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192 terms

CBCS Study Guide

STUDY
PLAY
When was the Health Information and Accountability Act (HIPAA) created?
1996
What are Medical Ethics?
Standards of conduct based on moral principals.
What are the two provisions of HIPPA?
1. Insurance Reform
2. Administrative Simplification
What is the False Claims Act (FCA)
A Federal law that prohibits submitting a false claim or making a false statement or representation in connection with a claim.
What is the National Correct Coding Initiative (NCCI)?
Initiative developed by CMS to promote national correct coding methods and control improper coding that leads to wrong payments of Part B health claims.
What are the two types of edits that the NCCI implements?
1. Column 1/ Column 2; identified unbundled codes.
2. Mutually Exclusive Edits: Codes that are unlikely to be performed on the same patient in the same day.
Who investigates and prosecutes Health Care fraud?
Office of Inspector General (OIG)
When can a provider share PHI without specific permission from the patient?
1. For treatment (discussing the case with another professional)
2.Payment (When providers submit claims on the patient's behalf).
3. Operations: Staff training and Quality Improvement.
What is Employer Liability?
Physicians are legally responsible for their actions and their employee's actions. a.k.a Respondant Superior. (Let the master answer.)
What is Employee Liability Insurance?
Protection against loss of money caused by failure through error or unintentional omission of the individual or service submitting the claim.
What is in a Medical Record?
-Social and Medical History
-Family History
-Physical Exam Findings
-Progress Notes
-Lab/Rad Results
-Consultation Reports
-Correspondence to the patient
When billing an insurance company, what information must be included?
-Date of Service (DOS)
-Place of Service (POS)
-Type of Service (TOS)
-Diagnosis
-Procedure(s)
How long should Medical Records be retained?
Governed by State and Local laws; should be retained indefinitely. For deceased patients, they should be kept at least 5 years.
-algia
Pain
-emia
Blood Condition
-itis
Inflammation
-megaly
-Enlargement
-meter
Measure
-oma
Mass
-osis
Abnormal condition
-pathy
Disease Condition
-rrhagia
Bursting forth blood
-rrhea
Discharge, Flow
-sclerosis
Hardening
-scopy
To view
-centisis
Surgical Puncture
-ectomy
Removal, Excision, Resection
-gram
Record
-lysis
Separation, Breakdown
-pexy
Surgical Fixation
-plasty
Surgical Repair
-rrhaphy
Suture
-scopy
Visual Examination
-stomy
Opening
-therapy
Treatment
-tomy
To cut into
a, an
Without
ante-
before
anti-
Against
brady-
Slow
dys-
Painful, difficult
endo-
Within
epi-
Above
ex-
out, out of
hemi-
Half
Hypo-
Below, deficient
Infra-
Below
inter-
Between
neo-
New
oglio-
Little, scanty
pan-
All
para-
Beside
per-
Through
poly-
Many
pre-
Before, in front of
pseudo-
False
sub-
Under
supra-
Above
tetra-
Four
arth/
cartilage
cephal/
head
cardi/
heart
cholecyst/
gall bladder
chondro/
cartilage
colp/
vagina
derm/
skin
enter/
intestine
episi/
vulva
gastro/
stomach
gloss/
tongue
hepato/
liver
hyster/
uteris
lapar/
abdomen
lact/
milk
lith/
stone
mast/
breast
myo/
muscle
nat/
birth
oophor
ovary
oste/
bone
pneum/
lung
rhin/
nose
salping/
fallopian tubes
stomat/
mouth
Anterior/Ventral
Front part of the body.
Posterior/Dorsal
Back part of the body.
Proximal
Near the point of attachment to the trunk.
Distal
Far from the point of attachment of the trunk.
Medial
Middle of the body.
Lateral
Side
Frontal, Coronal
Vertical plane dividing the body into Anterior and Posterior sections.
Sagittal
Vertical plane dividing the body to the left and the right sides.
Transverse/Cross Sectional
Horizontal plane dividing the upper and lower parts of the body.
What are the 2 types of glands on the skin?
1. Sebaceous (oil) glands
2. Suddiferous (sweat) glands
What are the 3 layers of skin?
1. Epidermis (Top layer)
2. Dermis (Middle layer)
3. Subcutaneous Layer
What is hair made of?
Karatin
What is the moon like white area at the base of the nail called?
Lunula
What are the 2 types of sweat glands?
1. Eccrine (secrete odor)
2. Apocrine (odorless sweat)
What hormones do the adrenal glands secrete?
Epinephrine and Steriods
Collagen
Structural protein found in skin and connective tissue.
Melanin
major skin pigment
Lipocyte
Fat cell
Macule
discolored, flat lesion
Vesicle
small collection of clear fluid; blister
Wheal
smooth, slightly elevated swollen area that is redder or paler than the surrounding skin
Alopecia
Absence of hair
Gangrene
Death of tissue due to loss of blood supply
Impetigo
Bacterial inflammatory skin disease with lesions, pustules and vesicles
Multigravida
A pregnant woman who has had at least one pregnancy.
What are bones connected together with?
fibrous bands of ligaments
What are bones made of?
Osseous
What are the insides of bones comprised of?
hematopoietic tissue
How are bones categorized?
The Axial Skeleton and the Appendicular Skeleton
What is the Axial Skeleton comprised of?
Skull, Ribcage and Spine.
What is the Appendicular Skeleton comprised of?
Shoulder, collar, pelvic, arms and legs.
Long Bones
Strong, broad and have large surfaces for muscles to attach to.
Short Bones
Small with irregular shapes (ie wrist and ankle)
Flat Bones
Bones covering body parts (ie shoulder blades, ribs, pelvic bones)
Sesamoid Bones
