Chapter 2 - medical coding Flashcards

Question

Electronic Submission of Medical Documentation System (esMD)

Answer 1

implemented to (1) reduce provider and review costs and cycle time by minimizing and eventually eliminating paper processing and mailing of medical documentation

Answer 2

mandated reporting and disclosure requirements for group life and health plans (including managed care plans), permitted large employers to self-insure employee health care benefits, and exempted large employers from taxes on health insurance premiums

Answer 3

services that describe patient encounters with providers for evaluation and management of general health status

Answer 4

provides civilian employees of the federal government with medical care, supervisors' benefits, and compensation for lost wages.

Answer 5

legislation passed in 1908 by President Theodore Roosevelt that protects and compensates railroad workers who are injured on the job

Answer 6

list of predetermined payments for health care services provided to patients (e.g., a fee is assigned to each CPT code)

Answer 7

prohibits sharing of medical information among health insurers and other financial institutions for use in making credit decisions; also allows banks to merge with investment and insurance houses, and which allows them to make a profit no matter what the status of the economy, because people usually house their money in one of the options; also called Gramm-Leach-Biliey Act

Answer 8

see Financial Services Modernization Act

Answer 9

traditional health care coverage subsidized by employers and other organizations (e.g., labor unions, rural and consumer health cooperatives) whereby part or all of premium costs are paid for and/or discounted group rates are offered to eligible individuals

Answer 10

expands the definition of medical care to include preventive service s

Answer 11

includes health care reform initiatives that amend the Patient Protection and Affordable Care Act to increase tax credits to buy health care insurance, eliminate special deals provided to senators, close the Medicare "donut hold," delay taxing of "Cadillac-healthcare plans" united 2018, and so on.

Answer 12

included i the American Recovery and Reinvestment Act of 2009 and amended the Public Health service Act to establish an Office of National Coordinator for Health Information Technology within HHS to improve health care quality, safety, and efficiency

Answer 13

contract between a policyholder and a third-party or government program to reimburse the policyholder for all or a portion of the cost of medically necessary treatment or preventive care by health care professionals

Answer 14

see health insurance marketplace

Answer 15

method Americans use to purchase health coverage that fits their budget and meet their needs, effective October 1, 2013

Answer 16

mandates regulations that govern privacy, security, and electronic transactions standards for health care information

Answer 17

provided federal grants for moderni-zing hospitals that had become obsolete because of a lack of capital investment during the Great Depression and WWII (1929-1945). In return for federal funds, facilities were required to provide services free, or at a reduced rates, to patients unable to pay for care

Answer 18

reimbursement methodology for home health agencies that uses a classification system called home health patient-driven groupings model (PDGM), which establishes a predetermined rate for health care services provided to patients for each 60-day episode of home health care

Answer 19

private health insurance policy purchased by individuals or families who do not have access to group health insurance coverage; applicants can be denied coverage, and they can also be required to pay higher premiums due to age, gender, and/or pre-existing medical conditions

Answer 20

system in which Medicare reimburses inpatient psychiatric facilities according to a patient classification system that reflects differences in patient resource use and costs; in replaces the cost-based payment system with a per diem IPF PPS

Answer 21

implemented as a result of the BBA of 1997; utilizes information from a patient assessment instrument to classify patients into distinct groups based on clinical characteristics and expected resource needs

Answer 22

classification system used to collect data for statistical purposes

Answer 23

designed to spur innovations in health information technology (health IT) by promoting research and development to enhance competitiveness in the United states

Answer 24

maximum benefit payable to a health plan participant

Answer 25

coverage for catastrophic or prolonged illnesses and injuries

Answer 26

providers who demonstrate that certified EHR technology is used for electronic prescribing, electronic exchange of health information in accordance with law and HIT standards, and submission of information on clinical quality measures; and hospitals that demonstrate that certified EHR technology is connected in a manner that provides for the electronic exchange of health information to improve quality of care and that the technology is used to submit information on clinical quality measures

Answer 27

objectives and measures that achieved goals of improved patient care outcomes and delivery through data capture and sharing, advance clinical processes, and improved patient outcomes; replaced by quality payment program (QPM).

Answer 28

cost-sharing program between the federal and state governments to provide health care services to low-income Americans' originally administered by the Social and Rehabilitation Service (SRS

Answer 29

includes the identification of disease and the provision of care and treatment as provided by members of the health care team to persons who are sick, injured, or concerned about their health status

Answer 30

see patient record

Answer 31

reimburses health care services to Americans over the age of 65

Answer 32

ended the Sustainable Growth Rate (SGR) formula for determining Medicare payments for health care providers' services, the Merit-Based Incentive Payment System (MIPS), and required CMS to remove Social Security Numbers (SSNs) from all Medicare cards, replacing them with new randomly generated Medicare cards, replacing them with new randomly generated Medicare beneficiary identifiers (MBIs) that will be appear on new Medicare cards

Answer 33

replaces SSN as health insurance claim number on new Medicare cards for transactions such as billing, eligibility status, and claim status

Answer 34

mandated the reporting of ICD-9-CM diagnosis codes on Medicare claims; in subsequent years, private third-party payers adopted similar requirements for claims submission. Effective October 1, 2015, ICD-10-CM (diagnosis) codes are reported

Answer 35

established to integrate the administration of Medicare Parts A and B fee-for-service benefits with new entities called Medicare administrative contractors (MACs); MACs replaced Medicare carriers, DMERCs, and fiscal intermediaries

Answer 36

requires implementation of a $400 billion prescription drug benefit, improved Medicare Advantage (formerly called Medicare+Choice) benefits, faster Medicare appeals decisions, and more

Answer 37

standardized notice provided to Medicare beneficiaries that they are outpatient receiving observation services and are not inpatients of a hospital or a critical access hospital (CAH)

Answer 38

eliminated PQRS, value-based payment modifier, and the Medicare EHR incentive program, creating a single program based on quality, resource use, clinical practice improvement, and meaningful use of certified EHR technology

Answer 39

data elements collected by long-term care facilities

Answer 40

developed by CMS to promote national correct coding methodologies to eliminate improper coding practices

Answer 41

nickname for the Patient Protection and Affordable Care Act (PPACA), which was signed into federal law by President Obama on March 23, 2010, and created the Health Care Marketplace

Answer 42

federal law that requires providers to keep copies of any government insurance claims and copies of all attachments filled by the provider for a period of five years; also expanded Medicare and Medicaid programs

Answer 43

group of data elements that represent core items of a comprehensive assessment for an adult home care patient and form the basis for measuring patient outcomes for purposes of outcome-based quality improvement

Answer 44

uses ambulatory payment classifications (APCs) to calculate reimbursement; was implemented for billing of hospital-based Medicare outpatient claims

Answer 45

focuses on private health insurance reform to provide better coverage for individuals with pre-existing conditions, improve prescription drug coverage under Medicare, extend the life of the Medicare Trust fund by at least 12 years, and create the health insurance marketplace

Answer 46

documents health care services provided to a patient

Answer 47

different types of health insurance payments made to providers for patient services

Answer 48

Latin term meaning "for each day," which is how retrospective cost-based rates were determined; payments were issued based on daily rates

Answer 49

web-based application that allows individuals to maintain and manage their health information (and that of others for whom they are authorized, such as family members) in a private, secure, and confidential environment

Answer 50

a person who signs a contract with a health insurance company and who, thus, owns the health insurance policy; the policyholder is the insured (or enrollee), and the policy might include coverage for dependents

