When was the Health Information and Accountability Act (HIPAA) created?
What are Medical Ethics?
Standards of conduct based on moral principals.
What are the two provisions of HIPPA?
1. Insurance Reform
2. Administrative Simplification
What is the False Claims Act (FCA)
A Federal law that prohibits submitting a false claim or making a false statement or representation in connection with a claim.
What is the National Correct Coding Initiative (NCCI)?
Initiative developed by CMS to promote national correct coding methods and control improper coding that leads to wrong payments of Part B health claims.
What are the two types of edits that the NCCI implements?
1. Column 1/ Column 2; identified unbundled codes.
2. Mutually Exclusive Edits: Codes that are unlikely to be performed on the same patient in the same day.
Who investigates and prosecutes Health Care fraud?
Office of Inspector General (OIG)
When can a provider share PHI without specific permission from the patient?
1. For treatment (discussing the case with another professional)
2.Payment (When providers submit claims on the patient's behalf).
3. Operations: Staff training and Quality Improvement.
What is Employer Liability?
Physicians are legally responsible for their actions and their employee's actions. a.k.a Respondant Superior. (Let the master answer.)
What is Employee Liability Insurance?
Protection against loss of money caused by failure through error or unintentional omission of the individual or service submitting the claim.
What is in a Medical Record?
-Social and Medical History
-Physical Exam Findings
-Correspondence to the patient
When billing an insurance company, what information must be included?
-Date of Service (DOS)
-Place of Service (POS)
-Type of Service (TOS)
How long should Medical Records be retained?
Governed by State and Local laws; should be retained indefinitely. For deceased patients, they should be kept at least 5 years.
Bursting forth blood
Removal, Excision, Resection
To cut into
out, out of
Before, in front of
Front part of the body.
Back part of the body.
Near the point of attachment to the trunk.
Far from the point of attachment of the trunk.
Middle of the body.
Vertical plane dividing the body into Anterior and Posterior sections.
Vertical plane dividing the body to the left and the right sides.
Horizontal plane dividing the upper and lower parts of the body.
What are the 2 types of glands on the skin?
1. Sebaceous (oil) glands
2. Suddiferous (sweat) glands
What are the 3 layers of skin?
1. Epidermis (Top layer)
2. Dermis (Middle layer)
3. Subcutaneous Layer
What is hair made of?
What is the moon like white area at the base of the nail called?
What are the 2 types of sweat glands?
1. Eccrine (secrete odor)
2. Apocrine (odorless sweat)
What hormones do the adrenal glands secrete?
Epinephrine and Steriods
Structural protein found in skin and connective tissue.
major skin pigment
discolored, flat lesion
small collection of clear fluid; blister
smooth, slightly elevated swollen area that is redder or paler than the surrounding skin
Absence of hair
Death of tissue due to loss of blood supply
Bacterial inflammatory skin disease with lesions, pustules and vesicles
A pregnant woman who has had at least one pregnancy.
What are bones connected together with?
fibrous bands of ligaments
What are bones made of?
What are the insides of bones comprised of?
How are bones categorized?
The Axial Skeleton and the Appendicular Skeleton
What is the Axial Skeleton comprised of?
Skull, Ribcage and Spine.
What is the Appendicular Skeleton comprised of?
Shoulder, collar, pelvic, arms and legs.
Strong, broad and have large surfaces for muscles to attach to.
Small with irregular shapes (ie wrist and ankle)
Bones covering body parts (ie shoulder blades, ribs, pelvic bones)
Small, rounded bones that resemble sesame seeds that are found near joints. (ie knee cap)
Forms the front part of the skull and the forehead.
Forms the sides of the cranium
Forms the back of the skull
Forms the two lower sides of the cranium
Forms the roof of the nasal cavity
In front of the temporal bones
Bones at the corner of each eye that cradle the tearducts
Bone that forms the wall between the nostrils
Upper roof of the mouth
Inferior nasal conchae
Interior of the nose
How many regions is the spinal/vertebral column divided into?
