mom- coding & ins. part 1

  1. actuaries
    figure premiums necessary to provide coverage to any given group of people
  2. first company to write health ins.
    • founded in 1847
    • replacement of income rather than hosp/surgery benefits
  3. Dallas texas, and health insurance.
    Baylor hospital provided hospital care to teachers for 6 a year
  4. premium
    basic cost of health care

    insurer agrees to provide certain benefits
  5. subscriber
    responsible for paying deductible, co payment, services not covered
  6. deductible
    portion of the bill must pay before insurance coverage is effective
  7. co-payment
    subscriber must pay to cover some portion of each bill
  8. co-insurance
    certain percentage of the bill
  9. group policy
    "blanket contract"

    group of employees, insured under a single policy

    lower premiums, better benefits
  10. individual policy
    "personal ins.

    insured to an individual

    higher premiums, less benefits
  11. government plan
    issued by government
  12. medicare
    • 65 or older,
    • disabled
    • blind
    • kidney dialysis
  13. part a of medicare
    hospital stays
  14. part b of medicare
  15. part d of medicare
  16. medicaid
    state & federal plan for low income
  17. champus/tricare
    gov. plan for armed services, retired from service, dependences of armed services
  18. accident & health ins.,
    benefits payable cause of disease, accidental injury, accidental dealth
  19. blue cross
    hospital care
  20. blue shield
    dr, lab, x-rays
  21. basic medical
    all/part of dr.s fees for non-surgical services, hospital, home care, office visits
  22. major medical
    against major illness/injury
  23. comprehensive majory medical
    both basic & major
  24. HMO (Health Maintenance Organization)
    specified group at a fixed periodic payment

    gov. hospital. employer
  25. IPA (Individual Practice Association)
    dr. contracts w/ ins. plan on a fixed capitation per month
  26. capitation
    payment of a health group is prepaid at a fixed amount for each pt. served w/o consideration of the service provided
  27. PPO (Preferred Provider Organization)
    plan where pt. must participate with certain dr.

    supply services @ a discounted/fixed fee
  28. special class ins.
    who do not quality for standard health ins, because of health reasons

    limited coverage
  29. special risk ins.
    protects a person from a certain type of accident/illness

    maximum benefit
  30. insured
    subscriber, member, policy holder,

    who the policy is issued to
  31. carrier
    the ins. co. who writes/administer the policy
  32. claim
    demand for payment
  33. beneficiary
    person designated to receive benefit
  34. provider
    who supplies the services
  35. assignment of benfites
    pt. signs to authorize payment og directly to dr.
  36. coordination of benefits
    pt. has more than 1 ins policy,

    coordinated payment to prevent duplication of overpayment
  37. fiscal intermdiary
    ins. co that processes clams,

    issues for state & federal agencies
  38. waiting period

    "elimination period"
    time limit before certain conditions are covered
  39. exclusions
    itens not covered by ins.
  40. precertification
    determines if policy will cover the procedure
  41. predetermination
    determines the amt. of coverage for the service
  42. payment of benefits
    • indemnity schedule
    • service plans
    • USC
    • RBRVS
  43. indemnity schedule
    ins. pays subscriber a set. amt. of money for a given service

    pt. is given a fee schedule when policy is started
  44. service benefit plan
    ins. agrees to pay for certain services w/o additional costs

    payments are higher

    no fee schedule
  45. UCR
    ins. pays based on dr's UCR

    • usual- dr's fee
    • customary- range of usual fees in geographical area
    • reasonable- applies to difficulty or complications
  46. RBRVs (resource based relative value scale)
    adopted by medicare in 1992

    amt. of resource required to perform a service is determined by this which was assigned to a CPT code
  47. what does the RBRV (resource based relative value scale) do?
    standardize payment with an adjustment for overhead costs in diff areas,

    fee schedule is basis for payment for dr's services under medicare part b

    nation uniform payment
  48. DRG's  (developed by yale)
    is 383 major diagnostic categories based on ICD-9 codes

    classifies pts. into groups based on principal or absence of comorbidities or complications and relevant criteria
  49. claim form CMS 1500 (center for medicare/Medicaid services)
    filing medicare/Medicaid claims

    use original top form printed in red for OCR scanners
  50. accepting assignemnt
    a form asks if your dr. will accept assignment, dr. will accept the fee that the isn determines

    check will be sent directly to dr.

