Help
Options
Didn't know it?
click below
click below
Knew it?
click below
click below
Don't Know
Remaining cards (0)
Know
retry
shuffle
restart
0:00
Embed Code - If you would like this activity on your web page, copy the script below and paste it into your web page.
Normal Size Small Size show me how
Normal Size Small Size show me how
CRIP Set 4
| Question | Answer |
|---|---|
| What are the billing and covered requirements for a pap smear screening? | Ordered and collected by authorized provider Patient did not have a screening in the previous 2 years Screening diagnosis code on the chart Based on payson's history. Patient is of childbearing age and has had an exam that indicated the presence of cervical or vaginal cancer or any other abnormalities during the previous 3 years Patient is high risk for developing cervical or vaginal cancer |
| What is considered high risk for developing cervical or vaginal cancer? | Sexual activity began at 16 years of age or younger Have more than five sexual partners in a lifetime Has a history of an STD Having less than three negative pap smears within the past 7 years Daughters of women who took DES during pregnancy |
| What is DES ? | Diethylstibestrol |
| What act was amended to include Medicare part B coverage for screening pelvic exam which includes clinical breast exam? | The balance budget act of 1997 |
| What are the elements and how many must be present for a screening pelvic exam with or without specimen collection for smears and cultures? | At least 7 Breast exam Digital rectal exam External genitalia Urethral meatus Urethra - masses, tenderness, or scarring Bladder examine for fullness, masses, or possible tenderness Vagina for appearance , estrogen effects, discharge, lesions, pelvic support, cysticil, rectocele Cervix- appearance, lesions, discharge Uterus- size, contour, position, mobility, tenderness, consistency, descent, or support A check for Oreganmegsly or nodularity Anus and perineum |
| Can a woman receive a screening pelvic exam more frequently than once every 35 months? | Yes, but only if there is evidence that the woman is at high risk |
| What does PSA stand for | Prostate specific antigen |
| What does PSA screen for? | Prostate cancer - it test that measures the level of prostate specific antigen in an individual's blood |
| For CMS, what does the prostate screening test include? | Screening digital rectal exam in a screening PSA blood test |
| How often is the PSA benefit? | Once every 12 months for men who have reached the age of 50 |
| What does CMS define as a screening digital rectal exam? | A clinical exam of an individual's prostate for nodules or other abnormalities of the prostate |
| What is medicare's colorectal cancer screening benefits? | Fecal occult blood test- every year Flexible sigmoidoscopy- once every 4 years Colonoscopy- once every 10 years Barium enema- only done as an alternative to cover a screening. Flexible sigmoidoscopy |
| Does Medicare require a physician order to receive a pneumococcal vaccine and for administration? | No |
| How often are a pneumococcal vaccines administered? | Usually once in a lifetime. However, revaccinations can be administered to individuals who are at high risk for a serious pneumococcal infection. |
| What is considered high risk for pneumonia? | 65 age or older? Immunocompetent adult who is also at increased risk for pneumococcal disease or as complications because of a chronic illness And any individual who may have a compromised immune system |
| are immunization record and a complete medical record needed to administer vaccines ? | No. If the patient is competent, it is acceptable for practitioners to rely on the patient's verbal history to determine prior vaccination status. Patient, even if the patient cannot remember his or her own vaccine history over the past 5 years, the vaccine should still be given |
| give information about influenza /flu vaccine | Administered once per flu season. CMS does not require that a provider order the vaccine |
| Hepatitis B. Vaccine | Covered if ordered by a doctor. Available to patients who are considered at high or intermediate risk of contracting hepatitis B. Medicare beneficiaries who are currently positive for antibodies for hepatitis B are not eligible for this benefit |
| What is the definition of intravenous infusion or IV? | An infusion lasting more than 15 minutes through a catheter, venous access device, or an IV access line |
| What is the definition for intravenous push or ivp? | When a drug is administered from a syringe and pushed into the venous access line |
