center for Medicare & Medicaid Services

Question 7

ESRD stands for:

Answer 7

End stage renal disease

Question 8

Medicare Part A covers:

Answer 8

Helps pay for IP hospital care as well as skilled nursing, hospice and home health.

Question 9

Medicare Part B covers:

Answer 9

Helps pay for medically necessary provider services and preventive services. This is an optional benefit for which the patient pays a monthly premium, an annual deductible, and generally has a 20% co-insurance.

Question 10

Medicare Part C covers:

Answer 10

or Medicare Advantage, combine Part A & B and sometimes D. The plan is managed by private insurers approved by Medicare.

Question 11

Medicare Part D covers:

Answer 11

Helps pay for prescription drug programs available to all Medicare beneficiaries for a fee.

Question 12

What are SOAP Notes

Answer 12

Evaluation and Management (E&M) services are provided in a standard format such as SOAP.
S-Subjective - The patient’s statement about his or her health, including symptoms.
O-Objective - The provider’s examination and documentation of the patient’s illness using objective. palpation, auscultation, and percussion. Tests and other services may be documented here as well.
A-Assessment - Evaluation and conclusion made by the provider. This is usually where the diagnosis that supports the services is found.
P-Plan - Course of action. Here the provider will list the steps for the patient, i.e., ordering additional tests, taking over-the-counter meds, etc.

Question 13

What does “Medical Necessity” mean:

Answer 13

Relates to whether the procedure or service is considered appropriate in a given circumstance. (CMS has developed policies based on regulations found in title XVIII of the SS Act. The National Coverage Determinations Manual describes whether specific services can be paid for under Medicare).

Question 14

What is “NCD” :

Answer 14

National Coverage Determinations. NCD explain when Medicare will pay for items. Each Medicare Administrative Contractor (MAC) interprets national policy into regional policy. These are called Local Coverage Determinations (LCD).

Question 15

What is an “ABN”:

Answer 15

Advanced Beneficiary Notice. Provider’s use this form (entitled Revised ABN CMS-R-131) when the service provided the Medicare may not cover. (Medicare may not pay for the service related to the patient’s condition, or as frequently as the proposed service or for an experimental service.

Question 16

What are the “ABN” requirements:

Answer 16

• The provider must provide a cost estimate within $100 or 25% of the actual cost.
• The ABN must be presented far enough in advance for the beneficiary has time to consider the options.
• The ABN must verbally reviewed with the beneficiary and answer questions before signing the ABN.
• The beneficiary is provided a copy and the original is retained by the provider.
• The ABN does not need to be signed. If the patient refuses to sign but still request the service, the provider and a witness should sign and retain the ABN.
• ABN’s are never required for emergent services.

Question 17

HIPAA stands for:

Answer 17

Health Insurance Portability and Accountability Act of 1996. Prevents healthcare fraud and abuse, administrative simplification and medical liability reform.
HIPAA excludes:
*Coverage for accident or disability
*Coverage issued as a supplement to liability insurance.
*Liability insurance, including automobile liability insurance.
* Worker’s comp
*Auto medical payment insurance
*credit only insurance
*Coverage for on-site medical clinics

Question 18

HCPCS stands for:

Answer 18

Healthcare Common Procedure Coding System

Question 19

CPT stands for:

Answer 19

Current Procedural Terminology

Question 20

CDT stands for:

Answer 20

Current Dental Terminology

Question 21

NDC stands for:

Answer 21

National Drug Codes

Question 22

NPI stands for:

Answer 22

National Provider Identifier

Question 23

Who enforces HIPAA:

Answer 23

Office for Civil Rights (OCR)

Question 24

What is HITECH:

Answer 24

The Health Information Technology for Economic and Clinical Health Act, enacted as part of the American Recovery and Reinvestment Act of 2009 to promote the adoption and meaningful use of health information technology.

Question 25

A providers Compliance Plan includes:

Answer 25

1. Conducting internal monitoring and auditing through performance of periodic audits.
2. Implementation of compliance and practice standards.
3. Designate a compliance officer.
4. Conduct appropriate training and ed on practice standards and procedures.
5. Responding appropriately to violations and disclosure to government entities.
6. Develop open lines of communication
7. Enforce disciplinary standards through well publicized guidelines.

Question 26

What is the OIG “Work Plan”:

Answer 26

Twice a year the OIG releases a work plan outlining its priorities for the fiscal year ahead.