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HCAN Quiz 4 > Quiz 4 > Flashcards

Quiz 4 Flashcards

(68 cards)

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1
Q

What is the billing function in health care

A

process of quantifying health care services to insurance carriers, 3rd party payors, and patients for reimbursement.

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2
Q

ICD-10

A

diagnosis, 3-7 digit alphanumeric code

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3
Q

ICD-10-CM

A

Clinical diagnosis

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4
Q

ICD-10-PCS

A

Hospital diagnosis

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5
Q

CPT

A

procedure

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6
Q

HCPCS

A

CPT for Medicare

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7
Q

What does NPI stand for

A

National Provider Identifier

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8
Q

When did NPI start

A

HIPAA 1996

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9
Q

What is NPI

A

10 digit unique alphanumeric number that is similar to a SSN, but it is given out to other providers

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10
Q

Who has to have an NPI

A

physicians, non physician extenders, CRNA

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11
Q

What is credentialing

A

verification of health care practitioners education, training, and work

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12
Q

What is UPD

A

Universal Provider Database, uniform application that any provider can complete for credentialing.

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13
Q

What are some payors additional requirements for credentialing?

A

Every 2 years

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14
Q

What are the different levels of an established patient office visit?

A

Level 1: 99211, patient gets blood pressure checked, less documentation Level 2: 99212 Level 3: 99213 Level 4: 99214 Level 5: 99215, 15-20 minutes of face time with doctor, more documentation

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15
Q

How much reimbursement does Medicare allow for a 99211?

A

$18

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16
Q

How much reimbursement does Medicare allow for a 99215?

A

$134

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17
Q

Why is documentation important

A

it is linked directly to reimbursement, the more specific and complex

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18
Q

Bellcurve

A

there is a normal distribution between 99211 and 99215

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19
Q

Skewed left

A

not using rescouces properly, not documenting appropriately, administration might be conservative

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20
Q

Skewed right

A

might have more severe cases, but still need good documentation, red flag for CMS, coders might not be trained properly

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21
Q

What does coding and reimbursement depend on?

A

Medical necessity= CPT+ICD-10

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22
Q

ABN

A

Advanced beneficiary notice, form that patient signs saying that they will pay out of pocket what Medicare doesn’t pay

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23
Q

Claim

A

itemized statement of services and costs from a health care provider submitted to payers for payment

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24
Q

UB04 (CMS 1450)

A

Hospital inpatient

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25
CMS 1500
Physician/ outpatient
26
"clean" claim
complete documentation that has no special circumstances and no defects
27
Chargemaster
list of facility charges for every service provided 103% above market level
28
How are Part A services paid
contract, per diem, percent of charges, DRG's
29
How are Part B services paid
based on fee schedule
30
fee schedule
set price that payers say are allowed and they they will pay. Can be negotiable in some states
31
priviledges
have to be credentialed in order to gain priviledges
32
What are the key components of billing
charge allowable deductible/copay actual payment contractual allowance bed debt
33
When does a claim begin
when a patient schedules an appointment or enters the clinic/hospital
34
What must be collected at the beginning of a revenu cycle for a claim
demographics medical history insurance carrier ABN HIPAA privacy form divers license and insurance PHI release form
35
Dx
Diagnosis
36
Charge capture
documentation recorded by a provider of service provided
37
scrub
check to ensure that claim is clean
38
where are claims sent after they are batched
clearinghouse or to payer
39
clearinghouse
3rd party organization contracted by a provider to scrub, transmit, and bill services to payers
40
What do clearinghouses generate?
audit trails, summary detailing all claims that were sent to the carrier along with upfront denials and rejections
41
claims adjudication process
clean claims that meet medical necessity are generally reimbursed
42
electronic remittance advice
electronic payment files, used to post payments from carriers back to billing system
43
EOB
explanation of benefits, statement sent to beneficiary explaining what was reimbursed
44
MACs
Medicare Administration Contracts
45
What MAC is Alabama under
Palmetto
46
How many MACs are with Part A and B
12
47
How many MACs are with DME
4
48
What do MACs do?
process Medicare claims make and account for Medicare payments enroll providers in Medicare programs
49
What are LCDs
local coverage determination, determining what is medically necessary
50
RACs
Recovery Audit Contractors
51
What is the purpose of RACs
identify and correct Medicare improper payments by both Part A and B, detection and collection of overpayments
52
What RAC does Alabama fall under
Cotiviti
53
What are the 2 types of reviews
automated- medical records not required complex- medical records required
54
ACO
Accountable Care Organizations
55
What does an ACO do
encourage providers to form new type of health care entity that improves quality of care, reduces cost, and improves transparency
56
Who is responsible in an ACO
physicians and hospitals share responsibilty for the patient
57
How many ACO's are there?
41
58
What do you need to qualify for ACO
minimum of 5000 Medicare beneficiaries for at least 3 years providers are jointly accountable for patient
59
MedPAC
independent body that advises congress on all things Medicare and Medicaid Has 17 members that have a background in healthcare
60
How can ACOs participate
it is voluntary
61
Who is eligible to form ACOs
hospitals group practice networks of individual practices partnerships/joint venture arrangements between hospitals and health professionals
62
Who is limited to one ACO?
primary care physicians: internal medicine, geriatric medicine, family practice
63
Who is allowed to participate in more than one ACO
acute care hospitals, surgical and medical specialites, rural health clinics, and qualified health centers
64
What are the 5 aspects to meeting proposed requirements
measures to assess the quality of care provided requirements for data submission quality performance standards reporting requirements public reporting
65
What are the 5 domains that are part of the quality performance measures
patient/caregiver experience care coordination patient safety prevention health at risk population: elderly, heart failure, hypertension
66
MACRA
Medicare Access and CHIP Reauthorization Act
67
What did MACRA create
repealed sustainable growth rate changed the way medicare rewards clinicians for value over volume streamlined multiple quality programs under the new merit based incentive system (MIPS) Gives bonus payments for participation in eligible alternative payemtn models Required removal of all SSN from Medicare cards by April 2019
68

HCAN Quiz 4 (2 decks)

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