    if dr fee is higher, they will write off the balance
  51. claims register
    a log of ins. as received & processed

    you can see what claim has been filed, n if it was paid

    follow-up w/I 30-45 days
  52. clean claim
    form that is filed w/ all data necessary for immediate processing w/ no erros

    if no sent w/I 30 days, have to pay 1.5% interest per month
  53. ICD9-CM means & is?
    international classification of Diseases, 9th Revision, Clinical Modifications

    codes diagnosis

    5 digit numerical code

    published annually by AMA
  54. CPT-4 means & is?
    Current Procedural Terminoloy, 4th Edition

    codes procedures

    has 3 levels
  55. level 1 of CPT-4
    codes contained in CPT book

    5 digit codes, 2 digit modifiers
  56. level 2 of CPT-4
    is HCPCS

    developed by CMS to describe services/supplies not covered in CPT book

    modifiers- alphanumerical or 2 letters

    maintained by CMS
  57. level 3 of CPT-4
    codes not common to all ins. carriers

    assigned by local medicare carrier

    not in level 1/2

    starts w/ a letter W-Z followed by 4 digits
  58. modifiers
    2 digit number to supply additional information

    in appendix a of cpt book
  59. multiple modifiers
    • when more than 1 is needed,
    • the 1st modifier used is 99
  60. sections of CPT book
    • em
    • anesthesia
    • surgery
    • radiology, nuclear medicine
    • pathology/lab
    • medicine
  61. separate procedures
    the separate procedure may be found in parenthesis

    used when procedure is ordinarily a component for a larger procedure and is performed alone
  62. unlisted procedures
    a code ending in 99, only used when coder cannot find a code to describe the procedure

    supply written description of procedure

    found in sections- medicine, surgery
  63. code changes
    summary of additions, deletions, revisions

    found in appendix b

    a dot placed before the code #
  64. index- always begin here
    • back of book,
    • alphabetical index
    • organs, anatomic sites, conditions, synonyms, eponyms (term including name of person), abbreviations
  65. guidelines
    at begin of book, explains terms applying to that section
  66. global billing concept
    surgery section, most procedures include 2 components in addition to ones listen

    • administration of anesthesia,
    • normal, uncomplicated follow-up care

    grouping of services into a "package"
  67. up-coding
    deliberate increase in the cpt-4 code, to receive higher reimbursement
  68. managed health care
    system for operatin health ins. program to ensure cost-effects delivery of all health care services
  69. principals of managed health care
    primary care physicians

    • require preauthorization,
    • increase o.p. care over IP hospitalization

    contacting w/ physicians/instituitions to achieve discounted rate & incentives for referrals
  70. managed care
    term used for a variety of prepaid health plans developed to provide health services at a low cost
  71. PCP
    primary care provider

    supervises/coordinates health care services for enrollees, except in emergencies

    "gatekeeper"- lowest possible price and avoiding nonessential care
  72. quality assurance "QA"
    assesses quality of care provided in health care
  73. Utilization Management "UM"
    reviews necessity of health care provided to patients
  74. preadmission certification, preadmission review, preauthorization
    reviews medical necessity of inpatient care prior to admission

    makes sure admission is necessary & appropriate

    grants prior approval for payment of services
  75. second surgical opinion
    managed care plans require a pt. to obtain a 2nd option prior to scheduling an elective surgery

    2nd dr. must recommend most economical way to do it.
  76. Utilization review organization "URO"
    third-party administration

    UR program evaluates medical necessity, appropriateness, efficient use of the services, procedures, facilities,
  77. HMO's
    health maintance orgainzation

    "managed care"

    prepaid plan

    agrees to provide service to every enrolled member for a prepaid amount/plan
  78. basic philosophy of an HMO
    • good health habits,
    • early detection
    • preventative care leads to healthier pts.

    a strong emphasis on well-care, early detection, efforts to lessen more serious /costly care
  79. history of HMO
    oldest privately own HMO

    founded in 1929,

    Ross-Loos Medical Group

    Kaiser Permanente medical program (1933)
  80. health maintenance organization act of 1973
    created authority for federal gov. to assist HMO development

