Medical Coding and Billing Fundamentals, Exams of Public Health

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HMAP 163 Midterm exam with complete

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CAD - ANSWER-Covered, Authorized, Dollar UCR - ANSWER-Usual, Reasonable, and Customary the amount paid for a medical service in a geographic area based on the providers in the area/similar medical service Subscriber - ANSWER-The one who owns the policy Guarantor - ANSWER-Person responsible for out of pocket expenses In network/participating provider - ANSWER-provider has a contract with the insurance company and agrees to accept the allowed payment amounts by the insurance as full payment. Out of network/non participating provider: - ANSWER-not under contract/can balance bill Deductible - ANSWER-the amount of expenses that must be paid out of pocket before an insurer will cover any expenses High deductible = lower premium lower deductible = higher premium Coinsurance - ANSWER-the amount of expenses that must be paid out of pocket before an insurer will cover any expenses Copayment - ANSWER-fixed amount your health insurance may require you to pay for a specific medical service or supply

Pre-certification - ANSWER-confirming that the procedure is covered under the policy Pre-authorization - ANSWER-determining the maximum dollar ($) amount that the insurance company will pay Coordination of benefits - ANSWER-used to establish the order in which health insurance plan pay claims when more than one plan exists ICD-10-CM - ANSWER-International Classification of Diseases, 10th Revision, Clinical Modification

1. 3-7 characters in length
2. Very specific
3. Digit 1: alpha
4. Digit ⅔: numeric (A12) etc
5. 4/7: alpha or numeric
6. XXX.XXX X (category. Etiology, anatomic site, severity. extension)
7. USE FOR CLAIMS WITH A DATE OF SERVICE AFTER OCTOBER 1, 2015 CPT - ANSWER-Current Procedural Terminology HCPCS - ANSWER-Healthcare Common Procedural Coding System Level II ICD-9-CM - ANSWER-ONLY USE FOR DATES OF SERVICES ON OR BEFORE SEPTEMBER 30, 2015 International Classification of Diseases, 9th Revision, Clinical Modification 3-5 characters in length WHO: world health organization First digit may be alpha or numeric Digits 2-5 are numeric XXX.XX (category. Etiology, anatomic site, manifestation) ICD-10-CM Conventions - ANSWER-NEC: Not elsewhere classified Identifies codes/index terms that specify a condition or disease which there is no separate code to identify it NOS: - ANSWER-Not Otherwise Specified

3. Omissions
4. Procedure linked to diagnosis incorrectly
5. Procedure was not medically necessary
6. All attachments include patient's name and policy
7. identification number
8. Verify printer alignment
9. Verify claim form signed appropriately 5010 electronic form ; - ANSWER-1)Do NOT interchange the letter "o" with the number "0" Substitute spaces for:
10. Dollar sign or decimal in charges or totals
11. Decimal point in a diagnosis code number
12. Dash in front of a procedure code modifier
13. Parentheses around area code in number
14. Hyphens on social security numbers
15. Expresses fees in WHOLE dollars with two zeros in
16. the cents column (ex. $324.00)
17. Birth dates (MM/DD/YYYY) (POS) - ANSWER-Point Of Service
18. Provides direct access to patient information through electronic network
19. Connects medical office and health plan's computer
20. Card swipe box Managing a Claim Registry or Diary: - ANSWER-Keep a register with the following information
21. Patients name
22. Dates of service
23. Amount of claim
24. Date the claim is submitted
25. Date the payment is received Follow up procedures: - ANSWER-1) Call carrier in 4-6 weeks if no payment was received
26. Use toll free number to call carrier
27. Have copy of claim ready for information

4. Payment may have been sent to patient
5. Claim may have to be resubmitted Insurance Carrier's Role: - ANSWER-Check codes and analyze information to ensure:
6. Coverage was in force at time of treatment
7. Physician has contract with carrier
8. No exclusions or restrictions
9. No pre-existing condition restrictions
10. Usual, customary fee ACAP: - ANSWER-alliance of claims assistant professionals AAPC: - ANSWER-American Academy of Professional Coders AHIMA: - ANSWER-American Health Information Management Association NEBA: - ANSWER-national electronic billers alliance Chart notes contain what info: - ANSWER-1) In person visits
11. telephone/email inquiries
12. List of present health problems
13. Physician's physical findings
14. Treatment plan
15. Laboratory or diagnostic results given or interpreted Operative reports contain : - ANSWER-1) Describes preoperative and surgical procedures
16. Physician dictation after surgery
17. Includes name of primary surgeon and assistants
18. Postoperative diagnosis
19. Specimens removed
20. Sponge count
21. Instrument inventory
22. Estimation of blood loss
23. Condition of patient when leaving

Open-Ended HMO (from table): - ANSWER-1) payment method: fee for service at HMO rates

