Billing and Coding Final

heyguysitsclaire's version from 2016-06-23 13:56

Section 1

Question Answer
Implied Contracta contract between physician and patient not manifested by direct words by implied from circumstance, general language or conduct of the patient
Expressed Contracta verbal or written agreement
Precertification a procedure done to determine whether treatment is covered under a patients health insurance policy
Preauthorizationa requirement for some health insurance plans to obtain permission for a service or procedure before it is done and to see whether the insurance program agrees it is medically necessary
Participating Providera physician who contracts with an HMO or other insurance company to provide services, as well as a physician who has agreed to accept a plans payments for service to subscribers.
Nonparticipating Providera physician without a contractual agreement with an insurance plan to accept an allowed amount and to render care to eligible beneficiary
Medicaid benefits vary from state to state. Always check is the patient is actually eligible and be sure to provide them with an ABN in case their insurance does not pay for the procedure or treatment
Medicare only covers procedures that are medically necessary. Part A: hospital -- Part B: preventative services, clinic visits, labs, etc -- Part C: Medicare advantage, full coverage -- Part D: Prescription drug benefits
CMS (Centers for medicare and medicaid services)EHR incentive program provides funding for facilities who are adopting EHR systems and who are following the requirements of meaningful use. CMS also provides HCPCS for additional codes that are not in CPT. Final judgement determined by a federal court review
Utilization Reviewcomposed of health care pros who also may provide care. Designed to provide feedback as to whether or not physicians are treating patients correctly as well as utilizing their resources effectively
Physicians Fee Profilecompilation of each physicians charges and the payments made to them over a given period of time for each specific pro service
Diagnostic Coding 2 Basic Principles must be accurate because payment for inpatient services rendered to the patient may be based on the diagnosis. in the outpatient setting the diagnosis code must correspond to the treatment or payment may be denied
Coding is used to..follow patients condition, support medical research and classify causes of mortality and morbidity
Primary Diagnosismain reason for the encounter, in an inpatient setting this is called the principle diagnosis may also be called CC

Section 2

Question Answer
How to use ICD-101st use alphabetic index, second go to the numerical before assigning a code (cross referencing), main term is the condition
Always code to....the highest degree of specificity, the more digits a code has, the more specific the description is
ICD10 from ICD9increased characters to 3-7, each code starts with a letter, 2nd and 3rd digits are numeric followed by a decimal, 4th-7th digtis can either be alpha or numeric, U is not being used, X is a placeholder when needed to reach 7 digits
Chapter 1certain infections, and parasitic diseases
Chapter 2 neoplasms
Chapter 3diseases of blood and the immune system
Chapter 4 endocrine, nutritional and metabolic diseases
Chapter 5mental, behavioral and neurodevelopemental disorders
Chapter 6diseases of the nervous system
Chapter 7diseases of the eye and adnexa
Chapter 8diseases of the ear and mastoid process
Chapter 9diseases of the circulatory system
Chapter 10diseases of the respiratory system
Chapter 11diseases of the digestive system
Chapter 12diseases of the skin and subcutaneous tissue
Chapter 13diseases of the musculoskeletal and connective tissue
Chapter 14diseases of the genitourinary system
Chapter 15pregnancy, childbirth and the puerperium
Chapter 16certain conditions originating in the perinatal period
Chapter 17congenital diseases
Chapter 18symptoms, signs and abnormal clinical findings
Chapter 19injury, poisoning and consequences of external causes
Chapter 20`external causes of morbidity
Chapter 21factors influencing health status and contact with health services

Section 3

Question Answer
Z codes supplementary classification of coding located in the last section. used when a person who is not currently sick encounters health services for some specific purpose such as to receive a vaccination or a check up
V-Y codes used for external causes of injury rather than the nature of the injury or disease and for coding adverse reactions of medications
A, D or S for external causes and injuries A- initial encounter... D-subsequent encounter... S-sequelae
A fractureinitial encounter for closed fracture
B fractureinitial encounter for open fracture
D fracturesubsequent encounter for fracture with routine healing
G fracturesubsequent encounter for fracture with delayed healing
K fracturesubsequent encounter for fracture with nonunion
P fracturesubsequent encounter for fracture with malunion
S fracturesequelae
Excludes Notes1- not coded her, this means that the diagnosis should never be used with the indicated code... 2- not included her, this means that the diagnosis is not hte one indicated
Neoplasm- Primarythe original location
Neoplasm- Secondarywhere it spread
Neoplasm- In Situhas not yet left the primary location
Neoplasm- Benignnot spreading
Neoplasm- Uncertainunknown type
Neoplasm- Unspecifiedwas not determined
Etiologymeans the cause of the problem
NECnot elsewhere classified
NOSnot otherwise specified
Comorbidity condition that exists with the primary condition of the patient, and complicates the treatment and management of the primary condition

Section 4

Question Answer
CPT codes are...5 digits long with no decimals
How to code using CPTsearch for the procedure or service in the alpha index and then cross reference in the tabular list in the appropriate section
Evaluation and Management (E/M)99201-99499
Radiology, Nuclear Medicine and Diagnostic Ultrasound70010-79999
Pathology and Laboratory80047-89398
Medicine90281-99607 (except for 99201-99499 which is E/M)
Symbols: bulletnew code
Symbols: trianglerevised codes or revised text
Symbols: plus signadd-on codes
Symbols: lighteningpending food and drug administration approval
Two subcatagories of office visitsnew patient and established patient
Seven elements when selecting an E/M code to billhistory, examination, medical decision making, nature of presenting problem, counseling, coordination of care, time
Problem Focusedsimple, one system
Expanded Problem Focused connecting systems
Detailedseveral systems
Comprehensivecomplex case involving one system or multiple systems
Unbundlingcoding and billing numerous CPT codes to identify procedures that usually are described by a single code
Upcodingcoding for a higher level procedure than what was performed in order to receive a higher reimbursement
Downcodingcoding for lower level procedures to avoid being audited