Ch. 19 - Procedural Coding Flashcards
(17 cards)
When choosing an E/M code, you must know whether the patient is . . .
A new or established patient and where the services took place
Who developed the Healthcare Common Procedure Coding System (HCPCS)?
The Centers for Medicare and Medicaid Services (CMS)
What are HCPCS Level I codes more commonly known as?
CPT Codes
Which type of codes, issued by CMS, are called national codes that cover many supplies?
HCPCS Level II
What type of claim are those in which each reported service is connected to a diagnosis that supports the procedure as necessary to investigate the patient’s condition?
Clean claims
What are the steps for locating the correct CPT code in order?
1.) Find the procedures provided on the superbill
2.) Verify the documentation on the procedures and services
3.) Use the alphabetic index to locate a code or range of codes
4.) Check all codes in the numeric index to determine the appropriate code
What are possible consequences of inaccurate coding and incorrect billing?
> Denied Claims
Delays in processing claims and receiving payments
Reduced payments
Fines and other sanctions
Loss of hospital privileges
Exclusion from payers’ programs
Prison sentences
Loss of MD license
The coding system developed by the CMS that is used in coding services for Medicare patients is . . .
HCPCS
Which key points are checked by a code review (audit)?
> Are the codes appropriate for the patient’s profile
Is there a clear and correct link between each diagnosis & procedure?
Have the payer’s rules about the diagnosis and the procedure been followed?
Does the documentation in the patient’s medical record support the reported services?
Do the reported services comply with all regulations?
Filing a claim for a service that was not provided is considered what?
Claim fraud
HCPCS Level II codes consist of how many alphanumeric characters?
5
What is the process for finding, correcting, and preventing illegal medical office practices?
A compliance plan
Analysis of the connection between diagnostic and procedural information to evaluate the medical necessity of reported charges is called what?
Code linkage
When a compliance plan is in place, what does it demonstrate to payers?
That honest, ongoing attempts have been made to find and fix weak areas of compliance with regulations.
What are the goals of a compliance plan?
> Prevent fraud and abuse
Ensure compliance with applicable federal, state, and local laws
Help defend providers if they are investigated or prosecuted for fraud
Intentions of a written compliance plan includes:
> audit & monitor compliance
Develop consistent written policies and procedures
Provide for ongoing staff training and communication
Respond to and correct errors