Answer 51

designed to help individuals avoid problems with health and injuries

Answer 52

a systematic method of documentation that consists of four components; database, problem list, initial plan, and progress notes

Answer 53

focus on improving patient access to health information and reducing the time and cost required of providers to comply with the programs' requirements; previously called EHR incentive programs

Answer 54

issues predetermined payment for services, such as bundled payments, capitation, case rates, and global payments

Answer 55

implemented skilled nursing facility (SNF) value-based purchasing (VBP) program

Answer 56

federal and state government health programs (e.g., Medicare, Medicaid, CHIP, TRICARE) available to eligible individuals

Answer 57

performs utilization and quality control review of health care furnished, or to be furnished, to Medicare beneficiaries

Answer 58

helps provides focus on quality of patient care and making patients healthier, includes advanced alternative payment models (Advanced APMs) and merit-based incentive payment system (MIPS); replaced the EHR incentive program (or Meaningful Use), Physician Quality Reporting System, and Value-Based Payment Modifier program

Answer 59

allows patient information to be created at different locations according to a unique patient identifier or identification number

Answer 60

payment system that reimburses physicians' practice expenses based on relative values for three components of each physician's services: physician work, practice expense, and malpractice insurance expense

Answer 61

type of health information exchange organization that brings together health care stakeholders within a defined geographic area and governs health information exchange among them for the purpose of improving health and care in the community

Answer 62

allows the large employer to assume the financial risk for providing health care benefits to employees; employer does not pay a fixed premium to a health insurance payer, but establishes a trust fund (of employer and employee contributions) out of which claims are paid

Answer 63

centralized health care plan adopted by some Western nations (e.g., Canada, Great Britain) and funded by taxes. The government pays for each resident's health care, which is considered a basic social service.

Answer 64

implemented (as a result of the BBA of 1997) to cover all costs (routine, ancillary, and capital) related to services furnished to Medicare Part A beneficiaries

Answer 65

type of single-payer system in which the government owns and operates health are facilities and providers (e.g., physicians) receive salaries; the VA health care program is a form of socialized medicine

Answer 66

created Medicare risk programs, which allowed federally qualified HMOs and competitive medical plans that met specified Medicare requirements to provide Medicare-covered services under a risk contract

Answer 67

company that provides health benefits claims administration and other outsourcing services (e.g., employee benefits managment) for self-insured companies; provides administrative services to health care plans; specializes in mental health case managment; and processes claims, serving as a system of "checks and balances" for labor-management

Answer 68

a health insurance company that provides coverage, such as BlueCross BlueSheild

Answer 69

used to generate the EMR, automating medical practice functions of registering patients, scheduling appointments, generating insurance claims and patient statements, processing payments from patient and third-party payers, and producing administrative and clinical reports

Answer 70

goal of providing every individual with access to health coverage, regardless of the system implemented to achieve that goal

Answer 71

based on fees typically charged by providers in a particular region of the country

Answer 72

developed the International Classification of Diseases (ICD)

Answer 73

a contract that protects the insured from loss. An insurance company guarantees payment to the insured for an unforeseen even (e.g., death, accident, and illness) in return for the payment of premiums. In addition to health insurance, types of insurance include automobile, disability, liability, malpractice, property, and life.

Answer 74

are designed to help individuals avoid health and injury problems. Preventive examinations may result in the early detection of health problems, allowing less drastic and less expensive treatment options

Answer 75

is a contract between a policyholder and a third-party payer or government health program to reimburse the policyholder for all or a portion of the cost of medically necessary treatment or preventive care provided by health care professionals

Answer 76

is a person who signs a contract with a health insurance company and who, thus, own the health insurance policy. The policyholder is the insured (or enrollee)

Answer 77

individuals who participate in group (e.g., employer sponsored), individual (or personal insurance), or prepaid health plans (e.g., managed care)

Answer 78

different types of health insurance payments made to providers for patient services

Answer 79

-commercial -BlueCross BlueSheild -Medicare -Medicaid -TRICARE -Workers' Compensation

Answer 80

required to assist patients with information about copayments, coinsurance, and so on. For detailed information about the patient's insurance coverage, it would be appropriate to refer the patient to their health insurance representative

Answer 81

-68% are covered by private health insurance -56.4% are covered by employment-based plans -10.2% are covered by direct-purchase health insurance plans -17.2% are covered by Medicaid -18.1% are covered by Medicare -3.6% are covered by military health care (e.g., CHAMPVA, TRICARE, VA) The reason the insurance coverage breakdown of covered persons is greater than 100% is because some people are covered by more than one insurance plan (.g., employment-based plan plus direct-purchase health insurance plan, employment plan plus Medicare). Thus, they are counted more than once when percentages are calculated

Answer 82

health insurance coverage subsidized by employers and other organizations (e.g., labor unions, rural and consumer health cooperatives). These plans distribute the cost of health insurance among group members to lessen cost of health insurance among group members to lessen cost and provide broader coverage then that offered through individual health insurance plans. The patient Protection and Affordable Care Act of 2010 includes a tax credit to help smaller businesses and small tax-exempt organizations afford the cost of covering their employees.

Answer 83

Private health insurance policy purchased by individuals or families who do not have access to group health coverage (e.g., Aetna)

Answer 84

Federal and state government health programs (e.g., Medicare, Medicaid, CHIP, Tricare) available to eligible individuals

Answer 85

Centralized health care system adopted by some Western nations (e.g., Canada) and funded by taxes. The government pays for each resident's health care, which is considered a basic social service

Answer 86

a type of single-payer system in which the government owns and operates health care facilities and providers (e.g., physicians) receive salaries (e.g., Finland, Great Britian)

Answer 87

the goal of providing every individual with access to health coverage, regardless of system implemented to achieve that goal (e.g., Obamacare)

Answer 88

since the early 1900s, when solo practices prevailed, managed care and group practices have increased in number, and health care services (like other aspects of society in this country) have undergone tremendous changes

Answer 89

access the online Student Resources for Understanding Health insurance by signing in a www.cengage.com to view Table 2-A, which contains additional significant events in health care reimbursement

Answer 90

-First health insurance policy - The Franklin Health Assurance Company of Massachusetts was the first commercial insurance company to provide private health insurance company to provide private health care coverage for injuries not resulting in death

Answer 91

FELA -President Theodore Roosevelt signed Federal Employers' Liability Act (FELA) legislation that protects and compensates railroad workers who are injured on the job

Answer 92

FECA The Federal Employees' Compensation Act (FECA) provides civilian employees of the federal government with medical care, survivors' benefits, and compensation for lost wages

Answer 93

Blue Cross -Justin Ford Kimball, an official at Baylor University in Dallas, introduced a plan to guarantee school teachers 21 days of hospital care for $6 a year. Other groups in Dallas joined, and the idea attracted nationwide attention. This is generally considered the first Blue Cross plan

Answer 94

Blue Shield -The first Blue Shield plan was founded in California. The Blue Shield concept grew out of the lumber and mining camps of the Pacific Northwest at the turn of the century. Employers wanted to provide medical care for their workers, so they paid monthly fees to medical service bureaus, which were composed of groups of physicians

Answer 95

Group Health Insurance -To attract wartime labor during World War II, group health insurance was offered for the first time to full-time employees. The insurance was not subject to income or Social Security taxes, making it an attractive part of an employee benefit package

Answer 96

Hill-Burton Act -The Hill Burton Act provided federal grants for modernizing hospitals that had become obsolete because of a lack of capital investment during the Great Depression and World War II (1929 to 1945). In return for federal funds, facilities were required to provide services free or at reduced rates to patients unable to pay for care

