The Business of Medicine Flashcards
(35 cards)
What is Coding?
The process of translating a written or dictated medical record into a series of numeric and alphanumeric codes.
How is Proper Code Assignment determined?
By both the content (documentation) in the medical record and by the unique rules that govern each code set in that instance (which vary depending on who pays for the patients care).
Coding is typically performed by…
Physician (coder audits to verify)
Coder
Outpatient Coders
Focuses On:
> Physician professional services
> Outpatient facility coding
Code Books Used:
> CPT
> HCPCS Level II
> ICD-10-CM
Works In:
> Physician offices
> Outpatient clinics
> Facility outpatient departments
Hospital Inpatient Coders
Code Books Used:
> ICD-10-CM
> ICD-10-PCS
Will also assign medical severity diagnosis related groups (MS-DRGs).
Risk Adjustment Coding
Risk adjustment diagnoses are pulled from claims data and medical record documentation in all settings.
Can Work For:
> Health plans
> Providers
> Other healthcare entities
Uses the ICD-10-CM
2 Primary Types of Insurance
1) Commercial
2) Government
Commercial Insurance Payers
Private payers that may offer both group and individual plans.
Contracts vary depending on the type of plan.
> All plans will typically include:
hospitalization, basic, and major
medical coverage.
Commercial (Non-Medicare) payers may develop their own medical policies that may not follow Medicare guidelines and are specified in private contracts between the payer and the practice or provider.
Example: BlueCross BlueShield
Government Insurance
A federal health insurance programs.
Example: Medicare & Medicaid
Medicare
A federal health insurance program ( administered by CMS), that provides coverage for people over the age of 65, blind, or disabled individuals, and people with permanent kidney failure or end-stage renal disease (ESRD).
Medicare Part A
Helps cover inpatient hospital care, as well as care provided in skilled nursing facilities, hospice care, and home healthcare.
Medicare Part B
Helps cover medically necessary physicians’ services, outpatient care, and other medical services (including some preventive services) not covered under Medicare Part A.
Is an optional benefit in which the patient must pay a premium, and which generally requires a yearly deductible and co-insurance.
Medicare Part C
Combines the benefits of Medicare Part A, Part B, & (sometimes) Part D.
Plans are managed by private insurers approved by Medicare.
Plans may charge different co-payments, coinsurance, or deductibles for services.
Is also called Medicare Advantage
Medicare Part D
A prescription drug program available to all Medicare beneficiaries.
Private companies approved by Medicare provide coverage.
Medicaid
A health insurance assistance program for some low-income people (especially children and pregnant women) sponsored by federal and state governments.
Administered on a state-by-state basis, but state programs must adhere to certain federal guidelines.
State-Funded Insurance Programs
Provide coverage for children up to 21 years of age and may include:
> Children’s Medical Services
> Children’s Indigent Disability
Services
> Children with Special Healthcare
Needs, among others.
RBRVS (resource-based relative value scale)
Used to standardize Medicare payments for physician services.
3 Components
> Physician work
> Practice expense
> Professional liability insurance
RBRVS Component - Physician Work
52% of a procedure/service total relative value.
Measured By:
> The time it takes to perform the
service
> The technical skill and physical
effort
> The required mental effort and
judgment
> Stress due to the potential risk to
the patient
RBRVS Component - Practice Expense
44% of a procedure/service total relative value.
Are resource-based and differ by site of service.
RBRVS Component - Professional Liability Insurance
4% of a procedure/service total relative value.
Resourced-based
Medical Necessity
Refers to whether a procedure/service is considered appropriate in a given circumstance.
Is generally the least radical procedure/service that allows for effective treatment of the patient’s complaint or condition.
National Coverage Determinations (NCDs)
Explain when Medicare will pay for items or services.
If a NCD doesn’t exist for an item, it’s up to the Medicare Administrative Contractor (MAC) to determine coverage.
Local Coverage Determinations (LCDs)
National policies that have been interpreted into regional policies by a Medicare Administrative Contractor (MAC).
Only have jurisdiction within their regional area.
Advance Beneficiary Notice (ABN)
A standardized form that explains to the patient why Medicare may deny the procedure/service.
Protects the provider’s financial interest by creating a paper trail that CMS requires before a provider can bill the patient for payment if coverage is denied for the stated procedure/service.
The provider must present the patient with a cost estimate for the proposed procedure/service that is within $100 or 25% of the actual cost (whichever is greater).
Non-Medicare payers may not recognize an ABN as their health plan contracts may have a “hold harmless” clause that prohibits the billing to the patient for anything other than co-pays or deductibles.
