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| Category | Information |
|---|---|
| Outpatient Coding | 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. |
| PCP | Primary Care Provider (Gate Keeper). |
| Physician Extenders | 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. |
| 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. |
| CMS Regulations | 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. |
| Medicaid | 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. |
| MEDIGAP Insurance | 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. |
| Workers Compensation | Insurance provided by employers to cover employees injured on the job. |
| Managed Care Organization (MCO) | Includes HMO, PPO, and POS plans. |
| HMO | Health Maintenance Organization. |
| PPO | Preferred Provider Organization. |
| POS | 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). |
| Physician Work | Accounts for just over half (52%) of a procedure/service total relative value. Is measured by the time it takes to perform the service. |
| Practice Expense | 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. |
| PE | Physician Expense. |
| MP | Malpractice. |
| 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. |
| Medical Necessity | 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 | HCFA, UB04. |
| 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. |
| NSF | National Standard Format – Limited byte carrying capacity. |
| ANSI | American National Standard Institute – Flexible format. |
| Medical Records | 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. |
| EOMB | 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. |
| Co-Pay | Is a set amount. |
| Coinsurance | Is a percentage of the service costs that patients pay. |
| UCR | Amounts commonly charged for a service within a particular geographic region. |
| EDI | Electronic Data Interchange. |
| Capitation | Pre-established payments to providers for enrollees over a period of time, whether the patient is seen or not by the provider. |
| Deductible | The amount the patient is financially responsible before an insurance policy provides payment. |
| CMS 1500 | Standard claim form used to submit physician office services to Medicare and other insurance payors. |
| TPA | 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. |
| Timely Filing | You must file the claim within a set amount of time your insurance contract indicates to be paid. |
| MCO | A health care provider or a group or organization of medical service providers who offers managed care health plans. |
| Participating Provider | Physician will accept the amount paid by the insurance company and will be responsible to write-off the non-allowed amount. |
| Denied Claim | Investigate to see why it was denied and re-bill with information to support payment. |
| Claim Adjudication | 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. |
| Medigap Policies | Health insurance sold by private insurance to help pay for some costs the medicare plan doesn’t cover. |
| EPSDT | Early and Periodic Screening, Diagnosis, and Treatment – Medicaid’s comprehensive preventative child health care program for individuals 0-21 years of age. |
| Medicaid Benefits | Federally funded program, and administered by each state. |
| Service Description | Is a description of the health care services you received, like a medical visit, lab tests or screenings. |
| Provider Charges | Is the amount your provider bills for your visit. |
| Allowed Charges | Is the amount your provider will be reimbursed; this may not be the same as the provider charges. |
| Remark Code | 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). |
| National Provider | Name for the identifier physicians and other healthcare providers must use when claiming Medicare reimbursement. |
| Medicare Part B | Pays for physician service. |
| Prospective Audit | Refers to auditing patient records against proposed billing information. |
| Qui Tam | 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. |
| ARRA | American Recovery and Reinvestment Act. |
| HITECH | 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. |
| Coinsurance | An arrangement where the patient and the insurance company share payment of a health care service. |
| AMA | CPT is published by the American Medical Association. |
| ICD 10-CM | The manual used to code diagnosis. |
| ICD 9-CM | Is revised every year on October 1st. |
| HCPCS | Is published by CMS. |
| COB | Coordination of Benefits. |
| COBRA | Consolidated Omnibus Budget Reconsideration Act. |
| DRG | Diagnosis Related Group. |
| SSN | Social Security Number. It has 9 digits. |
| DSM IV | 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. |
| Physician Edits | These code pairs apply to physicians, non-physician practitioners, and ambulatory surgery centers. |
| Outpatient Edits | 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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