CBCS Exam Study Guide

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Medical Billing & Coding as a Career

Claims assistant professional or claims manager, Coding Specialist, Collection Manager, Electronic Claims Processor, Insurance Billing Specialist, Insurance Coordinator, Insurance Counselor, Medical Biller, Medical & Financial Records Manager, Billing & Coding Specialist

What are Medical Ethics?

Standards of conduct based on moral principle. They are generally accepted as a guide for behavior towards pt's, dr's, co-workers, the gov, and ins co's.

What does acting within ethical behavior boundaries mean?

carrying out one's responsibilities w/ integrity, dignity, respect, honesty, competence, fairness, & trust.

Legal Aspects of of Medical Billing & Coding:

...

Compliance regulations:

Most billing-related cases are based on HIPPA and False Claims Act

Health Insurance Portability & Accountability Act (HIPPA)

Enacted in 1996, created by the Health Care Fraud & Abuse Control Program-enacted to check for fraud and abuse in the Medicare/Medicaid Programs and private payers

What are the 2 provisions of HIPPA?

Title I: Insurance Reform
Title II: Administrative Simplification

What is Title I of HIPPA?

Insurance Reform-primary purpose is to provide continuous ins coverage for worker & their dependents when they change or lose jobs. Also Limits the use of preexisting conditions exclusions Prohibits discrimination from past or present poor health Guarantees certain employees/indv the right to purchase new health ins coverage after losing job Allows renewal of health ins cov regardless of an indv's health cond. that is covered under the particular policy.

What is Title II of HIPPA?

Administrative Simplification-goal is to focus on the health care practice setting to reduce administrative cost & burdens. Has 2 parts- 1) development and implementation of standardized health-related financial & administrative activities electronically 2) Implementation of privacy & security procedures to prevent the misuse of health info by ensuring confidentiality

What is the False Claims Act (FCA)?

Federal law that prohibits submitting a fraudulent claim or making a false statement or representation in connection w/ a claim. Also protects & rewards whistle-blowers.

What is the National Correct Coding Initiative (NCCI)?

Developed by CMS to promote the national correct coding methodologies & to control improper coding that lead to inappropriate payment of Part B health ins claims.

How many edits does NCCI include?

2: 1)Column 1/Column 2 (prev called Comprehensive/Component) Edits
2) Mutually Exclusive Edits

Column 1/Column 2 edits (NCCI)

Identifies code pairs that should not be billed together b/c 1 code (Column 1) includes all the services described by another code (Column 2)

Mutually Exclusive Edits (NCCI)

ID's code pairs that, for clinical reasons, are unlikely to be performed on the same pt on the same day

What are the possible consequences of inaccurate coding and incorrect billing?

delayed processing & payment of claims reduced payments, denied claims fine and/or imprisonment exclusion from payer's programs, loss of dr's license to practice med

Who has the task of investigate and prosecuting health care fraud & abuse?

The Office of Inspector General (OIG)

Fraud

knowingly & intentionally deceiving or misrepresenting info that may result in unauthorized benefits. It is a felony and can result in fines and/or prison.

Who audits claims?

State & federal agencies as well as private ins co's

What are common forms of fraud?

billing for services not furnished, unbundling, & misrepresenting diagnosis to justify payment

Abuse

incidences or practices, not usually considered fraudulent, that are inconsistent w/ the accepted medical business or fiscal practices in the industry.

What are examples of Abuse?

submitting a claim for services/procedures performed that is not medically necessary, and excessive charges for services, equipment or supplies.

What is a method use to minimize danger, hazards, & liabilities associated w/ abuse?

Risk Management

Patient Confidentiality

All pt's have right to privacy & all info should remain privileged. Only discuss pt info when necessary to do job. Obtain a signed consent form to release medical info to ins co or other individual.

When may providers use PHI (Protected Health Information) w/o specific authorization under the HIPPA Privacy Rule?

When using for TPO, Treatment (primarily for the purpose of discussion of pt's case w/ other dr's) Payment (providers submit claims on behalf of pt's) & Operations (for purposes such as training staff & quality improvement)

What is Employer Liability?

Means physicians are legally responsible for their own conduct and any actions of their employees (designee) performed w/in the context of their employment. Referred to as "vicarious liability. A.K.A "respondent superior"-"let the master answer". Means employee can be sued & brought to trial

What is Employee Liability?

"Errors & Omissions Insurance"-protection against loss of monies caused by failure through error or unintentional omission on the part of the indv or service submitting the claim. ***Some dr's contract w/ a billing service (clearinghouse) to handle claims submission, & some agreements contain a clause stating that the dr will hold the co harmless from "liability resulting from claims submitted by the service for any account", means dr is responsible for mistakes made by billing service, errors & omissions is not needed in the instance. *****However, if dr ever asks the ins biller to do the least bit questionable, such as write of pt's balances for certain pt's automatically, make sure you have a legal document or signed waiver of liability relieving you of responsibility for such actions.

What is a Medical Record & what is it comprised of?

documentation of the pt's social & medical history, family history, physical exam findings, progress notes, radiology & lab results, consultation reports and correspondence to pt- Is the foremost tool of clinical care and communication.

What is a medical report?

part of the medical record & is a permanent legal document that formally states the consequences of the pt's exam or treatment in letter or report form. IT IS THIS RECORD THAT PROVIDES INFO NEEDED TO COMPLETE THE INS CLAIM FORM.

Reasons for Documentation

Important that every pt seen by dr has comprehensive legible documentation about pt's illness, treatment, & plans for following reasons:
*Avoidance of denied or delayed payment by ins co investigating the medical necessity of services
*Enforcement of medical record-keeping rules by ins co requiring accurate documentation that supports procedure & diagnosis codes.
*Subpoena of medical records by state investigators or the court for review
*Defense of professional liability claim

Retention Of Medical Records

Is governed by state & local laws & may vary from state-to-state. Most dr are required to retain records indefinitely, deceased pt records should be kept for @ least 5 years

Med Term

...

