CDEO Study Guide (Latest 2023 – 2024) Verified Content, Exams of Health sciences

Download CDEO Study Guide (Latest 2023 – 2024) Verified Content and more Exams Health sciences in PDF only on Docsity! CDEO Study Guide (Latest 2023 – 2024) Verified Content Congestive Heart Failure - A chronic condition in which the heart doesn't pump blood as well as it should. Hypertension - A condition in which the force of the blood against the artery walls is too high HEDIS - Healthcare Effectiveness Data and Information Set HIPAA - Health Insurance Portability and Accountability Act MPFS - Medicare National Physician Fee Schedule Multiple procedure rule - The highest value code is paid at 100%. The second highest value code is paid at 50%. Each additional code is paid at 25%. Add on codes are exempt from the multiple procedure rule. They are paid at 100%. Bullet symbol - Indicates new procedures and services added to the CPT book. Triangle symbol - Indicates that the description of the code has been revised Opposing horizontal triangles - Indicates new and revised text, other than in procedure descriptors Forbidden symbol - Identifies codes that are modifier 51 exempt and exempt from the multiple procedure rule Bull's-eye symbol - Identifies codes that include moderate sedation. When this is located next to a code, moderate sedation can not be reported separately. Unlisted procedure code - These are reported when an existing CPT code does not describe the procedure. To facilitate these claims, provide the operative report and suggest an appropriate fee. Chief complaint - The reason for the encounter. A CC is required for every encounter except a preventive service. If the CC is missing, you are to report CPT code 99499: Unlisted E&M service. "Follow up" can not be the reason for the visit. HPI - Description of the development of the patient's illness from the list of signs or symptoms, or from the previous encounter, to the present. The provider must document the HPI. There are 8 elements of the HPI. Location - Anatomical place, position, or site of the chief complaint. Quality - Characteristics about the problem, such as how it looks or feels. Severity - A degree or measurement of how bad it is. Duration - How long the chief complaint has been occurring, or the time when the complaint occurred, Timing - Measurement of when or at what frequency they noticed the complaint. Context - What the patient was doing, their environmental factors, the circumstances surrounding the complaint. Modifying factors - Anything that makes the problem better or worse Associated signs and symptoms - Associated secondary complaints. Three chronic conditions - The HPI can also be calculated based on documentation of the status of three chronic or inactive conditions ROS- Review of Symptoms - An account of the body systems obtained through a series of questions seeking to spot signs or symptoms the patient may be experiencing. This can be documented by the provider or staff. Fraud - CMS defines as making false statements or misrepresenting facts to obtain an underserved benefit or payment from a federal healthcare program. Examples on page 3 of study guide Abuse - CMS defines as an action act results in unnecessary costs to a federal healthcare program, either directly or indirectly. Examples on page 3 of study guide Federal False Claims Act (FCA) - SEE PAGE 3 STUDY GUIDE FOR A-G QUALIFICATIONS **(page 4, first full paragraph states: the FCA is violated by submitting a false claim with knowledge that it is false; however, the act states that a violation may occur even if here is not intent to defraud). DOES NOT apply to claims, records, or statements made under the IRS code of 1986. Reverse Federal False Claims Act - The final section (a.1.G) of the Federal False Claims Act, it provides liability where a person acts improperly to avoid paying money owed to the government. Examples are given on page 3 of study guide. Physician Self-Referral law AKA-Stark Law - Also known as he Stark Law; bans physicians from referring patients for certain services to entities in which the physician or an immediate family member has a direct or indirect financial relationships. These are designated as self-referrals. The Stark Law also bans the OIG Work Plan - This plan lists various projects that will be addressed during the fiscal year. These projects that will be undertaken by: 1. Office of Audit Services, 2. Office of Evaluation and Inspections, 3. Office of Investigations, 4. Office of Counsel to the Inspector General. It summarizes new AND ongoing reviews and activities that OIG plans to pursue during the next fiscal year and beyond. How the OIG chooses topics for the Workplan - Addresses the following: 1. Relative risks in the programs it oversees 2. Identifies areas most in need of attention 3. Setting priorities for the sequence and proportion of resources to be allocated **Each project will list the current focus area and state the primary objective of the review. The word "NEW" after a review title indicates that the review was not included in the previous Work Plan. Corporate Integrity Agreements (CIA) - The OIG will require this as a condition of NOT seeking exclusion from participation when an individual or entity seeks to settle civil healthcare fraud cases. This will last 5 years, BUT can be longer. Most of these agreements have core requirements (THESE CAN BE FOUND ON PAGE 8 OF STUDY GUIDE). Independent Review Organization (IRO) - THIRD PARTY medical review resource that provides objective, unbiased audits and reports when investigating CIAs for the OIG Discovery Sample - 50 sampling units randomly