NHA cbcs study guide Latest updated 2022, Exams of Health sciences

Download NHA cbcs study guide Latest updated 2022 and more Exams Health sciences in PDF only on Docsity! Medical Ethics Standards of conduct based on moral principles. Generally accepted as a guide for behavior towards patients, physicians, co-workers, the government, and insurance compaines. Compliance Regulations billing-related cases are based on HIPAA and False Claims Act. Health Insurance Portability and Accountability Act of 1996 (HIPPA) Created the Health Care Frad and Abuse Control Prpgram enacted nt check for fraud and abuse in the Medicare and Medicaid programs, and private payers. Two provisions of HIPPA Titile I: Insurance Reform Title II: Administrative Simplification Insurance Reform. -Primary purpose to provide continuous insurance coverage for workers and their dependents when they change or lose their jobs. -Limits the use of preexisting conditions exclusions -Prohibits discrimination for part or present poor health -Guarantees cetraom employees and individuals the right to purchase health insurance coverage after losing a job - Allows renewal of health insurance coverage regardless of an individual's health condition that is covered under the particular policy Administrative Simplification-The goal is to focus on the health care practice setting to reduce administrative cost and burdens. Two parts: 1. Development and implementation of standardized health-related financial and administrative activities electronically. 2. Implementation of privacy and security procedures to prevent the misuse of health information by ensuring confidentiality. False Claim Act (FCA) Federal law that prohibits submittimg a fraudulent claim or making statement or representation in connection with a claim. National Correct Coding Initiative (NCCI) Developed by the CMS to promote national correct coding methodologies and to control improper coding that leads to inappropriate payment of part B health insurance claims. Two type of NCCA edits - 1. Column 1 /Column 2 or Comprehensive Component Edits: identifies code pairs that should not be billed together because one code. Column 1 includes all the services described by another code in Column 2. 2. Mutually Exclusive Edits: identifies code pairs that, for clinical reason, are unlikely to be performed on the same patient on the same day. Office of Inspector General (OIG) Investigates and prosecute health care fraud and abuse. Fraud Knowingly and intentionally deceiving or misrepresenting information that may result in unauthorized benefits. Abuse Defined as incidents or practices, not usually considered fradulaent that are inconsistant with the accepted medical business or fiscal practices in the industry. Patient Confidentiality- All patients have the right to privacy, and all information should remain privileged. Discuss patient information with only the patient's physician or office personnel that need cetain information to do their job. Obtained a signed consent form to release medical infomation to the insurance company or other individual. Under HIPPA Privacy Rule, providers may use patient's Protected Health Information (PHI) without specific authorization for Treatment: primarily for the purpose of discussion fo the patient's case with other providers. Payment: providers submit claims on behalf of patients. Operations: for purposes such as stafff training and quality improvment. Employern Liability 3 sections of Alphabetic index Section 1: Index to Diseases: each term is followed by the code or codes that apply to that term Section 2: Table of Drugs and Chemiclas: contains list of drugs and chemicals with corresponding poisoning codes and E codes. Current Procedural Terminology (CPT) Codes used to report services and procedures by physicians. Published and updated anually by the American Medical Association (AMA) with a new one coming out each November and becoming effective on January 1st of the following calendar year. Category I codes respresent services and procedures widely used by many health care professional in clinical practice in multiple locations and have been approved by the FDA Category II codes supplemental codes used for performance measurements. Category III codes temporary codes for emerging technology, services and procedures. If a Category III code is available, it is reported instead of a Category I unlisted code. stand-alone code contain the full description of the procedure for the code indented codes codes are listed under associated stand-alone codes. To complete the description for indeneted codes, one must refer to the portion of the stand alone code description before the semi-colon add-on codes used for procedures that is always performed during the same operative session as another surgery in addition to the primary service/procedure and is never performed separatley. Never stand alone, they are always reported in addition to a primary procedure code. Modifier -51 (multiple procedures) exempt modifiers provide the means by which the reporting physician can indicate that a service or procedurethat has been performed has been altered by some specific circimstance but not change in