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33 Cards in this Set

  • Front
  • Back
A manual containing a list of descriptive terms and identifying codes used in reporting medical services and procedures performed and supplies used by physicians and other professional health care providers in the care and treatment of patients.
The Physicians' Current Procedural Terminology, Fourth Edition (CPT-4)
HCPCS group that contains the AMA Physicians' CPT Codes. These are 5 digit codes, accompanied by descriptive terms, used for reporting services performed by health care professionals.
Level 1
HCPCS group that consists of the HCPCS National Codes used to report medical services, supplies, drugs, and durable medical equipment not contained in the Level 1 Codes. These codes begin with a single letter, followed by four digits.
Level 2
HCPCS group in preparation of standardization for the full implementation of the Health Insurance Portability and Accountability Act (HIPAA), CMS has instructed carriers to eliminate local procedures and modifier codes from their claim processing system
Level 3
Each main term can stand alone, or it can be followed by up to ______ modifying terms.
3
What are the three ways a CPT code can be displayed
1. A single Code
2. Multiple Codes
3. A Range of Codes
Patient notes MUST support the use of
Modifiers
A _____ provides the means by which the reporting health care provider can indicate that a service or procedure performed has been altered by some specific circumstance, but its definition or code has not been changed.
Modifier
When a rarely used, unusual, variable, or new service or procedure is performed, many third-party payers require a ___________ to accompany the claim to help determine the appropriateness and medical necessity of the service or procedure.
Special report
What are the two types of CPT codes
1. Stand alone
2. Indented Codes
The ________________ are found at the beginning of the CPT manual. The E/M section of the CPT is divided into broad categories, including office visits, hospital visits, and consultation
Evaluation and Management (E/M) Codes
Every visit regardless of location must include at least two of which three components,
1. history
2. examination
3. medical decision making
An individual who is new to the practice, regardless of location of service, or one who has not received any medical treatment by the health care provider or any other provider in that same office within the past 3 years
New Patient
An individual who has been treated previously by the health care provider, regardless of location of service, within the past 3 years.
Established Patient
The health insurance professional must establish what level of service the patient received. Levels of service are based on what 3 key components
1. History
2. Examination
3. Complexity of medical decision making
In determining the complexity of decision making, the health insurance professional must consider what 3 elements
1. How many diagnostic and treatment options were considered
2. The amount and complexity of data reviewed
3. The amount of risk for complications, morbidity, and mortality.
During World War 2, Congress authorized the creation of the ___________________________, which provided maternity care and car infants up to 1 year of age for wives and children of service members
Emergency Maternal and Infant Care Program
The name for the total health care system of the U.S. uniformed services.
Military Health System
The service member, whether in active duty, retired, or deceased, is called the _______.
Sponsor
The sponsors relationship to the beneficiary (spouse, child, parent) creates eligibility under __________.
TRICARE
After eligibility has been established, the individual must be listed in the Department of Defense's _________________________________________________.
Defense Enrollment Eligibility Reporting System (DEERS)
___________ is a computerized data bank that lists all active and retired military service members
DEERS
TRICARE _______ is a fee-for-service option that has basically the same benefits as the original CHAMPUS program.
Standard
Family members of military service personnel in the Army Reserves and National Guard, called ___________, are eligible for TRICARE standard only if the RC is ordered to active duty for more than 30 consecutive days or if the orders are for an indefinite period.
Reserve Components (RCs)
TRICARE ______ is a preferred provider option (PPO)
Extra
TRICARE ______ is a health maintenance organization (HMO) type of managed care option in which MTFs are the principal source of health care.
Prime
TRICARE __________ is a comprehensive health benefits program established by the National Defense Authorization Act.
For Life (TFL)
This program is available to uniformed service retirees, their spouses, and their survivors who are age 65 or older, are Medicare- eligible, are enrolled in Medicare Part A and have purchased Medicare Part B Coverage
TRICARE for Life (TFL)
TRICARE claims should be submitted within __ days from the date services were rendered or as soon as possible after the care is rendered. No payment is made for incomplete claims or claims submitted more than 1 year after services re rendered for PARs and nonPARs.
30
CHAMPVA is health care benefits program for dependents of veterans who:
1. Have been rated by the Department of Veteran Affairs (VA) as having a total and permanent service-connected disability
2. Are survivors of veterans who died from VA-rated service-connected conditions or who, at the time of death, were rated permanently and totally disabled from a VA-rated service-connected condition
3. Survivors of individuals who died in the line of duty that was not due to misconduct and who are not otherwise entitled to TRICARE benefits.
CHAMPVA benefit pre-authorization is required for what certain types of services
1. Dental Care
2. Durable medical equipment with a total purchase price or total rental price o more than $300
3. Hospice services
4. Mental health/substance abuse services
5. Organ and bone marrow transplants
All CHAMPVA claims, whether electronic or paper, should be sent to what address ?
VA Health Administration Center
CHAMPVA
PO Box 65024
Denver, Co 80206-9024
In contrast to SSDI, individuals receiving SSI because of blindness or disability have no work requirements but must meet a ______________, a detailed and comprehensive questionnaire that establishes financial need.
Financial means test