5 Written questions
5 Matching questions
- Services not Rendered
- NOS - Not Otherwise Specified
- NPI (National Provider Identifier)
- Stark Law
- a The simplest scheme of HC fraud is the billing for services that were never rendered to patients
- b This is a unique identification number for covered health care providers which they use to bill Medicare for their services
- c a physician is prohibited from making any referral to a provider of designated health services if the physician has a "financial relationship" with the provider. a healthcare provider is prohibited from submitting for services rendered to patients referred in violation of the statute
- d using tow codes when a combined code exists
- e Means Unspecified (don't know yet)
Used when the coder does not have enough information to select a more definitive diagnosis (ie. Cultures are pending)
5 Multiple choice questions
- Billing for services not provided or not at the level billed for
False Claims Act- allows individuals to file claims against companies that they think have defrauded the government. More than $17 billion dollars have been recovered by the government since 1987
- used to enclose synonyms, alternative wordings or explanatory phrases
- Procedures in which the follow-up is generally non-existent or varies with the patient's underlying condition
When billing for a starred procedure, the charge does not include any pre or post-operative care
- It's how we get paid.
Avoid denials/delay in payment
Avoid audit by coding properly
Documentation must support code
"If it isn't documented, you didn't do it"
- are placed after an incomplete term which requires one or more of the modifying terms that follow it in order to make the code assignable to a given category.
5 True/False questions
Reflex Testing → Automatically running a test based on a previous test result w/o the MD/PA requesting the second test
Incident To → • A Medicare billing provision that enables services provided by NNPs (non-physician providers) in an office or clinic setting to be reimbursed at 100% of the physician fee schedule by billing using the physician's NPI (otherwise reimbursed 85%)
HCPCS → Pronounced "hick picks"
Health Care Financing Administration's Common Procedural Coding System
HCFA (Health Care Financing Administration) Now CMS (Centers for Medicare and Medicaid Services) was/is the governing agency of Medicare and Medicaid
CPT (Common Procedural Terminology)
National Codes or alpha-numeric codes
Local codes (phased out in 2003)
Modifier 51 → "MULTIPLE PROCEDURES"
List the major procedure first, with the additional lesser procedure(s) secondary with mod 51
For example, if a 100 sq. cm. knee wound is debrided, then reconstructed with a medial gastrocnemius muscle flap and split thickness skin graft, the procedure is reported:
15738 Muscle flap
15000-51 Wound preparation
The major procedure is the muscle flap and the "-51" modifier is not appended to its CPT code. The secondary procedure CPT codes take the "-51" modifier.
Modifiers → 2-digit numeric code
Used to indicate that a procedure has been altered by some specific circumstance, but not changed in its definition