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112 Cards in this Set
- Front
- Back
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Coding |
The process of translating written or dictated medical records into a series of numeric or alpha-numeric codes |
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Medical coders or coding specialists |
Technicians who specialize in coding Assign a code to each diagnosis, service/procedure, and (when applicable) supply, using classification systems |
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What are the two types of coders? |
- Outpatient/Professional coders - Inpatient/Facility coders |
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Outpatient coding |
Focuses on physician services
Work in physician offices, outpatient clinics and facility outpatient departments
Work with Ambulatory Payment Classifications
Usually have more interaction throughout the day and must communicate well with physicians Coders working in physician offices will mainly deal with Medicare part B |
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Outpatient coders "tools" |
CPT, HCPCS Level II, and ICD-10-CM |
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What organization is an outpatient coder certified through? |
AAPC |
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What certification do outpatient coders receive? |
CPC- Certified Professional Coder |
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Technicians who specialize in coding inpatient hospital services are called? |
Health information choices, medical record coders, coder/abstractors, or coding specialists |
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Inpatient hospital coding duties |
Assign MS-DRGs for reimbursement Tend to have less interaction throughout the day |
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What organization is an inpatient coder certified through? |
AHIMA |
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What certification do inpatient coders receive? |
CCS- Certified Coding Specialist |
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Inpatient or facility coders "tools" |
ICD-10-CM and ICD-10-PCS |
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What is the difference between Professional and Facility Coders? |
Professional- Code procedures and diagnoses for a physician Facility- Code for a facility Inpatient coders use ICD–10–CM and ICD–10–PCS |
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Documentation |
The recording of pertinent facts and observations about an individual's health history, including pay and present illnesses, tests, treatments, and outcomes |
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Medicaid |
A health insurance assistance program for some low-income people (especially children and pregnant women) sponsored by federal and state governments. It is administered on a state-by-state basis, and coverage varies-although each of the state programs adheres to certain federal guidelines |
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Medicare Severity-Diagnosis Related Groups |
Determines the amount the hospital will be reimbursed if the patient is covered by Medicare or other insurance programs using the MS-DRG system |
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State's scope of practice |
Each provider has differing levels of education. As such each state has guidelines for each level of provider |
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What is a provider? |
Anyone or entity that renders medical care, services or supplies |
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Physicians |
"MD" Undergo four years of college and four years of medical school, plus three to five years or more of residency (training in a specialty of practice). A physician can continue training in a sub-specialty, referred to as a fellowship |
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Mid-level providers |
Known as physician extenders because they extend the work of a physician Ex. PA's and NP's Often reimbursed at a lower rate than physicians |
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Physician assistant |
A mid-level provider Licensed to practice medicine with physician supervision Takes approximately w 26 and 1/2 months to complete a PA program |
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Nurse practitioners |
Have a master's degree in nursing |
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Self-payers |
Patients who pay in full for medical services by themselves (no insurance) |
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Two types of insurance payers |
Private insurance plans and government insurance plans |
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Commercial carriers |
Private payers that offer both group and individual plans |
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Medicare provides coverage for: |
People over the age 65, blind or disabled individuals, and people with permanent kidney failure or ESRD |
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Who administers Medicare? |
Centers for Medicare & Medicaid Services (CMS) |
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List of parts of the Medicare program |
Medicare part A Medicare part B Medicare part C Medicare part D |
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Medicare part A |
Helps to cover inpatient hospital care, as well as care provided in skilled nursing facilities, hospice care, and home healthcare |
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Medicare part B |
Helps to cover medically necessary doctors' services, outpatient care and other medical services (including some preventative services) not covered under Medicare part A An optional benefit for which the patient must pay a premium, and which general requires a gravely co-insurance. |
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Medicare part C |
Also called Medicare Advantage Combines benefits of parts A, B and C Plans are managed by private insurers approved by Medicare and may include Preferred Provide Organizations, Health Maintenance Organizations and others Plans may charge different copayments, coinsurance or deductibles for services |
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CMS-hierarchical condition category |
Risk adjustment model which provides adjusted payments based on a patient's diseases and demographic factors |
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Medicare part D |
A prescription drug coverage program available to all Medicare beneficiaries Private companies approved by Medicare provide the coverage |
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Limiting charge |
Limits set on what can be charged for each CPT code for Medicare services, even if a provider is non-participating |
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SOAP: Subjective |
The patient's statement about his or her health, including symptoms |
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SOAP: Objective |
The provider assesses and documents the patient's illness using observation, palpation, auscultation, and percussion. Tests and other services performed may be documented here as well |
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SOAP: Assessment |
Evaluation and conclusion made by the provider This is usually where the diagnosis(es) for the services are found |
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SOAP: Plan |
Course of action Where the provider will list the next steps for the patient, whether it is ordering additional tests, or taking over the counter medication etc. |
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Operative reports |
Used to document the detail of a procedure performed on a patient Most will have a header and a body in the report |
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What might be included in the header of an operative report? |
-date and time of the procedure -names of the surgeon, co-surgeon, assistant surgeon -type of anesthesia and anesthesia provider name -pre-operative and post-operative diagnoses -procedure performed -complications |
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What might be included in the body of an operative report? |
-indication for surgery -details of the procedure(s) -findings |
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Operative Report Coding Tips |
1. Diagnosis code reporting 2. Start with the procedures listed 3. Look for key words 4. Highlight unfamiliar words 5. Read the body |
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Medical necessity |
