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Chapter 10 Coding for Medical Necessity
reviewing and studying
Terms in this set (37)
Advance Beneficiary Notice
is a form that a patient signs and is responsible for paying the bill if the Medicare denies the claim. Medicare patients need to sign this when it is felt Medicare may not pay for the service and the patient would be responsible for the bill.
Contains the diagnositc statement and may include the physician's rationale for the diagnosis.
Review of patient records and CMS-1500 (UB-04) claims to assess coding accuracy and whether documentation is complete.
Local Coverage Determination
Formerly called local medical review policy (LMRP); Medicare administrative contractors create edits for national coverage determination rules that are called LCDs.
A particular diagnosis (e.g., hypertension) may not receive direct treatment during an office visit, but the provider has to consider that diagnosis when considering treatment for other conditions.
Medicare Coverage Database
Used by Medicare administrative contractors, providers, and other healthcare industry professionals to determine whether a procedure or service is reasonable and necessary for the diagnosis or treatment of an illness or injury; contains national coverage determinations (NCDs), including draft policies and proposed decisions; local coverage determinations (LCDs), including policy articles; and national coverage analyses (NCAs), coding analyses for labs (CALs), Medicare Evidence Development & Coverage Advisory Committee (MedCAC) proceedings, and Medicare coverage guidance documents.
Narrative Clinic Note
Using paragraph format to document health care.
National Coverage Determination
Rules developed by CMS that specify under what clinical circumstances a service or procedure is covered (including clinical circumstances considered reasonable and necessary) and correctly coded; Medicare administrative contractors create edits for NCD rules, called local coverage determinations (LCDs).
Documentation of measurable or objective observations made during physical examination and diagnostic testing.
Varies from a short narrative description of a minor procedure that is performed in the physician's office to a more formal report dictated by the surgeon in a format required by the hospitals and ambulatory surgical centers (ASCs).
Outpatient Code Editor
Software that edits outpatient claims submitted by hospitals, community mental health centers, comphrehensive outpatient rehabilitation facilities, and home health agencies; the software reviews submissions for coding validity (e.g., missing fifth digits) and coverage (e.g., medical necessity); OCE edits result in one of the following dispositions: rejection, denial, return to provider (RTP), or suspension.
Statement of the physician's future plans for the work-up and medical management of the case.
Outline format for documenting health care; "SOAP" is an acronym derived from the first letter of the headings used in the note: Subjective, Objective, Assessment, and Plan.
Part of the note that contains the chief complaint and the patient's description of the presenting problem.
Veteran's Health Information System and Technology Architecture. VistA electronic health record was developed by the U.S. Department of Veterans Affairs.
Is it recommended that an authentication legend be generated?
Yes, it is recommended that an authentication legend be generated when the procedure is completed.
What is require by Medicare?
a waiver is require for all outpatient and physician office procedures not covered by Medicare (ABN).
What information is needed by hospitals and ambulatory surgical centers?
information is date of surgery, patient i.d., pre and post-op diagnosis, list of procedures performed, and names of primary and secondary surgeons.
What is the primary purpose?
is of the patient record is to provide continuity of care.
What has to be linked?
the diagnosis with the procedure/service is to prove medical necessity.
Why is the patient record important?
important to the health care facility because it contains documenation of all health care services provided to the patient and supports the following: diagnosis, justifies treatment, and records treatment results.
Medical Managed Diagnoses
are also known as secondary diagnosis or coexisting diagnosis. may or may not receive treatment during an encounter.
Should highlighter or other marker be used on original documents?
No, you never use highlighter or other marker on original documents to ensure accracy when coding case reports.
are used to select procedures, services, and supplies provided to hospital emergency department patients and outpatients.
How many diagnoses can be reported on the CMS-1500 form in block 21?
Up to 4 diagnoses
What must patient record documentation justify?
must justify and support the medical necessity of procedures and services reported to payers.
What does a health specialist review?
it reviews the patient record when assigning codes to diagnoses, procedures, and services.
What does patient record serve as?
the business record for a patient encounter and is maintained in a paper or automated format.
How many majors does health care providers use?
use two major formats for documenting clinic notes.
What type of form is a CMS-1500?
it is a outpatient claim form.
How many locations are diagnostic test results documented?
Global Surgery Period
includes the preoperative assessment, surgery, and postoperative care.
What does diagnosis or condition code have to be linked to?
linked with each procedure or service code on the CMS-1500 claim.
contains an E/M CodeBuilder that can be used to audit patient record documenation to ensure that codes submitted to payers are arrcurate.
What is requested by third-party payers?
the copies of reports for the patient reocrd to process insurance claims.
What are commonly used by providers?
abbreviations are commonly used by providers when documenting patient care.
What has the Joint Commission implemented?
a patient safety goal to help reduce the numbers of medical errors related to incorrect use of terminology. to facilitate compliance with the goal, the Joint Commission issued a list of abbreviations, acronyms, and symbols that should no longer be used by providers.
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