Lec 6: Language Of Payment/Coding/Billing

Question 1

Assignment of Benefits:

Answer 1

Payment of medical benefits DIRECTLY to the provider rather than the member/subscriber, requires written release

Question 2

Authorization:

Answer 2

Gatekeeper/primary care provider approval for hospitalization or care

Question 3

Balance Billing:

Answer 3

The administrative practice of holding the pt financially responsible for the remainder of medical service charges, beyond the insurer’s allowed amount.

Does not apply when a managed care contract contains a “hold harmless” clause

Question 4

Cost sharing:

Answer 4

Patient responsible for portion or % of total charge

Methodology to reduce utilization

Question 5

Denial:

Answer 5

Refusal by insurer to reimburse services that have been rendered

Can be for various reasons

Question 6

Explanation of Benefits (EOB)

Answer 6

Insurer-provided description of provider services and explanation of those covered and denied

Question 7

Policyholder:

Answer 7

Purchaser of an insurance policy

In group health insurance, this is usually the employer who purchases policy coverage for its employees

Question 8

Pre-authorization:

Answer 8

Insurance company review of care before delivery to establish appropriateness of payment

Question 9

Pre-existing condition:

Answer 9

Physical or mental condition of patient occurring before start of insurance coverage

Question 10

Profiling:

Answer 10

Data collection by insurers on billing and utilization by providers

Question 11

What is needed to get paid for professional services?

Answer 11

Professional license
Business structure
Services available
Price list
Business policies (registration and verification of info)
Reimbursement contracts, arrangement
Charge system
Billing processes
Accounting procedures
Collection procedures
Documentation system

Question 12

PT relationship with payers: Cultivate a reputation for _________, appropriate documentation (payers track this information)

Answer 12

QUALITY care

Question 13

Office staff relationship with payers:

Answer 13

Phone courtesy
Competence
Reliability

Question 14

What does the client admissions process include?

Answer 14

Medical record
Business account
Authorizations/consents

Question 15

Client Admissions Process: What is included in medical record ?

Answer 15

Demographics

Patient record

Question 16

Client Admissions Process: What is included in business account?

Answer 16

Payment info

Question 17

Client Admissions Process: What is included in authorizations/consents

Answer 17

Informed consent
Confidentiality/HIPAA
Assignment of benefits

Question 18

AOB: A patient’s voluntary signed agreement to a provision such as “I hereby request assignment of payment of all insurance benefits to the ___________”

Answer 18

Provider of service

Question 19

AOB: The provider then directly submits the claim to the ______

Answer 19

Payer

Question 20

AOB: Provider must typically be __________

Answer 20

participating

Question 21

AOB: Alternative- patient pays for service and submits for reimbursement from _______

Answer 21

Insurer

Question 22

Billing for services: Bills submitted to patient or third party payer, or provided to __________ to prepare bills

Answer 22

Claims clearinghouse

Question 23

Billing for services: most billing is now ______

Answer 23

Electronic

Question 24

Billing for services: there is an importance of _______

Answer 24

CLEAN CLAIMS

Question 25

Fee Determination: A provider must know their ______ in order to determine _____

Answer 25

Costs | Fees

Question 26

Fee determination: Basing charges on ______ plus reasonable profit avoid ________________

Answer 26

COST Anticompetitive pricing issues

Question 27

Fee determination: A single fee schedule with fee discounts based on policy and arrangements with payers is more _________ than multiple fee schedules

Answer 27

Defensible

Question 28

Claim submission: Must verify 4 things

Answer 28

Patient info Person responsible for bill Insurance info, including primary and secondary Coordination of benefits

Question 29

Coordination of benefits: Generic term for situations where the patient have have coverages under _________

Answer 29

More than one insurance plan

Question 30

Coordination of benefits: Health Vs. Liability insurer:

Answer 30

Primary pay or may be decided by liability (workers comp or auto)

Question 31

Coordination of benefits: Medicare patients with supplemental coverage -- A medicare patient may have supplemental coverage, either ______ or _______