| Should Administration charges for contrast, keep vein open, or for flushing related to IV Administration be reported? | No |
| What are the three different types of injection and infusion services? | Initial service Sequential Administration Concurrent Administration |
| If billing for chemotherapy concurrent Administration, how do you Bill? | Currently there is no code established for the billing of concurrent chemotherapy. Therefore, multiple drugs which are given in the same session are considered to be sequential rather than concurrent |
| If an IV infusion in an ivp are both performed, which one is considered the initial service? | The infusion |
| If both chemotherapy and non-chemotherapy substances are administered by an IV, which one are considered initial service? | Chemotherapy |
| Why would hydration not be considered an initial service? | If Administration of substances by an IV are performed in the same visit. |
| What drugs are never given for hydration? | Calcium, magnesium, sodium phosphate, sodium bicarb, and potassium phosphate |
| If banana bags are used or any other treatment with the dextrous higher than 5%, is it hydration or therapeutic? | Therapeutic. You would never bill as a hydration service |
| What are the CPT codes used for chemotherapy infusions? | 96413- initial first hour 96415- each additional hour greater than 30 minutes past the prior hour 96416- initiation of prolonged infusion via implanted or portable pump 96417- additional chemo infusate added after the prior infusate stops sequential |
| What are chemotherapy injection or infusions lasting less than 16 minutes CPT codes? | |
| 96409 - initial injection 96411- additional injection with additional substance/ drug | |
| What are the therapeutic, diagnostic, or prophylactic non-chemotherapy infusion cpts lasting greater than 15 minutes? | 96365- initial first hour 96366 - each additional hour greater than 30 minutes past the prior hour 96367- additional infusate different substance infuse before or after the initial service- sequential 96368- additional infusate different substance added during the infusion- concurrent |
| What are the CPT codes for therapeutic, diagnostic, or prophylactic non-chemotherapy infusions or injections less than 16 minutes? | 96374- initial injection 96375- additional injection with a different substance/ drug- sequential 96376- each additional injection of the same substance/drug er than 30 minutes past the prior injection or same drug |
| What are the CPT codes for hydration infusions over greater than 30 minutes? | 96360- initial infusion, 31 minutes to 1 hour 96361- each additional hour at least 30 minutes past the prior hour |
| What documentation should be included in the medical record when injections and infusions are being administered? | Number of IV given, gauge of needle, attempts used, person who inserted the substance/ drug, list of all meds. /Iv injected or infused, route of admin, site of admin, rate change, PT. Vitals, physician order, amount /dosage admin, rate drug infused, total infused, start and stop time for injection or infusion |
| Does CMS guideline specified that it is required to document the start and stop times for infusions? | No. However, it is highly recommended that they be documented. Otherwise it will be hard to justify the number of hours billed for the infusions |
| How are infusions billed that are started outside the hospital? | If an ambulance has already started the infusion the hospital can bill for for the service. This includes the hospitals who should report for an initial hour of infusion. Facilities can also charge for additional or sequential infusion services that may have been provided as well. |
| A physician orders an IM injection; the nurse splits the dose and gives the patient half in the right thigh and the other half in the left thigh. Would you Bill one injection or two? | According to the AMA, if there is doc doc that supports that two injections were given in two different sites, then two injections should be billed. This is because supper prep and admin of the specific drug occurred because the single dose was split. |
| A physician ordered a pharmaceutical to be given 1gm IV push, but the nurse gave the medication IM instead. Can you bill for the IM injection even though the physician ordered IV push? | If a clarification, order for the route of admin is not obtained from the provider but the admin service is documented, the admin service provided, IM injection, can be bill. If the nurse administers and docs a drug admin route that is different from the order, the code for the actual drug admin route provided to the PT should be charged. |