Whether a procedure or service is considered appropriate in a given circumstance Generally the least radical service/procedure that allows for effective treatment of the patient's complaint or condition |
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The National Coverage Determinations Manual |
Describes whether specific medical items, services, treatment procedures, or technologies can be paid for under Medicare Services and procedures are covered only when linked to designated, approved diagnoses Non-covered items are deemed not reasonable and necessary |
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National Coverage Determinations |
Explain when Medicare will pay for items or services |
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Medicare Administrative Contractor |
Responsible for interpreting national policies into regional policies |
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Local Coverage Determinations |
Further define what codes are needed and when an item or service will be covered Only have jurisdiction within their regional area Includes information on the National Coverage Policy it's attached to Explains when the service is indicated or necessary Gives guidance on coverage limitations Describes the specific CPT codes to which the policy applies Will list ICD-10-CM codes that support medical necessity for the given service or procedure |
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What form is provided to a patient to indicate a service may not be covered by Medicare and the patient may be responsible for the charges? |
ABN |
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Common reasons Medicare may deny a procedure or service |
-Medicare does not pay for the service/procedure for the patient's condition -Medicare does not pay for the procedure/service as frequently as proposed -Medicare does not pay for experimental procedures/services |
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When presenting a cost estimate on an ABN for a potentially non-covered service, the cost estimate should be within what range of the actual cost? |
$100 or 25% |
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What payer may not recognize an ABN |
Non-Medicare payers |
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Title II of HIPPA addresses the need for |
-National standards for electronic healthcare transactions and code sets -National unique identifiers for providers, health plans and employers -Privacy and Security of health data |
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What act of HIPPA is most relevant to coders? |
Title II |
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Title II of HIPPA |
Preventing Healthcare Fraud and Abuse; Administration Simplification; Medical Liability Reform |
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HIPPA: Under federal guidelines a covered entity is |
1. A healthcare provider - Doctors - Clinics - Psychologists - Chiropractors - Nursing homes - Pharmacies 2. A health plan - Health insurance companies - HMO's - Company health plans - Government programs that pay for healthcare 3. A healthcare clearinghouse |
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Who would NOT be considered a covered entity under HIPPA? |
Patient |
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Under HIPPA, what would be a policy requirement for "Minimum Necessary"? |
Only individuals whose job requires it may have access to protected health information |
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Which act was enacted as part of the American Recovery and Reinvestment Act of 2009 and affected privacy and security? |
HITECH |
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What document has been created to assist physician offices with the development of compliance manuals? |
OIG Compliance Plan Guidance |
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What document should be referred to when looking for potential problem areas identified by the government indicating scrutiny of the services within the coming year? |
OIG Work Plan |
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Transactions definition according to CMS |
Electronic changes involving transfer of information between two parties for a specific purpose |
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Examples of transactions |
1. Heath claims and equivalent encounter information 2. Enrollment and disenrollment in a health plan 3. Eligibility for a health plan 4. Healthcare payment and remittance advice 5. Health plan premium payments 6. Health claim status 7. Referral certification and authorization 8. Coordination of benefits |
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HIPPA |
Provides federal protections for personal health information when held by covered entities.
If an entity is not covered it does not have to comply with the Privacy or Security Rule Protects the privacy of individually identifiable health information Sets national standards for the security of electronic protected health information |
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Who enforces the HIPPA Privacy Rule? |
The OCR, The Office of Civil Rights |
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HIPPA "Minimum Necessary" requirement |
Only the minimum necessary protected health information should be shared to satisfy a particular purpose If information is not required to satisfy a particular purpose, it must be withheld |
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National Provider Identifier and Employer Identification Number |
Unique identifiers required in all transactions EIN's are issued to employers by the IRS |
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Under the Privacy Rule, the minimum necessary standard did not apply to |
-disclosures to or requests by a healthcare 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 HIPPA 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 |
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Benefits of HITECH |
-established four categories of violations and minimum and maximum penalties -allows patients to request an audit trial showing all disclosures of their health information made through an electronic -requires an individual be notified if there is an unauthorized disclosure or use of his or her health information |
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What is a compliance plan? |
A written set of instructions outlining the process for coding and submitting accurate claims, and what to do if mistakes are found |
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Benefits of a compliance plan |
-faster, more accurate payment of claims -fewer billing mistakes -diminished chances of a payer audit -less chance of running afoul of self-referral and anti kickback statues -increased accuracy of physician documentation may assist in enhancing patient care -show the physician practice is making a good faith effort to summit claims appropriately -sends a signal to employees that compliance is a priority -provides a means to report erroneous or fraudulent conduct so that it may be corrected |
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The Patient Protection and Affordable Care Act |
Makes compliance plans mandatory as a condition of participation in federal healthcare programs No implementation date yet |
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The Office Of the Inspector General |
A government agency tasked to protect the integrity of Department of Health & Human Services programs, as well as the health and welfare of the beneficiaries of PPACA programs |
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OIG Compliance Plan Guidance key actions |
-conduct internal monitoring and auditing through the performance of periodic audits -implement compliance and practice standards through the development of written standards and procedures -designate a compliance officer or contact(s) to monitor compliance efforts and enforce practice standards -conduct appropriate training and education on practice standards and procedures -respond appropriately to detected violations through the investigation of allegations and the disclosure of incidents to appropriate government entities -develop open lines of communication to keep practice employees updated regarding compliance activities -enforce disciplinary standards through well-publicized guidelines |
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Description of a medically necessary service
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Using the least radical service/procedure that allows for effective treatment of the patient's complaint or condition.
