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
An inpatient amount that a Medicare patient is responible for.
What is a Deductible
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 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
Another name for Medicare Part C.
What is Medicare Advantage?
What process confirms accurate charge capture in the 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 is used for direction of processes?
Trainual
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
What is EDI
Electronic Data Interchange-Computer to computer communication protocol used to route HIPPA compliant files.
HMOs and PPOs may require a ___________ from a patient's primary care physician before a patient can be seen.
Referral
Medicare Secondary Payor Questionnaire (MSPQ)
Name the two types of bills forms used to bill a payer.
Facility (technical) claim from the hospital and professional claim from the physician. (UB & 1500)
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.