| What items should be included in the CDM for pharmacy? | Revenue codes assigned for facility billing, NDC, assignment of hcpcs code, drug divisors needed to equate to the appropriate billable units, average wholesale price, constant verification that compound drugs are set up and charged appropriately, |
| Why is it important to make sure the pharmacy CDM is set up appropriately? | Because of the complexity of this department, it can be very challenging to maintain accurate data. If any of the items listed above is incorrect, it could have a huge reimbursement impact for the facility. |
| What is the difference between single dose vials versus multi-dose vials? | Single dose vials- do not contain an antimicrobial preservative, must be used within 6 hours, maybe build for the dose administered plus any waste Multi-Dose vials- containing preservative, maybe used up to 28 days, may only be billed for the dose administered |
| When billing for wastage of a single dose vials what is the process? | Line 1 - code and amount used Line 2 - code and amt of wastage and modifier JW |
| Why would drug divisors and multipliers be used? | Because CMS requires that drugs, biological, and radiopharmaological units are reported on the UB form to reflect the dose provided to the patient based the actual HCPCS code description. |
| What are the units of measurement that can be used when adding a new drug to the pharmacy system or CDM? | CM - centimeter G - Gram MG - milligram ML - milliliter SQ CM - squared centimeter |
| What must a valid pharmacy order include? | Patient's name, name of drug including the frequency, route, and dosage, duration or quantity of the infusion, if ordered, reason for the order, any type of instruction specific to the drug, name in the signature of the individual prescribing the drug, date and time the order was written |
| What are the key pharmacy documentation essential for nursing? | Level of complexity provided, for example hydration, chemo, etc Name of med admin Location or access site Route of admin Start/ stop times per med Dose administered in any wastage Flushing the lines Doc of any complications Any changes to the physician order Removal of the IV and when therapy was discontinued |
| Are self-administered drugs covered under Medicare? | No unless the drug is an integral part of the procedure such as eye drops or ointments used during the procedure or if it is covered by a statute such as an anti-cancer oral drugs. |
| What are the different types of self-administered drugs and how are they provided? | They are provided on an outpatient beach. This and some drugs include: creams and ointments, tablets/capsules given orally, suppositories, injections such as insulin, inhalation drugs. |
| If an injectable drug appears on the Medicare administrative, contractor's exclusion list is the drug covered and is the drug admin charge covered? | No |
| Isn't ABN needed when an injectable drug appears on the MAC SAD exclusion list? | No, but hospitals should consider relaying invoted patients and informing them that the drugs are an exclusion of benefits to help reduce patient complaints. |
| What are some things that can be done to eliminate patient complaints for drugs that are not covered? | Allow patients to bring their own drugs, create a discount policy for low-income patients, lower the charge for self-administered drugs. |
| What is national drug codes or NDC? | Created by CMS to help identify drugs that could be reimbursed. The FDA is responsible for maintaining them. |
| What are the three components of each NDC? | The first component- assigned by FDA, identifies the vendor who manufactured, package, and distributed the drug Second component- assigned by manufacturer, identifies the product info such as generic name, dosage, strength Third component- assigned by manufacturer, indicates size of the product |
| How long is the NDC and what are the three types of configurations possible? | It is 10 digits and the configurations are 4-4- 2 5-3-2 5-4-1 |
| For billing purposes, what does the digit code must be converted to? | It must be converted to 11 digits in the configuration is done by inserting a leading zero in one of the components to result in a 5-4-2 configuration. 4-4-2 to 5-4-2 (09999-9999-99) 5-3-2 to 5-4-2 (99999-0999-99) 5-4-1 to 5-4-2 (99999-9999-09) |
| Is it considered fraud if a facility bills for an NDC other than the one that was truly dispensed? | Yes |
| Does Medicare reimburse for routine or related dialysis treatment , which are covered and paid for under the end-stage renal disease perspective payment system, when furnished to ESRD patients in the outpatient department of a hospital? | No |