Answer 31

Medical insurance | Medicaid

Question 32

Coordination of benefits: IF BOTH SPOUSES HAVE COVERAGE: In adults, each spouse's employee health insurance is the primary payer for his/her care; spouse's family coverage is _______

Answer 32

Secondary

Question 33

Coordination of benefits: IF BOTH SPOUSES HAVE COVERAGE: With children, if one parent has family coverage and the other only individual coverage, then the _________ is the only payer

Answer 33

Family coverage

Question 34

Coordination of benefits: IF BOTH SPOUSES HAVE COVERAGE: If both have family coverage, most states use the ______

Answer 34

Birthday rule | The insurance of the parent with the bday earlier in the calendar year pays first

Question 35

Coordination of benefits: Once the primary payer has processes the claim, the provider or patient must resend to _________, along with the primary insurer's __________ or __________

Answer 35

Secondary insurer Explanation of Benefits Remittance Notice

Question 36

Coordination of benefits: True or false, the secondary insurance will never pay more than the patient's liability remaining after the primary payer has processed the claim

Answer 36

True

Question 37

Copayments: May be collected when service is provided, or _____

Answer 37

Billed later

Question 38

Copayments are the expectation that

Answer 38

Is the patient responsibility

Question 39

Copayments are the same as balance billing, T/F?

Answer 39

False. They differ

Question 40

Insurers expect that having the pt share the expense of the medical care will result in the patient having an ________ to limit their own care

Answer 40

Incentive

Question 41

Medicare Advanced Beneficiary Notice is what?

Answer 41

For medicare providers, if the service is known to be non covered or not medically necessary, the provider have the the patient sign an ABN

Question 42

What is an NPI?

Answer 42

National Provider Identifier 10 digit numeric ID that must be used on claim forms submitted to payors by individual and organization health care providers who meet the definition of a covered entity under HIPAA

Question 43

What is the intent of an NPI?

Answer 43

To further streamline electronic claims processes already in place

Question 44

Out of Network Model: Limited Insurance Contracts: Collect payment directly from patients at the time of service and provide an _________ for the to submit to their health insurer

Answer 44

Itemized bill

Question 45

Out of Network Model: Limited Insurance Contracts: Collect from patients at the time of service and offer to send ________ to their insurer on their behalf

Answer 45

Courtesy bills

Question 46

Out of Network Model: Limited Insurance Contracts: Accept __________, bill the _________, and bill the ________ for the balance once the insurer has paid.

Answer 46

Assignment Insurer Patient

Question 47

Cash practice: No insurance contracts: Opt out of all _______ insurance contracts

Answer 47

Private

Question 48

Cash practice: no insurance contracts: Patient pay in full at the __________ or insurer is billed directly and patient is billed for the ____________ Usually ______ patient cost sharing

Answer 48

Time of service Balance not covered by the plan HIGHER

Question 49

Cash practice: Physical therapists are not permitted to opt out of _________ for covered services

Answer 49

Medicare

Question 50

Cash practice: Noncovered services: Providing services that are _____ covered services under most insurance plans

Answer 50

NOT

Question 51

Cash practice: Noncovered services: Practice determines the value of the service, establishes the fee, and in most cases, collects the fee at the ____________

Answer 51

Time the service is delivered

Question 52

Code for Billing: Diagnoses: When billing for services provided by a PT, must specify the ______

Answer 52

Medical Diagnosis | ICD-10 as of 10/1/15

Question 53

Codes for Billing: Interventions:

Answer 53

CPT-4

Question 54

ICD-9 and ICD-10CM are the official system of assigning codes to diagnoses and procedures associated with _______ in the US

Answer 54

Hospital utilization

Question 55

ICD-10 features about ________ codes

Answer 55

69,000

Question 56

The new ICD-10 allows clinicians to be far more specific with IDing patient health conditions and will provide better data top measure and track health care utilization and quality of care, T/F?

Answer 56

True

Question 57

ICD-10 has how many characters? First 3 for? Next 3 for? 7th for?

