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|Focuses on physician professional services and outpatient facility coding. Coders should learn CPT, HCPCS Level 2 and ICD-10-CM.
|Hospital Inpatient Coding
|Focuses on a different subset of skills, where coders will work with ICD-10-CM and ICD-10-PCS. Coders assign medical severity diagnosis related groups (MS-DRGs).
|Types of Providers
|1. Primary Care Provider (PCP) 2. Physician Extenders 3. Participating Providers 4. Non Participating Providers.
|Primary Care Provider (Gate Keeper).
|Mid-level provider, Advanced Practice Registered Nurse (ARPN), Nurse Practitioner (NP), Physician Assistant (PA), Clinical Nurse Specialist (CNS).
|Participating Providers – Par Provider or In Network Provider (INN)
|Is one contracted with the health insurance company to provide service to plan members for specific pre-negotiated rates.
|Non Participating Providers – Non Par Provider or Out of Network Provider (OON)
|Is one not contracted with the health insurance plan.
|2 Primary Types of Insurers
|Private Insurance Plans, Government Insurance Plans.
|Commercial Insurance or Non Federal Insurance
|Are private payers that may offer both group and individual plans. Contracts they provide may include hospitalization, basic and major medical coverage.
|Government Insurance or Federal Insurance
|The most significant insurance is Medicare.
|Is a federal health insurance program administered by the Centers for Medicare and Medicaid Services (CMS).
|Centers for Medicare and Medicaid Services (CMS)
|Provides coverage for people over the age 65, blind or disabled individuals, and people with permanent kidney failure or ESRD.
|Determine the coding requirements for Medicare and non-Medicare payers alike.
|Medicare Program is Made Up of Several Parts
|Medicare Part A, Medicare Part B, Medicare Part C, Medicare Part D.
|Medicare Part A
|Cover inpatient hospital care, as well as care provided in skilled nursing facilities, hospice care, and home healthcare.
|Medicare Part B
|Covers medically necessary physicians’ services, outpatient care and other medical services (including some preventive services). Medicare Part B is an optional benefit for which the patient must pay a premium and which generally require a yearly deductible and co-insurance.
|Medicare Part C (Medicare Advantage)
|Combines benefits of Part A and Part B and sometimes Part D. Plans are managed by private insurers approved by Medicare. The plans may charge different co-payments, co-insurance, or deductibles for services.
|Medicare Part D (Prescription Drug Coverage Program)
|Available to all Medicare beneficiaries. Private company approved by Medicare provide coverage.
|Is a health insurance assistance program for some low income people, children and pregnant women sponsored by federal state and state government.
|State-Funded Insurance Programs
|Providing coverage for children up to 21 years of age may include crippled children’s services, children’s medical services, children’s indigent disability services and children with special health care needs.
|CHAMPUS or TRICARE
|– Civilian Health and Medical Program of the Uniformed Services – Insurance linked to military services also known as TriCare – Benefits program for active duty and retired members of the military.
|CHAMPVA (Civilian Health and Medical Program of the Department of Veterans Affairs)
|Is a health care benefits program for permanently disabled veterans and their dependents.
|Privately purchased individual or group health insurance policies designed to supplement medicare coverage. Benefits may include payment of Medicare deductibles co-insurance and balance bills, as well as payment for service not covered by Medicare.
|Insurance provided by employers to cover employees injured on the job.
|Managed Care Organization (MCO)
|Includes HMO, PPO, and POS plans.
|Health Maintenance Organization.
|Preferred Provider Organization.
|Point of Service Plan.
|Medical Physician Fee Schedule (MPFS)
|Look up tool, provides information on each procedure code including the global surgery indicator.
|Resource Based Relative Value Scale (RBRVS)
|To determine how much money medical provider should be paid. Assigns procedures performed by a physician and other medical provider a relative value which is adjusted by geographic region.
|Resource Costs are Divided Into 3 Components
|1. Physician Work 2. Practice Expense 3. Professional Liability Insurance (PLI).
|Accounts for just over half (52%) of a procedure/service total relative value. Is measured by the time it takes to perform the service.
|Accounts 44% of the total relative value for each service. Its relative values are resource based and differ by site of service.
|Professional Liability Insurance (PLI)
|Accounts for 4% of the total relative value for each service.
|Physician Fee Schedule (PFS)
|CMS annually publishes PFS information on its website.
|GPCI (Geographic Cost Index)
|Used to realized the varying cost based on geographic location.
|CF (Conversion Factor)
|This is a fixed dollar amount used to translate the RVU’s into fees.
|Refers to whether a procedure or service is considered appropriate in a given circumstance.
|National Coverage Determination, (NCD)
|Explain when Medicare will pay for items or service.
|Medicare Administrative Contractor (MAC)
|Is responsible for interpreting national policies into regional policies, called Local Coverage Determination (LCD).
|Local Coverage Determination (LCD)
|Explain when a given service is indicated or necessary, give guidance on coverage limitations, describe the specific CPT codes to which the policy applies, and list ICD-10-CM codes that support medical necessity for the given service or procedure.
|Advance Beneficiary Notice (ABN)
|Is a written beneficiary notification to the beneficiary indicating that the insurer may not reimburse the cost of the procedure and therefore the patient may be liable to pay.
|Types of Claims
|1. Paper Claims 2. Electronic Claims.