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What form is provided to a patient to indicate a service may not be covered by Medicare and the patient may be responsible for the charge?
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ABN
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ABN's may not be recognized by?
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non–Medicare payers
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When presenting a cost estimate on an ABN for a potentially non-covered service, the cost estimate should be within what range of the actual cost?
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$100. or 25% whichever is greater
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Who would NOT be considered a covered entity under HIPAA?
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Patient
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Under HIPAA, what would be a policy requirement for "Minimum Necessary?"
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Only individuals whose job requires it may have access to protected health information.
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Which Act was enacted as part of the American Recovery and Reinvestment Act of 2009 (ARRA) and affected privacy and security?
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HITECH
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What document has been created to assist physician offices with the development of compliance manuals?
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OIG Compliance Plan Guidance
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What document should be referred to when looking for potential problem areas identified by the government indicating scrutiny of the service within the coming year?
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OIG Work Plan
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According to the example LCD from Novitas Solutions, measurement of vitamin D levels is indicated for patients with which condition?
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Fibromyalgia
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What document has been created to assist physician offices with the development of Compliance Manuals?
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OIG Compliance Plan Guide
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What document should be referred to when looking for potential problem areas identified by the government indicating scrutiny of the services within the coming year?
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OIG Work Plan
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What type of professional might skilled coders become?
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Consultants, educators, medical auditors
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What is a mid–level provider?
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physician assistants (PA), and nurse practitioners (NP)
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What are the different parts of Medicare?
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Part A, B, C, D
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Evaluation and management services are often provided and documented in a standard format such as SOAP, What does SOAP represent?
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Subjective
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What are five tips for coding operative reports?
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Diagnosis code reporting, Start with the procedure listed, Look for key words, Highlight unfamiliar words, Read the body
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What is medical necessity?
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Relates to whether a procedure or service is considered appropriate in a given circumstance
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What is not a common reason Medicare may deny a procedure or service?
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Covered Service
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Under the Privacy Rule, the minimum necessary standard does not apply to these types of disclosures except?
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Uses or disclosures that are not required by other law
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When coding an operative report, what action would NOT be recommended?
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Coding from the header without reading the body of the report.
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HIPAA was made into law in what year?
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1996
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A medical record contains information on all but what areas?
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Financial records
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LCD's only have jurisdiction in their _________area.
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Regional
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Although voluntary, a compliance plan may offer several benefits such as?
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faster, more accurate payment of claims
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Technicians who specialize in coding are called?
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Coding Specialists
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AAPC credentialed coders have proven mastery of?
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All code sets
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Accurate and thorough diagnosis coding is important for Medicare Advantage (Part C) claims because reimbursement is impacted by?
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The patient's health status. CMS–HCC risk adjustment model provides adjusted payments based on a patient's diseases and demographic factors.
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Healthcare providers are responsible for developing ____________ of ____________ ____________ and policies and procedures regarding privacy in their practices.
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Notices of Privacy Practices
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According to AAPC's Code of Ethics, a member shall use only __________ and ___________ means in all professional dealings.
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legal and ethical
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The OIG recommends that the physician's practice enforcement and disciplinary mechanisms be?
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Consistent
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Each October the OIG releases a __________ outlining its priorities for the fiscal year ahead.
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Work Plan
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National Coverage Determinations serve what purpose?
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To spell out CMS policies on when Medicare will pay for items or services
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The ___________ describes whether specific medical items, services, treatment procedures, or technologies are considered medically necessary under Medicare.
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National Coverage Determination Manual
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HITECH provides a ___________ day window which any violation not due to willful neglect may be corrected without penalty?
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30
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What type of health insurance provides coverage for low–income families?
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Medicaid
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What code set is used for procedures? |
CPT |
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What code set is used for diagnoses? |
ICD-10-CM |
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What code set is used for supplies and drugs? |
HCPCS Level II |
