HHP 435

  1. CPT Codes
    • Current Procedure Terminology
    • 5 digit codes used to identify specific medical services
  2. ICD-9 Codes
    • International Classification of Diseases
    • 3, 4, & 5 digit codes used to identify specific injury/disease diagnoses
  3. HCPCS Level II Codes
    • Healthcare Common Procudure Coding System
    • Required for reimbursement of Durable Medical Equipment (DME)
    • Letter followed by 4 digits
  4. Beneficiary
    Person eligible to recieve benefits of an insurance policy
  5. Dependent
    Person eligible to receive benefits of an insurance policy by virtue of relationship to policy holder
  6. Health Plan
    Outline of services covered by insurer/employer
  7. Exclusions
    Specified services, procedures, disorders, and durable medical equipment (DME) that are not covered by a health plan
  8. Participating provider
    • service provider who has entered into contrct with a payer
    • acceptance of payer fee schedule or discounted rates
    • no balance billing
    • full charge to patient for uncovered services
  9. Patient Encounter Form (charge sheet)
    form for documentation of diagnosis and procedures administered on a specific service date
  10. Claim
    • form sent to insurance company of TPA requesting payment for medical services provided to benificiary
    • CMS-1500(medicare) or UB-92(hospitals)
  11. Clean Claim
    Claim form containing all info necessary for processing
  12. Explanation of Benefits (EOB)
    report explaining how an insurance company or TPA processed a claim
  13. Chondromalacia
    Often designated as an excluded degenerative conditon by payors
  14. Patellofemoral tendinitis
    generally considered as a covered injury
  15. Medicare definition of fraud
    intentional deception or misrepresentation that an individual knows to be false, or does not believe to be true, and makes knowing that the deception could results in some unauthorized benefit to himself or some other person
  16. 2 primary concerns of medicare fraud
    • 1. offering or accepting kickbacks
    • 2. waiver of deductible/coinsurance
Card Set
HHP 435
Unit 2 Review