|Types of Paper Claims
|Health Care Financing Administration (HCFA)
|Also called CMS-1500. Standard medical claim form used for submitting Medicare Part B (outpatient billing).
|Uniformed Bill (UB 04)
|Also called as CMS 150. Paper claim for Medicare Part A (inpatient billing).
|Types of Electronic Claims
|1. NSF 2. ANSI.
|National Standard Format – Limited byte carrying capacity.
|American National Standard Institute – Flexible format.
|Chronologically documents patients care between providers, facilitate claims receive and payments and can serve as legal documents. All services provided to the patient must be supported and documented.
|EOB (Explanation of Benefits)
|Documents are protected health information. A report with details the results of processing a claim.
|Explanation of Medicare Benefits, Remittance Advice.
|EOB or EOMB
|A statement sent by a health insurance company to cover individuals, explaining what medical treatments and/or services were paid for on their behalf. Commonly attached to a check or statement of electronic payment.
|EOB Typically Describes
|The payee, the payer, and the patient. The services performed. Doctor’s fee and what the insurer allows. The amount the patient is responsible for. Adjustment reasons, adjustment codes.
|Is a set amount.
|Is a percentage of the service costs that patients pay.
|Amounts commonly charged for a service within a particular geographic region.
|Electronic Data Interchange.
|Pre-established payments to providers for enrollees over a period of time, whether the patient is seen or not by the provider.
|The amount the patient is financially responsible before an insurance policy provides payment.
|Standard claim form used to submit physician office services to Medicare and other insurance payors.
|A company that provides health benefits claims administration, processes claims and other outsourcing services for self-insured companies.
|COB (coordination of benefits)
|Prevents multiple insurance plans from paying benefits covered by other plans when the patient has more than one policy.
|You must file the claim within a set amount of time your insurance contract indicates to be paid.
|A health care provider or a group or organization of medical service providers who offers managed care health plans.
|Physician will accept the amount paid by the insurance company and will be responsible to write-off the non-allowed amount.
|Investigate to see why it was denied and re-bill with information to support payment.
|Claim is reviewed by the insurance company to make sure it correct for demographics, codes, payer rules have been followed and are covered benefits under the patients insurance contract.
|Utilization Review Organization
|The insurance companies will hire companies to review the appropriateness and medical necessity of procedures, surgeries and other services. This takes the burden off the insurance company off not authorizing a service due to cost.
|Health insurance sold by private insurance to help pay for some costs the medicare plan doesn’t cover.
|Early and Periodic Screening, Diagnosis, and Treatment – Medicaid’s comprehensive preventative child health care program for individuals 0-21 years of age.
|Federally funded program, and administered by each state.
|Is a description of the health care services you received, like a medical visit, lab tests or screenings.
|Is the amount your provider bills for your visit.
|Is the amount your provider will be reimbursed; this may not be the same as the provider charges.
|Is a note from the insurance plan that explains more about the costs, charges and paid amounts for your visit.
|HIPAA Standards Code Sets
|1. Codes for Dental Procedures and Nomenclature (CDT) 2. Healthcare Common Procedure Coding System (HCPCS).
|Name for the identifier physicians and other healthcare providers must use when claiming Medicare reimbursement.
|Medicare Part B
|Pays for physician service.
|Refers to auditing patient records against proposed billing information.
|A lawsuit initiated by a private citizen on the government’s behalf.
|Hospital Authorization for Emergency Patients
|Hospitals can request insurance prior authorization for patients with emergency medical conditions once the patient is admitted to the hospital as an inpatient.
|Patient (under HIPAA)
|Would not be considered a covered entity under HIPAA.
|HIPAA “Minimum Necessary” Policy
|Only individuals whose job requires it may have access to protected health information.
|American Recovery and Reinvestment Act.
|Health Information Technology Economic and Clinical Health Act.
|OIG Compliance Plan Guidance
|A document that is created to assist physician offices with the development of compliance manuals.
|OIG Work Plan
|A document to be referred to when looking for potential problem areas identified by the government indicating scrutiny of the services within the coming year.
|An arrangement where the patient and the insurance company share payment of a health care service.
|CPT is published by the American Medical Association.
|The manual used to code diagnosis.
|Is revised every year on October 1st.
|Is published by CMS.
|Coordination of Benefits.
|Consolidated Omnibus Budget Reconsideration Act.
|Diagnosis Related Group.
|Social Security Number. It has 9 digits.
|Diagnostic and Statistical Manual of Mental Disorders, fourth edition.
|Advanced Billing Contract Codes
|Codes are alphanumeric representatives of alternative medicine, nursing and other integrative health care interventions.
|MACs or FIs
|CMS delegates the daily operation of the Medicare program to these entities.
|Medicare Part A
|Covers most medically necessary hospital, skilled nursing facility, home health, and hospice care.
|Medicare Part B
|Covers most medically necessary doctor, preventative care, medical equipment, hospital outpatient services, lab tests, mental health care, home and ambulance. Always requires monthly premium.
|These code pairs apply to physicians, non-physician practitioners, and ambulatory surgery centers.
|These edits apply to the following types of bills: hospitals, skilled nursing facilities, home health agencies, outpatient physical therapy and speech language pathology providers, and comprehensive outpatient rehabilitation facilities.
|National Coverage Determination (NCD)
|Is a US nationwide determination of whether Medicare will pay for an item or service.
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