selected to review for a CIA claims review. Used to determine the net financial error rate. If error rate exceeds 5%, a Full Sample must be reviewed, along with a Systems Review. Certificate of Compliance Agreement (CCA) - A letter certifying that a provider will continue to operate its existing compliance programs and to report to the OIG for a LESSER PERIOD of time, which is usually THREE (3) YEARS. Compliance Plans - Represents comprehensive documentation that a provider, practice, facility, or other healthcare entity is taking steps to adhere to the federal and state laws that affect it. ***7 Mandatory Elements located on PAGE 9 of Study Guide) Compliance Plan Guidance (CPG) - Developed by the OIG for a variety of healthcare settings, they provide a comprehensive framework, standards, and principles by which an effective internal compliance program may be established and maintained. Issued for individual and small group physician practices in the Federal Register on October 5, 2000 (BENEFITS and RISKS listed on pages 10 and 11 in study guide) 4 Additional risk areas for physicians are listed in the APPENDIX. Affordable Care Act of 2010 - Makes compliance programs mandatory for providers and other healthcare providers who offer services and procedures to Medicare and Medicaid patients. Health Care Financing Administration (HCFA) - Established in 1977 to administer the Medicare and Medicaid programs. Renamed the Centers for Medicare and Medicaid (CMS) in 2001, it is the largest agency within the Department of Health an Human Services (HHS). Centers for Medicare and Medicaid (CMS) - Administers Medicare, Medicaid, and the Children's Health Insurance Program (CHIP) Internet Only Manual (IOM) - Originally paper-based, the CMS manual is offered online. Conditions of Participation (CoP)/Conditions for Coverage (CfC) - Standards set forth in the Federal Register that must be met in order to participate in Medicare and Medicaid Programs, they include: Ambulatory Surgical Centers (ASCs), Critical Access Hospitals (CAHs), Hospitals, and Medical Records. ASC - Ambulatory Surgical Centers CAH - Critical Access Hospitals NCCI - National Correct Coding Initiative ---Implemented by CMS to promote correct coding methodologies AND to control improper assignment of codes that results in inappropriate reimbursement. CCM - Correct Coding Modifier--a "carrier only" indicator for both the Comprehensive/Component Table. This indicator determines whether a CCM causes the code pair to bypass the edit. Internal Audit - Performed by members of the organization. Periodic internal audits may be conducted by coding staff trained in auditing for coding and compliance . At minimum, internal audit should be conducted annually. External Audit - Performed by an individual or group not a part of the organization or the practice. Provides framework for developing a remedy for isolated users. May be more objective than internal audits. Typically conducts baselines audits for each practitioner. Should be 10-15 records per practitioner and include a random sampling of E&M levels and/or surgical procedures. 0 - A CCM is not allowed and will not bypass the edits 1 - A CCM is allowed and will bypass the edits Prospective Audit - Performed prior to claim submission so that variances of coding may be corrected prior to claim submission. When this type is performed, it must be done in a timely manner to avoids delays in submission. Retrospective Audit - Performed on claims that have already been submitted for payment. If variances are found, decisions must be made concerning potential corrections, including refunding of overpayments. An auditor reviews the record documentation, encounter form, claim form, EOB and/or RA, and the payer policies to determine if and where there are errors in the process. Focused Audit - Looks at one item, one type of service, or on provider. MUE - Medically Unlikely Edit---CMS developed the edits to help reduce the paid claims error rate for Medicare Part B claims. These are defined as the MAXIMUM units of service that a provider would report, under most circumstances, for a single beneficiary, on a single date of service, for a specific HCPCS/CPT code. Scope of the Audit - Determines the range of the activities and the period of records subjected to examination. The Institute of Internal Auditors defines objective and the scope as: Audit objectives represent the high level goals and anticipated accomplishments of the review and address controls and risk associated with the client's activity. The audit's scope defines the parameters to be used toward achieving those objectives. Global Surgery Package - The time, effort, and services required to complete a procedure are bundled together to form a surgery package. Minor surgery has 0-10 global days. Major surgery has 90 global days. Status Indicators - Surgical CPT codes are assigned global surgery status indicators based on risk factors associated with medical procedures. 000, 010, 090, MMM, XXX, YYY, ZZZ. (See pg 47) Modifiers - Indicate that the service or procedure performed has been altered but the definition of the code has not changed. Modifiers can affect reimbursement and, used properly, can break the global package. Random Audit - The selection of medical records will be chosen by chance and each service is as likely to be chosen for audit as any other service. Peer Review - Performed if the clinical decision making is questioned, based on documented exam and treatment plan . 22 - Increased procedural service. Requires more time or effort than is typically required. Must attach documentation when claim is sent.