| If an ESRD outpatient cannot obtain his or her regular scheduled dialysis treatment at a certified ESRD facility, will Medicare reimburse for this? | Yes, opps does allow for payment of non-routine dialysis treatment furnished to ESRD outpatients in the outpatient department of a hospital that is not certified as an ESRD facility. |
| What reasons would allow for payment of an unscheduled dialysis treatment? | The dialysis is performed following or in connection with a dialysis related procedure like a vascular access procedure or a blood transfusion. Following a treatment for an unrelated medical emergency Emergency dialysis is needed for ESRD patients who would otherwise have to be admitted has inpatients in order for the hospital to receive payment |
| How are non-esrd certified outpatient dialysis treatments billed? | HCPCS code G0257 and with TOB of 13X or 85X only |
| When can HCPCS code 90935 for hemodialysis procedure with a single physician eval may be reported and reimbursed? | The patient is a hospital inpatient with or without ESRD and has no coverage under part A, but has part B coverage. Should this occur, the service must be reported on TOB 12Xor TOB 85X. The hospital outpatient does not have ESRD and is receiving the hemodialysis in the hospital outpatient department. In this case, the service needs to be reported on a TOB 13X or TOB 85X. |
| When can cvs 90945 for dialysis procedure other than hemodialysis within single physician eval be reported? | By a hospital paid under oPPS or CAH method I or method II on TOB 12X, 13X, or 85X |
| What is Epogen? | Erythropoietin stimulating agent or ESA. A drug that is used to treat a lower than normal number of red blood cells caused by chronic kidney disease in patients who are on dialysis to lessen the need for red blood cell transfusions. Also, when ESRD patients come into the hospital for an unscheduled emergency dialysis treatment, this may also need to be administered. |
| What are the two things that renal dialysis facilities are required to report for all Medicare patients who receive Epogen products? | Hemoglobin in hematocrit. Hemoglobin readings before the start of the billing. Are reported with a value code of 48 on the claim. Blood sample must be obtained before dialysis treatment. If unavailable, facilities must report value as 99.99 Hematocrite readings must be obtained before dialysis treatments and the levels reported on the UB claim with a value code of 49. This reflects the most recent reading taken before the start of the billing period. |
| What are the revenue codes to report the administration of Epogen? | 0634 - admin less than 10,000 units 0635 - admin greater than 10,000 units |
| What is the documentation needed to adress in the medical record for an ESRD patient that requires more than 10,000 units of Epogen per Administration? | Iron deficiency Conditions such as infection, inflammation, malignancies Any unrecognized blood loss Bone marrow dysplasia or refractory anemia for any reason other than renal disease Vitamin B12 or a folic acid deficiency Any circumstance in which the bone marrow is replaced with other tissue Pt's wait, dose required, historical records of amounts given, and the hematocrite response to date |
| What are the billing guidelines for Epogen administered to non-ESRD patients? | Hcpcs j0881 1 or j0885 With a modifier EA - anemia, chemo induced EB - anemia, radio induced EC - anemia, non-chemo/radio If one of the modifiers are not on the claim it will be returned to the provider/facility |
| What are the situations that will result in a denial for Epogen for ESRD pts? | J0881 or J0885 ESRD patients and any of the following diagnoses are on the claim: B12 deficiency, iron deficiency, hemolysis, bleeding, erythroid cancers, anemia and cancer PT with folate deficiency, anemia associated with acute chronic myelgenous leukemias. |
| What are the situations that will result in a denial for? Epogen for non ESRD pts? | J0881 or J0885 Non ESRD pts with diagnosis on the claim: any type of anemia in cancer or cancer treatment patients due to bone marrow fibrosis, anemia of cancer that's not related to any cancer treatment, prophylactic used to prevent chemotherapy induced anemia, prophylactic used to reduce tumor hypoxia, patients with erythropoietin type resistance due to neutralizing antibodies, anemia that is due to cancer treatments. If patient have uncontrolled hypertension. If billed with modifier EB |
Created by:
PRO Teacher
larae711
Popular Medical sets