Cpc Chapter 1

Front 1

What is Medicare Severity-Diagnosed Related Groups? (MS-DRG)

Back 1

Used to determine the amount the hospital will be reimbursed if the patient is covered by Medicare or other insurance programs using the MS-DRG system.

Front 2

What is EHR?

Back 2

Electronic Health Records

Front 3

What types of codes do Outpatient coders use?

Back 3

1. CPT

2. HCPCS Level II

3. ICD-10-CM

4. Ambulatory Payment Classifications (APCs)

Front 4

What types of codes do inpatient hospital

coders use?

Back 4

1. ICD-10-CM

2. ICD-10-PCS

3. MS-DRGs

Front 5

How many years of college do physicians

undergo?

Back 5

4 years of college, 4 years of medical school,

and 3-5 years of residency, with the option to continue training in a subspecialty, or a

'fellowship'

Front 6

What is a 'mid-level' provider?

Back 6

Physician Assistants (PA) or Nurse

Practitioners (NP). Also known as physician

extenders; require oversight by a physician.

Front 7

How long does a Physician Assistance program take?

Back 7

26 1/2 months

Front 8

What education do Nurse Practitioners have?

Back 8

Master's Degree in Nursing

Front 9

What are the 2 types of payers?

Back 9

1. Private Insurance Plans

2. Government Insurance Plans

Front 10

What is a Commercial Carrier?

Back 10

Private payers that offer both group and

individual plans, including contracts for

hospitalizations, basic, and major medical

coverage.

Front 11

What is Medicare?

Back 11

The primary government payer in the US. It is

the federal health insurance program,

administered by CMS, that provides coverage

for people 65 and older, blind or disabled, and people with permanent kidney failure or

end-stage renal disease (ESRD)

Front 12

What are the 4 parts of Medicare?

Back 12

1. Medicare Part A

2. Medicare Part B

3. Medicare Part C

4. Medicare Part D

Front 13

What is Medicare Part A?

Back 13

Covers inpatient hospital care, as well as care provided in skilled nursing facilities, hospice, and home health.

Front 14

What is Medicare Part B?

Back 14

Covers 2 types of services:

1. Medically necessary provider services

needed to diagnose or treat a medical condition that meet accepted standards of medical

practice

2. Preventive services to prevent illness or

detect it at an early stage

Front 15

What is Medicare Part C?

Back 15

Medicare Advantage combines the benefits of parts A, B, and sometimes D. The plans are

managed by private insurers approved by

Medicare and my include PPOs, HMOs, and

others.

Front 16

What is Medicare Part D?

Back 16

Prescription drug program available to all

Medicare beneficiaries for a fee. Private

companies approved by Medicare provide the coverage.

Front 17

What is Medicaid?

Back 17

A health insurance assistance program

sponsored by federal and state governments

for low-income people administered on a state-by-state basis

Front 18

What is a par provider/

Back 18

A participating provider contracted with private and/or government programs, required to

accept the allowed payment amount

determined by the insurance carrier as the fee for payment, as well as follow all other

guidelines stipulated by the contract

Front 19

What is a limiting charge?

Back 19

A set limit on what the patient can be charged, even if the physician is a non-participant in

Medicare

Front 20

What is a Medical Record?

Back 20

The provider's documentation of pertinent

facts and observations about a patient's health history, including past and present illnesses, tests, treatments, and outcomes

Front 21

What are SOAP notes?

Back 21

S - Subjective - The patient's statement about their health, including symptoms

O - Objective - The provider's examination and documentation of the patient's illness using observation, palpitation, auscultation, and percussion. Tests and other services performed may be documented here as well

A - Assessment - Evaluation and conclusion made by the provider. This is usually where the dx that supports the services rendered is found

P - Plan - Course of action where the provider will list the next steps for the patient.

Front 22

What is an Operative Report?

Back 22

Used to document the detail of a procedure performed on a patient; header & body.

Front 23

What should the header in an operative report include?

Back 23

*Date & time of the procedure

*Names of the surgeon, co-surgeon, assistant surgeon

*Type of anesthesia and anesthesia provider

*Pre-operative and post-operative dx

*Procedure performed

*Complications

Front 24

What should the body in an operative report include?

Back 24

*Indications for surgery

*Details of the procedure(s)

*Findings

Front 25

What are the 5 Operative Report Coding Tips important for coders?

Back 25

1. Diagnosis code reporting - use post-operative dx for coding unless that are further defined dx/additional dx found in the body. Also use dx found in the pathology report if applicable.

2. Start with the procedures listed - start the research process by focusing on the procedures listed in the header.

3. Look for key words - this may help with locations & anatomical structures involved, surgical approach, procedure method/type/size/and number

4. Highlight unfamiliar words - research

5. Read the body - All procedures reported should be documented within the body

Front 26

What is Medical Necessity

Back 26

Relates to whether a procedure or services is considered appropriate in a given

circumstance

Front 27

What is National Coverage Determination

(NCD)?

Back 27

Explains when Medicare will pay for items or

services.

Front 28

What is a Medicare Administrative Contractor (MAC)?

Back 28

Responsible for interpreting national policies into regional policies?

Front 29

What are Local Coverage Determinations

(LCD)?

Back 29

Regional policies; define what codes are

needed and when an item or services will be

covered; jurisdiction only within their region

Front 30

What is an ABN?

Back 30

Advanced Beneficiary Notice; a standardized form used when a Medicare beneficiary

requests or agrees to receive a procedure or

service that Medicare may not cover

Front 31

What are the 3 reasons Medicare may deny a procedure or service?

Back 31

1. Medicare doesn't pay for the procedure/service for the patient's

condition

2. Medicare doesn't pay for the procedure/service as frequently as

proposed

3. Medicare doesn't pay for experimental procedures/services

Front 32

What is a reasonable estimate the provider

must present the patient with a for a cost

estimate in an ABN?

Back 32

Within $100 or 25% of the actual costs,

whichever is greater.

Front 33

What is HIPAA?

Back 33

Health Insurance Portability and Accountability Act

Front 34

Under federal guidelines, HIPAA defines a covered entity as who?

Back 34

*Doctors

*Clinics

*Psychologists

*Dentists

*Chiropractors

*Nursing homes

*Pharmacies

* Health insurance companies

*HMOs

*Company health plans

*Government programs that pay for healthcare

*Healthcare clearinghouse

Front 35

What are the standard code sets designated to Electronic Healthcare Transactions?

Back 35

1. HCPCS (Healthcare Common Procedure Coding System)

2. CPT (Current Procedural Terminology)

3. CDT (Common Dental Terminology

4. ICD-10-CM

5. NDC (National Drug Codes)

Front 36

What is the definition of minimum necessary

requirement in accordant to HIPAA?

Back 36

Only the minimum necessary protected health information should be shared to satisfy a

particular purpose. If information is not

required, it must be withheld.

Front 37

Under the Privacy Rule, the minimum

necessary standard doesn't apply to _________

Back 37

1. Disclosures to/request by a healthcare provider for treatment

purposes

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

3. Uses or disclosures made pursuant to an individual's authorization

4. uses or disclosures required for compliance with HIPAA

5. Disclosures to the US Department of HHS when disclosure of info is

required for enforcement purposes

6. Uses or disclosures required by other law

Front 38

What is HITECH?

Back 38

Health Information Technology for Economic and Clinical Health Act

Front 39

Why was HITECH enacted?

Back 39

To promote the adoption and meaningful use

of health information technology.

Front 40

What are the 6 ethical principles of AAPC Code

of Ethics?

Back 40

1. Integrity

2. Respect

3. Commitment

4. Competence

5. Fairness

6. Responsibility