Answer 97

Taft-Hartley Act -The Taft-Hartley Act of 1947 amended the National Labor Relations Act of 1932, restoring a more balanced relationship between labor and management. An indirect result of Taft-Hartley was the creation of third-party administrators (TPAs), which administer health care plans and processes claims, thus serving as a system of checks and balances for labor and management; they also contracted to provide employee benefits management and other services

Answer 98

ICD -The World Health Organization (WHO) developed the International Classification of Diseases (ICD), a classification system used to collect data for statistical purposes

Answer 99

Major Medical insurance -Insurance companies began offering major medical insurance, which provided coverage for catastrophic or prolonged illness and injuries. Most of these programs incorporate large deductibles and lifetime maximum amounts. A deductible is the amount for which the patient is financially responsible before an insurance policy provides payment. A lifetime maximum amount is the maximum benefits payable to a health plan participant

Answer 100

Medicare and Medicaid -Medicare (Title XVII of the Social Security Amendments of 1965) provides health care services over the age of 65. (It was originally administered by the Social Security Administration) -Medicaid (Title XIX of the Social Security Amendments of 1965) is the cost-sharing program between the federal and state governments to provide health care services to low-income Americans. (It was originally administered by the Social and Rehabilitation Service (SRS)). -CHAMPUS - Amendments of the Defendants' Medical Care Act of 1956 created by the Civilian Health and Medical Program-Uniformed Services (CHAMPUS), which was designed as a benefit for dependents of personnel serving in the armed forces as well as uniformed branches of the Public Health Service and the National Oceanic and Atmospheric Administration. The program is now called TRICARE -CPT - Current Procedural Terminology (CPT) was developed by the American Medical Association. Each year an annual publication is prepared, which includes changes that correspond to significant updates in medical technology and practice

Answer 101

Self-insured group health plans -Self-insured (or self-funded) employer-sponsored group health plans allow large employers to assume the financial risk for providing health care benefits to employees. The employer does not pay a fixed premium to a health insurance payer, but establishes a trust fund (of employer and employee contributions) for self-insurance purposes, out of which claims are paid -OSHA - The Occupational Safety and Health Act of 1970 (OHSA) was designed to protect all employees against injuries from occupational hazards in the workplace

Answer 102

CHAMPVA -The Veterans Healthcare Expansion Act of 1973 established the Civilian Health and Medical Program of the Department of Veterans Affairs (CHAMPVA) to provide health care benefits for dependents of veterans rated as 100% permanently and totally disabled as a result of service-connected conditions, veterans who died as a result of service-connected conditions, and veterans who died on duty with less than 30 days of active service -HMOs - The Health Maintenance Organization Assistance Act of 1973 authorized federal grants and loans to private organizations that wished to develop health maintenance organizations (HMOs), which are responsible for providing health care services to subscribers in a given geographic area for a fixed fee

Answer 103

-ERISA - The Employee Retirement Income Security Act of 1974 (ERISA) mandated reporting and disclosure requirements for group life and health plans (including managed care plans), permitted large employers to self-insure employee health care benefits, and exempted large employers from taxes on health insurance premiums. A copayment (copay) is a provision in an insurance policy that requires the policyholder or patient to pay a specified dollar amount to a health care provider for each visit or medical service received. Coinsurance is the percentage of costs a patient shares with the health plan. For example, the plan pays 80% of costs and patient pays 20%

Answer 104

-HCFA - to combine health care financing and quality assurance programs into a single agency, the Health Care Financing Administration (HCFA) was formed within the Department of Health and Human Services (DHHS). The Medicare and Medicaid programs were also transferred to the newly created agency. (HCFA is now called the Centers for Medicare and Medicaid Services, or CMS).

Answer 105

DHHS With the department of the Office of Education, the Department of Health, Education and Welfare (HEW) became the Department of Health and Human Services (DHHS).

Answer 106

OBRA The Omnibus Budget Reconciliation Act of 1981 (OBRA) was federal legislation that expanded the Medicare and Medicaid programs; also, requires providers to keep copies of any government insurance claims and copies of all attachments filled by the provider for a period of five years

Answer 107

DRG The Tax Equity and Fiscal Responsibility Act of 1982 (TEFRA) created Medicare risk programs, which allowed federally qualified HMOs and competitive medical plans that met specified Medicare requirements to provide Medicare requirements to provide Medicare-covered services under a risk contract. TEFRA also enacted a prospective payment system (PPS) (or prospective payment methodology), which issues a predetermined payment for patient services, such as bundled payments, capitation, case rates, and global payments. Previously, reimbursement was generated on a per diem basis, which issued payment based on daily rates. The PPS implemented in 1983, called diagnosis-related groups (DRGs), reimburses hospitals for inpatient stays

Answer 108

HCFA-1500 HCFA (now called CMS) required providers to use the HCFA-1500 claim (now called the CMS-1500 claim), which is submitted for reimbursement of Medicare physician office procedures and services to submit Medicare claims. The HCFA Common Procedure Coding System (HCPCS) (now called Healthcare Common Procedure Coding System) was created, which included CPT, level II (national), and level III (local) codes. (Commercial payers also adopted HCPCS coding and use of the CMS-1500 claim)

Answer 109

COBRA The Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA) allows employees to continue health care coverage beyond the benefit termination date by paying appropriate premiums

Answer 110

-Tricare - The CHAMPUS Reform Initiative (CRI) of 1988 resulted in a new program, TRICARE, which includes options such as TRICARE Price, TRICARE Extra and TRICARE Standard (Chapter 16 covers TRICARE claims processing) -CLIA - Clinical Laboratory Improvement Act (CLIA) legislation established quality standards for all laboratory testing to ensure the accuract, reliability, and timeliness of patient test results regardless of where the test was performed. The Medicare Catastrophic Coverage Act mandated the reporting of ICD-9-CM (now ICD-10-CM) diagnosis codes on Medicare claims, in subsequent years, private third-party payers adopted similar requirements for claims submission

Answer 111

CPT E/M codes The American Medical Association (AMA) implemented major revisions of CPT, creating a new section called Evaluation and Management (E/M), which describes patient encounters with providers for the purpose of evaluation and management of general health status

Answer 112

RBRVS A new fee schedule for Medicare services was implemented as part of the Omnibus Reconciliation Acts (OBRA) of 1989 and 1990, which replaced the regional "usual and reasonable" payment basis with a fixed fee schedule calculated according to the Resource-Based Relative Value Scale (RBRVS) system. The RBRS payment system reimburses physicians' practice expenses based on relative values for three components of each physician's service: physician work, practice expense, and malpractice insurance expense. Usual and reasonable payments were based on fees typically charged by providers according to speciality within a particular region of the country. A fee schedule is a list of predetermined payments for health care services provided to patients (e.g., a fee is assigned to each CPT code). The patient pays a copayment or coinsurance amount for services rendered, the payer reimburses the provider according to its fee schedule, and the remainder is a "write off" (or loss). RBRVS is now known as the Medicare physician fee schedule (MPFS), which is covered in chapter 9. *Example: A patient received preventive care evaluation and management services from the family practitioner. The total charges were $125, and the patient paid a $20 copayment during the office visit. The third-party payer reimbursed the physician the fee schedule amount of $75. The remaining $30 owed is recorded as a loss (write off) for the business.*

Answer 113

-NCCI - The national correct coding initiative (NCCI) was created by CMS to promote national correct coding methodologies and eliminate improper coding (additional content about the NCCI is in chapter 5 & 10) -HIPAA - the Health Insurance Portability and Accountability Act of 1996 (HIPAA) governs privacy, security, and electronic transactions standards for health care information. The primary intent of HIPAA is to provide better access to health insurance, limit fraud and abuse, and reduce health care administrative costs (Additional content about HIPAA is located in Chapter 5)

Answer 114

-BBA of 1997 - the Balances Budget Act of 1997 (BBA) addresses health care fraud and abuse issues. The DHHS Office of the Inspector General (OIG) provides investigative and audit services in health care fraud cases. -CHIP - The Children's Health Insurance Program (CHIP) (or State Children's Health Insurance Program (SCHIP) was also established to provide health assistance to uninsured, low-income children, either through separate programs or through expanded eligibility under state Medicaid programs.

