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CRIP, section 2
Certified Revenue Integrity Professional - Overall review of charge capture
| Question | Answer |
|---|---|
| What does HINN stand for and explain | Hopsital Issued Notice of Non-Coverage This is basically the ABN, but for IP care rather than OP. shows what is not covered and what the patient's responsibility would be if/when charges are not covered. |
| - What does ABN stand for and when is it required? | Adv Beneficiary Notice of Non Coverage - for MC pt's, required - when svc doesn't meet/not expected to meet reasonable and nec requ for OP svcs. - Frequency exceeds limits - svcs are deemed experimental/inv - svcs not safe or effetive for care of the pt. |
| Triggering events for ABN to be presented to patient | - Initiation - beginning of new trmt/plan of care where it is believed that the svcs will not be covered. - Reduction: in frequency/duration of services - Termination: and pt elects to continue care that MC doesn't deem med neccessary |
| When would you NOT obtain an ABN? | - patient is in the ER - pt being seen for a medical emergency - if pt is under duress |
| What are the requirements to be met when having ABN signed? | Must be explained to and comprehended by the the pt or pt's POA, provided on approved CMS form, fully filled in and provided far enough in advance that the pt/POA has time to consider options. Must be signed and dated. |
| Define and explain modifier 91: | Repeat Clinical Diagnostic Lab Test. - Used when it is necessary to repeat the same lab on the same day in order to receive multiple test results. -DO NOT USE if the re-run is to confirm initial results due to testing problems. |
| Define and explain modifier 77: | Repeat Procedure by Another Physician - Use when repeated by another physician in a separate session, same day. - Procedure should be billed as normal and then the repeat should be listed on another line with the modifier. |
| Define and explain modifer 76: | Repeat Procedure by Same Physician - indicates the procedure was repeated by the same physician in a separate session on the same day and by the same physician. - bill code on 1 line as usual and then again on a second line with the modifier |
| Define and explain Modifier 74: | Discontinued OP proc after anesthesia administered. - only for proc's requ anesthesia - if pt was prepped, in procedure room and after induction of anesthesia. * if at least 1 proc was done, report what was completed and do not list canceled proc. |
| Define and explain Modifier 73: | Discontinued OP Procedure prior to anesthesia - terminated after surgery prep and taken to procedure room but prior to anesthesia. - only for procedures requiring anesthesia |
| Define and explain Modifier 59: | Distinct Procedural Svc - Identifies prc/svcs not normal together, but it is appropriate on this claim. Indicates the charge is distinct & ind. |
| What does a Modifier 59 represent? | Represents: - diff proc/svc - diff site or organ system - sep incision, excision or lesion - sep inury or area of injury not usually encountered or performed on the same day by the same physician. |
| List and describe the subsets of Modifier 59: | XE: Svc distinct b/c it occurred in a separate encounter XS: b/c it was performed on a separate organ/structure. XP: distinct b/c it was performed by a different practitioner XU: distinct b/c it does not overlap usual compenets of the main svc. |
| Define and explain Modifier 50: | Bilateral Procedure Use when: CPT description doesn't specific laterality Report on 1 line w/ mod and 1 unit use only on paired organ or body part done in same session |
| When should Modifier 50 NOT BE used? | With non specific codes The procedure was on 2 different body parts code description includes the word "bilateral" or unilateral When the organ is considered mid-line (does have a RT and LT) |
| Define and explain Modifier 25 | Significant, separately identifiable E/M svc, same physician and same day. Mod is appended on the E/M svc Use when: Svc is beyond the usual E/M being performed A separate Hx was taken, separate physical performed and separate medical decision noted. |
| List the usual other services that necessitate modifier 25: | The "other" services usually have a pmt status indicator of T or S, such as x-rays, infusions, etc. |
| What is a Modifier? | - 2 digit numeric/alpha-numeric code appended to HCPCS/CPT code to define the charge to another level of specificity. - Can impact reimbursement -Can act as multipliers to increase/decrease reimb - Can provide more info to allow claim to be processed |
| What does MUE stand for and describe | Medically Unlikely Edit - Put in place by CMS to review # of units of svc reported on a claim for certain charges - Designed to reduce errors due to clerical entry errors and incorrect coding based on anatomic considerations |
| Can you use an ABN to bill the patient for services with an MUE | NO |
| What steps should be taken when reviewing an MUE denial? | - Confirm DOS - confirm no duplicate charges for same DOS - Validate the charges |
| What does MS-DRG stand for and describe | MC Severity Diagnosis Related Group This is the way that IP svcs are valued. When related OP svcs are provided hours prior to an IP admission, the OP charges are bundled. This is called the MS-DRG Payment Window. |
| What must be considered when decision if an OP svc is subject to be bundled with an IP admission? | - The date the OP services were rendered - The relationship of the OP and IP provider - If the svcs are diagnostic or non diagnostic OP dx and procedure codes should go on the IP claim even though they will be bundled b/c an outlier pmt is possible. |
| What should happen if the IP svcs are deemed not medically necessary but there are OP svcs provided prior to admission? | The OP charges during the hour window (MS-DRG Payment Window) should not be added to the IP claim, but billed as OP Svcs. In this case, bill type 13x should be used as opposed to 12x for IP claims |
Created by:
Amy17349
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