Medicare and Healthcare Coding: A Comprehensive Guide, Exams of Nursing

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Guide Notes 2024

"hold harmless clause" Correct Answer is * found in some non-Medicare health plan contracts

• prohibits billing to patient for anything beyond deductibles and co-pays. A compliance plan may offer several benefits, including: Correct Answer is * more accurate payment of claims
• fewer billing mistakes
• improved documentation and more accurate coding
• less chance of violating self-referral and anti-kickback status A healthcare clearing house is a Correct Answer is entity that processes nonstandard health information they receive from another entity into a standard format A key provision in HIPAA is the Minimum Necessary requirement. this means Correct Answer is only the minimum necessary protected health information should be shared to satisfy a particular purpose. A medically necessary service is the Correct Answer is least radical service/procedure that allows for effective treatment of the patients' complaint or condition A patient sustaining an injury to her great saphenous vein would have sustained injury to which of anatomical site? Correct Answer is Leg APC Correct Answer is Ambulatory Payment Classification ARRA Correct Answer is American Recovery and Reinvestment Act (of 2009) ASC Correct Answer is Ambulatory Surgical Centers Abuse consists of Correct Answer is payment for items or services that are billed by providers in error that should not be paid for by Medicare. An ABN protects the provider's financial interest by

Correct Answer is creating a paper trail that CMS requires before a provider can bill the patient for payment if Medicare denies coverage for the stated service or procedure. An entity that processes nonstandard health information they receive from another entity into a standard format is considered what? Correct Answer is Clearinghouse As a part of Health Care Reform, the Affordable Care Act of 2010 amended the definition of fraud to remove the __________ requirement Correct Answer is intent By statute, all work RVUs, must be examined no less often than Correct Answer is every 5 years CF Correct Answer is Coversion Factor - fixed dollar amount used to translate the RVUs into fees CMS Correct Answer is Centers for Medicare and Medicaid CMS developed polices regarding medical necessity are based on regulations found in title XVIII, $1862(a) of the Correct Answer is Social Security Act CMS will accept the ____________ for either a "potentially non=covered" service or for a statutorily excluded service Correct Answer is CMS-R- CMS-R- Correct Answer is ABN form or Advance Beneficiary Notice which explains to the patient why Medicare may deny the particular service or procedure. CPT Correct Answer is Current Procedural Terminology CY 2013 Conversion Factor Correct Answer is $25. Commercial (non-Medicare) may develop their own medical policies which do not follow Medicare guidelines and are specified in Correct Answer is private contracts between the payer and practice or provider

DRG

Correct Answer is Diagnosis Related Group Does Medicare Part B generally require a yearly deductable and copayment? Correct Answer is yes E/M OR E&M Correct Answer is Evaluation and Management EHR Correct Answer is Electronic Health Record Formula for Calculating Facility Payment amounts Correct Answer is [(Work RVU * Work GPCI) + (Transitioned Facility PE RVU * PE GPCI) + (MP RVU * MP GPCI)] * CF Formula for Non-Facility Pricing Amount Correct Answer is [(Work RVU * Work GPCI) + (Transitioned Non-Facility PE RVU * PE GPCI) + (MP RVU * MP GPCI)] * (CF) GPCI Correct Answer is Geographic Practice Cost Index GPCI is used to Correct Answer is realize the varying cost based on geographic location HCPCS Correct Answer is Healthcare Common Procedure Coding System HHS Correct Answer is Department of Health and Human Services HIPAA provides federal protections for Correct Answer is personal health information when held by covered entities. HIPAA stands for Correct Answer is Health Insurance Portability and Accountability Act of 1996 HITECH Correct Answer is The Health Information Technology for Economic and Clinical Health Act HITECH allows patients to request Correct Answer is an audit trail showing all disclosures of their health information made through an electronic record.

