Insurance Billing and Coding FINAL EXAM

In the healthcare profession, there is a recognized process of transforming verbal descriptions of a patients disease process, disorder, or injury into universal numeric or alphanumeric formats is known as __________

Coding

The main purposed for medical coding are: Optimizing _________________, ensuring the ___________________, and makes it __________________

reimbursement for the provider, insurance carrier accepts the claim, easier to collect the data

The presence of an illness of disease

morbidity

deaths that occur from a disease

mortality

Determination of the nature of a cause of a disease and the art of distinguishing one disease from another is known as

diagnosis

The book used for diagnosis coding in the medical office in the United States today

ICD-10-CM

ICD-10-CM stands for

International Classification of Diseases 10th revision, Clinical Modification

The new compliance date for ICD-10-CM

October 1, 2015

ICD-10-CM for diagnosis coding

used in all healthcare settings, physicians offices and outpatient clinics

How many chapters are in the tabular list?

21

ICD-10-CM code structure: includes an alphabetic list of_________________________________

terms and corresponding codes

ICD-10-CM code structure: includes a tabular list of

codes divided into chapters based on body system/condition

Uses placeholder “___” for future expansion

x

First character for ICD-10-CM codes is always a ________

letter

All letters of the alphabet are used except for ____

U

Main term for “Acute depressive reaction”

reaction

adjectives (oftentimes the name of the person who first discovered the disease or used the instrument) used to describe specific operations, surgical instruments, diseases and parts of the anatomy

eponym

Used when an individual who is not currently sick visits the medical facility for a specific purpose

Z codes

Note: _______ code from the alphabetic index alone

never

ICD codes have a minimum of ____ characters and a maximum of ___ characters

3, 7

A code is _____ if it has not been coded to the full number of characters required. Choosing the most specific code means coding only what is known to be a fact and documented in the health record

invalid

Essential steps to diagnostic coding

locate the diagnosis in the patients chart, determine the main term, find the main term in the alphabetic index then verify in the tabular index, cross reference the code found in the alphabetic index to the tabular list

Tabular list - format and structure of codes - codes are listed

alphanumerically

itis

inflammation

nephr

kidney

neo

new

cost/o

rib

glyco

sugar

-ectomy

surgical removal

supra

above

hypertension

high blood pressure

ICD-10-CM and CPT-4 are updated

yearly

ICD codes for

diagnosis

CPT codes for

procedures

Chief complaint

main reason for visit

CPT-4 stands for

Physicians’ Current Procedural Terminology, 4th Edition

CPT is a manual containing a list of descriptive terms and identifying codes used in reporting:

medical services, procedures performed, supplies used in the care and treatment of patients

HCPCS stands for

Healthcare Common Procedural Coding System

Level I codes used for ________, level II codes used for ___________

outpatient, inpatient

Level I: AMA CPT five-digit codes

5 digit codes accompanied by descriptive terms and used for reporting services performed by healthcare professionals

Evaluation/Management

first section that you see in a CPT book

The CPT Manual - Anesthesiology

the physical status modifier indicates the patients condition prior to the administration of anesthesia

Organization of the CPT Manual (6 main sections of CPT Coding)

E/M, Anesthesiology, Surgery, Radiology, Pathology/Laboratory, Medicine

Evaluation and Management - This section covers the _______________ of ___________. It includes ________, ___________, and other types of ___________

assessment and management, patient care, office visits, consultations, patient encounters

A doctor conducting a routine check-up would use codes from this section to bill their services

Evaluation and Management

Anesthesiology - this section focuses on the _______ of _________ and the _________________

administration, anesthesia, services related to it

When a patient undergoes surgery and receives anesthesia, the anesthesiologist uses codes from this section to document their work

Anesthesiology

Surgery - this section encompasses a wide range of _______, from minor to major _________

surgical procedures, operations

Codes for appendectomies or heart surgeries can be found here, detailing the specific procedures performed

Surgery

Radiology (including nuclear medicine and ultrasound) - this section includes _________ such as ____, ____, and __________, along with __________

imaging services, X-rays, MRIs, ultrasounds, nuclear medicine procedures

If a patient has a CT scan, the healthcare provider will use codes from this section to bill for that imaging service

