Ch 1 Flashcards
(24 cards)
Outpatient coding
Focuses on physician professional services and our patient facility services. Cpt, hcpcs level II, and icd-10-cm codes.
Hospital inpatient coding
Coders will work with icd-10-cm codes and icd-10-pcs codes. Will also assign medical severity diagnosis related groups (ms-drgs)
Ms-drgs
Medical severity diagnosis related groups
Apcs
Ambulatory payment classifications
Risk adjustment coding
Focused on diagnosis coding using the icd-10-cm code set
NPPs
Non-physician providers
Mid level providers or physician extenders. Physician assistants. Nurse practitioners
Commercial insurance
Prívate payers that offer group and individual plans.
Government insurance
Ex is Medicare. A federal insurance plan
Medicare
Coverage for people over 65, disability or end stage renal disease. (Esrd)
Medicare part a
Inpatient hospital care. Care from skilled nursing, hospice , and home health
Medicare part b
Medically necessary physicians services, outpatient care, and other medical services.
Cms
Centers for Medicare and Medicaid services
Medicare part c
(Medicare advantage)
Also called Medicare advantage. Combined benefits of Medicare part A&Band sometimes D. Plans are managed by private insurers.
Medicare part d
Prescription drug program
Medicaid
For low income people. Especially children and pregnant women. Sponsored by state and federal government.
Medicare necessity
Whether a procedure is “reasonable or necessary” for diagnosis or treatment of patient.
NCD
National coverage determination. Explains when Medicare will pay for items or services.
MAC
Medicare administrative contractor. Responsible for interpreting national policies into regional policies.
LCD
Local coverage determination. They have jurisdiction only within their regional area. If an NCD doesn’t exist for an item, it’s up to the Mac to determine coverage.
ABN
Advanced beneficiary notice
Is a standardized form that explains to the patient why Medicare may deny the service or procedure. It protects the providers financial interest by creating a paper trail that cms requires before a provider can bill the patient for payment if coverage is denied.
Estimate should be within $100 or 25% of the actual costs. Whichever is greater.
Hold harmless
Prohibits the billing to the patient for anything other than co-pays or deductibles.
HIPPA
Health insurance portability and accountability act.
Protects health information.
HITECH
health technology for economic and clinical Health act.
Addressed privacy and security concerns associated with the electronic transmission of health information.
OIG
Office if inspector general
Mandated by public law to engage in exhibited to test the efficiency and economy of. Government programs to include investigation of Suspected healthcare fraud or abuse.