HITECH requires that an individual be notified if Correct Answer is there is an unauthorized disclosure or use of his or her health information. HITECH was enacted as part of Correct Answer is the American Recovery and Reinvestment Act of 2009 (ARRA) HMO Correct Answer is Health Maintenence Organization Hemiplegia is a disorder caused by a defect in which anatomic system? Correct Answer is nervous ICD-9-CM Correct Answer is International Classification of Disease, 9th Clinical Modification IF: Work RVUs = 0. Work GPCI = 1. Practice Expense CPCI = 0. MP GPCI = 0. transitioned non-facility practice RVUs = 0. Calculate non-facility pricing amount for cpt code 99212 using 2011 CF of $33. Correct Answer is $39.51 Non-facility pricing amount (physician office, private practice) If a sevice fails to support medical necessity requirements per the LCD, and the service is not covered, the practice would be responsible for obtaining a(n) Correct Answer is Advance Beneficiarly Notice of NonCoverage (Advance Benefiary Notice, or ABN) If an NCD doesn't exist for a particular item, its up to the ______ to determine coverage. Correct Answer is MAC

If an inbuilding pharmacy delivers medication (for home use) to an individual receiving outpatient chemotherapy, which part of Medicare should be billed for the pain medication by the pharmacy? Correct Answer is Part D Incus, stapes, _____ Correct Answer is malleus Intentional billing of services not provided is considered Correct Answer is LCD Correct Answer is Local Coverage Determinations LCDs have jurisdiction only within Correct Answer is their regional area LCDs give guidance when Correct Answer is * a given service is indicated or necessary,

• give guidance on coverage limitations
• describe the specific CPT codes to which the policy applies
• lists IICD-9-CM codes that support medical necessity for the given service or procedure MP Correct Answer is Malpractice MS-DRG Correct Answer is Medical Severity-Diagnosis Related Group Medicaid is a Correct Answer is a health insurance assistance program for some low-income people Medicaid is adminisitered on a Correct Answer is state by state basis adhering to certain federal guidelines. Medicare Part B helps to cover Correct Answer is medically necessary physicians' services ouptatient care other medical services (including some preventative services) not covered under Part A Medicare Part B premiums are paid by Correct Answer is the patient

Medicare Part C combines the benefits of Correct Answer is Part A and Part B and sometimes Part D Medicare Part C is also called Correct Answer is Medicare Advantage Medicare Part C plans are managed by Correct Answer is private insurers approved by Medicare. Medicare Part D is a Correct Answer is prescription drug coverage program Medicare Part D is a coverage provided by Correct Answer is private companies approved by Medicare Medicare Part D is available to Correct Answer is all Medicare beneficiaries. Medicare part A helps to cover: Correct Answer is inpatient hospital care care provided in skilled nursing facilities hospice care home health care Medicare payments for physician services are standardized using a Correct Answer is resource-based relative value scale (RBRVS) NCD Correct Answer is National Coverage Determinations NCD explain Correct Answer is when Medicare will pay for items or services. NP Correct Answer is Nurse Practitioner OCR Correct Answer is Office of Civil Rights OIG Correct Answer is Office of the Inspector General

OIG Compliance Program for Individual and Small Group Physician Practices include the following key actions Correct Answer is * Implement compliance and practice standards through the development of written standards and procedures.

• designate a compliance officer or contac to monitor compliance efforts and enforce practice standards
• conduct appropriate training and education of practice standards and procedures
• conduct internal monitoring and auditing through the performance of periodic audits
• respond appropriately to detected violations through the investigation of allegations through the investigation of allegations and the disclosure of incidents to appropriate government entitities
• Develop open lines of communication
• Enforce disciplinary standards through well-publicized guidelines PA Correct Answer is Physician Assistant PE Correct Answer is Physician Expense PFS Correct Answer is Physician Fee Schedule PHI Correct Answer is protected health information PLI Correct Answer is Professional Liability Insurance Published Conversion factor for CY 2012 Correct Answer is $34. Published conversion factor for CY 2011 Correct Answer is $33. RBRVS Correct Answer is Resource Based Relative Value System RUC Correct Answer is Relative Value Update Committee Resource costs for RBRVS are divided into three componentes: Correct Answer is physican work practice expense

professional liability insurance Sebacious glands are a part of which anatomic system? Correct Answer is Integumentary The ABN form is entitled Correct Answer is Revised ABN CMS-R-131 and is available with instructions as a free download on the CMS website. The ABN is a standardized form that Correct Answer is explains to the patient why Medicare may deny the particular service or procedure. The OIG is mandated by public law to engage in activities to test Correct Answer is the efficiency and economy of government programs to include investigation of suspected health care fraud or abuse. The amount on an ABN should be within how much of the cost to the patient? Correct Answer is $100 or 25% of cost RATIONALE: CMS instructions stipulate, "Notifires msut make a good faith effort to insert a reasonable estimate....the estimate should be within $100 or 25% of the actual costs, whichever is greater. The myocardium is thickest around which chamber of the heart? Correct Answer is left ventricle The term "medical necessity refers to Correct Answer is whether a procedure or service is considered appropriate in a given circumstance. The tunica vaginalis is part of which system? Correct Answer is male reproductive Under the Privacy rule, the minimum necessary standard of HIPAA does not apply to Correct Answer is * disclosures to or requests by a health care provider for treatment purposes

