Health Insurance
HMO
Health Maintenance Organization
ICD
International Classification of Diseases
CPT
Current Procedural Terminology
CMS
Centers for Medicare & Medicaid Services
PMS
Practice Management Software or Practice Management System
Health insurance must cover essential health benefits including which two services? Elective procedures are not covered.
Medically Necessary
Preventative Services
What is Book 1 and Book 2 in the ICD Book and where are the located?
Book 1- Tabular List (back)
Book 2- Alphabetic Index (front)
What is Book 1 and Book 2 in the CPT Book and where are the located?
Book 1- Tabular List (front)
Book 2- Alphabetic Index (back)
What is the accepted acronym that can be used for all boxes requiring a signature?
SOF
Signature on File
Money that is expected but not yet received AND money that is owed but not yet paid?
Accounts Receivable
Accounts Payable
Describe the 3 parts of insurance cost sharing.
Deductible: set dollar amount paid by policyholder before insurer starts to pay for services, maximum limit
Co-insurance: begins after deductible has been met, policyholder pays percentage of bill, insurance company pays rest (80 insurance/20 subscriber)
Copayment: set dollar amount paid by policyholder for each office visit, no limit
What are the 3 parts of an ICD code found in the alphabetic index?
Main Term, Non-Essential Modifier, Sub Term (Essential Modifier)
What are the 3 categories of codes in the CPT book?
Category 1- reimbursement
Category 2- data collection (end in F)
Category 3- temporary (end in T)
Name each section of the CMS 1500
Section 1: Carrier Block
Section 2: Patient/Insured
Section 3: Provider/Supplier
Process of comparing transactions to the account balance AND 1 reason the balances may not match
Reconciliation
Issues: Mathematical Errors, Pending Transaction, Outstanding Check, Numbers transposed, Missed record or Duplicate record
Describe the 3 types of private insurance plans.
Employer/Group: Health plans offered by employers
Self-Funded: Health plans offered to employees paid with funds from within the company
Individual: plans purchased by consumer off the marketplace, do not qualify for either of above
All about Numbers!
How many alphanumeric digits can an ICD code be minimum and maximum?
How many body system Chapters are in the ICD book?
3 minimum, 7 maximum
21 Body Systems Chapters (Chapter 22 is U codes= temporary)
Place of Service, Levels of Service, and Contributing Factors codes can be found in which section?
E/M Evaluation and Management Section
Name that Term!
Software that finds common billing errors
Claims with incorrect, missing, or insufficient data
Claims Scrubber
Dirty Claim
Accounts less than 30 days
Accounts greater than 120 days
Explain who is covered in each of the Government sponsored insurance plans.
Medicare, Medicaid, CHIP, TRICARE, CHAMPVA
Medicare: 65+ older, disabled, ESRD
Medicaid: indigent, low-income, below federal poverty level
CHIP: low income children
TRICARE: Active/Retired military & families
CHAMPVA: Families of deceased or disabled veterans
Give 5 examples of a ICD code statement
Answers will vary.
Give 5 examples of a CPT code statement
Answers will vary.
How is primary and secondary insurance determined when both plans are equal in coverage/benefits?
Example, a minor with divorced parents who each carry health insurance.
Birthday Rule- whichever insured birthday comes first in the calendar year
Describe 1 type of check and 1 type of endorsement
Personal Check: drawn by a bank against funds deposited to a personal account
Cashier's Check: cashier's check is a bank's own check, drawn on itself
Money Order: prepaid paper payment method that guarantees funds, making it a safe alternative to cash or personal checks
Business Check: check coming directly from company's account, with three checks per page and a perforated stub at the left side of the check.
Voucher Check: detachable stubs which provide a detailed record of the payment
Electronic Check: digital form of a check that comes directly from an account, need routing and account number from bottom of a check- write check as VOID
Blank endorsement: most common, the bearer signs the back
Restrictive endorsement: specifies the purpose of the endorsement, it is used in preparing checks for deposit to the provider's checking account (mobile deposit, for deposit only)
Special endorsement: Includes words specifying the person to whom the endorser makes the check payable. *new owner of the check, both need to sign
Qualified endorsement: disclaiming or destroying any future liability of the endorser. Remove self from responsibility if the check gets returned "without recourse"