Answer 115

SNF PPS -The Skilled Nursing Facility Prospective Payment System (SNF PPS) is implemented (as a result of the BBA of 1997) to cover all costs (routine, ancillary, and capital) related to services furnished to Medicare Part A beneficiaries. The SNF PPS generates per diem payments for each admission; these payments are case-mix adjusted using a resident classification system called Resource Utilization Groups (RUGs), which was replaced by the patient-driven payment model (PDPM) (using data elements called the Minimum Data Set (MDS), which is a group of data elements collected by long-term care facilities) and relative weights developed from staff time data

Answer 116

HH PPS - The Omnibus Consolidated and Emergency Supplemental Appropriations Act (OCE-SAA) of 1999 amended the BBA of 1997 to require the development and implementation of a Home Health Prospective Payment System (HH PPS), which reimburses home health agencies at a predetermined rate for health care services provided to patients. The HH PPS was implemented October 1, 2000, and uses the Outcomes and Assessments Information Sets (OASIS), a group of data elements that represent core items of a comprehensive assessment for an adult home care patient and form the basis for measuring patient outcomes for purposes of outcome-based quality improvement. -FSMA - the Financial Services Modernization Act (FSMA) (or Gramm-Leach-Bliley Act) prohibits sharing of medical information among health insurers and other financial institutions for use in making credit decisions

Answer 117

-The Outpatient Prospective Payment System (OPPS), which uses ambulatory payment classifications (ACPs) to calculate reimbursement, is implemented for billing of hospital-based Medicare outpatient claims -BIPA - the Medicare, Medicaid, and CHIP Benefits Improvement and Protection Act of 2000 (BIPA) required implementation of a $400 billion prescription drug benefit, improved Medicare Advantage (formerly called Medicare+Choice) benefits, required faster Medicare appeals decisions, and more. -CDHPs - Consumer-driven health plans (CDHPs) are introduced as a way to encourage individuals to locate the best price with the goal of holding down health care costs. These plans are organized into three categories: 1. Employer-paid high deductible insurance plans with special health spending accounts to be used by employees to cover deductibles and other medical costs when covered amounts are exceeded. 2. Defined contribution plans, which provide a selection of insurance options; employees pay the difference between what the employer pays and the actual cost of the plan they select. 3. After-tax savings accounts, which combine a traditional health insurance plan for major medical expenses with a savings account that the employee uses to pay for routine care

Answer 118

CMS - On June 14, 2001, the Centers for Medicare and Medicaid Services (CMS) became the new name for the Health Care Financing Administration (HCFA)

Answer 119

IRF PPS - The Inpatient Rehabilitation Facility Prospective Payment System (IRF PPS) is implemented (as a result of the BBA of 1997), which utilizes information from a patient assessment instrument to classify patients into distinct groups based on clinical characteristics and expected resource needs. Separate payments are calculated for each group, including the application of case-and facility-level adjustments -QIOs - CMS announced that quality improvement organizations (QIOs) will perform utilization and quality control review of health care furnished, or to be furnished, to Medicare beneficiaries. QIOs replaced peer review organizations (PROs), which previously performed this function -EIN - the employer identification number (EIN), assigned by the Internal Revenue Service (IRS), is adopted by DHHS as the National Employer Identification Standard for use in health care transactions

Answer 120

MMA - the Medicare Outpatient Observation Notice (MOON) adds new prescription drug and preventive benefits, provides extra assistance to people with low incomes, and calls for implementation of a Medicare contracting reform (MCR) initiative to improve and modernize the Medicare fee-for-service system and to establish a competitive bidding processes to appoint MACs. The Recovery Audit Contractor (RAC) program was also created to identify and recover improper Medicare payments paid to health care providers under fee-for-service Medicare plans. The Hospital Inpatient Quality Reporting (Hospital IQR) program was created and authorized CMS to pay hospitals that successfully report designated quality measures a higher annual update to their payment rates -MCR - The Medicare contracting reform (MCR) initiative was established to integrate the administration of Medicare Parts A and B fee-for-service benefits with new entities called Medicare administrative contractors (MACs). MACs replaced Medicare carriers, DMERCs, and fiscal intermediaries to improve and modernize the Medicare fee-for-service system and establish a competitive bidding process for contracts

Answer 121

IPF PPS The Inpatient Psychiatric Facility Prospective Payment System (IDF PPS) is implemented as a requirement of the Medicare, Medicaid, and CHIP Balanced Budget Refinement Act of 1999 (BBRA). The IPF PPS includes a patient classification system that reflects differences in patient resource use and costs; the new system replaces the cost-based payment system with a per diem IPF PPS. about 1,800 inpatient psychiatric facilities, including freestanding psychiatric hospitals and certified psychiatric units in general acute care hospitals, are impacted

Answer 122

ARRA - The American Recovery and Reinvestment Act of 2009 (ARRA) authorized an expenditure of $1.5 billion for grants for construction, renovation, and equipment, and for the acquisition of health information technology systems. DHHS established electronic health record (EHR) meaningful use objectives and measures during three stages to achieve the goal of improved patient care outcomes and delivery as well as data capture and sharing (2011-2012), advance clinical processes (2014), and improved outcomes (2016). Effective 2011, Medicare provided annual incentives to physicians and group practices for being a "meaningful EHR user"; Medicare will ultimately decrease Medicare Part B payments to physicians who are eligible to be, but fail to become, "meaningful EHR users." -HITECH Act - The Health Information Technology for Economic and Clinical Health Act (HITECH Act) (included in American Recovery and Reinvestment Act of 2009) established an Office of National Coordinator for Health Information (ONC) within HHS to improve health care quality, safety, and efficiency. (in 2012, the NHIN evolved into the eHealth Exchange).

Answer 123

PPACA - the Patient Protection and Affordable Care Act (PPACA) focuses on private health insurance reform to provide better coverage for individuals with pre-existing conditions, improve prescription drug coverage under Medicare, and extend the life of the Medicare Trust fund by at least 12 years. Its goal is to provide quality affordable health care for Americans, improve the quality and efficiency of health care, and improve public health. Americans purchase health coverage that fits their budget and meets their needs by accessing the health insurance marketplace (or health insurance exchange) in their state. The marketplace indicates if individuals qualify for free or low-cost coverage available through Medicaid or the children's Health Insurance Program (CHIP). PPACA also amended the time period for filing Medicare fee-for-services (FFS) claims to one calendar year after the date of service. PPACA also provides a risk adjustment program to lessen or eliminate the influence of risk selection on premiums charged by health plans and includes the risk adjustment model and the risk transfer model. The goal is improved coverage so that consumers --whether they are healthy or sick -- whether they are healthy or sick -- can select the best plan for their needs -HCERA The Health and Education Reconciliation Act (HCERA) amended the PPACA to implement health care reform initiatives, such as increasing tax credits to buy health care insurance, eliminating special deals provided to senators, closing the Medicare "donut hole," delaying taxes on "Cadillac health care plans" until 2018, implementing revenue changes (e.g., 10% tax on indoor tanning services) and so on. HCERA also modified higher education assistance provisions, such as implementing student loan reform.