• disclosures to the individual who is the subject of the information
• uses or disclosures made pursuant to an individual's authorization
• uses or disclosures required for compliance with the HIPAA Administrative Simplification Rules
• Disclosures to the US Dept of Health and Human Services when disclosure of info is required under the Privacy Rule for enforcement purposes.

• Uses or disclosures that are required by other law What OIG document should a provider review for potential problem areas that will receive special scrutiny in the upcoming year? Correct Answer is OIG work plan What is an NCD interpreted at the MAC level considered? Correct Answer is LCD Each MAC (Medicare Adminstrative Contractor) is responsible for interpreting national policies into regional policies, or Local Coverage Determinations What is the result of a ureteral blockage? Correct Answer is Urine will not be able to flow from the kidney to the bladder When does the OIG release a work plan outlining its priorities for the fiscal year ahead? Correct Answer is October When should an ABN be signed? Correct Answer is When a service is not expecgted to be covered by Medicare. RATIONALE: This form explains to the patient why a service MAY be denied by Medicare. The ABN form should be completed for services potentially con-covered by Medicare to advise the patient of potential financial responsibility. Which of the following has a refraction function in the eye? macula retina lens iris Correct Answer is lens Which of the following is a function of the pancreas?
• supplies digestive enzymes manufactures melatonin
• stimulates growth
• secretes vasopressin Correct Answer is supplies digestive enzymes Which of the following is a renal calculus?
• Pyelectasia
• Hydroureter

• Nephrolithiasis
• Pyonephrosis Correct Answer is Nephrolithiasis Who is responsible for interpreting national policies into regional polices, called LCDs? Correct Answer is each MAC (Medicare Administrative Contractor) Whose responsibility is it to develop and implement policies, best suited to its particular circumstances, to meet HIPAA requirements. Correct Answer is the entity covered by HIPAA Work RVUs reflect Correct Answer is The relative levels of time and intensity associated with furnishing a Medicare PFS service and account for ~50% of the total payment associated with a service. compliance plan Correct Answer is a written set of instructions outlining the process for coding and submitting accurate claims, and what to do if mistakes are found. fraud Correct Answer is to purposely bill for srevices that were never given or to bill for a service that has a higher reimbursement than the service provided. AMA Correct Answer is American Medical Association The ICD-9-CM Coordination and Maintenance Committee, which is co-chaired by the Correct Answer is NCHS (National Centers for Health Statistics) and the CMS (Centers for Medicare & Medicaid Services) Maintenance of hte ICD-9-CM is performed by Correct Answer is the Coordination and Maintenance Committee ICD-10 accommodates Correct Answer is advancements in medical knowledge of disease and disease processes, where ICD-9_CM has become outdated and insufficient. ICD-9CM is published in ___ volumes Correct Answer is 3 Volume 1 of the ICD-9-CM Correct Answer is Tabular List: Diagnosis codes organized in order by code

Volume 2 of the ICD-9-CM Correct Answer is Index to Diseases: Diagnosis codes organized in an alphabetic index Volume 3 of the ICD-9-CM Correct Answer is Alphabetic Index and Tabular List of Procedures: Procedures performed in the inpatient setting Volumes 1 and 2 are used to assign diagnosis codes that establish Correct Answer is medical necessity for services rendered. The first step in 3rd party reimbursement is Correct Answer is establishing medical necessity Information required by payers to determine the need for care Correct Answer is 1. knowledge of the emergent nature or severity of the patient's complaint or condition

