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define: Medical Ethics

standards of conduct based on moral priciples

define: Compliance Regulations

most billing-related cases are based in HIPAA and False claims act

what is HIPAA?

Health Insurance Portability and Accountability Act of 1996.

why was HIPAA created?

it created the Health Care Fraud and Abuse Control Program enacted to check for fraud and abuse in medicare abd medicaid programs, and private payers

What are the 2 provisions in HIPAA?

title 1: Insurance Reform.. title 2:Administrative Simplification

what is the purpose of title 1 in HIPAA?

the primary purpose is to provide continuos insurance coverage for workers and their dependents when they change or lose their jobs.

what is the purpose of title 2 in HIPAA?

the goal is to focus on the health care practice setting to reduce administrative costs and burdens

Define: False Claims Act (FCA)

federal law that prohibits submitting a false claim or making a false statement or representation in connection with a claim. it also protects and rewards persons involved in whistle-blower cases

define: National Correct Coding Initiative (NCCI)

to control improper coding that leads to inappropriate payment of part B health insurance claims

what are the 2 types of edits in the NCCI?

1. column 1/column 2 (previously called comprehensive/component) Edits 2. Mutually Exclusive Edits

what does the 1st edit in the NCCI do?

identifies code pairs that should not be billed together because one code (column 1) includes all the services described by another code (column 2)

what does the 2nd edit in the NCCI do?

identifies code pairs that, for clinical reason, are unlikely to be performed on the same patient on the same day.

define: Fraud

knowingly and intentionally deceiving or mispresenting information that may result in unauthorized benefits

is fraud a felony?

yes fraud is a felony and can result in fines and/or a prison sentence

define: Abuse

incidents or practices, not usually considered fraud, that are inconsistant with the accepted medical business or fiscal practices in the industry

define: Patient Confidentiality

All patients have the right to privacy. Discuss patient info only with the patients physician or office personel. Obtain a signed consent form to release medical information to the insurance company or other indivisual

define: Medical Records

documentation on the patients social and medical history, family history, physical examination findings, progress notes, radiology and lab results, consultation reports and correspondence to patient.

what is DOS?

date of service

what is POS?

place of service

what is TOS?

type of service

what is dx or DX?


what is HX?


define: Retention of Medical Records

most physicians are required to retain records indefinately; decreased patient records should be kept for atleast 5 yrs

what are the types of bones?

axial skeleton & appendicular skeleton

what is the axial skeleton?

consists of the skull, rib cage, and spine

what is the appendicular skeleton?

is made up of the shoulder, collar, pelvi and arms and legs

how many parts are there in a ribcage?


what numbers are the true ribs and what are they?

1-7 they attach directly to the sternum in the front of the body

what numbers are the False Ribs and what are they?

8-10 are attached to the sternum by cartilage

what numbers are floating ribs and what are they?

11-12 , they are not attached at all

define: Femur

thigh bone

what is ROM?

range of motion

define: fracture

a broken bone

what are the types of fractures?

comminuted, compression, impacted, hairline, pathologic

define: comminuted

the bone is crushed and or shattered

define: compression

the fractured area of bone collapses on itself

define: impacted

the bone is broken and the ends are driven into each other

define: hairline

a minor fracture appears as a thin line on x-ray and may not extend completely through the bone

define: Pathologic

any fracture occuring spontaneously as a result of disease

define: Sprain

is a traumatic injury to a joint involving the soft tissue

define: Strain

a lesser injury, usually a result of overuse or over stretching

define: Dislocation

a bone is completely out of place and subluxation is partially out of joint.

define: Chief Complaint

a brief statement describing the symptom, problem, diagnosis, or condition that is the reason a patient seeks medical care.

what are the 3 volumes of the ICD-9-CM

Volume 1- diseases: tabular list Volume 2-diseases: Alphabetic Index Volume 3- Procedures: Tabular List and Alphabetic Index

what does Volume 1 consist of?

contains the disease and condition codes and descriptions, also contains the V codes and E codes

what does Volume 2 consist of?

the alphabetic index of Volume 1

what does Volume 3 consist of?

contains codes for surgical, theraputic, and diagnostic procedures; used primarily by hospitals

What are V codes?

are supplementary classification codes used to identify health care encounters for reasons other than illness or injury

What are E codes?

supplementary classification codes used to describe the reason or external cause of injury, poisoning and other adverse affects

when is the ICD usually updated?

in October

What does the Hypertension table consist of?

contains a list of conditions that are due to or associated with hyper tension

Malignant -Hypertension

an accelerated, severe form of hypertension with vasular damage and a diastolic pressure of 130mmHg or greater

Benign -Hypertension

mild or controlled hypertension and no damage to the vascular system or organs

Unspecified -Hypertension

this is not specified as benign or malignant in the diagnosis or medical record

how many columns are there in the neoplasm table?