Diagnosis suffixes:

...

-algia

pain

-emia

blood condition

-itis

inflammation

-megaly

enlargement

-meter

measure

-oma

tumor, mass

-osis

abnormal condition

-pathy

disease condition

-rrhagia

bursting forth of blood

-rrhea

discharge, flow

-sclerosis

hardening

-scopy

to view

Procedural Suffixes:

...

-centesis

surgical puncture

-ectomy

removal, resection, excision

-gram

record

-graphy

process of recording

-lysis

separation, breakdown, destruction

-pexy

surgical fixation

-plasty

surgical repair

-rrhapy

suture

-scopy

visual examination

-stomy

opening

-therapy

treatment

-tomy

incision, to cut into

Common Prefixes:

...

a, an

without

ante

before

anti

against

brady

slow

dys

painful, difficult

endo

inside, within

epi

upon, above

ex

out, out of

hemi

half, partial

hypo

below, deficient

infra

below

inter

between

oligo

scanty, little

para

beside

per

through

pre

before, in front of

pseudo

false

supra

above, beyond

tetra

four

Common Root Words

...

arth

cartilage

cephal

head

cardi

heart

cholecyst

gall bladder

chondro

cartilage

colp

vagina

enter

intestine

episi

vulva

gastro

stomach

gloss

tongue

hepato

liver

hyster

uterus

lapar

abdomen

lith

stone

mast

breast

myo

muscle

oophor

ovary

pneum

lung

salping

fallopian tubes

stomat

mouth

Directional Terms:

...

Anterior, Ventral

front surface of the body

Posterior, Dorsal

back side of the body

Superior

above another structure

Inferior

below another structure

Proximal

near the point of attachment to the trunk

Distal

far from the point of attachment to the trunk

Medial

pertaining to the middle of the body

Lateral

pertaining to the side

Frontal, Coronal

Vertical plane dividing the body into anterior & posterior portions

Sagittal

vertical plane dividing the body into right & left sides

Transverse, Cross-sectional

Horizontal plane dividing the body into upper & lower portions

Anatomy & Physiology

A professional medical coder must have knowledge of anatomy & physiology so that coding assignment is quick & accurate.

What is the 1st body system for which medical procedures are described in the CPT manual?

The Integumentary System (the skin and it's accessory organs) Integument means covering. It is a complex system of specialized tissues containing glands, nerves and blood vessels.

How much area does the skin cover?

an area of 22 sq ft (an average adult). It is the largest organ of the body

What is the main function of the skin?

To protect the deeper tissues from excessive loss of minerals, heat & water. It also provides protection form diseases by providing a barrier. It accomplishes its diverse functions w/ assistance from the hair, nails and glands.

SEBACEOUS (OIL) GLANDS & SUDDORIFERIOUS (SWEAT GLANDS)

produce secretions that allow the body to be moisturized or cooled.

How many layers to the skin?

3;
1) Epidermis (thin, cellular membrane layer that contains keratin)
2) Dermis (dense, fibrous, connective tissue that contains collagen)
3) Subcutaneous layer (thicker & fatter tissue)

Hair, Nail & Glands

...

Hair

composed of tightly fused meshwork of cells filled w/ hard protein called karatin. Has its roots in the dermis & together w/ their coverings, is called HAIR FOLLICES. Main function is to assist in regulating body temp. Holds heat when body is cold by standing on end & holding a layer of air as insulation.

Nails

cover & protect the dorsal surface of the distal bones of the fingers & toes. Part that is visible is nail body, nail root is under skin @ the base of the nail and nail bed is the vascular tissue under the nail that appears pink when the blood is oxygenated or blue/purple when it is oxygen deficient.

What is the moon like white area of the nail called?

lunula

What is the eponychium?

the cuticle at the lower part of the nail sometime referred to as such

SEBACEOUS GLANDS

located in the dermal layer of the skin over the entire body, expect for palm of hands and soles of feet. Secrete oily substance called SEBUM. SEBUM CONTAINS LIPIDS THAT HELP LUBRICATE THE SKIN & MINIMIZE WATER LOSS. It is the overproduction of sebum during puberty that contributes to acne in some people

SUDDORIFEROUS GLANDS

sweat glands that are tiny, coiled gland found on almost all body surfaces. They are most numerous in the palms and soles of feet. Coiled sweat glands originate in the dermis and straighten out to extend up through the epidermis. Tiny opening at surface is called a PORE.

How many types of sweat glands?

2;
1) eccrine sweat glands (most common)
2) apocrine sweat glands (secrete orderless sweat)

What organ secretes hormones?

the adrenal glands, they secrete epinephrine & steriods

Integumentery Vocabulary

...

Albino

deficient in pigment (melanin)

Collagen

structural protein found in the skin & connective tissue

Melanin

major skin pigment

Lipocyte

a fat cell

Macule

discolored, flat lesion (freckles,, tattoo marks)

Polyp

benign growth extending from the surface of the mucous membrane

Fissure-

groove or crack like sore

Nodule

solid, round or oval elevated lesion more than 1 cm in diameter

Ulcer

open sore on the skin or mucous membrane

Vesicle

small collection of clear fluid; blister

Wheal

Smooth, slightly elevated, edematous (swollen) area that is redder or paler than the surrounding skin

Alopecia

absence of hair form areas where it normally grows

Gangrene

death of tissue associated w/ the loss of blood supply

Impetigo

bacterial inflammatory skin disease characterized by lesion, pustules, and vesicles

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