Download Healthcare Reimbursement and Coding: Understanding Medicare, HIPAA, and ICD-9-CM and more Exams Medical Genetics in PDF only on Docsity!
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"hold harmless clause" - correct answer * found in some non-Medicare health plan contracts
- prohibits billing to patient for anything beyond deductibles and co-pays. A compliance plan may offer several benefits, including: - correct answer * more accurate payment of claims
- fewer billing mistakes
- improved documentation and more accurate coding
- less chance of violating self-referral and anti-kickback status A healthcare clearing house is a - correct answer entity that processes nonstandard health information they receive from another entity into a standard format A key provision in HIPAA is the Minimum Necessary requirement. this means - correct answer only the minimum necessary protected health information should be shared to satisfy a particular purpose. A medically necessary service is the - correct answer least radical service/procedure that allows for effective treatment of the patients' complaint or condition A patient sustaining an injury to her great saphenous vein would have sustained injury to which of anatomical site? - correct answer Leg APC - correct answer Ambulatory Payment Classification ARRA - correct answer American Recovery and Reinvestment Act (of 2009)
ASC - correct answer Ambulatory Surgical Centers Abuse consists of - correct answer payment for items or services that are billed by providers in error that should not be paid for by Medicare. An ABN protects the provider's financial interest by - correct answer creating a paper trail that CMS requires before a provider can bill the patient for payment if Medicare denies coverage for the stated service or procedure. An entity that processes nonstandard health information they receive from another entity into a standard format is considered what? - correct answer Clearinghouse As a part of Health Care Reform, the Affordable Care Act of 2010 amended the definition of fraud to remove the __________ requirement - correct answer intent By statute, all work RVUs, must be examined no less often than - correct answer every 5 years CF - correct answer Coversion Factor - fixed dollar amount used to translate the RVUs into fees CMS - correct answer Centers for Medicare and Medicaid CMS developed polices regarding medical necessity are based on regulations found in title XVIII, $1862(a) of the - correct answer Social Security Act CMS will accept the ____________ for either a "potentially non=covered" service or for a statutorily excluded service - correct answer CMS-R- CMS-R-131 - correct answer ABN form
GPCI - correct answer Geographic Practice Cost Index GPCI is used to - correct answer realize the varying cost based on geographic location HCPCS - correct answer Healthcare Common Procedure Coding System HHS - correct answer Department of Health and Human Services HIPAA provides federal protections for - correct answer personal health information when held by covered entities. HIPAA stands for - correct answer Health Insurance Portability and Accountability Act of 1996 HITECH - correct answer The Health Information Technology for Economic and Clinical Health Act HITECH allows patients to request - correct answer an audit trail showing all disclosures of their health information made through an electronic record. HITECH requires that an individual be notified if - correct answer there is an unauthorized disclosure or use of his or her health information. HITECH was enacted as part of - correct answer the American Recovery and Reinvestment Act of 2009 (ARRA) HMO - correct answer Health Maintenence Organization Hemiplegia is a disorder caused by a defect in which anatomic system? - correct answer nervous
ICD-9-CM - correct answer International Classification of Disease, 9th Clinical Modification IF: Work RVUs = 0. Work GPCI = 1. Practice Expense CPCI = 0. MP GPCI = 0. transitioned non-facility practice RVUs = 0. Calculate non-facility pricing amount for cpt code 99212 using 2011 CF of $33.9764 - correct answer $39.51 Non-facility pricing amount (physician office, private practice) If a sevice fails to support medical necessity requirements per the LCD, and the service is not covered, the practice would be responsible for obtaining a(n) - correct answer Advance Beneficiarly Notice of NonCoverage (Advance Benefiary Notice, or ABN) If an NCD doesn't exist for a particular item, its up to the ______ to determine coverage. - correct answer MAC
Medicare Part B helps to cover - correct answer medically necessary physicians' services ouptatient care other medical services (including some preventative services) not covered under Part A Medicare Part B premiums are paid by - correct answer the patient Medicare Part C combines the benefits of - correct answer Part A and Part B and sometimes Part D Medicare Part C is also called - correct answer Medicare Advantage Medicare Part C plans are managed by - correct answer private insurers approved by Medicare. Medicare Part D is a - correct answer prescription drug coverage program Medicare Part D is a coverage provided by - correct answer private companies approved by Medicare Medicare Part D is available to - correct answer all Medicare beneficiaries. Medicare part A helps to cover: - correct answer inpatient hospital care care provided in skilled nursing facilities hospice care
home health care Medicare payments for physician services are standardized using a - correct answer resource-based relative value scale (RBRVS) NCD - correct answer National Coverage Determinations NCD explain - correct answer when Medicare will pay for items or services. NP - correct answer Nurse Practitioner OCR - correct answer Office of Civil Rights OIG - correct answer Office of the Inspector General OIG Compliance Program for Individual and Small Group Physician Practices include the following key actions - correct answer * Implement compliance and practice standards through the development of written standards and procedures.
