General
All administrative and clinical functions that contribute to the capture, management and collection of patient service activities is called what?
Revenue Cycle
The first step in allowing the insurance company to denote their intentions of coverage and payment is called what?
Prior authorization or pre-certification or pre-determination [any are acceptable]
What documents are developed by MACs to provide guidelines on medical necessity, documentation, coding and billing for specific services?
Local Coverage Determination (LCD) and Local Coverage Articles (LCA)
What does the acronym CDM stand for?
Chargemaster or charge description master - a list of all CPT/HCSP codes used in the Department for billing purposes.
How often should patient's demographic and insurance information be confirmed?
Every visit.
The code billed by the hospital for a traditional Medicare patient for a clinic visit evaluation and management service is ________.
G0463
The acronym "NCD" stands for what?
National Coverage Determination - utilized if there is a nationwide determination of whether Medicare will pay for item or service.
What is the process when the front office coordinator enters the patient's insurance and demographic information before the patient's visit?
Pre-registration
How frequently should the NCD/LCD log on the Hub be reviewed by PDs for updates and revisions?
Monthly
CPT and HCPCS codes describe?
What was done - the service, procedure or supply provided to the patient.
If ______________ is not obtained prior to providing services, the services may be denied.
Prior authorization/precertification/predetermination and/or referral.
My patient is coming to the WCC for the first time. He was seen in the hospital emergency room last year. Will I bill his clinic visit as new or established?
Established
The front office coordinator collects a $25 co-pay. This is called a(n):
Up-front collection of patient responsibility
What document must be provided to a patient who is self-pay?
Good faith estimate
What tool can be utilized in the WCC for the Program Director to calculate what expected Medicare reimbursement Medicare would be?
Comprehensive List of Procedures
(also acceptable: Bioskin calculator)
What process confirms accurate charge capture in the i-heal and hospital system?
Daily reconciliation
If a claim cannot be filed because the practice professional did not complete documentation, the claim could be denied for what cause?
Timely filing.
I am billing for both a procedure and a clinic visit on the same day. What modifier will be attached to the clinic visit evaluation and management code?
Modifier 25
What document on the Hub includes FAQs about billing and reimbursement?
Revenue Cycle Manual
When scheduling patients, it's important for what to occur before services are provided?
Check insurance eligibility and benefits and obtain prior authorization if required.
For OPPS hospitals, Medicare reimburses 80% of _____.
APC
Which type of code tells a payor why a service or procedure was performed?
ICD-10 code
What should be reviewed for non-Medicare payors to ensure medical necessity is met for wound care services and determine if authorization is required?
Payor policy
(also acceptable: medical policy, clinical policy)
The tool used to establish the clinic visit evaluation and management level for hospital billing is called the what?
CLOC or Clinic Level of Care or Points Tabulation Tool
Which staff member in the WCC is responsible to monitor all parts of the revenue cycle to ensure they are being done correctly?
Program Director
HMOs and PPOs may require a ___________ from a patient's primary care physician before a patient can be seen in the Wound Care Center.
Referral
Medicare Secondary Payor Questionnaire (MSPQ)
Name the two types of bills patients receive for treatment in the Wound Care Center.
Facility (technical) claim from the hospital and professional claim from the physician, NP or PA
If the ICD-10 code(s) on the claim does not support the CPT code(s), the claim may be denied for lack of _____________ _______________.
Medical necessity.
In order to bill both a clinic visit evaluation and management service and a procedure on the same day, the service must be _____________ and ________________ _______________.
Significant, separately identifiable.