INSURANCE
When the covered party is required to pay a portion of their insurance coverage; typically represented in a percentage format
UCR; Usual, customary, reasonable- •UCR is the amount paid for a medical service in a geographic area based on what providers in the area usually charge for the same of similar service.
˜Translation or transformation of written descriptions of diseases, illnesses, or injuries into numeric or alphanumeric codes
Define the purpose of procedural coding
To charge for services completed during patient care
CMS-1500
List 3 forms of cost sharing
Deductible
Co-Insurance
Copayment
Define utilization management/ review
Form of patient care review by healthcare professionals who do not provide the care but are employed by health insurance companies
TRUE OR FALSE: The current version of the ICD being used is 11
False; Currently we are using the ICD-10
Where are the 2 most common place of services?
Office and hospital
Process by which an insurance carrier allows a provider to submit insurance claims directly to the carrier electronically
Provide the 4 parts of Medicare and what they include
Part A: Hospital benefits
B: Outpatient services
C: Medicare advantage
D: Drugs
Maximum dollar amount that insurance plan will pay for procedure/service
Allowable charge
October 1 of each year
What are the three main components for determining level of service for E/M coding?
History, examination, and medical decision making
What information is required in the 3 sections of the CMS form?
Section 1: Carrier information
Section 2: Patient/ Insured information
Section 3: Provider information
Provide 3 different types of government insurance
Medicare
Medicaid
Tricare
CHAMPVA
Define eligibility
Ensuring that member has active coverage for date of service and benefits to cover requested procedure or service
Explain the structure and format of the ICD-10 Manual
Tabular List with 21 chapters
Alphabetic Index
What is the difference between bundled codes and unbundled codes?
Bundled codes are where are steps of a procedure are included in one code
Unbundled codes require each step to be listed separately
Fraud is intentionally performing an act that will result in overpayment of a service rendered
Abuse is unintentionally doing something that results in higher payment for a service rendered
The main difference between fraud and abuse is intention
Health maintenance organizations (HMO)
Preferred provider organizations (PPO)
Exclusive provider organizations (EPO)
Explain the MAIN differences between HMO, PPO, EPO
HMO: Services are not covered for providers outside of the insurance network
PPO: Patients are allowed to see out-of-network providers at a higher cost
EPO: Mixture of HMO and PPO with patients not being able to see out-of-network providers, but have discounts for seeing in-network providers like a PPO
Walk through the process to code a diagnosis
Diagnosis is found in diagnostic statement
Located in the alphabetic index; conventions are reviewed
Locate the selected code in Tabular list
Review all notes, conventions and requirements
Code is assigned
Which code set includes things like durable medical equipment, ambulance transport, surgical supplies?
HCPC (Healthcare Common Procedure Coding System Code Set)
Define EOB
Explanation of Benefits: A breakdown of payments made by the patient, insurance company and any discounts received for using a certain provider. This comes with the check from the insurance company. It is not a bill and should always be compared to the total, payments and balance of a patient's account