- designate a compliance officer or contac to monitor compliance efforts and enforce practice standards
- conduct appropriate training and education of practice standards and procedures
- conduct internal monitoring and auditing through the performance of periodic audits
- respond appropriately to detected violations through the investigation of allegations through the investigation of allegations and the disclosure of incidents to appropriate government entitities
Sebacious glands are a part of which anatomic system? - correct answer Integumentary The ABN form is entitled - correct answer Revised ABN CMS-R-131 and is available with instructions as a free download on the CMS website. The ABN is a standardized form that - correct answer explains to the patient why Medicare may deny the particular service or procedure. The OIG is mandated by public law to engage in activities to test - correct answer the efficiency and economy of government programs to include investigation of suspected health care fraud or abuse. The amount on an ABN should be within how much of the cost to the patient? - correct answer $100 or 25% of cost RATIONALE: CMS instructions stipulate, "Notifires msut make a good faith effort to insert a reasonable estimate....the estimate should be within $100 or 25% of the actual costs, whichever is greater. The myocardium is thickest around which chamber of the heart? - correct answer left ventricle The term "medical necessity refers to - correct answer whether a procedure or service is considered appropriate in a given circumstance. The tunica vaginalis is part of which system? - correct answer male reproductive
Under the Privacy rule, the minimum necessary standard of HIPAA does not apply to - correct answer * disclosures to or requests by a health care provider for treatment purposes
- disclosures to the individual who is the subject of the information
- uses or disclosures made pursuant to an individual's authorization
- uses or disclosures required for compliance with the HIPAA Administrative Simplification Rules
- Disclosures to the US Dept of Health and Human Services when disclosure of info is required under the Privacy Rule for enforcement purposes.
- Uses or disclosures that are required by other law What OIG document should a provider review for potential problem areas that will receive special scrutiny in the upcoming year? - correct answer OIG work plan What is an NCD interpreted at the MAC level considered? - correct answer LCD Each MAC (Medicare Adminstrative Contractor) is responsible for interpreting national policies into regional policies, or Local Coverage Determinations What is the result of a ureteral blockage? - correct answer Urine will not be able to flow from the kidney to the bladder When does the OIG release a work plan outlining its priorities for the fiscal year ahead? - correct answer October When should an ABN be signed? - correct answer When a service is not expecgted to be covered by Medicare. RATIONALE: This form explains to the patient why a service MAY be denied by Medicare. The ABN form should be completed for services potentially con- covered by Medicare to advise the patient of potential financial responsibility.
Whose responsibility is it to develop and implement policies, best suited to its particular circumstances, to meet HIPAA requirements. - correct answer the entity covered by HIPAA Work RVUs reflect - correct answer The relative levels of time and intensity associated with furnishing a Medicare PFS service and account for ~50% of the total payment associated with a service. compliance plan - correct answer a written set of instructions outlining the process for coding and submitting accurate claims, and what to do if mistakes are found. fraud - correct answer to purposely bill for srevices that were never given or to bill for a service that has a higher reimbursement than the service provided. AMA - correct answer American Medical Association The ICD-9-CM Coordination and Maintenance Committee, which is co-chaired by the - correct answer NCHS (National Centers for Health Statistics) and the CMS (Centers for Medicare & Medicaid Services) Maintenance of hte ICD-9-CM is performed by - correct answer the Coordination and Maintenance Committee ICD-10 accommodates - correct answer advancements in medical knowledge of disease and disease processes, where ICD-9_CM has become outdated and insufficient. ICD-9CM is published in ___ volumes - correct answer 3
Volume 1 of the ICD-9-CM - correct answer Tabular List: Diagnosis codes organized in order by code Volume 2 of the ICD-9-CM - correct answer Index to Diseases: Diagnosis codes organized in an alphabetic index Volume 3 of the ICD-9-CM - correct answer Alphabetic Index and Tabular List of Procedures: Procedures performed in the inpatient setting Volumes 1 and 2 are used to assign diagnosis codes that establish - correct answer medical necessity for services rendered. The first step in 3rd party reimbursement is - correct answer establishing medical necessity Information required by payers to determine the need for care - correct answer 1. knowledge of the emergent nature or severity of the patient's complaint or condition
- All signs, symptoms, complaints, or background facts describing the reason for care, such as required follow-up care. Volume 3 of the ICD-9-CM includes procedure codes and is typically used by - correct answer facilities for inpatient services. V codes are commonly used when - correct answer the patient presents for treatment with no complaints. examples of common reasons to report V codes: - correct answer screening tests routine physicals personal or family history of a disease or disorder
__________ _________ provides an alternative view of the contents of ICD-9-CM and contains the _____ _____ ______ _____ _______ - correct answer Appendix E; 3 digit categories in ICD-9-CM Section I of the official guidelines includes - correct answer conventions, general coding guidelines, and chapter specific guidelines NEC - correct answer Not elsewhere classifiable NEC is used when - correct answer the ICD-9-CM system does not provide a code specific for the patient's condition. Selecting a code with the NEC classification means - correct answer the provider documented more specific information regarding the patient's condition, but there is not a code in ICD-9-CM that reports the condition accurately NOS - correct answer Not otherwise specified NOS is the equivalent of - correct answer unspecified NOS is used only when - correct answer the coder lacks the information necessary to code to a more specific 4th or 5th digit subcategory [] - correct answer Brackets are used to enclose synonyms, alternate wording, or explanatory phrases slanted brackets - correct answer indicate multiple codes are required : - correct answer colon is used in Volume I (tabular list) after an incomplete term requiring one or more of the descriptions that follow to make it assignable to a given category
The ___ is used after an incomplete term which requires one or more of the descriptions that follow to make it assignable to a given category - correct answer :, colon boldface type - correct answer used for all codes and titles in the Tabular list Italicized type - correct answer used for all exclusion notes and to identify codes that should not be used for describing the primary diagnosis excludes - correct answer terms following "excludes" notes are to be reported with a code from another category. includes - correct answer appears immediately after a three-digit code title to further define or clarify the category use additional code - correct answer signals the coder an additional code should be used, if the information is available, to provide a more complete picture of the diagnosis. When seeing the instruction to use additional code, which code goes first? - correct answer When sequencing codes, the codes listed under the "use additional code" are secondary 282.42 Sickle-cell thalassemia with crisis ** Sickle-cell thalassemia with vaso-occlusive pain ** Thalassemia Hb-S disease with crisis Use additional code for the type of crisis, such as: ** acute chest syndrome (517.3) **splenic sequestration (289.52)
HICN - correct answer Health Insurance Claim Number