Radiology

Pathology and laboratory: this section covers _________ and ______________, including _________ and ________

laboratory tests, pathology services, blood tests, biopsies

When a lab processes blood work for cholesterol levels, it uses codes from this section to report the tests performed

Pathology and laboratory

Medicine (except anesthesiology)- This section includes a variety of _____________ and ____________ that do not fall under the other categories, such as ____________ and ________________

medical services, procedures, immunizations, physical therapy

A patient receiving a flu shot would have this service coded from this section

Medicine

Five-digit procedure and services codes are presented in numeric order except for the __________ section

Evaluation and Management Section

E/M codes are presented first - used _______, used by most physicians for reporting _______________, ______________ are three factors to consider for correct E/M code

most often, key categories of their service, place of service, type of service, and patient status

Consultations 2 subheadings

inpatient and outpatient

Modifiers are used to give

additional information about a code

when using multiple modifiers, the first one you use is ____

-99

Physical status modifiers are used when coding _______

anesthesia

Place of service is always #__

11

The first step in using the CPT book is to find the ______ which is the ________

main term, procedure

Main terms can _________ or be followed by up to ______ modifying terms or ________

stand alone, 3, subterms

The semicolon is used to

separate main and subordinate clauses in the code descriptions

A ___________ needs to accompany any rarely used, unusual variable, or new service performed (unlisted procedure)

special report

Two types of CPT codes

Stand alone, indented

Stand alone codes contain the ___________ of the ________ without _________________

full description, procedure, addtional explanation

Indented codes refer to the common _______ of _______ listed in the ___________

portion, procedure, preceding entry

The term used when an insurance company feels the code matches a higher level of service than was given. The code is changed and reimbursement is granted at a lower amount.

Downcoding

called code creep, overcoding and overbilling. ________ involves assigning a code to a procedure that is much higher than the correct code for the true level of service given. _______ can be seen as fraud

Upcoding

5 billing and coding errors

no documentation for services billed, no signature or authentication of documentation, invalid codes billed due to old resources, unbundling of procedure codes, misinterpreted abbreviations, no chief complaint listed for each visit

Information you need to verify insurance coverage

policy number, group number, patient demographics, and insurance provider contact information

Three steps you would take to verify active coverage

Call the Insurance provider. Use the online verification portal, document verification details.

Policy number is

Specific to the individual

Group number indicates

Employer group plan

How would you document this verification in an EHR system?

Note the date, time, verification number ,representative name, coverage status

Types of health Insurance

Indemnity, managed care

Indemnity

Fee for service

Policy holder pays a periodic fee

Premium

Better coverage

Higher premium

Dr accepts insurance (participating provider)

In network

Dr is not a participating provider

Out of network

Three terms for a policy holder

Subscriber, insured, member

Premium (paid by policyholder)- the amount paid ________ to the ________ for ________ AKA the total amount of _______

Periodically, insurance company, health coverage, insurance

Benefits

Payments for medical services

Dependents

Spouse or children of insured

Third-party payer

Health plan

Second party

Doctor

First party

Patient

The _____ carrier is typically called the _______

Insurance, Health plan

Deductible (fixed yearly payment)

What the patient pays out of pocket before the insurance company pays

Coinsurance (% owed after deductible met)

When a patient pays a percentage of their medical expenses. Her insurance pays the remaining percentage

Copayment

Fee at the time of visit

Precertification/preauthorization

Approved documentation

Blue Cross/ Blue Shield is a ____________ or _________ and __________________ that provide _____________ to its ___________

nationwide federation, nonprofit, for-profit service organizations, prepaid healthcare services, subscribers

Private commercial carriers examples

Aetna, Cigna, Travelers, UHC

Medicare was created in _______ by the _________ and is administered by the _________

1965, social security act, centers for Medicare and Medicaid services (CMS)

Medicare provides benefits to individuals ____ years or older and individuals younger than x years of age with _______

65, certain disabilities

Patients who have Medicare part ___ do not _____________ for this coverage

A, pay premiums