medicare & hcpcs study guide

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Medigap policy

supplemental plans designed by the federal government but sold by private commercial insurance companies to cover the cost of Medicare deductibles, copayments, & coinsurance, which are considered "gaps" in Medicare coverage

HCPCS

Healthcare Common Procedure Coding System. coding system that consists of CPT, national codes (level II), & local codes (level III); local codes were discontinued in 2003; previously known as HFCA Common Procedure Coding System

hospice

autonomous , centrally administered program of coordinated inpatient & outpatient palliative (relief of systoms) services for terminally ill patients & their families

medicare part A

reimburses institutional providers for inpatient, hospice, & some home health services

Medicare part B

reimburses noninstitutional health care providers for outpatient services

respite care

the temporary hospitalization of a hospice patient for the purpose of providing relief from duty for the nonpaid person who has the major day-to-day responsibility for the care of the terminally ill, dependent patient

Medicare benefit period

replaced current medicare general coverage intructions that were found in Chapter II of the Medicare Carriers Manual, Intermediary manual, various provider manuals, and Program Memorandum documents

Medicare general Enrollment period

January 1 throught March 31 of each year; Part B coverage starts on july 1 of that year

Level II permanent codes

maintained by the HCPCS national panel, composed of representatives from the BCBSA, the Health Insurance, Association of America HIAA & CMS

per diem

"for each day" how retrospective cost-based rates are determined; payments are issued based on daily rates

RUGS

Resosurce Utilation Groups. based on data collected from resident assessments (using data elements called the Minimum Data Set, or MDS) & relative weithts developed from staff time data

DRG's

diagnosis-related group. prospective payment system that reimburses hospitals for inpatient stays (what is wrong with the patient)

CDT coding system

Current Dental Terminology. Dental codes

ambulatory surgery center

state-licensed, Medicare-certified supplier (not provider) of surgical health care services that must accept assignment on Medicare claims.

Balance billing

billing beneficiaries for amounts not reimbursed by payers (not including copayments & coinsurance amounts); this practice is prohibited by Medicare regulations.

ABN

Advance Beneficiary Notice. document that acknowledges patient responsibility for payment if Medicare denies the claim. BILLING TIP: PURPOSE OF OBTAINING A ABN IS TO ENSURE PAYMENT FOR A PROCEDURE OF SERVICE THAT MIGHT NOT BE REIMBURSED UNDER MEDICARE

OASIS

Outcomes & Assessment Information Set. group of data elements that represent core items of a comprehensive assessemnt for an adult home care patient & form the basis for measuring patient outcomes for purposes of outcome-based quality improvement

Roster billing

enables Medicare beneficiaries to participate in mass PPV (pneumococcl pneumonia virus) & influenza virus vaccination programs offered by Public Health Clinics (PHC's) and other entites that bill Medicare cariers; not used to submit single patient bills

medicare limiting charge for non-par providers

mediare-allowed fee for nonPARs is 5% below the PAR fee schedule, but the nonPAR physician may charge a maximum of 15% above the nonPAR approved rate (or 10% above the PAR fee schedule)The limiting charge is the maximum fee a nonPar may charge for a covered service. regardless of who is responsible for payment & whether Medicar is primary or secondary

Case mix

the types & categories of patients treated by a health care facility or provider

outpatient payment prospective

uses ambulatory payment classification (APCs) to claculate reimbursement; was implemented for billing of hospital-based Medicare outpatient claims

inpatient psychiatric facility payment prospective

(IPF PPS) system in which Medicare reimburses inpatient psychiatric facilities according to a patient classification system that reflects differences in patient resource use & costs; it replaces the cost-based payment system with a per diem IPF PPS.

medicare Select

type of Medigap policy available in some states where beneficiaries choose from a standarized Medigap plan

par provider

contracts with a health insurance plan & accepts whatever the plan pays for procedures or services performed

non-par provider

does not contract with the insurance plan; patients who elect to receive care from nonPARs will incur higher out-of-pocket expenses

medicare summary notice

previously called an Explanation of Mediare Benefits or EOMB; notifies Medicare beneficiaries of actions taken on claims

Could a CPT and HCPCS code be used together?

yes, (depending on services provided)CPT code is for the administration of an injection (J code) & the HCPCS code is to identify the medication is the most common scenario: EX:ICD9 code diagnosis CPT Injection & HCPCS is the medication in the injection.

Ambulance services...When would Medicare pay?

the patients life is in danger or if the patients health does not permit them to be transported any other way (ex: paralyzed)

Why do we use modifiers?

modifiers are used when the information provided by a HCPCS code description has to be supplemented to identify specific circumstances that may apply to an item or service

How DRG's are used

is based on the patients principal & secondary diagnoses the DRG determines how much payment the hospital receives. (This is a flat rate). (The more complicated the diagnosis the more money they will pay & the longer you may be able to stay)

Time limits for filing a medicare claim

December 31 of the year in which wervices were provided, unless the deadline is extended to December 31 of the following year. (The federal government budget fiscal year begins October 1 which means that dates of service October 1 through December 31 are processes as part of the next fiscal year)

Medicare part D....what does this cover?

prescription drugs

medicare.... Under what conditions is it primary? Secondary?
SECONDARDY
medicare is secondary when the patient is eligible for medicare & is covered by one or more of the following plans
-employer-sponsored group health plan (EGHP) that has more than 20 covered employees
-disabiility coverage through an employer-sponsored group health plan tha has more than 100 covered employees
-End-Stage Renal Disease case covered by employer-sponsored group lan of any size during the first 18 month os the pt eligibility for Medicare
-third-party liability policy
-a workers' compensation program
-Veterans Administration (VA) preauthorized services for a beneficiary who's eligible for both VA & medicare benefits
-Federal Black Lung Program that covers currently or formerly employed coal miners

PRIMARY
-employee eligible for group health plan but has declined to enroll or recently dropped coverage
-employee currently employed, but not yet eligible for group plan coverage or has exhaused benefits under the plan
-health ins. plan is only for self-employed indivdual
-health ins. plan was purchased as an individual plan & not obtained through a group
-patient under 65 has medicare because of disability or ESRD & not covered by an employer-sponsored plan
-pt under 65 has ESRD has an employer-sponsored plan but has been eligible for Medicare for more than 30 months
-pt left a company & has elected to continure coverage in the group health plan under federal COBRA rules
-patient has both medicare & medicaid (crossover patient)

When is Medicare not primary?

see secondary notes ****remember 3 of these*********

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