Answer 124

-i2 Initiative - the Investing in Innovations (i2) Initiative facilitated innovations in health information technology (health IT) by promoting research and development to enhance competitiveness in the United States -esMD - the Electronic Submission of Medical Documentation System (esMD) was implemented to: 1. reduce provider costs and cycle time by minimizing and eventually eliminating paper processing and mailing of medical documentation to review contractors, and to 2. reduce costs and time for review contractors

Answer 125

ACOs - Accountable care organizations (ACOs) help physicians, hospitals, and other health care providers work together to improve care for people with Medicare. Under the Medicare Shared Savings Program (Shared Savings Program), ACOs entered into agreements with CMS, taking responsibility for the quality of care furnished to Medicare beneficiaries in return for the opportunity to share in savings realized through improved care. For 2019, CMS implemented the Pathways to Success, which redesigns the participation options to encourage ACOs to transition to performance-based risk more quickly (and increase savings for the Medicare Trust Funds). -eHealth Exchange - Effective 2012, the eHealth Exchange transitioned from the federal Office of the National Coordinator for Health IT to a private sector initiative to facilitate the transformation of health care delivery in the United States through simplified, standardized electronic information and technology to achieve improved quality of care, better health outcomes, and reduced costs. The eHealth Exchange is a health information exchange network for securely sharing clinical information over the Internet nationwide, and it spans all 50 states and is the largest health information nationwide, and it spans all 50 states and is the largest health information exchange infrastructure in the United States. Participants include large provider networks, hospitals, pharmacies, regional health information exchanges, and many federal agencies -RHIO - A rural health information organization (RHIO) is a type of health information exchange organization that brings together health care stakeholders within a defined geographic area and governs health information exchange among them for the purpose of improving health and care in that community

Answer 126

-Protecting Access to Medicare Act (PAMA) of 2014 - Implemented the skilled nursing facility (SNF) value-based purchasing (VBP) program. PAMA also required significant changes to how Medicare pays for clinical diagnostic laboratory tests under the Clinical Laboratory Fee Schedule (CLFS); effective January 1, 2018, payment amounts for most tests equals the weighted median of private payer rates) -Improving Medicare Post-Acute Care Transformation (impact) ACT OF 2014 - Requires the reporting of standardized patient assessment data elements (SPADE) for post-acute care (PAC) providers, including skilled nursing facilities, home health agencies, inpatient rehabilitation facilities, and long-term care hospitals. SPADE data collection enables data collection, outcome enables data collection, outcome comparison, exchangeability of data, and comparison, exchangeability of data, and comparison of quality within and across PAC settings. Standarized data also has the potential to improve patient outcomes by improving coordination of care and discharge planning. As a result, CMS established a quality reporting program (QRP) for all PAC providers

Answer 127

Medicare Access and CHIP Reauthorization Act (MACRA) of 2015 - Makes three important changes to how Medicare pays those who provide care to Medicare beneficiaries: -Ends Sustainable Growth Rate (SGR) formula for determining Medicare payments for health care provider services. -Creates new framework for rewarding providers for delivering better care, not just more care -Combines existing quality reporting programs into one new system, the quality payment program (QPP) that includes alternate payment systems (APMs), merit-based incentive payments (MIPS), and MIPS-APMs -also required CMS to remove Social Security numbers (SSNs) from all Medicare cards by 2019. A new randomly generated Medicare beneficiary identifier (MBI) replaced by the SSN-based health insurance claim number on new Medicare cards

Answer 128

NOTICE Act - The Notice of Observation Treatment and Implication for Care Eligibility Act (NOTICE Act) requires hospital to provide the Medicare Outpatient Observation Notice (MOON) to Medicare patients who receive observation services as outpatients for more than 24 hours to inform them that they are an outpatient receiving observation services and are not an inpatient of a hospital or a critical access hospital (CAH). -CURES Act - The 21st Century Cures Act (CURES Act) reduces EHR documentation burden on providers while maintaining quality, and encourages certification of health IT for speciality providers and sites of service. The CURES Act also improves risk adjustment for Medicare Advantage plans by considering total number of diseases/conditions, using at least two years of diagnostic data, providing separate adjustments for dual eligible (Medicare/Medicaid) individuals, evaluating mental health and substance use disorders, evaluating chronic kidney disease, and evaluating payment rates for end-state renal disease

Answer 129

eCQMs - CMS, AHRQ, and ONC integrated electronic clinical quality measures (eCQMs) into the eCQI resource Center as part of the United States Health Information Knowledgeable (USHIK), which is a publicly available database with technical measures and specifications for calculating quality metrics established for federal payment reimbursements

Answer 130

Clinical quality Language (CQL) Clinical Language (CQL) is a Health Level Seven International (HL7) authorizing language standard that is intended to be human readable. It is part of the effort to synchronize standards used for electronic clinical quality measures (eCQMs) and clinical decision support (CDS). eCQMs and CDS share common requirements and data elements, and support health care quality improvement. For example, the impact of a CDS intervention may be assessed with an eCQM

Answer 131

The Patient Protection and Affordable Care act (PPACA) was signed into federal law on March 23, 2010, and resulted in the creation of a Health Insurance Marketplace (or Health insurance exchange), abbreviated as the Marketplace, effective October 1, 2013. The PPACA is abbreviated as the Affordable Care Act (ACA), and it was nicknamed Obamacare (because it was signed into federal law by President Obama). The Health Insurance Marketplace does not replace other health insurance programs (e.g., individual and group commercial health insurance, Medicaid, Medicare, TRICARE). -The Marketplace allows Americans to purchase health coverage that fits their budget and meets their needs. It is a resource where individuals, families, and small businesses can: -learn about their health coverage options -compare health insurance plans based on costs, benefits, and other important features -choose a plan -enroll in coverage

Answer 132

help people with low to moderate income and resources pay for health coverage. Information includes ways to save on the monthly premiums and out-of-pocket costs of coverage available through the Marketplace and information about other programs, including Medicaid and the Children's Health Insurance Program (CHIP). The Marketplace encourages competition among private health plans, and it is accessible through websites, call centers, and in-person assistance. In some states it is run by the state, and in others it is run by the federal government.

Answer 133

-Be a U.S. citizen or national (or be lawfully present) -Live in the United States -Not be incarnated

Answer 134

-Helping patients Keep their Plan: DHHS permitted people with ACA-noncompliant plans in the individual and small group markets to renew them, and that policy was set to expire in 2017. On February 23, 2017, DHHS announced that people will be allowed to keep their pre-ACA plans if they like them -More Calendar Flexibility - More Options for Patient: in 2017, DHHS pushed back a range of deadlines for decisions to be made by insurers, allowing insurers to provide better choices to consumers. DHHS also eliminated a step in the approval process, allowing insurers to reduce regulatory costs and pass the savings on to the individual. -Tax Cuts and Job Acts of 2017: The health care mandate was repealed, eliminating the tax penalty under the ACA for individuals who do not buy health insurance.