    • gives grants, loans to initial operating cost
    • requires most employers to offer HMOs as an alternative to traditional health care
  81. services provided by HMO
    • preventative care
    • hospitalization
    • x-ray, lab
    • physical therapy
    • pharmacy
  82. types of HMOs
    • prepaid group practice model
    • staff model
    • independent practice association (IPA)
    • network HMO's
  83. prepaid group practice model
    dr's form a group contact with a health plan

    drs are not employeed paid by health plan
  84. staff model
    health plan hires doctors directly & pays them a salary
  85. independent practice association
    drs are independent who continue to practice in their own office,

    drs paid for services from premiums collected

    drs share any surplus or deficit

    IP may pay each dr a set amt. in advanced (capitation)

    may pay fee charged for services

    may contract w/ several IPA's at the same time
  86. network HMO's
    contracts w/ 2 or more group practices to provide health ins.
  87. examples of HMO's
    • Kaiser permanente founded in 1933
    • blue cross/ blue shiedl
    • medi-cal in california
    • medicare
  88. preferred provider organization (PPO)
    preserves the fee-for-service conept

    insurer (inc. co.) contracts w/ a dr and they agree on predetermined list of charges

    care is not prepaid

    usually a deductible & coinsurance
  89. obtaining precer/preuahtoirzation
    copy id card on both sides

    call plan, keep a record of requirements on a reference guide

    (reference guide, documents the call)
  90. information to obtain from plan/and card
    • name, address, phone #, copay, deductible
    • hospital benefits for IP, OP, surgery
    • 2nd opinion, preauthorization requirements
    • participating hospitals, labs, doctors
    • call for precert, give pt. letter & sign outlining the plain requirements, possible restrictions or non-covered items
    • referrals are required, explain to pt that w/o the referral, it will be their responsibility to pt for doctors fees
  91. regular referral
    takes 3-10 days,

    • when pt. has not responded to PCP's treatment/meds,
    • doctor believes pt needs to see specialist
  92. urgent referral
    takes 24 plus hrs

    when urgent matter occurs, but it is not life threatening
  93. stat referrals
    approved by telephone immediately after faxing papers to UR department

    emergency situations, life/death situations, loss of limb, miscarriage,

    pt gets letter w/ authorization and approved services

    pt needs to present authorization letter to specialist on day of service
  94. authorization
    dr must have letter before seeing the pt.

    if no letter, deny services

    if pt. seen w/o the letter && it was never authorized, pt. cannot bill for the services
  95. authorization letter contains
    • authorization number,
    • date received by UR, date approved, expiration date,
    • diagnosis code
    • name, address, phone of specialist
    • number of authorized visits to specialist
  96. medical record audit
    audited at any time by the MC (managed care carrier)

    MC has right to access any chart on demand

    must make sure chart is properly assembled & maintained at any time
  97. information loked at during the audit
    • security of records,
    • is confidentiality maintained
    • is chart organized, n in chronological order
    • complete, contain family/persona/past/social history of pt
    • dated entries
    • name on each page
    • legible chart
    • all entries signed
    • are missed appts. documented
    • has dr. initialed all entries
  98. ROA means
    received on account

    give receipt unless check-unless they request one

    if 3rd party payment note on the ledge that it was a 3rd party
  99. ROA can be?
    ROA ins.

    ROA cash

    ROA check
  100. adjustments
    necessary for prof. discounts in, dis-allowance's write-off..

    enter amt. of adjustment in adjustment colum

    amt. is subtracted from balance
  101. NSF means
    non-sufficient funds (check

    when check is accepted then returned from back for non-payment

    must re-add balance back-onto pts. balance

    decrease amt. from checkbook balnace
  102. how much do collection agency's typically charge?
  103. end of day summarizing are entered in ink or pencil?
  104. when editing end of day summarizing how many lines cross out the wrong number?
    one line
  105. accounts receivable control tells you what?
    how much money is on the books

    how much money owed to dr.