How many bones are in the spine?
What are the 5 regions of the spine?
Upper Arm bone
Lower medial arm bone
Lower arm bone in line with the thumb
Bones the palm of the hand
Smaller, lateral leg bone
Hind foot bone
Middle of the foot bone
What are synovial joints?
Free moving joints that are surrounded by joint capsules.
What are bursae?
Sacs of fluid located in-between the bones of the joint and tendons that hold the muscles into place.
Movement away from the midline
Movement toward the midline
Turning the palm or foot upward
What is a Comminuted Fracture?
The bone is crushed or shattered.
What is a compression fracture?
The fractured area of the bone collapses on itself.
What is a Colles Fracture?
A break at the distal end of the bone, usually when someone tries to break their fall.
What is a Complicated Fracture?
The bone is broken and pierces an organ.
How many volumes is the ICD-9 manual divided into?
1. Volume 1; Tabular List
2. Volume 2; Diseases, Alphabetic Index
3. Volume 3; Procedures, tabular list and index
When are V codes used?
-When a person who is not sick/injured seeks health services for a specific thing (immunizations, organ donors)
-When a person with a chronic condition presents for specific treatment of that condition (diabtetes)
-When a circumstance influences the patients health status, but is not a current illness (family history)
-Birth status of a newborn
When are E codes used?
In the cause of injury, poisoning, accidents or other adverse effects.
How many digits does an ICD-9 Category code have?
3 (ex 311)
How many digits does an ICD-9 Subcategory code have?
4. (ex 311.0)
How many digits does an ICD-9 Subclassification code have?
5. (ex 311.56)
What are the 3 classifications of Hypertension?
1. Malignant (Accelerated and severe)
2. Benign (Mild or controlled)
3. Unspecified (Not specified in the Medical Record)
What is primary malignancy?
The original cancer site. Malignant tumores are considered primary unless documented as secondary or metastatic.
What is secondary malignancy?
Cancer that has spread to a secondary site.
What is Carcinoma in situ?
Cancer that has localized and not spread at all.
What is Benign?
Noninvasive, non-spreading, nonmalignant.
Who developed HCPCs codes?
What does a triangle in the CPT book next to a code mean?
A change in the code description since the last edition.
What does a bullet in the CPT code book next to a code mean?
A new procedure or service since the previous edition.
What are the key components of E/M?
-History of Present illness
-Review of Symptoms
-Past, Family and Social History
2. Physical Exam
3.Medical Decision Making Complexity
What does a Surgical Package (aka Global Surgery) include?
-Surgical Procedure Performed
-Local infiltration/metatarsal/digit block/anesthesia
-Pre-Op E/M services on day before surgery
-Immediate Post-Op care
-Normal, uncomplicated Post-Op care
How is Usual, Customary and Reasonable pricing calculated?
1. The provider's usual charge for the service
2. The average charge of all the other providers in the same geographical area
3. The actual charge submitted on the claim
The lowest amount is used as basis for the payment.
How is Medicare's RBRVS calculated?
1. The amount of time, intensity of effort and medical skill required for the service
2.Overhead; the practice costs related to performing the service
3. Cost of Medical Malpractice insurance
Who does TRICARE cover?
Active, retired, survivors and their families of the Armed Forces.
What is CHAMPVA
Provides medical benefits to spouses and children of veterans with total, permanent, service related disabilities- or have died.
Can you have TRICARE and CHAMPVA at the same time?
What is the name of the claim form that is standard for submitting claims?
How is the Patients DOB entered on the claim form?
What is Assignment of Benefits?
Reimbursement is sent directly from payer to the provider.
What is Fiscal Intermediary?
An insurance company that bids for a contract with CMS to handle the Medicare program in a specific area.
What is a Qualified Diagnosis
A working diagnosis that has not yet been established.
What is the Civil Monetary Penalties Law (CMPL)?
A law passed by the Federal Government to prosecute cases of Medicaid fraud.