Answer 135

It can provide coverage for those transitioning among different coverage options (e.g., individual who is between jobs, student taking time off from school, middle-class families who do not have access to subsidized ACA plans). New legislation also allows states to use federal funding for subsidizing premiums for association health plans and short-term health insurance plans. Consumers can purchase ACA plans with the subsidies, and coverage for pre-existing conditions remains in place (and insurers may not charge higher premiums for individuals with pre-existing conditions)

Answer 136

Health care providers are responsible for documenting and authenticating legible, complete, and timely patient records in accordance with federal regulations (e.g., Medicare Conditions of Participation) and accrediting agency standards (e.g., The Joint Commission). The provider is also responsible for correcting or altering errors in patients record documentation.

Answer 137

A patient record (or medical record) documents health care services provided to a patient and includes patient demographic (or identification) data, documentation to support diagnoses and justify treatment provided, and the results of treatment provided. The primary purpose of the record is to provide for continuity of care, which involves documenting patient care services so that others who treat the patient have a source of information to assist with additional care and treatment. The record also serves as a communication tool for physicians and other patient care professionals, and assist in planning individual patient care and documenting a patient's illness and treatment

Answer 138

-evaluating the quality of patient care -providing data for use in clinical research, epidemiology studies, education, public policy making, facilities planning, and health care statistics -Serving the medico-legal interests of the patient, facility, and providers of care

Answer 139

-a teaching hospital participates in an approved Graduate Medical Education Residency Program in medicine, osteopathy, dentistry, or podiatry. -A teaching physician is a physician, other than an intern or resident, who involves residents in Patient care. Generally, the teaching physician must be present during all critical or key portions of the procedure and immediately available to furnish services during the entire service (for services to be payable under the Medicare Physician Fee Schedule).

Answer 140

-Proper and needed for the diagnosis or treatment of a medical condition -Provided for the diagnosis, direct care, and treatment of a medical condition -Consistent with standards of good medical practice in the local area -Not mainly for the convenience of the physician, patient, or health care facility

Answer 141

The patient record serves as a Medico-legal document and a business record. If a provider performs a service but does not document it, the patient (or third-party payer) can refuse to pay for a service, resulting in lost revenue for the provider. In addition, because the patient record serves as an excellent defense of the quality of care administered to a patient, missing documentation can result in problems if the record has to be admitted as evidence in a court of law

Answer 142

is a systematic method of documentation that consists of four components: -Database -Problem list -Initial plan -Progress notes

Answer 143

-Chief complaint -Present conditions and diagnoses -Social data -Past, personal, medical, and social history -Review of systems -Physical examinations -Baseline laboratory data

Answer 144

of the record and contains a numbered list of the patient's problems, which helps index documentation throughout the record

Answer 145

-Diagnostic/management plans (plans to learn more about the patient's condition and the management of the conditions_ -Therapeutic plans (specific medications, goals, procedures, therapies, and treatments used to treat the patient) -Patient education plans (education about conditions for which the patient is being treated)

Answer 146

Subjective (S) (patient's statement of signs and symptoms, including severity and duration [e.g., "I have had a very painful headache for the past three days"]) -Objective (O) (observations about the patient, such as physical findings, or lab or x-ray results [e.g., chest x-ray negative]) -Assessment (A) (judgment, opinion, or evaluation made by the health care provider [e.g., acute headache]) -Plan (P) (diagnostic, therapeutic, and education plans to resolve the problems [e.g., patient to take Tylenol as needed for pain])

Answer 147

Although the terms electronic health record (EHR) and electronic medical record (EMR) are often used interchangeably, the EHR is a more global concept that includes the collection of patient informaiton documented by a nuber of providers at different facilities regarding one patient. The EHR uses multidisciplinary (many specialities) and multi-enterprise (many facilities) recording keeping approaches to facilitate record linkage, which allows patient information to be created at different locations according to a unique patient identifier or identification number.

Answer 148

-Provides access to complete and accurate patient health problems, status and treatment data, and promotes coordination of patient care -Allows access to evidence-based decision support tools (e.g., drug interaction alerts) that assist providers with decision making -automates and streamlines a provider's workflow, ensuring that all clinical information is is communicated -prevents delays in health care response that result in gaps in care (e.g., automated prescription renewal notices) -Supports the collection of data for uses other than clinical care (e.g., billing, outcomes reporting, public health disease surveillance/reporting, and quality management)

Answer 149

and the possibility that evaluation and management elements not actually performed during an encounter will be automatically documented (populated) by the software

Answer 150

-Includes a patient's medication lists, problem lists, clinical notes, and other documentation -Allows providers to prescribe medications, as well as order and view results of ancillary tests (e.g., laboratory, radiology) -Alerts the provider about drug interactions, abnormal ancillary testing results, and when ancillary tests are needed

Answer 151

-Registering patients -scheduling appointments -generating insurance claims and patient statements -processing payments from patient and third-party payers -producing administrative and clinical reports

Answer 152

providers who demonstrate that certified EHR technology is used for electronic prescribing, electronic exchange of health information in accordance with law and HIT standards, and submission of information on clinical quality measures; and hospitals that demonstrate that certified EHR technology is connected in a manner that provides for the electronic exchange of health information to improve quality of care and that the technology is used to submit information on clinical quality measures

Answer 153

that certified EHR technology was used to submit information on clinical quality measures according to stages of meaningful use (objectives and measures that achieve goals of improved patient care outcomes and delivery through data capture and sharing, advance clinical processes, and improved patient outcomes)

Answer 154

the American Recovery and Reinvestment Act (ARRA), enacted in 2009, implemented measures to modernize the nation's infrastructure, including the Health Information Technology for Economic and Clinical Health (HITECH) Act, which supported the concept of EHRs/meaningful use. Meaningful use required the use of certified EHR technology in a meaningful manner (e.g., electronic prescribing) to ensure that certified EHR technology submitted information about quality of care and other measures to the Secretary of Health and Human Services (HHS).

Answer 155

-Engaging patients and families in their health -ensuring adequate privacy and security protection for personal health information -improving care coordination -improving population and public health -improving quality, safety, and efficiency and reducing health disparities

Answer 156

CMS maintains (eCQMs), which use data from electronic health records (EHR) and health information technology systems to measure health care quality. Measures apply to processes, observations, treatments, and outcomes, which serve to qualify the quality of care provided by health care systems. Measuring and reporting eCQMs data helps ensure that care is delivered safely, effectively, equitably, and timely. Promoting Interoperability (PI) programs (previously called EHR incentive programs) focus on improving patient access to health information and reducing the time and cost required for providers to comply with the programs' requirements.

Answer 157

The Medicare Access and CHIP reauthorization act (MACRA) of 2015 ended the sustainable growth rate (SGR) formula and meaningful use payment adjustments (and its separate quality reporting incentives). MACRA consolidated certain law performance programs, implementing a new quality payment program (QPP), which helps providers focus on quality of patient care and making patients healthier that includes advanced alternative payment models (Advances APMs) and merit-based incentive payment system (MIPS).

Answer 158

unsustainable decreases in the Medicare Physician Fee Schedule (MPFS). To avoid decreases in reimbursement, Congress was required to pass a new lay every year authorizing the current fee schedule and a small increase for inflation. MACRA eliminated the SRG law and the Congressional requirement for annual MPFS legislation

Answer 159

is a payment approach that gives added incentive payments to provide high-quality and cost-efficient care; APMs can apply to a specific clinical condition, a care episode, or a population

Answer 160

are a subset of APMs and include new ways for CMS to reimburse health care providers for care provided to Medicare beneficiaries. Providers who participate in an Advanced APM through Medicare Part B may earn an incentive payment for participating in the innovative payment model.