2. All signs, symptoms, complaints, or background facts describing the reason for care, such as required follow-up care. Volume 3 of the ICD-9-CM includes procedure codes and is typically used by Correct Answer is facilities for inpatient services. V codes are commonly used when Correct Answer is the patient presents for treatment with no complaints. examples of common reasons to report V codes: Correct Answer is screening tests routine physicals personal or family history of a disease or disorder In order for a V code to be listed first, Correct Answer is it must meet the definition of a principle or first-listed diagnosis code E codes are used to report Correct Answer is how an injury occurred and where the injury occurred. Appendix A Correct Answer is Morphology of Neoplasms Morphology codes consist of ___ digits Correct Answer is 5 The first 4 digits of a morphology code identify the Correct Answer is histological type of the neoplasm

The fifth digit in a morphology code indicates Correct Answer is behavior of the neoplasm Appendix B Correct Answer is Deleted 10/1/2004 - contained Glossary of Mental Disorders. Appendix C Correct Answer is Classification of Drugs by American Hospital Formulary Service List Number and Their ICD-9-CM equivalents Appendix C is available to Correct Answer is assist in coding of adverse effects Appendix D Correct Answer is Classification of Industrial Accidents According to Agency. Appendix D is used primarily for Correct Answer is statistical purposes. It provides information about employment injuries. Appendix E Correct Answer is List of 3 digit categories __________ _________ provides an alternative view of the contents of ICD-9-CM and contains the _____ _____ ______ _____ _______ Correct Answer is Appendix E; 3 digit categories in ICD-9-CM Section I of the official guidelines includes Correct Answer is conventions, general coding guidelines, and chapter specific guidelines NEC Correct Answer is Not elsewhere classifiable NEC is used when Correct Answer is the ICD-9-CM system does not provide a code specific for the patient's condition. Selecting a code with the NEC classification means Correct Answer is the provider documented more specific information regarding the patient's condition, but there is not a code in ICD-9-CM that reports the condition accurately NOS Correct Answer is Not otherwise specified

NOS is the equivalent of Correct Answer is unspecified NOS is used only when Correct Answer is the coder lacks the information necessary to code to a more specific 4th or 5th digit subcategory [] Correct Answer is Brackets are used to enclose synonyms, alternate wording, or explanatory phrases slanted brackets Correct Answer is indicate multiple codes are required : Correct Answer is colon is used in Volume I (tabular list) after an incomplete term requiring one or more of the descriptions that follow to make it assignable to a given category The ___ is used after an incomplete term which requires one or more of the descriptions that follow to make it assignable to a given category Correct Answer is :, colon boldface type Correct Answer is used for all codes and titles in the Tabular list Italicized type Correct Answer is used for all exclusion notes and to identify codes that should not be used for describing the primary diagnosis excludes Correct Answer is terms following "excludes" notes are to be reported with a code from another category. includes Correct Answer is appears immediately after a three-digit code title to further define or clarify the category use additional code Correct Answer is signals the coder an additional code should be used, if the information is available, to provide a more complete picture of the diagnosis. When seeing the instruction to use additional code, which code goes first? Correct Answer is When sequencing codes, the codes listed under the "use additional code" are secondary

282.42 Sickle-cell thalassemia with crisis ** Sickle-cell thalassemia with vaso-occlusive pain ** Thalassemia Hb-S disease with crisis Use additional code for the type of crisis, such as: ** acute chest syndrome (517.3) **splenic sequestration (289.52) correct sequence for sickle-cell thalassemia crisis with acute chest syndrome in correct sequence are: Correct Answer is 282.42, 517. Code first Correct Answer is instruction used in categories not intended to be the principal diagnosis. These codes are written in italics with a note. The note requires the underlying disease (etiology) be recorded first and the particular manifestation be recorded second. This note only appears in the tabular index use addtional code, if applicable Correct Answer is the causal condition note indicates this code may be assigned as a diagnosis when the causal condtion is unknown or not applicable. If a causal condition is known, the code should be sequenced as the principal diagnosis. a combination code indicates Correct Answer is a single code is used to classify 2 diagnoses, a diagnosis with an associated secondary process (manifestation), or a diagnosis with an associated complication eponym Correct Answer is this term indicates the code describes a disease or syndrome named after a person modifiers Correct Answer is essential modifiers are subterms listed below the main term in alphabetical order, and are indented 2 spaces other Correct Answer is "other" or "other specified" codes (usually with 4th digit 8 or 5th digit 9 are used when the information in the medical record provides detail for which a specific code does not exist. official coding and reporting guidelines are provided by Correct Answer is CMS and NCHS Never code directly from the Correct Answer is Index to Disease

HICN

Correct Answer is Health Insurance Claim Number