define: Medical Ethics
standards of conduct based on moral priciples
define: Compliance Regulations
most billing-related cases are based in HIPAA and False claims act
what is HIPAA?
Health Insurance Portability and Accountability Act of 1996.
why was HIPAA created?
it created the Health Care Fraud and Abuse Control Program enacted to check for fraud and abuse in medicare abd medicaid programs, and private payers
What are the 2 provisions in HIPAA?
title 1: Insurance Reform.. title 2:Administrative Simplification
what is the purpose of title 1 in HIPAA?
the primary purpose is to provide continuos insurance coverage for workers and their dependents when they change or lose their jobs.
what is the purpose of title 2 in HIPAA?
the goal is to focus on the health care practice setting to reduce administrative costs and burdens
Define: False Claims Act (FCA)
federal law that prohibits submitting a false claim or making a false statement or representation in connection with a claim. it also protects and rewards persons involved in whistle-blower cases
define: National Correct Coding Initiative (NCCI)
to control improper coding that leads to inappropriate payment of part B health insurance claims
what are the 2 types of edits in the NCCI?
1. column 1/column 2 (previously called comprehensive/component) Edits 2. Mutually Exclusive Edits
what does the 1st edit in the NCCI do?
identifies code pairs that should not be billed together because one code (column 1) includes all the services described by another code (column 2)
what does the 2nd edit in the NCCI do?
identifies code pairs that, for clinical reason, are unlikely to be performed on the same patient on the same day.
knowingly and intentionally deceiving or mispresenting information that may result in unauthorized benefits
is fraud a felony?
yes fraud is a felony and can result in fines and/or a prison sentence
incidents or practices, not usually considered fraud, that are inconsistant with the accepted medical business or fiscal practices in the industry
define: Patient Confidentiality
All patients have the right to privacy. Discuss patient info only with the patients physician or office personel. Obtain a signed consent form to release medical information to the insurance company or other indivisual
define: Medical Records
documentation on the patients social and medical history, family history, physical examination findings, progress notes, radiology and lab results, consultation reports and correspondence to patient.
what is DOS?
date of service
what is POS?
place of service
what is TOS?
type of service
what is dx or DX?
what is HX?
define: Retention of Medical Records
most physicians are required to retain records indefinately; decreased patient records should be kept for atleast 5 yrs
what are the types of bones?
axial skeleton & appendicular skeleton
what is the axial skeleton?
consists of the skull, rib cage, and spine
what is the appendicular skeleton?
is made up of the shoulder, collar, pelvi and arms and legs
how many parts are there in a ribcage?
what numbers are the true ribs and what are they?
1-7 they attach directly to the sternum in the front of the body
what numbers are the False Ribs and what are they?
8-10 are attached to the sternum by cartilage
what numbers are floating ribs and what are they?
11-12 , they are not attached at all
what is ROM?
range of motion
a broken bone
what are the types of fractures?
comminuted, compression, impacted, hairline, pathologic
the bone is crushed and or shattered
the fractured area of bone collapses on itself
the bone is broken and the ends are driven into each other
a minor fracture appears as a thin line on x-ray and may not extend completely through the bone
any fracture occuring spontaneously as a result of disease
is a traumatic injury to a joint involving the soft tissue
a lesser injury, usually a result of overuse or over stretching
a bone is completely out of place and subluxation is partially out of joint.
define: Chief Complaint
a brief statement describing the symptom, problem, diagnosis, or condition that is the reason a patient seeks medical care.
what are the 3 volumes of the ICD-9-CM
Volume 1- diseases: tabular list Volume 2-diseases: Alphabetic Index Volume 3- Procedures: Tabular List and Alphabetic Index
what does Volume 1 consist of?
contains the disease and condition codes and descriptions, also contains the V codes and E codes
what does Volume 2 consist of?
the alphabetic index of Volume 1
what does Volume 3 consist of?
contains codes for surgical, theraputic, and diagnostic procedures; used primarily by hospitals
What are V codes?
are supplementary classification codes used to identify health care encounters for reasons other than illness or injury
What are E codes?
supplementary classification codes used to describe the reason or external cause of injury, poisoning and other adverse affects
when is the ICD usually updated?
