Documentation (content)
Proper code assignment is determined both by _____________ in the medical record and by the unique rules that govern each code
... [Show More] set in that instance
An auditor
The role a coder may take on to verify that the documentation supports the codes the physician has selected
Query the physician
If the medical record is inaccurate or incomplete, it will not translate properly to the language of codes. What can a coder do in order for the medical record to be complete and accurate so they can bill properly?
Quarterly (usually)
How often are codes and insurance payment policies updated?
NPP
Non-Physician Provider (also known as mid-level providers or physician extenders)
PA
Physician assistant
NP
Nurse practitioner
Commercial and Government
The two types of primary insurances
Commercial Carriers
Private payers that may offer both group and individual plans
Medicare
The most significant government insurer; a federal health insurance program
People over 65, blind or disabled individuals, and people with permanent kidney failure or end-stage renal disease
Medicare provides coverage for what kind of people?
ESRD
end-stage renal disease
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
Covers medically necessary physicians' services, outpatient care, and other medical services (including some preventive services) not covered under Medicare Part A. It can be an optional benefit.
Medicare Part C
Also called Medicare Advantage, combines the benefits of Medicare Part A, Part B, and-sometimes- Part D. The plans are managed by private insurers approved by Medicare.
Medicare Part D
A prescription drug program available to all Medicare beneficiaries.
Medicaid
A health insurance assistance program for some low-income people (especially children and pregnant women) sponsored by federal and state governments.
RBRVS
Resource-Based Relative Value Scale
Resource-Based Relative Value Scale (RBRVS)
Medicare payments for physician services are standardized using _____ and are divided into three components.
The physician work component, practice expense, and professional liability insurance (PLI)
The three components used to determine resource cost for physician services.
The Physician Work component
Accounts for just over half (52 percent) of a procedure's/service's total relative value and is measured by time it takes to perform a service, technical skill, and physical effort.
Practice Expense
Accounts for 44 percent of the total relative value for each service and differ by site of service. For example, the expense of providing services in the hospital vs a physician's office.
PLI
Resource-Based Professional Liability Insurance
Professional Liability Insurance (PLI)
Accounts for 4 percent of the total relative value for each service
CMS website
Where can you find Physician Fee Schedule (PFS) information?
PFS
Physician Fee Schedule
Medical Necessity
Refers to whether a procedure or service is considered appropriate in a given circumstance
NCD
National Coverage Determinations
National Coverage Determinations (NCD)
Explains when Medicare will pay for items or services
MAC
Medicare Administrative Contractor
Medicare Administrative Contractor (MAC)
Responsible for interpreting national policies into reginal polices.
Local Coverage Determinations (LCD)
Regional policies converted from national polices by a Medicare Administrative Contractor (MAC).
ABN
Advance Beneficiary Notice
Advanced Beneficiary Notice (ABN)
A standardized form that explains to the patient why Medicare may deny the service or procedure
HIPAA
The Health Insurance Portability and Accountability Act
Health Insurance Portability and Accountability Act (HIPAA)
Provides federal protections for protected health information when held by covered entities
HIPAA covered entities
A healthcare provider, a health plan, and a healthcare clearinghouse
PHI
Protected Health Information
Minimum Necessary requirement
A key provision of HIPPA, under which only the _______ protected health information (PHI) should be shared to satisfy a particular purpose.
HITECH
Health Information Technology for Economic and Clinical Health Act
Health Information Technology for Economic and Clinical Health Act (HITECH)
Allows patients to request an audit trail showing all disclosures of their health information made through an electronic record.
Health Information Technology for Economic and Clinical Health Act (HITECH)
Requires that an individual be notified if there is an unauthorized disclosure or use of his or her health information.
OIG
Office of Inspector General
Fraud
To purposely bill for services that were never given or to bill for a service that has a high reimbursement than the services provided; The person does not have to possess knowledge of the violation for it to still be a considered offense.
Abuse
Consists of payment for items or services that are billed by providers in error that should not be paid for by Medicare.
Compliance Plan
A written set of instructions outlining the [Show Less]