its definition or code. A triangle symbol in the CPT manual that represents a change in the code description since the last edition. The change may be minor or significant and it could be and addition, deletion or revision. Two trianguar symbols represents changes in the text or definition between the triangles bullet a new procedure or service code added since the previous edition of the manual a plus sign indicates a add-on codes circle with a line through it Exemption from the use of modifier -51 CPT Modifiers two-digit add- on codes attached to regular codes to tell third party payers of circumstances in which the serices procedures were altered. Listed in Appendix A -24 Unrelated E/M Services by the Same Physician During a Postoperative Period -26 Professional Component -32 Mandated Services -50 Bilateral Procedure -51 Multiple Procedures -58 Staged or Related Procedure or Service by the same Physician during the Postoperative Period -78 Return to Operating Room for a Related Procedure during the Postoperative Period -79 Unrelated Procedure by the Same Physician During the Postoperative Period -90 Reference (Outside) Laboratory -99 Multiple Modifiers Unlisted Procedures considered experimental, newly approved, or seldom used may not be listed in the CPT Manual. Key components of E/M are History, Chief Complaint (CC), History of present illness,(HPI), Review of systems (ROS), Past,family and social history (PFSH), physical examination, Medical decision making complexity -persons 65 years or older, retired on Social Security benefits -those diagnosed with end-stage rental disease (ESRD) -kidney donors to ESRD patients (all expenses related to the kidney trasplantation are covered) Part A- Hospital Insurance for the Aged and Disabled. Covers inpatient, hospice, and home health services, such as: bed patient in the hospital, patient in a psychiatric hospital, bed patient in a nursing facility, patient recieving home health care services, terminally ill patient who has six monts or less to live and needs hospice care, terminally ill patients who needs respite care Part B Supplementary Medical Insurance (SMI). Supplement to Part A., paid through beneficiaries' soc sec benefits. It has an annual deductible and beneficiaries pay 20%. Part C Medicare Managed Care Plan (Formerly Medicare Plus(+) Choice Plan) created to offer a number of healthcare services in available under Part A and Part B. Part D Prescription Drugs Medicare beneficiaries can enroll and have a choice among several plans that offer drug coverage for which they pay a monthly premium. Medicare Claim Status types Clean claim: has all required fields accurately filled out, contains no deficiencies and passes all edits. Dirty Claim: contains errors or omissions, Invalid Claim: contains complete, necessary information, but is incorrect or illogical in some way, Rejected Claim: requires investigation and needs further clarification Advance Beneficiary Notice document provided to a Medicare beneficiary by a provider prior o service being rendered letting the beneficiary knowof his/her responsibility to pay if Medicare denies the claim Medigap or Medicare Supplemental Insurance To pay for medical services and items tha t Medicare does not cober and Medicare's coinsurance and dedutibles, beneficiaries may purchase a supplemental insurance. Private insurance designed to help pay for those amounts that are typically the patient;s responsibility under Medicare. Medicaid federal program administrated by state and governments to provide medical assistance to the needy. Each state sets its own guidelines for eligibility and services. payer of last resort Medicaid workers compensation is a state-required insurance plan, the coverage of which provides benifits to employees and their dependents for work related injury, illness or death disability insurance defined as reimbursement for income lost as a result of a temporary of permanent illness or injury liabiltiy insurance policy that covers losses to a third party caused by the insure, by an object owned by the insured, or on premises owned by the insured Tricare managed health care program fo active duty and retired members of the armed forces, their families, and survivors. Service benefit program that requires no premium. CHAMPVA created to povide medical benefits to spouses and children of veterans with total, permanent service related disabilities or for surviving spouses and children of a veteran who died as a result of service related disability types of claims paper claims or electronic claims through clearhinghouses CMS-1500 Standardized claim form 2 major sections of CMS-1500 Blocks 1-13 patient information Blocks 14-33 refers to physician infromation non-covered benefits is any procedure or service reported on the insurance claim form that is not listed in the payer's master benefit list unauthorized benefits a procedure or service provided without proper authorization or was not covered by a current authorization medically necessity edits -procedure codes match the diagnosis codes -procedures are not elective -procedures are not exeperimental -procedures are essential for treatment -procedures are furnished at an