What does the Hypertension table consist of?
contains a list of conditions that are due to or associated with hyper tension
an accelerated, severe form of hypertension with vasular damage and a diastolic pressure of 130mmHg or greater
mild or controlled hypertension and no damage to the vascular system or organs
this is not specified as benign or malignant in the diagnosis or medical record
how many columns are there in the neoplasm table?
further classified as to primary, secondary, or carcinoma in situ
Primary Malignancy -Neoplasm
the original cancer site
Secondary Malignancy -Neoplasm
cancer that has metastasized (SPREAD) to a secondary site either adjacent or remote region of the body
Carcinoma (Ca) in situ -Neoplasm
cancer that is localized and has not spread to adjacent tissues or distant parts of the body
noninvasive, non-spreading, nonmalignant
Uncertain Behavior -Neoplasm
uncertain wether benign or malignant; border line malignancy
Unspecified Nature -Neoplasm
a neoplasm is identified; however no nature of the tumor is documented in the diagnosis or medical record
what are the 3 sections of the alphabetic index?
section 1: index to diseases, section 2: table of drugs and chemicals, section 3: index to external xauses of injury (E codes)
what is CPT?
current procedural terminology
define: Stand Alone Codes
contain the full description of the procedure for the code
define: Indented Codes
these are codes listed under associated stand-alone codes.
define: Add-On codes
used for procedures that is always performed during the same operative session as another surgery in addition to the primary service/procedure and is NEVER PERFORMED SEPERATELY
provide the means by which the reporting physician can indicate that a service or procedure that has been performed has been altered by some specific circumstance but not changed in its definition or code
what does a triangle represent?
a change in the code description since the last edition.
what does 2 triangle symbols represent?
changes in the text or definition between the triangles
what does a bullet represent?
a new procedure or service code added since the previous edition of the manual
what does a plus sign represent?
indicates and add-on code
what does a circle with a line through it represent?
exemption from the use of modifier -51
what is (E/M) codes?
Evaluation and Management. they cover physicians services that are performed to determine the best course for patient care.
what is CC?
what is HPI?
History of Present Illness
what is ROS?
Review Of Systems
what is PFSH?
Past Family and Social History
what is another word for Surgical Package?
global surgery... includes a variety of services rendered by a surgeon
one who purchases the contract
define: Insurance Carrier
one who provides the benefits plan or a gvt program developed to reimburse the policyholder of all or most medical expenses
define: Group Insurance
when a group of employees and their dependents are insured under 1 group policy issued to the employer
define: Personal Insurance
an insurance plan issued to an indivisual
define: Pre-paid Health Plan
pre-determined set of benefits covered under one set annual fee
define: Indemnity Insurance
also known as fee for service
define: Health Maintenance Organization (HMO)
a managed care benefits plan that provides a wide range of medical services to indivisuals that have been enrolled into the program. LOW COST
define: Preffered Provider Organization (PPO)
similar to HMO. PPO's charge a higher premium than HMO's in the exchange for more flexability and more options for the beneficiaries
define: Point-of-Service Plan (POS)
a managed care plan that gives beneficiaries the option whom to see for services.
define: fee schedule
a list of charges for services performed
what is Medicare's Resource Based Relative Value Scales (RBRVS) Payment Schedule
under this schedule, a procedures relative value is the sum total of three elements: 1-work 2-overhead 3-malpractice
how much does medicare pay?
what does the beneficiary pay?
deductible, premium, 20% coinsurance, non-covered services
the federal gvts health insurance program created by the Social Security Act of 1965 titled Health insurance for the aged and disabled. it is run by the CMS
Centers for Medicare and Medicaid Services (CMS) was previously known as what?
Health Care Financing Administration (HCFA)
how many parts does medicare have?
what is part A in Medicare?
hospital insurance for the aged and disabled
what is part B in Medicare?
Supplementary Medical Insurance (SMI)
what is part C in Medicare?
Medicare Managed Care Plans
what is part D in Medicare?
define: Clean Claim
accurately filled out, contains no deficiencies and passes all edits
define: Dirty Claim
define: Invalid Claim
contains complete, necessary information but is incorrect in some way
define: Rejected Claim
requires investigation and needs further clarification
pays for medical services and items that medicare does not cover
a federal program administered by state governments to provide medical assistance to the needy
define: Workers Compensation
state required insurance plan, the coverage of which provides benefits to employees and dependents for work related injury, illness, or death
define: Disability Insurance
reimbursement for income lost as a result of a temporary or permanent illness or injury
define: Liability Insurance
a policy that covers losses to a third party caused by the insured, by an object owned by the insured, or on premises owned by the insured.
a regionally managed health care program for ACTIVE duty and RETIRED members of the armed forces, their families, and survivors
what does CHAMPVA ctand for?
Civilian Health and Medical Program of the Veteran Affairs
created to provide medical benefits to spouses and children of benefits
what is the Gender Rule?
male of house hold is primary payer
Waht is the birthday rule?
who evers b-day is first is primary
define: Blue Cross
covers hospital services, outpatient care, some institutional services, and home care
define: Blue Shield
covers physician services, and in some cases, dental, outpatient services and vision care
an entity that recieves transmissions of claims from physicians offices, seperates the claims by carriers and performs software edits on each claim to check for errors.
What are blocks 1-13 in the CMS-1500 referring to?
what are blocks 14-33 in the CMS-1500 referring to?
what is the life cycle of an insurance claim?
1-claims submission 2-claims processing 3-claims adjudicatin 4-Payment