Small, rounded bones that resemble sesame seeds that are found near joints. (ie knee cap)
Frontal Bone
Forms the front part of the skull and the forehead.
Parietal Bones
Forms the sides of the cranium
Occipital Bone
Forms the back of the skull
Temporal Bones
Forms the two lower sides of the cranium
Ethmoid Bone
Forms the roof of the nasal cavity
Sphenoid Bones
In front of the temporal bones
Zygoma
Cheek Bone
Lacrimal Bones
Bones at the corner of each eye that cradle the tearducts
Maxilla
Upper Jawbone
Mandible
Lower Jawbone
Vomer
Bone that forms the wall between the nostrils
Palatine Bones
Upper roof of the mouth
Inferior nasal conchae
Interior of the nose
How many regions is the spinal/vertebral column divided into?
5
How many bones are in the spine?
26
What are the 5 regions of the spine?
1. Cervical
2. Thoracic
3.Lumbar
4. Sacral
5. Coccygeal
Cervical
Neck Bones
Thoracic
Upper Back
Lumbar
Lower Back
Sacral
Sacrum
Coccygeal
Coccyx (Tailbone)
Humerus
Upper Arm bone
Ulna
Lower medial arm bone
Radius
Lower arm bone in line with the thumb
Carpals
Wrist bones
Metacarpals
Bones the palm of the hand
Phalanges
Finger Bones
Tibia
Shin
Fibula
Smaller, lateral leg bone
Malleolus
Ankle
Tarsal
Hind foot bone
Metatarsal
Middle of the foot bone
Phalanx
Toe Bones
What are synovial joints?
Free moving joints that are surrounded by joint capsules.
What are bursae?
Sacs of fluid located in-between the bones of the joint and tendons that hold the muscles into place.
Abduction
Movement away from the midline
Adduction
Movement toward the midline
Supination
Turning the palm or foot upward
Eversion
Turning Outward
Inversion
Turning Inward
Protraction
Moving forward
Retraction
Moving backward
What is a Comminuted Fracture?
The bone is crushed or shattered.
What is a compression fracture?
The fractured area of the bone collapses on itself.
What is a Colles Fracture?
A break at the distal end of the bone, usually when someone tries to break their fall.
What is a Complicated Fracture?
The bone is broken and pierces an organ.
How many volumes is the ICD-9 manual divided into?
1. Volume 1; Tabular List
2. Volume 2; Diseases, Alphabetic Index
3. Volume 3; Procedures, tabular list and index
When are V codes used?
-When a person who is not sick/injured seeks health services for a specific thing (immunizations, organ donors)
-When a person with a chronic condition presents for specific treatment of that condition (diabtetes)
-When a circumstance influences the patients health status, but is not a current illness (family history)
-Birth status of a newborn
When are E codes used?
In the cause of injury, poisoning, accidents or other adverse effects.
How many digits does an ICD-9 Category code have?
3 (ex 311)
How many digits does an ICD-9 Subcategory code have?
4. (ex 311.0)
How many digits does an ICD-9 Subclassification code have?
5. (ex 311.56)
What are the 3 classifications of Hypertension?
1. Malignant (Accelerated and severe)
2. Benign (Mild or controlled)
3. Unspecified (Not specified in the Medical Record)
What is primary malignancy?
The original cancer site. Malignant tumores are considered primary unless documented as secondary or metastatic.
What is secondary malignancy?
Cancer that has spread to a secondary site.
What is Carcinoma in situ?
Cancer that has localized and not spread at all.
What is Benign?
Noninvasive, non-spreading, nonmalignant.
Who developed HCPCs codes?
CMS
What does a triangle in the CPT book next to a code mean?
A change in the code description since the last edition.
What does a bullet in the CPT code book next to a code mean?
A new procedure or service since the previous edition.
What are the key components of E/M?
1. History
-Chief complaint
-History of Present illness
-Review of Symptoms
-Past, Family and Social History
2. Physical Exam
3.Medical Decision Making Complexity
What does a Surgical Package (aka Global Surgery) include?
-Surgical Procedure Performed
-Local infiltration/metatarsal/digit block/anesthesia
-Pre-Op E/M services on day before surgery
-Immediate Post-Op care
-Normal, uncomplicated Post-Op care
How is Usual, Customary and Reasonable pricing calculated?
1. The provider's usual charge for the service
2. The average charge of all the other providers in the same geographical area
3. The actual charge submitted on the claim

The lowest amount is used as basis for the payment.
How is Medicare's RBRVS calculated?
1. The amount of time, intensity of effort and medical skill required for the service
2.Overhead; the practice costs related to performing the service
3. Cost of Medical Malpractice insurance
Who does TRICARE cover?
Active, retired, survivors and their families of the Armed Forces.
What is CHAMPVA
Provides medical benefits to spouses and children of veterans with total, permanent, service related disabilities- or have died.
Can you have TRICARE and CHAMPVA at the same time?
No.
What is the name of the claim form that is standard for submitting claims?
CMS-1500
How is the Patients DOB entered on the claim form?
MM/DD/YY
What is Assignment of Benefits?
Reimbursement is sent directly from payer to the provider.
What is Fiscal Intermediary?
An insurance company that bids for a contract with CMS to handle the Medicare program in a specific area.
What is a Qualified Diagnosis
A working diagnosis that has not yet been established.
What is the Civil Monetary Penalties Law (CMPL)?
A law passed by the Federal Government to prosecute cases of Medicaid fraud.