apporiate level accept assignment provider agrees to accept what the insurance comany approves as payment in full for the claim inpatient term used when a patient is admitted to the hospital with the expectation that the patient will stay for a period of 24 hours or more outpatient patient who receives treatment in any of the following setting: physician's office, hospital clinic, emergency department, hospital same-day surgery unit, ambulatory surgical center ( patient is released within 23 hours), hospital admission for observation peer review organization (PRO) state based group pf physicians working under government guideline to review cases and determine their appropriatness and quality of professional care Civil Monetary Penlties Law law passed by the federal government to prosecute cases of Medicaid fraud The Good Samaritan Act developed to protect healthcare professionals from liabiltiy of any civil damages as a result of rendering emergency care remittance advice electronic or paper-based report of payment sent by the payer to the provider Patient Care Partnership (Patient Bill of Rights) developed to promote the interests and well being of patients and residents of the healthcare facility. This bill still has not become law pphysician doctor of medicine or osteopathy, dental medicine, dental surgery, podiatric medicine, optometry, or chiropractice medicine legally authorized to practice by the state in which he/she performs health practitioner includes, but not limited to, physician assistant, cetified nurse-midwife, qualified psychologist, nurse practitioner, clinical social worker, physical therapist, occupational therapist, respiratory therapist, cettfied nurse anesthetist, or any other practitioner as may be specified. group practice group of two or more physicians and non-physician practitioners legally organized in a partnership, professional corporation, foundation, not-for-profit corporation faculty practice plan, or similar association parcticipating physician one who has a contract with a health insuranc plan and accepts whatever the plan pays for procedures or serices rendered nonparticipationg physician one who has no cntract with the health insurance plan HIPAA HEALTH INSURANCE REFORM - TITLE I HIPAA revision that allows employees to continue health coverage, when the leave the job HIPAA HEALTH INSURANCE REFORM - TITLE II HIPAA revision that affects the Biller; Administrative Simplification-electronic transactions, National Identifiers for providers, EDI to secure PHI - HITECH HHS Health and Human Services suffix - ectomy surgical repair (appendectomy) suffix - ostomy create a surgical opening i.e ureterostomy suffix - pexy/pexsis surgical fixation; to hold or fasten together i.e nephropexy suffix - tomy to cut into i.e urethrotomy suffix -centesis to puncture or aspirate i.e. amniocentesis suffix - megaly enlargement m splenomegaly suffix - lysis breakdown or separate such as loss of muscle function suffix- gram or graphy to record or a record of i.e. electrocardiogram or arthrography suffix- rrhea discharge or burst forth lactorrhea ROS review of systems i.e. body systems endocrine system glands that secrete hormones for growth and development endocrine system thyroid, pituitary, adrenals and diabetes are part of what body system lymphatic system distributes fluids and nutrients throughout the body lymphatic system lymph nodes are a part of which body system integumentary system regulates body temperature and sensory receptors to external stimuli integumentary system the skin absorbs Vitamin D through which body system to determine which insurance is primary or secondary Notice of Privacy Practices NPP document that must be given to all new patients indicating how their PHI will be used, also known as the Patient Care Partnership is the treatment, payment and operations TPO per HIPAA, an authorization is not needed when using patient's PHI for treatment, payment and operations in the office is ROI an authorization to release PHI to other parties, which is signed by the patient PHI protected health information de-identify to remove any information that can identify the patient from the documentation, i.e name, social security, address, telephone number is to _____ the document disclosure giving PHI to an outside party, with patient permission is called employer based self insured plans economically based insurance plans created and funded by employers is called preauthorization authorization from the insurance company PRIOR to performing the procedure is called denied procedures that will not be paid by the insurance company, because of reasons such as timely filing, terminated policy or non-covered services are considered rejected procedures that are not paid by the insurance company, because of incorrect information are considered Stark Law physicians may not transfer a patient to another facility before stablizing the patient, also known as the Anti dumping law EDI exchange data interchange EDI the method of electronically transferring encrypted information encryption the format for transmitting electronic claims Final Rule the act issued by the Office of Civil Rights that indicates business associates