Answer 161

-Lump-sum inventive payment (2019-2024) to some participating health care providers -Increased transparency of physician-focused payment models -Higher annual payments (beginning in 2026) to some participating health care providers Examples of APMs include accountable care organizations (ACOs), patient-centered medical homes, and bundled payment models.

Answer 162

-Quality. -Resource use -Clinical practice improvement -meaningful use of certified EHR technology

Answer 163

The Promoting Interoperability (PI) Programs to highlight enhanced goals of the program, better contextualize program changes, and because the incentive payments have ended for Medicare and Medciaid

Answer 164

-An individual is defined as a single clinician, identified by a single National Provider Identifier (NPI) number tied to a single Tax Identification Number (TIN). When reporting as an individual, the payment adjustment is based on performance and data for each MIPS category -a group is defined as a single TIN with two or more eligible clinicians as identified by the NPIs (including at least one MIPS-eligible clinician) who have reassigned their Medicare billing rights to the TIN. When reporting as a group, the payment adjustment is based on the group's performance

Answer 165

-Qualified registry -Qualified clinical data registry (QCDC) -Electronic health record (EHR) -Attestation

Answer 166

CMS-approved entity that collects clinical data and submits measures and activities data for certain performance categories to CMS; in 2018, the Quality, Program Interoperability, and Improvement Activities performance categories were used to collect data and report data (Program Interoperability replaced Advancing Care Information as the performance category name in 2019.)

Answer 167

CMS-approved entity that collects and reports clinical data for the purpose of patient and disease tracking to foster improvement in patient quality of care; data collected covers quality measures across multiple payers and is not limited to Medicare beneficiaries

Answer 168

Use of Certified Electronic Health Record Technology (CERHRT), which is rquired for participation in the Program Interoperability performance category of MIPS

Answer 169

using the hhtp://qpp.cms.gov website to verfy that measures associated with certain MIPS components, Program Interoperability, and Improvement Activities, were conducted

Answer 170

Routine Administrative Medicare Claims process

Answer 171

submission of CPT category II quality data codes and HCPCS level II G-Codes on eligible claims that demonstrate compliance with Quality performance measures; reporting such codes indicates which patients should be added to the calculation based on quality measures, such as reporting data about age-appropriate colonoscopy screenings

Answer 172

-CMS Web Interface -Consumer Assessment of Healthcare Providers and Systems (CAHPS)

Answer 173

secure Internet-based data submission mechanism (portal) available only to groups with 25 or more MPS-eligible clinicians; reporting all 15 sets of performance measures is required

Answer 174

optional Quality performance measure available only to groups with 2 or more eligible clinicians; MIPS-eligible clinicians may be awarded points under the Improvement Activities performance measure category for administering the survey

Answer 175

2017 to identify high priority areas for quality measurement and improvement. Its purpose is to iprove outcomes for patients, their families, and providers while also reducing burden on clinicians and providers. The intent is to move toward value-based payments by focusing efforts of the same quality areas and provide specificity (e.g., address high impact measure areas that safeguard public health, provide patient -centered and meaningful care to patients)

Answer 176

1) They are participating in an Advances APM but do not meet Medicare patient or payment count thresholds for qualifying Advanced aPM participant (QP) or a partially qualified Advanced APM participant (PQ) or 2) if they are participating in an APM that is not considered an Advanced APM. MIPS APMs are a hybrid of MIPS and Advanced APMs, and they have different reporting requirements and scoring (as compared with MIPS or Advanced APMs)

Answer 177

MIS participants decide whether to report data as an individual (e.g., single clinician with a NPI) or with a group (e.g., two or more eligble clinicians who have reassigned their Medicare billing rights to a single tax identification number). (Clinicans can also participate in MIPS AMPs, a hybrid of MIPS and Advanced APMs, for which there are different reporting requirements and scoring).

Answer 178

-Quality -Cost -Improvement activities -Promoting interoperability (PI) (bonus points can be earned)

Answer 179

(Some data is reported on CMS-1500 claims). Clinicians also review benchmarked data for quality, improvement activities, and PI measures to compare their results to national and regional data.

Answer 180

allows an entity to measure and compare its own data against that of other agencies and organizations for the purpose of continuous improvement

Answer 181

(e.g., EHR allows for reporting of selected measures), adhere to documentation requirements to achieve targeted measures, and strive to meet benchmarks (comparative data) to achieve optimal results

Answer 182

-Cost measures are evaluated automatically through administrative claims data -CMS calculates the Medicare spending per beneficiary (MSPB) and total per capita cots (TPCC) measures -MSPB and TPCC results are sent to each clinician -Clinicians compare their score with national median scores and percentile ranks, identify areas of needed improvement, and implement a cost improvement plan

Answer 183

Clinicians must ensure that the measures are supported by the reporting method selected (e.g., EHR allows for reporting of selected measures), adhere to documentation requirements to achieve targeted measures, and strive to meet benchmarks (comparative data) to achieve optimal results

Answer 184

achieve, measure, and report targets results. Clinicians must ensure that necessary functionality has been activated in the practice's EHR (e.g., e-prescribing, patient portal, direct messaging between patient and clinicians)

Answer 185

the amounts paid by the insurance company for covered healthcare items and sevices

Answer 186

describe anything the insurance company will not cover. They can vary from plan to plan, but typical exclusion is for pre-existing medical conditions. These are conditions that were diagnosed and treated before the individual was enrolled in the health insurance plan. The conditions tend to be chronic or long-term and can include diabetes, COPD, cancer, rheumatoid arthritis, epilepsy, depression, and sleep apnea.

Answer 187

-Pregnancy and childbirth -Infertility treatments -dental treatments -cosmetic surgery -prescription drugs Covered benefits and excluded services are outlines in the health insurance plan's coverage documents

Answer 188

the term means that the insurance company screen the applicants to find out about their health status and risk factors. Based on this information, decision is made whether to insure the applicant and under what terms. If an applicant seems too risky, the insurance company can deny him or her coverage

Answer 189

is a policy that is issued to an individual regardless of age, pre-existing conditions, or other factors that might predict the use of health services. Premiums for this type of coverage are usually higher than premiums for policies that are medically underwritten

Answer 190

you'll need to understand the terms related to covered expenses that are the responsibility of the patient; deductible, coinsurance, and copayment (copay)

Answer 191

is the amount of money that a patient must pay for covered medical expenses before the insurance reimbursements begin. Deductibles are usually an annual amount. A growing number of individuals are opting for a high-deductible health plan (or HDHP).

Answer 192

Plans with higher deductibles tend to have lower premiums; however, the deductible amount can be as high as $10,000 a year. A healthy individual who rarely gets sick or injured would save money under this plan

Answer 193

Coinsurance is the percentage of costs a patient shares with their health insurance. A common example is 80/20 coverage where the insurance pays 80% of the bill, and the patient is responsible for the other 20%

Answer 194

is a specified dollar amount that the patient must pay to a healthcare provider for each visit or medical service received. You'll usually find this information on the patient's insurance card.