Answer 57

3-7 characters First 3: Category of Dx Next 3: Etiology, an anatomical site, severity, vital clinical details 7th: Type of patient encounter (initial, subsequent, sequela)

Question 58

CPT: Listing of descriptive terms and IDing codes for ________

Answer 58

Reporting medical services and procedures

Question 59

What is the purpose of CPT?

Answer 59

To provide a uniform language that accurately describes medical, surgical, and diagnostic services, and thereby serves as an effective means for reliable nationwide communication among physicians and other HCP, patients, and third parties

Question 60

CPT is used for what?

Answer 60

Payment Outcome assessments Other data collection

Question 61

Relationship of code to payment: Existence of code does not necessarily mean that ______

Answer 61

The provider will be paid for that code

Question 62

Payment policy for coding is dependent on what?

Answer 62

Individual payors and their policies

Question 63

Who first developed CPT?

Answer 63

AMA

Question 64

There is a regulation for requiring the use of CPT for PT and OT services, T/F?

Answer 64

True

Question 65

What are the most common codes utilized by PTs?

Answer 65

Category I codes: 5 digit code

Question 66

Are Physical Medicine and Rehab Caterogry I codes exclusive to PT?

Answer 66

No

Question 67

There are three different kinds of PT Evals, what are they?

Answer 67

Low, moderate, or high complexity

Question 68

Is there a code for PT re-eval?

Answer 68

Yes, as of 1/1/2017

Question 69

Therapeutic procedures include:

Answer 69

``` Therex Neuromuscular re-ed Gait training Manual therapy Therapeutic activities ```

Question 70

Supervised modalities do not require what?

Answer 70

Do not require direct one-on-one contact by the provider

Question 71

How many supervised modalities codes can you bill per visit?

Answer 71

Only one, regardless of the number of body parts treated

Question 72

What is an example of a supervised modality?

Answer 72

Hot/cold packs Diathemy Unattended e-stim

Question 73

Constant attendance modalities require what?

Answer 73

That a provider have direct one-on-one contact with the patient for all of the minutes represented in billing

Question 74

What is an example of constant attendance modalities?

Answer 74

Iontophoresis US Contrast baths

Question 75

What is the CMS 8-minute rule?

Answer 75

For any single, time CPT code in which one unit is defined as 15 minutes, a provider is required to bull one unit of care for greater than or equal to 8 minutes and less than 23 minutes

Question 76

CMS 8 Minute Rule: Two units of care can be billed for a specific CPT code for greater than or equal to _____ minutes and less than _____ minutes

Answer 76

23 minutes | 38 minutes

Question 77

CMS 8 Minute Rule: 3 units of care can be billed for a specific CPT code for greater than or equal to _____ minutes and less than _____ minutes

Answer 77

38 minutes | 53 minutes

Question 78

CMS 8 Minute Rule: 4 units of care can be billed for a specific CPT code for greater than or equal to _____ minutes and less than _____ minutes

Answer 78

53 minutes | 68 minutes

Question 79

CMS 8 Minute Rule: 5 units of care can be billed for a specific CPT code for greater than or equal to _____ minutes and less than _____ minutes

Answer 79

68 minutes | 83 minutes

Question 80

Group Therapy Code: This is to be used when care is provided to more than one person during the same _____

Answer 80

Time interval

Question 81

What are modifiers?

Answer 81

Increase the specificity of the CPT code Example: can be used to describe that the service was provided on both of the patient's legs or during a distinct time interval

Question 82

What is the purpose of correct coding initiative?

Answer 82

To develop correct coding methodologies to curtail improper unbundling or services for Medicare Part B claims

Question 83

A code pair edit is a combination of ________ that cannot be billed together because either the code pair represents services that are considered mutually exclusive or one code in the pair is considered a component of a more comprehensive procedure code

Answer 83

Two CPT codes

Question 84

If the prohibited code combo is reported to the carrier, only ______ will be reimbursed

Answer 84

One code

Question 85

Medicare will only pay for ____ 15 minute codes in an hour, unless you have a PTA, you can bill for more

Answer 85

4