    should be no more than 2-3 mnths gross charges on the books
  106. trial balance of accounts receivable
    totals of balances from all ledges should equal the accounts receivable on the pegboard

    do monthly

    add balances from ledger cards together, should be the same amt. on accts. receivable
  107. one write check writing
    incorporates pegboard to write checks,
  108. 3 components of E/M codes
    • history
    • examination
    • medical decision making
  109. when was E/M coding added to CPT?

    represents 65% of medicare part B payments
  110. services that are in E/M coding section?
    well & sick visits

    case management services

    preventive & prolonged services
  111. concurrent care
    provision of similar services (hospital visits to the same pt but more than 1 doctor in same day)
  112. categories in the E/M
    • office/outpatient
    • hospital observation services
    • hospital inpatient
    • consultation
    • emergency department services
  113. e/m services include
    • examinations
    • evaluations
    • treatments
    • conferences w/ or concerning pt.
    • preventive pediatric & adult care
    • nursing facility services
    • home service
  114. 6 levels of the E/M
    • history
    • examination
    • medical decision making
    • counseling
    • coordination of care
    • nature of presenting problem
    • time
  115. problem focused history
    chief complaint, brief history/PI, problem pertinent to system review
  116. detailed history
    CC extended history of PI, extended system review, pertinent to past, family, social history
  117. comprehensive history
    CC, extended history of PI, complete system review, complete past family/social history
  118. problem focused exam
    exam that is limited to the affected body area
  119. extended problem focused exam
    exam of affected body area/organ system & other symptoms related to organ system
  120. detailed exam
    extended exam of affected body area & other symptomatic or related organ
  121. comprehensive exam
    single system specialty exam or complete multi-system exam
  122. moderate complexity
    • multiple dx,
    • moderate amt. of data to review
    • moderate risk of complications/morbidity/mortality
  123. high complexity
    • extensive dx
    • extensive data to review
    • high risk of complications/morbidity/mortality
  124. medical decision making
    refers to complexity of establishing a dx, or selecting management option
  125. morbidity
    state of being diseased
  126. comorbidity
    a disease coexisting w/ primary disease
  127. straightforward decision making
    • minimal # of dx
    • minimal complexity of data to review
    • minimal risk of complication
  128. low complexity decision making
    • limited # of dx
    • limited complexity of data to review
    • low risk of complications
  129. counseling
    discussion w/ pt. or family concerning the services provided
  130. coordination of care
    what other care must be coordinated to take care of pt.
  131. nature of presenting problem
    presenting problem is a disease, condition, illness, injury, symptom, sign, finding, compliant, or other reason for the fivis
  132. minimal presenting problem
    may not require presence of dr, but service is provided under dr. supervision
  133. self limited or minor presenting problems
    it runs a definite prescribed course
  134. low severity presenting problem
    risk of morbidity w/o treatment is low
  135. moderate severity of presenting problem
    risk of morbidity w/o treatment is moderate
  136. high severity of presenting problem
    risk of morbidity w/o treatment is high to extreme
  137. modifiers
    • used to modify certain circumstances
    • 2 digits attached after the CPT code
    • don't use a dash, just 1 blank space
  138. modifier 21
    prolonged evaluation/management service
  139. modifier 24
    unrelated e/m service by same dr. during postoperative period
  140. modifier 52
    reduced services
  141. CMS-1500
    Center for medicare & Medicaid services insurance claim form
  142. when was the CMS-1500 developed && by who?
    • 1975
    • AMA
  143. medical abstacting
    a brief summary taken from the pts chart
  144. special release form
    must be singed by pt.

    • mental
    • psychological
    • alcohol
    • drug
    • aids
  145. code injections
    • name of med
    • amount of med
    • how it was given
  146. code x-rays
    • part of body filmed
    • number/types of views
  147. coding itemized lab tests
    • if outside lab give
    • name, address
  148. coding lacerations
    • length in cm
    • exact location
    • type of repair (simple, intermediate, complex)
  149. coding tumros
    • type
    • size
    • location
  150. coding unlisted CPT codes
    • codes ending in 99
    • send detailed report
    • copies of lab, operative, pathology reports
  151. claims register
    • helps w/ cash flow
    • tells at a glance which claims are delinquent && follow-up on those makes it easier
    • helpful to all staff
    • keep it up to date
Card Set
mom- coding & ins. part 1
coding, ins. part 1