Answer 195

The Affordable Care Act (nicknamed Obamacare) was signed into federal law in 2010 by President Obama and created a Health Insurance Marketplace (also referred to as "the Marketplace" or "Exchange") in 2013. Individuals and families who do not have health insurance through their employment are eligible to use the Health Insurance Marketplace to compare plans and purchase coverage that meets their needs and fits their budget

Answer 196

-Medicare -Medicaid -Children's Health Insurance Program (CHIP) -Workers' Compensation -Military healthcare -Indian Health Service (IHS)

Answer 197

On July 30, 1965, President Lyndon B. Johnson signed into law legislation that established the Medicare program to make access to healthcare a universal right for older Americans. Today it is the largest, single healthcare program in the United States. Medicare is a federal health insurance program for people aged 65 and older, people under age 65 with certain disabilities, and people of all ages with ESRD (requiring dialysis or a kidney transplant)

Answer 198

Part A- reimburses facilities for inpatient care, skilled nursing care, hospice care, and home healthcare Part B- reimburses physicians for inpatient and outpatient services

Answer 199

-Medicaid is a joint federal and state program to provide medical insurance -It applies to people with limited income and resources -The eligibility rules are different for each state -States can tailor their Medicaid programs to best serve the people of their state, so there's a wide variation in the services offered.

Answer 200

an agency within the Department of Health and Human Services that administers the Medicare and Medicaid programs.

Answer 201

was created in 1997 to give health insurance and preventive care to 1 in 7 uninsured American children. Many of these children come from uninsured working families that earned too much to be eligible for Medicaid, but can't afford private insurance. All 50 states, the District of Columbia, and the territories have CHIP plans.

Answer 202

is a plan that is mandated by state government requiring employers to cover employees who get sick or injured on the job. Although workers' compensation statutes vary by state, benefits provide wage replacement, medical treatment, and vocational rehabilitation

Answer 203

Tricare and CHAMPVA

Answer 204

a healthcare program for active-duty and retired uniformed services members and their families

Answer 205

Healthcare coverage for spouses, widows, and children of veterans with disabilities that are entirely service-related

Answer 206

is an agency within the U.S. Department of Health and Human Services. It is responsible for providing a comprehensive health-service delivery system to Native (North) American individuals and First Nations Peoples who live in Alaska. The IHS is the primary health advocate for Indigenous People, and its goal is to raise their health status to the highest possible level. Provision for the federal government to provide these health services to members of federally recognized Tribes was established by numerous treaties, laws, Executive Orders, and Supreme Court decisions between the federal government and Native (North) American nations dating as far back as 1787.

Answer 207

The information in medical records provides a complete history of the patients health, including all diagnoses and treatments. Healthcare providers are responsible for documenting legible, complete, timely, and accurate patient records in accordance with federal regulations and accrediting agency standards, such as The Joint Commission

Answer 208

founded in 1951, the Joint Commission is the nation's oldest and largest standards-setting and accrediting body in healthcare. The Joint Commission seeks to continuously improve healthcare for the public by evaluating healthcare organizations and inspiring them to excel in providing safe and effective care of the highest quality and value. The Joint Commission accredits and certifies more than 22,000 healthcare organizations and programs in the United States

Answer 209

-Continuity of care -Cost control -Legal document -Financial document

Answer 210

Medical records provide the vital information for any physician who assumes responsibility for the patient's care

Answer 211

Medical records control the cost of healthcare by eliminating unnecessary or redundant services

Answer 212

Medical records help healthcare providers defend against malpractice claims or other inquires concerning patient care

Answer 213

Medical records provide documentation that a doctor saw a patient or performed a service, and that ensures payment by third-party payers

Answer 214

-healthcare providers -insurers -coders/billers -transcriptionists/Medical Scribes -Patients -Clinical Documentation Improvement Specialists -Auditors -Clinical Researchers -Lawyers

Answer 215

Documentation in the Medical record serves as the basis for coding. In addition, the information in the record must support the codes submitted on claims for third-party payer reimbursement. If a provider performs a service but does not document it in the record, the insurance carrier can refuse to pay for that service. Also, missing documentation can result in problems if the record is admitted as evidence in a court of law. The patient's diagnosis must also justify the services and procedures provided. This is called medical necessity and requires the provider to document that the treatment provided was proper and needed for the patient's medical condition and consistent with standards of good medical practice.

Answer 216

1. document the patient's clinical problems and treatment plans; and 2. communicate with other members of the healthcare team about the care that is rendered. The SOAP format is a common way of organizing chart notes in medical records.

Answer 217

SOAP is an acronym that stands for "Subjective, Objective, Assessment, and Plan"

Answer 218

These are the patient's observations about how he or she is feeling. The current symptoms are identified, and these are often documented in the patient's own words

Answer 219

This is the physical examination and is information the physician can observe or measure, such as vital signs, swelling, skin lesions, deformities, muscle spasms, and so forth. The physician will also review results of lab work and diagnostic tests

Answer 220

These are the physician's diagnoses

Answer 221

This is what the physician is going to do to address the patient's diagnoses. It may involve information for self-care, further testing to confirm diagnosis, prescription medication, referral to a specialist, lab work, physical therapy, or surgery.

Answer 222

A digital version of the patient's chart in a medical office. The data that is contained in an EMR cannot be electronically shared with other physicians, specialists, or institutions

Answer 223

Health information in a digital format that is created and shared by providers across more than one healthcare setting, such as hospitals, emergency departments, laboratories, ambulatory surgery centers, and outpatient diagnostic facilities. The EHR contains information from all providers and organizations involved in a patient's care, and authorized staff from multiple healthcare facilities can access that record.

Answer 224

is what differentiates the EHR from the EMR. The greatest advantage of EHRs is their ability to coordinate care among all providers. Interoperability is the capacity of systems to communicate and exchange information with one another

Answer 225

-Shares up-to-date patient data across care settings -Eliminates redundant care, which saves time and money -Improves quality of care due to reduction in errors in the medical record -Reduces administrative costs, such as transcription services -Saves office space compared to paper charts -Provides advanced clinical capabilities, such as E-Prescribing (exchanging prescription information electronically between prescribers and pharmacies) -Can be viewed on multiple user devices; desktop computers, laptop computers, tablet computers, and smartphones

Answer 226

Cloud-based software that is designated to support many of the administrative and financial functions of a medical practice is Practice Management Software. Many vendors offer practice management software to automate a variety of tasks

Answer 227

-Centralizing patient registration information -Scanning of insurance cards and photo ID -Scheduling appointments -Verifying insurance eligibility -Managing authorizations and referrals -Providing medical coding tools -Processing insurance claims -Printing patient statements -Generating financial reports

Answer 228

The "cloud" is actually a network of computers that work together to store and process enormous amounts of data. This is called cloud computing. These computer networks are housed inside warehouses across the globe known as data centers. Rather than saving files on your computer's hard drive, you can store your digital information in these data centers where there's almost unlimited storage space

Answer 229

Practice management software has been instrumental in automating and streamlining many administrative and financial tasks in a medical office that used to be time consuming and prone to errors. Using practice management software results in medical practices that are more efficient, productive, and profitable. Next, are screenshots that illustrate some of the administrative and financial functions that can be handled by practice management software

Answer 230

Advantages of using software for appointment scheduling increases searching, cancelling, and rescheduling appointments with ease. Times that the physicians are not available are clearly blocked off on the schedule.

Answer 231

After the patient's primary and secondary insurances have been billed, the payments and adjustments are posted to the patient's account

Answer 232

Any amounts that remain after insurance are posted are the patient's responsibility. An itemized statement is generated that specifies the balance due on the patient's account.

Answer 233

Reports provided by practice management software have many uses in a medical office. Financial reports are particularly useful for tracking insurance payments and accounts receivable.

Answer 234

Having a practice management system that is integrated into the EHR is key to increasing accuracy and efficiency, which can have a positive impact on the medical practice's earnings. When the practice management software and the EHR share electronic data, medical codes and notes flow smoothly between the two, which saves the manual steps that are time-consuming and often create the possibility of errors.

Chapter 2 - medical coding Flashcards

(259 cards)