Malignant -Neoplasm

further classified as to primary, secondary, or carcinoma in situ

Primary Malignancy -Neoplasm

the original cancer site

Secondary Malignancy -Neoplasm

cancer that has metastasized (SPREAD) to a secondary site either adjacent or remote region of the body

Carcinoma (Ca) in situ -Neoplasm

cancer that is localized and has not spread to adjacent tissues or distant parts of the body

Benign -Neoplasm

noninvasive, non-spreading, nonmalignant

Uncertain Behavior -Neoplasm

uncertain wether benign or malignant; border line malignancy

Unspecified Nature -Neoplasm

a neoplasm is identified; however no nature of the tumor is documented in the diagnosis or medical record

what are the 3 sections of the alphabetic index?

section 1: index to diseases, section 2: table of drugs and chemicals, section 3: index to external xauses of injury (E codes)

what is CPT?

current procedural terminology

define: Stand Alone Codes

contain the full description of the procedure for the code

define: Indented Codes

these are codes listed under associated stand-alone codes.

define: Add-On codes

used for procedures that is always performed during the same operative session as another surgery in addition to the primary service/procedure and is NEVER PERFORMED SEPERATELY

define: Modifiers

provide the means by which the reporting physician can indicate that a service or procedure that has been performed has been altered by some specific circumstance but not changed in its definition or code

what does a triangle represent?

a change in the code description since the last edition.

what does 2 triangle symbols represent?

changes in the text or definition between the triangles

what does a bullet represent?

a new procedure or service code added since the previous edition of the manual

what does a plus sign represent?

indicates and add-on code

what does a circle with a line through it represent?

exemption from the use of modifier -51

what is (E/M) codes?

Evaluation and Management. they cover physicians services that are performed to determine the best course for patient care.

what is CC?

chief complaint

what is HPI?

History of Present Illness

what is ROS?

Review Of Systems

what is PFSH?

Past Family and Social History

what is another word for Surgical Package?

global surgery... includes a variety of services rendered by a surgeon

define: Policyholder

one who purchases the contract

define: Insurance Carrier

one who provides the benefits plan or a gvt program developed to reimburse the policyholder of all or most medical expenses

define: Group Insurance

when a group of employees and their dependents are insured under 1 group policy issued to the employer

define: Personal Insurance

an insurance plan issued to an indivisual

define: Pre-paid Health Plan

pre-determined set of benefits covered under one set annual fee

define: Indemnity Insurance

also known as fee for service

define: Health Maintenance Organization (HMO)

a managed care benefits plan that provides a wide range of medical services to indivisuals that have been enrolled into the program. LOW COST

define: Preffered Provider Organization (PPO)

similar to HMO. PPO's charge a higher premium than HMO's in the exchange for more flexability and more options for the beneficiaries

define: Point-of-Service Plan (POS)

a managed care plan that gives beneficiaries the option whom to see for services.

define: fee schedule

a list of charges for services performed

what is Medicare's Resource Based Relative Value Scales (RBRVS) Payment Schedule

under this schedule, a procedures relative value is the sum total of three elements: 1-work 2-overhead 3-malpractice

how much does medicare pay?


what does the beneficiary pay?

deductible, premium, 20% coinsurance, non-covered services

define: Medicare

the federal gvts health insurance program created by the Social Security Act of 1965 titled Health insurance for the aged and disabled. it is run by the CMS

Centers for Medicare and Medicaid Services (CMS) was previously known as what?

Health Care Financing Administration (HCFA)

how many parts does medicare have?


what is part A in Medicare?

hospital insurance for the aged and disabled

what is part B in Medicare?

Supplementary Medical Insurance (SMI)

what is part C in Medicare?

Medicare Managed Care Plans

what is part D in Medicare?

Prescription Drugs

define: Clean Claim

accurately filled out, contains no deficiencies and passes all edits

define: Dirty Claim

contains errors

define: Invalid Claim

contains complete, necessary information but is incorrect in some way

define: Rejected Claim

requires investigation and needs further clarification

define: Medigap

pays for medical services and items that medicare does not cover

define: Medicaid

a federal program administered by state governments to provide medical assistance to the needy

define: Workers Compensation

state required insurance plan, the coverage of which provides benefits to employees and dependents for work related injury, illness, or death

define: Disability Insurance

reimbursement for income lost as a result of a temporary or permanent illness or injury

define: Liability Insurance

a policy that covers losses to a third party caused by the insured, by an object owned by the insured, or on premises owned by the insured.

define: TRICARE

a regionally managed health care program for ACTIVE duty and RETIRED members of the armed forces, their families, and survivors

what does CHAMPVA ctand for?

Civilian Health and Medical Program of the Veteran Affairs

define: CHAMPVA

created to provide medical benefits to spouses and children of benefits

what is the Gender Rule?

male of house hold is primary payer

Waht is the birthday rule?

who evers b-day is first is primary

define: Blue Cross

covers hospital services, outpatient care, some institutional services, and home care

define: Blue Shield

covers physician services, and in some cases, dental, outpatient services and vision care

define: Clearinghouse

an entity that recieves transmissions of claims from physicians offices, seperates the claims by carriers and performs software edits on each claim to check for errors.

What are blocks 1-13 in the CMS-1500 referring to?

patient Information

what are blocks 14-33 in the CMS-1500 referring to?

physician information

what is the life cycle of an insurance claim?

1-claims submission 2-claims processing 3-claims adjudicatin 4-Payment

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