are also covered entities responsible for protecting PHI implied consent a patient wordlessly lifts his arm for an injections, indicting permission for the MA to give the injections informed consent a physician explained to the patient the procedure and the possible problems that could result from the procedure implied consent non verbally giving permission by action or gesture informed consent being informed of all aspects including the pros, cons and prognosis of a procedure is called OCR Office of Civil Rights OCR the federal organization designated by HHS to investigate privacy and confidentiality complaints OIG the federal organization that levies penalties and fines for fraud, specifically Medicare and Medicaid is OIG Office of Inspector General minimum necessary releasing only what is necessary to comply with a request for patient PHI is called reconciliation the process of determining how much the provider has been reimbursed and what the patient still owes is called ABN Advanced Beneficiary Notice ABN a document signed by the patient that indicates they will be responsible for any charges not covered by Medicare HITECH a reform of the HIPAA act that concerns patient privacy, and protecting PHI, TITLE II, Medicare Part A hospital or inpatient coverage False Claims Act this act protects insurance companies from physician overcharging or creating false claims, it also has whistleblower provisions included Medicaid insurance that covers those who are economically below the poverty line or indigent is called Medicare insurance for those persons 65 years and older, or disabled or with end stage renal failure is called Medicare Part B medical or out patient coverage Medicare Part D coverage for prescriptions consent permission to treat CMS Centers for Medicare and Medicaid Services birthday rule what determines which insurance is primary for a patient who is covered on both parent's insurance? birthday rule the parent whose birthday is first in the calendar year, determines which insurance is primary adjudication the insurance process of reviewing a claim for payment adjustment often called the write off or discount, this is the difference between the total charges and the allowed amount add on codes the + symbol indicates an add on code, which is a CPT code that cannot be used without another primary CPT code allowed charges the contractual amount the provider will received from the insurance carrier assignment of benefits the authorization from the patient for payment for services to be sent directly to the provider accepting assignment the provider agrees to the amount the carrier will pay for the services, this is called AMA organization that maintains the CPT manual WHO organization that maintains the ICD-9 manual beneficiary Medicare and Medicaid use this term to describe the insured fraud intentional act to deceive for financial gain audit formal examination of patient medical records and accounts bundle code a group of related procedures covered by one single code CHAMPVA insurance covering retired and disabled veterans clearinghouses a company that receives data from the provider, scrubs it for errors and forwards it on to the insurance company is code linkage the process of joining a diagnosis code and a procedure code for the purpose of justifying medical necessity compliance officer or privacy officer individual responsible for reviewing office polices and procedures to make sure they are HIPAA compliant CPOE a process of electronic order entry for physicians which reduces medical errors chief complaint reason why the patient is seeking to see a physician CHIP Children's Health Insurance Program CHIP program that provides health insurance to all uninsured children and teens, who are not enrolled in Medicaid CMS 1500 what is the paper format for outpatient health insurance claims XII 837 P ERA remittance advice delivered electronically global period number of days around a surgical procedure that are billed as part of the surgical package guarantor person responsible for the medical bill insured policyholder or Medicare beneficiary late effct a condition extending out of an original resolved condition MCO Managed Care Organization meaninful use a set of requirments that is designed to encourage the implementation of EHR technology medigap insurance purchased by Medicare beneficiaries to cover the 20% not covered by Medicare NEC Not Elsewhere Classified OCR- transmission opitcal character recognition NOS Not Otherwise Specified PAR participating provider - innetwork OSHA Ocupational Safety and Health Administration Administration NON-PAR non participating provider- out of network POS point os service POS hybrid between HMO and POS HMO Health Maintence Organization PPO Preferred Provider Organization HMO health plan where patient requires a referral to see a specialist PPO health plan where referrals are not needed, but the patient pays a little higher cost PCP primary care provider PCP to contain cost MCOs used a PCP to control patient's overall health, known also as the gatekeeper UCR insurance carriers determine fees by charged based on geographical area, speciality, usual cost UCR Usual, Reasonable and