Reimbursement, HIPAA and Compliance Flashcards

Flashcards on Reimbursement, HIPAA, and Compliance in Medical Coding

Reimbursement

The coding system drives .

getting paid

Coding is about statistical purposes, not just .

skews

Incorrect code selection ___ statistical accuracy.

specificity

Coding to the highest ___ improves statistical data.

provider's work

A key responsibility of a coder is optimizing payment for the ___.

increase/decrease

Using modifiers can ___ or ___ payment.

Upcoding

Increasing payment through code manipulation is considered .

abuse

Improper coding, even if due to ignorance, is considered .

The Elderly

is the fastest growing generation.

65 and over

Medicare is the primary insurance for those aged __.

insurance

Medicare changes often influence other companies.

1965

Medicare was established around __.

hospital

Part A of Medicare covers insurance.

supplemental/non-hospital

Part B of Medicare covers services.

Advantage (Part C)

Medicare offers additional coverage for copays.

prescription drugs

Medicare Part D covers .

beneficiaries

Those covered under Medicare are called .

ESRD

stands for End-Stage Renal Disease.

Health and Human Services (HHS)

Medicare is managed by the Department of ___.

Medicare and Medicaid Services

CMS stands for Centers for .

federally

Medicare is funded; Medicaid is state funded.

Administrative Contractors

MAC stands for Medicare .

Social Security

Medicare is funded through tax.

beneficiary

The __ pays 20% of costs plus an annual deductible under Medicare Part B.

medical necessity

Medicare doesn't pay for procedures lacking .

Quality Improvement

QIO stands for Organizations.

patients

QIOs aim to improve quality, timing, and cost of care for Medicare .

beneficiaries

BFCC assists Medicare directly.

Diagnosis Related Groups

MSDRGs stands for Medicare Severity .

A

Diagnosis codes drive reimbursement in Medicare Part __.

UB04

CMS 1450 is also called the form.

semi-private

Medicare Part A covers a - room.

A

Medicare Part B pays for services not covered under Part __.

premium

Under Medicare Part B, beneficiaries pay a monthly .

CM

Coding for Part B uses CPT, HCPCS, and ICD-10 __ codes.

PPOs

Medicare Part C provides Plus Choice programs, like HMOs and __.

prescriptions

Medicare Part D provides coverage for __.

Accountability

HIPAA stands for Health Insurance Portability and Act.

1996

HIPAA was established in __.

privacy/security

HIPAA aims to ease information transfer and maintain .

provider

NPI is the national identifier.

Federal Register

The publishes laws governing HIPAA.

RBRVS

Outpatient resources are based on a relative value scale called .

1992

Physician payment reform was implemented in __.

RBRVS

The national fee schedule replaced the .

Value

RVU stands for Relative __ Unit.

Conversion

CF stands for Factor.

Index

GPCI stands for Geographic Practice Cost __.

Allowance

MAAC stands for Maximum Actual __ Charge.

Fraud

is intentional deception.

Abuse

is often due to ignorance, not intentional.

signature

Services and charges lacking a patient's are problematic.

Inspector

OIG stands for Office of the __ General.

necessity

Lack of medical is common in abuse cases.

common sense

The best way to protect yourself is to use .

Abuse

reviews involve checking the propriety or medical necessity of service.

Fraud

reviews determine whether billed services are furnished .

Kickbacks

are ultimately bribes.

Healthcare

Managed Care organizations are responsible for service for groups as well as a person.

Preferred Provider Organization

A _ _ is allowing in and out of network groups.

Health Maintenance Organization

A _ _ is a total package healthcare.

reimbursement

Coding systems ultimately drive for services rendered by healthcare providers.

statistical

Accurate coding data assist in the aspects and change the future of procedures and policies surrounding disease processes.

payment

Your role is to assist with the statistical aspects of coding and optimizing the for the work the provider is doing.

Modifiers

are used to ensure that codes are accurately assigned based on documentation and can either increase or decrease reimbursement.

Upcoding maximizing

is never appropriate even done of out ignorance.

elderly

The is the fastest growing patient population segment, and its growth impacts coding and the medical field.

Medicare

When someone turns 65 they go on .

largest

Medicare is the insurance carrier and drives changes that other insurances eventually follow.

A/B

Medicare was established in 1965 and originally had two main parts, being part ____ and part ____.

False

Medicare is only for people 65 and older.

HHS or DHHS/CMS

Managing medicare is ran through the and through .

True

If i live in Texas, my medicaid will be different from someone in Florida.

Social Security Tax

Medicare is funded from the ___ ___ ___.

Part B

Which part of medicare is the beneficiary responsible for %20 of the costs for plus an annual deducible?

True

You will not have to pay for medical necessary items under medicare.

QIO

are a way to get consumers, patients, physicians, hospitals, and other caregivers to improve quality in healthcare.

CMS 1450 or UB04 form

What form is used for the hospital when they submit charges for everything that happened to the patient?

Diagnoses

In Medicare A the _ drives reimbursement.

Medicare Severity Diagnosis Related Groups

MSDRGs are used to determine costs, what does the abbreviation stand for?

True

Even if you have a family history with diabetes, part A still covers you.

False

Medicare typically pays for personal convenience items in the hospital.

Premium

With part B you purchase and pay a monthly _

B

CPT and HCPCS codes are used in which part of Medicare?

ICD-10 CM / CPT/ HCPCS

Inpatient coding uses codes only, while oupatient uses _ and __.

C

Medicare _ allows you to choose Medicare plus choice programs.

True

Medicare part D began in 2006, and it mainly assists in prescription drug coverage.

True

Transferring medical records was addressed by HIPAA around 1996.

HIPAA

stands for health information portability accountability act .

HIPAA/Fraud/Compliance laws

The federal register publishes all things compliance, including _ ,, and __.

Change fee schedules

For outpatient and outpatient facilities changes, November and December is when they .

Resource Based Relative Value Scale

RBRVS stands for?

Work and Skill required / Overhead / Malpractice insurance

What are the major components to RVUs?

Pay Scale

GPCI is the geographic practice cost index used to determine the by state rather than specific locations .

Billions

How many billions of dollars a year are lost due to fraudulent actions in Medicare and medicaid?

True

CMS focuses on Medicare fraud and abuse.

True

CMS does not work with kickbacks and bundling services.

Inspector General

The OIG stands for the office of the _ _.

Truthful / accurate / ask questions

The best way of protecting yourself is to be , , and _.

One organizations

Managed care offers services under _ _.