2. referral is NOT required
3. patients choice of provider: Non participating providers are paid at 80% of HMO rates Independent providers association (IPA) (from table): - ANSWER-1) payment method: capitation, Or for SPECIALISTS fee for service at HMO rates
4. referral is required
5. patients choice of provider: No, Only in network providers are covered point of service (POS) ( from table) : - ANSWER-1) payment method: fee for service at HMO rates
6. referral is required
7. patients choice of provider: No, Only in network providers are covered Preferred Provider Organization (PPO) (from table): - ANSWER-1) payment method: fee for service at HMO rates
8. SOME referrals is required
9. patients choice of provider: non participating are paid at 80% of UCR rates indemnity policy (from table) : - ANSWER-1) payment method: 80% of UCR fee for service basis
10. referral is NOT required
11. patients choice of provider: providers are eligible for 80% of UCR rates Employer Insurance Programs: - ANSWER-1) Health insurance for employees
12. Monthly premiums vary for individual or family policy Group rate
13. Large employers get better rate than small employers
14. Dental and vision policies can be offered separately Commercial health Insurance: - ANSWER-1) Owned and run by private companies
15. Private companies controls the price of premiums
16. paid and specify the benefits they will provide Ex: Blue Cross and Blue Shield

indemnity policy information: - ANSWER-1) known as traditional 80/

2. Has the least amount of structural guidelines = most flexible
3. Patients are also able to see the producer of their house
4. Patients able to see specialists without having to obtain referrals from another provider
5. Premiums generally higher
6. An annual deductible must be satisfied
7. Provider paid a percentage of charges, patient pays the rest Health Maintenance Organization (HMO): - ANSWER-1) Type of managed care
8. Provide comprehensive health care with a focus on wellness and preventative care
9. Members choose a plan & PCP to oversee a medical care
10. Several froms: 4a) Taff model 4b) Group model 4c) Open ended 4d) POS 4e) PPO Exclusive Provider Organization (EPO): - ANSWER-1) Similar to HMO
11. Patient must use the EPO's providing network when receiving care
12. Patients must use the health plan's provider network exclusively
13. Does not require patients to have a PCP
14. Referral not necessary to see a specialist Consumer-Driven Health Plans: - ANSWER-1) Options for insurance and managed-care plans
15. High-deductible health policies with low premiums
16. Covers most health costs
17. Three forms available: 4a) Health savings account 4b) Health reimbursement account 4c) Flexible spending account Health Savings Account (HSA): - ANSWER-1) tax sheltered
18. Must be paired with a qualified health pant

3) CHAMPVA

4) CHAMPUS

Medicare: - ANSWER-1) Created by the Social Security Act in 1965

2. available for 65 and older (ELDERLY) , people with end stage renal disease
3. FEDERAL Medicare Plans: - ANSWER-Part A; Hospital Coverage Part B : Medical expenses Part C; Advantage plan Part D; drug coverage Medicare Part A: - ANSWER-Hospital expenses such as:
4. room, board and other inpatient services,
5. limited stay in a skilled nursing facility, and
6. helps cover hospice care and home-health care. Part of Medicare Original plan included in the Advantage Plan Medicare Part B: - ANSWER-helps cover medical expenses such as:
7. doctor's services,
8. outpatient services and other medical supplies.
9. It also covers some preventive services
10. fee of 148.50 ( Original plan) part of medical original included in advantage plan Medicare Part C (Medicare Advantage) - ANSWER-- in the medical original plan it covers the 20% not originally covered

• it is an add on to the original plan (medigap)
• has a fee when added on to the original plan enables beneficiaries to select a managed care plan as their primary coverage Original Medicare plan - ANSWER-1) Covers 80% of the cost for most medical bills. You pay the remaining 20% of costs, with no yearly limit on what you pay out-of- pocket.

2. You can buy a Medicare Supplement Insurance (Medigap) policy to help pay your share of costs.
3. If you want drug coverage, you can join a separate Drug plan (Part D).
4. Can use any doctor or hospital that takes Medicare, anywhere in the U.S Medicare advantage plan - ANSWER-1) All your Part A and Part B benefits are provided by Medicare-approved private companies.
5. Use doctors and hospitals in the plan's network (for non-emergency or non- urgent care).
6. Most plans include drug coverage.
7. Many plans include extra benefits, like vision, hearing, dental, and more.
8. Yearly limit on your out-of-pocket costs. Medicaid: - ANSWER-1) DUO; A federal and state assistance program that pays for health care services for people who cannot afford them, low income etc.
9. managed by CMS (centers for medicare and medicaid services )
10. must see participating provider Tricare (CHAMPUS) - ANSWER-1) Military and dependents, retired and dependents, dependents of service personnel who died while active duty
11. Retired military moved to medicare and Tricare for Life after age 65
12. As of 2018 two regions: TriWest Tri-East
13. active till widowed persons get remarried TRIcare 4 programs: - ANSWER-1) TRICARE Select
14. TRICARE Prime
15. TRICARE for LIfe
16. TRICARE Young Adult CHAMPVA - ANSWER-1) Departments of Veteran Affairs shares cost
17. Operates like indemnity plan
18. Pays providers' fee-for-service
19. Deductibles and copayments apply 5 )Patients choose own physicians
20. cant be eligible for TRIcare

5. DRGs ( diagnosis related groups) Fraud And Abuse: - ANSWER-1) Improper claims submission= fraud and abuse
6. Rules of compliance associated with claims submission
7. Code properly, file accurate claims
8. Penalties imposed on office