Customary turnaround time length of time the carrier takes to process and pay a claim SOAP progress note format SOAP - S subjective or opinion SOAP - O objective or facts SOAP - A assessment or diagnosis SOAP- P plan or treatment Rendering Physician the physician that saw the patient is called the the person at the top is responsible for all those under his/her guidance is called subclassification 5th digit of the ICD-9 subcategory 4th digit of ICD-9 category first three digits of the ICD-9 RED what color does the paper CMS 1500 print out in suffix A the suffix of the Medicare Identification Number that indicates the wage earner is referring provider the provider a patient was sent to by the PCP, for healthcare services self pay uninsured patient ambulatory care out patient care U/A urinalysis UTI urinary tract infection creatinine test urine test for the kidneys BUN blood, urea and nitrogren a blood test for kidney function attending physician staff physician in a hospital edema retention of excess fluid also known as swelling veins takes blood from the heart arteries takes blood away from the heart suffix - ia excessive i.e. polyuria which is excessive urination cystitis inflammation of the bladder is called mortality the medical term for death is morbidity the medical term for illness is morphology what is the study of the behavior of a neoplasm metastasized the spreading of a neoplasm to another area or organ is said to have in situ a neoplasm that is localized and has not spread is permanent codes CPT Category I codes are what type of codes performance measure codes CPT Category II codes have 4 digits and a letter at the end, they are called emerging technology or temporary codes CPT Category III codes are ICD-9 International Classification of Diseases- Version 9 CPT Current Procedural Terminology ERISA Employee Retirement Income Security Act, regulates self insured plans COBRA Consolidated Omnibus Budget Reconciliation Act, allows employee to continue existing coverage under his past employers plan for a limited time is known as etiquette social behavior in the medical field hematoma a localized collection of blood, a blood tumor service line the line on the CMS 1500 that indicates the services provider, 24 a-j send an appeal to the insurance company a patient's claim was denied, for policy termination, but the biller finds out the claim was active, the biller should ask the patient to follow up with the insurance company the Biller calls and finds the claim is in pending status, awaiting patient information, the Biller should follow the Birthday Rule, Mom's insurance is primary Alice is covered by both her parent's insurance, her Dad's DOB is March and the Mom's DOB is MAY, which insurance is primary for Alice Subjective the patient has a family history of heart disease, this information is located in which section of the Progress notes Objective the physiican examined the patient's swollen leg, this information is located in which section of the Progress notes Assessment the physician diagnosed the patient with CHF, this information is located in which section of the Progress notes Plan the patient was given a referral to see a Nephrologist, this information is located in which section of the Progress notes the upper right hand corner where is the insurance name and address located on the CMS 1500 box 24 J the locator box that indicate which physician saw the patient is locater or fields 12 and 13 where do the words "signature on file" appear on the CMS 1500 top portion what area of the CMS 1500 contains the patient or insured's informatioin bottom portion what area of the CMS 1500 contains the provider's information the clearinghouse and the provider HIPAA considers the 3rd party payer a covered entity, other covered entities include NOS the Coder was unable to use a more detailed code because the provider did not provide addiitonal documentation, the code would then include which acrynm NEC the Coder was unable to find a more detailed code in the manual and therefore had to settle for a code that included the acrynm Medicare the patient has end stage renal failure, her primary insurance covers part of the services, which insurance will she be able to use to cover the rest Medicaid the patient had just been laid off and unable to afford the COBRA premiums, he might be eligible for which insurance Medicare Part A the patient was 67 years old, as an inpatient, which part of Medicare covers the hospital stay an add on code the Coder found a code for the removal of 10 skin tags, but the patient has 12 removed, the Coder had to use another code to cover the remaining 2 skin tags, is code is called Referring Provider Dr. Barnes, the PCP sent the patient to see an Dr Reynolds, an Endocrinologist. Dr Reynolds is considered the Medicare Part B the 68 year old patient saw his physician, which part of Medicare would cover these outpatient services Rendering Provider Dr Barnes is part of the University Primary Care Center , which has 5 other doctors. When the Biller completes the claim she will indicate that Dr Barnes is which provider Accepting Assignment the provider is a PAR provider for BCBS, therefore the provider agrees to