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Terms in this set (62)
Responsibilities of Insurance Specialist
Know how to use ICD-10 CM and CPT code books.
Assignment of Benefits
An authorization form signed by the patient allowing the insurance payments to be sent directly to the physician.
Government sponsored- The civilian health and medical program of the Veterans Administration, covers the spouse and unmarried dependent children of a veteran with permanent total disability from a service related injury and the surviving spouse and children of veterans who died of a service related disability. A person cannot be covered by both CHAMPUS AND CHAMPVA. CHAMPUS and CHAMPVA are billed after all other insurance coverages except Medicaid.
Health insurance policy purchased by an organization or corporation that covers a defined group of individuals (ie employees of a company)
Procedures, conditions or services not covered by the insurance policy. Not all carriers have the same exclusions.
A specified amount of annual out-of-pocket expenses for covered health care services the insured must pay to a health care provider before the insurer pays benefits. Also describes as the amount paid by the patient before an insurance plan or government plan begins to cover the individual's health care costs.
Copayment or Copay
A fixed dollar amount, or stipulated fee per visit or service the insured must pay to the provider. Also describes as the contribution the subscriber makes to cover some portion of each medical bill. Paid at the time of service.
Participating Provider; In-Network Provider; Preferred Provider
Physician or medical facility who has a contract with a particular insurance carrier by which he/she/they agree to accept the carrier's allowed amount as payment in full for services provided in exchange for direct payment from the carrier. The difference between the provider's actual charge and the carrier's allowed charge is written off by the provider and the patient is not required to pay that portion. THE PROVIDER THEN BILLS THE PPO (Preferred Provider Organization)
Non Participating Provider; out-of-Network Provider; Nonmember Physician
Provider who does not contract with a particular carrier (does not "accept assignment") and does not accept the carriers allowed amount as payment in full. The patient is responsible for whatever portions of the bill are covered. Physicians are free to choose whom they will or will not contract with. The patient has financial incentive to see a physician with in PPO.
A benefit paid to an insured while disabled. Also, a benefit paid by an insurer for a loss under a policy.
A legal document that modifies the protection of a policy.
A policy that covers all the employees of one company under a master contract. the employee's policy is always primary.
A claim that has no deficiencies, the carrier does not have to investigate further, and the claim passes all electronic edits in the Medicare program.
Special Risk Insurance
Protects a person in the event of a specific accident or disease
A hospital report that states the patients current condition, status and final prognosis, including diagnosis, procedures and complications.
Names of the disease, condition, illness or injury
Centers for Medicare and Medicaid Services (replaces Health Care Financing Administration-HCFA)
Occupational Safety and Health Administration- Office of the federal government which protects employees on the job against health and safety hazards
Advance Beneficiary Notice (ABN)
Document that acknowledges patient responsibility for payment if Medicare denies the claim
Insurance claim form used by Medicare and accepted by nearly all insurance carriers. Formerly HCFA 1500 form
Review organization which conducts admission and concurrent review and prepares a discharge plan for a hospitalized patient.
A written management plan that outlines good billing practices.
Linking the diagnosis code to a procedure code for medical necessity.
Main reason for the encounter (visit)
A type of hospital reimbursement-"Diagnostically Related Groups"
A fixed per capita amount for each patient enrolled, regardless of the number of services provided. May be monthly, quarterly or annually.
Social Security Disability Insurance- Provides benefits for workers with short term disability
Dorlans's and Stedman's
Commonly used medical dictionaries
Maintaining a constant internal environment in the human body
Premature Ventricular Contractions-abnormal EKG readings
Examples of common Lab reports
urinalysis, culture and sensitivity, CBC and hematocrit
Found at the beginning of each section of the CPT book and help to define items that are necessary to appropriately interpret and report procedures and services in that section.
NCCI- Nation Correct Coding Initiative
Law to control and prevent the unbundling of codes
What information should be obtained in a new pt interview?
1. Pt name, address, phone #, ssn, birth date. If pt is a minor - Name of parent or guardian.
2.Reason for visit
3. If the pt has insurance. if so obtain all pertinent info. (co name, all ID #, policy # and name of insured) Determine whether or not preauthorization is needed. Also obtain Release of information signature from patient at time of apt.
Advantage for electronic claim submission
Saves time for everyone, mistakes are noticed quickly, it increases cash flow.
Reasons for Overpayments from 3rd party carriers due to
Overburdened Claim departments, lost form or misfiled claim. Do not hesitate to contact a carrier with questions.
Max Number of ICD 10 CM Codes on claim forms is
Volumes I and II of ICD 10 - CM designed for the
intent of use in both providers office and institutional diagnostic coding (primarily physicians offices)
to be used by institutions for coding services rendered to inpatients such as fee for the use of the operating room, laboratory, and x-ray equipment, nursing services, housekeeping services and certain procedures performed in hospital settings, etc.. ( HOSPITAL SETTINGS)
2 main parts of the ICD 10- CM
Disease Index and Tabular Index
In order to code accidents
Professional biller codes the precipitating causes of the accident.
Surgical Procedures Fall into 2 categories
Excision or Removal (-ectomy) -to cut off
Debridement (cleaning) of a wound
When reporting a skin lesion
you must know the site and the size in centimeters
When the description reads "open treatment of a closed fracture or dislocation'
an incision has been made over the fracture and some type of fixation device is usually applied.
Endoscopy codes in CPT are classified according to
Anatomical site, extent of the examination, purpose of the endoscopy-Diagnostic vs Surgical, type of scope used
E&M section includes
Location of service (place), New or established patient(patient status), Length of time of service(time).
Most of the insurance industry refers to these services as "mental or behavorial health services"
Used with consult code to report decision for surgery
Used when physician has elected to terminated surgery or diagnostic procedure because of extenuating circumstances that threaten well being of the patient. Only used if the surgical prep has started in the operating room or the induction of anesthesia has been initiated.(equipment failure, health issue other wise unnoticed)
Used when the surgeon preformed only the surgical portion of the surgical package and personally administered any required local anesthesia. Pre and/or Post operative evaluation/care was preformed by another physician.
Return to the OR. Used to report unplanned circumstances that require the return to the operating room for complications of the initial operations such as a 'bleeder' or surgical wound dehiscence.
A new procedure or service is performed by a surgeon during the normal postoperative period of a previously performed but unrelated surgery.
Repeat Procedure by another physician-reported when a physician other than the original physician performs a repeat procedure because of special circumstances involving the original study or procedure.
Two Surgeons Co-Surgeons- Report when two primary surgeons are required during an operative session, each performing distinct parts of a reportable procedure.
Surgical team -Reported when surgery preformed is highly complex and requires services of a skilled team of 3 or more physicians.
Assistant Surgeon- reported when one physician assist another during an operative session.
Resource Based Relative Value Scale System
RBRVS has 3 separate cost factors
1. Physician work factor
2. Provider's practice expenses less malpractice expenses (overhead costs)
3.Cost of professional liability insurance(malpractice insurance)
In order to code a laceration
the number of sutures is NOT needed.
The pathology report is required in order to code
skin neoplasms and excisions of lesions
Manipulation of a fracture OR dislocation and reduction of a fracture are or are not the same thing?
are the same thing
How should the treatment of fractures be documented on the patient's record
as either opened or closed
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