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24 Cards in this Set

  • Front
  • Back
Physician services are
typically billed on a
CMS- 1500 form
Medicare Part A
covers inpatient hospital care, as well as care provided in skilled nursing facilities, hospice
care, and home health care
Medicare Part B
covers medically necessary physician services, outpatient care, and other medical services
not covered by Part A. Coders working in physician offices will mainly work with Part B Medicare.
Medicare Part C
is also called Medicare Advantage.
This coverage is managed by private insurers and may
include a combination of Part A, Part B and sometimes Part D services.
Medicare Part D
is a prescription drug coverage program available to Medicare beneficiaries
SOAP note
S= Subjective (what the patient says)
O= Objective (what the dr. observes)
A= Assessment (provider's conclusion)
P= plan (course of action to treat illness or injury)
Definition of Medical Necessity
are proper and needed for the diagnosis or treatment of your medical condition,

are provided for the diagnosis, direct care, and treatment of your medical condition,

meet the standards of good medical practice in the local area

aren’t mainly for the convenience of you or your doctor.
National Coverage Determinations (NCD's)
Describe whether specific medical items, services, treatment, procedures, or technologies can be paid for under Medicare.
Advance Beneficiary Notification
(ABN)
If you are providing this service and the patient’s diagnosis does not support the medical necessity
requirements according to this particular policy your practice would be responsible for obtaining an___

The ABN is a standardized form that explains to
the patient why Medicare may deny the particular service or procedure. An ABN protects the provider’s financial interest by creating a paper trail that CMS requires before a provider can bill the patient for payment if Medicare denies coverage for the stated service or procedure
HIPAA's Administration Simplification
addresses national standards for electronic transactions and code sets; establishes unique identifiers for providers, health plans, and employers to be used nationally; and provides federal protection for the privacy of personal health information.
HIPAA version used for electronic
transactions such as enrollment, eligibility, payment and remittance advice is referred to as
ASC x12 version 5010
7 actions of a successful compliance program
1. Conduct internal monitoring and auditing through the performance of periodic audits
2. Implement compliance and practice standards through the development of written
standards and procedures.
3. Designate a compliance officer to monitor compliance efforts and enforce practice
standards.
4. Conduct appropriate training and education on practice standards and procedures.
5. Respond appropriately to detected violations through the investigation of allegations and the
disclosure of incidents to appropriate government entities
6. Develop open lines of communication with staff meetings, newsletters, and other lines of communication;
7. Enforce disciplinary standards through well publicized guidelines.
Diagnosis code reporting
use the post-operative diagnosis for
coding unless there are further defined diagnoses or additional diagnoses found in the body or findings of the operative report. If a pathology report is available, use the findings from the pathology report for the diagnosis
Start with the procedures listed
or the coder who is new to coding a procedure, one way of quickly starting the research process is by focusing on the procedures listed in the header.
Read the note in its entirety to verify the procedures performed.
Procedures listed in the header may not be listed correctly and procedures documented within the body of the report may not be listed in the header at all; however, it will help a coder with a place to start
Medicare Administrative Contractor (MAC)
is responsible for interpreting national policies into regional policies. These are called Local Coverage Determinations (LCD). The LCDs further define what codes are needed and when an item or service will be covered. LCDs have jurisdiction only within their regional area.
Ways to be considered reasonable and necessary
Furnished in accordance with accepted standards of medical practice for the diagnosis or treatment of the patient's condition or to improve the function of a malformed body memeber
furnished in a setting appropriate to the patient's medical needs or condition
ordered and furnished by qualified personnel
one that meets but does not exceed the patient's medical needs
at least as beneficial as an existing and available medically appropriate alternative
HCPCS
(Healthcare Common Procedure Coding
System
NDC
National Drug Codes
minimum necessary standard
does not apply to the following:
Disclosures to or requests by a health care provider
for treatment purposes.

Disclosures to the individual who is the subject of
the information.

Uses or disclosures made pursuant to an individual’s authorization.

Uses or disclosures required for compliance with the
HIPAA Administrative Simplification Rules.

Disclosures to the U. S. Department of Health &
Human Services (HHS) when disclosure of information is required under the Privacy Rule for enforcement purposes.

Uses or disclosures that are required by other law.
HITECH - Health Information Technology for Economic and Clinical Health Act,
Portions of HITECH strengthen HIPAA rules by addressing privacy and security concerns associated with the electronic transmission of health information. HITECH establishes four categories of violations—depending on the covered entity’s level
of culpability for releasing protected information—and minimum and maximum penalties. HITECH also “lowers the bar” for what constitutes a violation, but provides a 30-day window during which any violation not due to willful neglect may be corrected without penalty.
enacted 2009
HIPAA regulations exclude:
coverage for an accident, disability income insurance or any combination thereof
supplement liability insurance
liability insurnace general and automobile
credit-only insurance
coverage for on-site medical clinics
OIG work plan
released in oct every year. announces potential problems with claims on submissions that will target special scrutiny
OIG compliance program for individual and small group practices
Guidance for compliance in physician's offices today
AAPC Code of Ethics
Maintain and enhance the dignity, status, integrity, competence, and standards of our profession.

Respect the privacy of others and honor confidentiality.

Strive to achieve the highest quality, effectiveness and dignity in both the process and products of professional work.

Advance the profession through continued professional development and education by acquiring and maintaining professional competence.

Know and respect existing federal, state and local laws, regulations, certifications and licensing requirements applicable to professional work.

Use only legal and ethical principles that reflect the profession’s core values and report activity that is perceived to violate this Code of Ethics to the AAPC
Ethics Committee.

Accurately represent the credential(s) earned and the status of AAPC membership.

Avoid actions and circumstances that may appear to compromise good business judgment or create a conflict between personal and professional interests