26 terms

MB112 Week 3

Why should medical coders ensure that they code accurately and completly?
to optimize reimbursement for services provided
Why should coders ensure that the data reported are as accurate as possible?
For classification and study purposes and also to obtain appropriate reimbursement.
What is Medicare Part B for?
pays for physician services and durable medical equipment not paid for under Part A. Helps pay for medically necessary professional services, outpatient hospital services, home health care, and a number of other medical services and supplies that are not covered by Part A.
Who was Medicare originally designed for?
People aged 65 and over.
Quality improvement Organization
For example, a QIO provider renders a service that costs $100 and bills Medicare for the service; Medicare allows $58, and the provider accepts the Medicare payment as payment in full.
For Non-QIO Providers
-Payment goes to the patient on all claims.
-a 5% lower fee schedule than that for QIO providers.
-Slower processing of claims is the norm.
-A statement on the Medicare Summary Notice (MSN) sent to the patient reminds the patient that the use of a participating physican will lower out-of-pocket expenses.
What is Medicare Part A for?
Pays for hospice care for terminally ill patients when a physician has certified that the patient is terminally ill and is expected to live 6 months or less if the disease runs its normal course.
How are Medicare Part B services reported?
using ICD-9-CM codes for the diagnosis, CPT codes for the procedure services, and HCPCS codes for the additional supplies and services.
What is Medicare Part C?
also known as "Medicare Advantage Organizations (formerly Medicare + Choice) and is a set of health care options from which Medicare beneficiaries can choose their helth care providers.
What is Medicare Part D for?
Drugs. The Medicare Prescription Drug, Improvement, and Modernization Act of 2003 established a prescription drug benefit under Part D of the Medicare program.
are activities involving the transfer of health care information.
is the movement of electronic data between two entities and the technology that supports the transfer.
Why was physician payment reform implemented?
1. Decrease Medicare expenditures
2.Redistribute physicians' payments more equitably
3. Ensure quality health care at a reasonable rate.
What was one of the additions of section 1848 "Payment for Physician Services" to the Omnibus Budget Reconciliation Act of 1989.
Replacement of the maximum actual allowable charge (MAAC), which limits the total amount non-QIO physicians could charge.
What forms does fraud take?
The most common forms of Medicare fraud are:
-Billing for services not furnished
-Misrepresenting a diagnosis to justify a payment
-Soliciting, offering, or receiving a kickback
-Unbundling, or "exploding," charges.
-Falsifying certificates of medical necessity, plans of
treatment, and medical records to justify payment
-Billing for additional services not furnished as billed- up
-Routine waiver of copayment
Most surgery subsections are defined according to what?
Medical specialtly or body system (e.g., integumentary or respiratory).
What do the section guidelines do?
define terms that are necessary to know for appropriately interpreting and reporting the procedures and services contained in the section.
What is the purpose of the notes?
The information in the notes indicates the special instructions unique to particular codes or groups of codes.
Why are the notes important?
the information contained in them is not usually available in the section guidelines.
What are parenthetical phrases or expressions?
The additional information enclosed in parentheses. They sometimes follow the code or group of codes and provide further information about codes that may be applicable.
What are unlisted codes?
These codes identify procedures or services throughout the Surgery section for which there is no CPT code.
What must be included with the claim when using an unlisted code?
a special report describing the procedure must accompany the claim.
What is included in the surgical package?
The operation itself
local anesthesia
"typical postoperative follow-up care"
one related E/M encounter prior to the procedure
immediate follow-up care(including written orders)
"routine Preoperative and Post operative care-including minor complications-and up to a predefined number of days before and after the surgery".
Do all third party payers have the same idea of what constitutes a surgical package?
What is the period of time following each surgery called?
Global (postoperative) surgery period
The global period is usually what?
90 days for major surgery
10 days for minor surgery