Medical Coding Flashcards

1
Q

healthcare systems

A

-expenditure
-quality
-availability
-populations health
-upfront costs

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2
Q

types of insurance

A

-employer-provided (private)
-medicare (federal)
-medicaid (state)

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3
Q

choosing insurance plans (private)

A

-deductibles- paid before insurance plan contributes to service/cost
-copayments- paid to every medical visit
-coinsurance- percentages of cost paid
-premiums- paid regardless of use/claim

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4
Q

employer provided

A

-affordable health care act 2010- lower healthcare costs- pre-tax cash to buy choice of insurance
-expand coverage- maximize time of short-term insurance plans
-network must be used

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5
Q

no insurance

A

-emergency medical treatment and labor act (EMTALA) 1986- ensure public access to emergency services regardless of ability to pay
-hippocratic oath- medical oath of ethics
-large medical bills- bankruptcy

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6
Q

US department of health and human services

A

-enhance the health and well-being of all Americans by promoting and providing:
-medical services
-public health services
-social services
-centers for medicare and medicaid services

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7
Q

medicare (federal)

A

-age >65 no matter income
or
-severe disabilities- ie- end stage renal disease, transplant no matter income
-funds:
-taxes- 2.9% split between employee and employer
-individual premiums
-tax deductible programs

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8
Q

medicaid (jointly operated by state and federal)

A

-low cost or free health insurance for - low income, disabilities, pregnant women
-service coverage is state-dependent- dental, vision, hearing
-cost vary from state to state
-may be full vs. supplemental coverage (after medicare or supplemental insurance)
-outcomes affect state reimbursement

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9
Q

federal vs state

A

-federal oversees all states- establish mandatory requirements for each state to receive federal funds
-states determine specific eligibility- duration, amount, type of service, scope of practice
-states “fee for service” to providers

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10
Q

high healthcare costs

A

-administrative
-drugs
-wages
-new technologies
-diverse charges (medical institution dependent)
-liability insurance

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11
Q

history of coding and classification

A

-ICD-10
-wordwide comparison
-london bills of mortality- classification of causes of death created ICDs -> documentation

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12
Q

who you should care about reimbursement and coverage issues

A

-knowledge of billing and coding rules is a marketable skill
-influences your scope of practice
-assists you when discussing practice compensation models and your work contract
-knowledge of rules helps to avoid allegation of fraud and abuse

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13
Q

documentation: old and new rules

A

-the old rule- if it wasnt written in the chart, it didnt happen
-new rule
-even if it is written in the chart, if it isnt medically necessary it wont be reimbursed
-outweigh costs and benefit

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14
Q

overview of the coding process

A

-you have a new pt who requires evaluation for a symptom
-diagnostic studies may be required
-a prescription for treatment (medication of physical therapy) based on your diagnosis is generated

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15
Q

EMR

A

-an interview (history) and diagnostic evaluation (physical examination) are performed
-check templates before signing a note

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16
Q

medical coding

A

-a numeric expression of a pts diagnosis and any service performed on that pt
-Prior to the advent of diagnosis related groups, coding was used primarily for research and public health planning.
-Coding allow for the study of disease patterns, treatment modalities and causes of mortality.
-Translates diagnoses and procedures into numbers for the purpose of statistically capturing data.

17
Q

your documented examination is translated into codes

A

-ICD- international classification of diseases
-CPT- current procedural terminology

18
Q

ICD

A

-international classification of diseases
-describes the pts symptoms, condition, complaint or problem
-justifies medical necessity
-16,000 increased to 70,000
-modernization of health care- recognizing advances in medicine
-reduce coding errors
-tracks public health and risk, increased data
-greater achievement of the benefits of an EHR

19
Q

CPT codes

A

-Every service or procedure provided is characterized with a five-digit code.
-Continuous update – over 8,000 codes currently available.
-Provides a common language to describe and document medical and surgical services provided.
-Creates an accurate record of services performed for continuity of care as part of the patient’s medical record.
-PAs are critical in this process.

20
Q

CPT utilization

A

-medicare, medicaid, private payers
-provides payers with a summary of patient care
-used for billing purposes
-E & M coding- evaluation and medical management
-the process of a provider assigning a CPT code to for billing

21
Q

ICD codes are linked to procedure codes (CPT)

A

-requires the proper coupling of ICD and CPT codes

22
Q

3 components determine the cost of a typical patient visit/encounter

A

-history component- CC- required & cannot be inferred , HPI cannot be documented by staff, ROS & PFSH can be documented by staff, PFSH (past, family, social history)
-physical exam- number of organ systems examined
-medical decisions making: assessment and plan- # dx or management options, amount of data/complexity, risk level to the pt