accept the fee the insurance company will pay, this is called the provider Locator box 13, Assignment of Benefits, was left blank on the CMS1500, therefore the payment would be sent to the patient, by the insurance company, had this box been completed, payment would have gone directly to rejection the claim was not paid because the name was misspelled, this kind of nonpayment code is called a 9 pm the collection agency was not able to call the patient after what time in the evening Medicare the patient has Medicare, but is also covered by her working spouse's insurance at his job, which insurance is secondary CHIP the patient was not eligible for Medicaid but needed coverage for her son, she can apply for FDCPA Emerson Collections Company must conduct their activities unde the guidance of which laws Respondent Superior the Managing Doctors of the the practice were sued, because of an error a staff member made, this Mangering Doctors fall under what rule implied consent the MA needed to get the patient's weight, when the patient stepped onto the scale his actions were considered informed consent the physician reviewed the surgery procedure, then the patient signed the documents acknowledging he understood, this process is called index then tabular the Coder followed the coding guidelines, when locating the code in the ICD-9 manual, the guidelines instruct the Coder to code from the E codes the Biller code the leg fracture, then the fall from the ladder, the code for the fall can be found in which coding section V codes the Biller needed to code the patient's counseling session, which areas of the ICD-9 manual would the code be found the diagnosis code the referral document was incomplete, it contained the patient's name, the referring physician's information and the number of referral visits, but was missing what information red when the Biller printed out the CMS 1500, the locator boxes printed out in what color courtesy write off the physician who saw the patient wanted the remaining balance to be waive,d the Biller when into the patient's account and did a trancation called a the global period two weeks after the surgery, the patient went to see the surgeon for a follow up visit. This visit is considered to be within which periord of time medical necessity the diagnosis indicated that the procedure was necessary to treat the problem, the relationship between diagnosis and procedure is reasonable or shows modifier 78- unplanned return to the operation room by same physician following initial or an unrelated procedure the patient was back in the operating room for an emergency gall bladder removeal one week after cardiac bypass surgery, the modifier used would be the allowed amount the total charges for the visit were $150, Cigna paid the physician $142. The amount paid by Cigna is called the write off the total charges for the visit were $175, BCBS paid the physician $163. The difference between the total charges and allowed amount is called modifier 71, repeat procedure by same physician the surgeon had an appendectomy performed, but was taken back into the operationg room because of hemmoraging, this correct modifier is the Aged Claims Report the claim went unpaid for 63 days, the claim can be found on which report Dermatologist the patient has execma, which physician would best treat this problem $95 the patient's out of pocket expense for an office visit charge of $130 wiht a copay of $30 and a unmet deductible of $65. The patient's out of pocket expense is PSA test the physician suspected prostate cancer, which lab test would be performed to confirm or rule out this suspicion Otitis Media the patient complained of an earache, the physician's diagnosis was outpatient care another word for ambulatory care is Urologist which specialist would you see for cystitis venipuncture for potassium which laboratory test detects abnormal levels of the element potassium in the blood gastrorrhaphy the claim was received at BCBS, as a clean claim, and ready for processing for payment, the process is called NPI# HIPAA gives each provider a unique identifying number known as the the encounter the document that lists the services rendered, the charges for those services and the diagnosis code to support the services is called minimum necessary protocol the Biller review the information to be disclosed to make sure that she was disclosing the minimum amount of information needed, as per the request, this is called privileged communication information that takes place between a patient and the medical office is considered patient bill of rights the patient decided to forgo the surgery and find a homeopathic doctor, this is covered under the negligence the physician could not prove that he had reviewed the patient's EKG report because it was not signed, this can allow for a legal case of oophorectomy surgical removal of the ovaries megalycardia enlarged heart correct coding procedures locate main term in index, confirm code details in the tabular order of coding diagnosis code by order of severity which codes need a external causes code which injury and poisonings system updates are kept off site 2 types of accounting single and double entry