AAHAM CRCS CERTIFICATION Chapter 4
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| show | The process of submitting and following up on claims in order to be paid for healthcare services provided.
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| What are the different types of insurances and payers? | show 🗑
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| Who does Medicare cover? | show 🗑
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| show | Beneficiary
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| show | End stage renal disease
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| How many parts does Medicare have? | show 🗑
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| What is Medicare part A called? | show 🗑
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| What does Medicare part A cover? | show 🗑
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| show | No
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| show | Beneficiaries who have worked enough quarters per SSA requirements will qualify for coverage without a premium.
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| Does Medicare part A have a deductible? | show 🗑
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| show | It's 60 days of inpatient hospital services than a beneficiary can opt to use after having used 90 days of inpatient hospital services in a benefit.
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| show | Once in the beneficiaries lifetime, but it can be split among multiple hospital stays.
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| show | Yes, it comes with a high coinsurance, 50% of the Medicare part A deductible per day.
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| If a patient did not want to use their lifetime reserve days, what would happen after 90 days? | show 🗑
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| What is Medicare part b called? | show 🗑
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| What does Medicare part b cover? | show 🗑
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| When must a beneficiary sign up for Medicare part b? | show 🗑
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| show | Yes, they pay a premium each month
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| show | Yes
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| What are Medicare part b covered preventative services? | show 🗑
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| What vaccines are covered under Medicare part b prevented services? | show 🗑
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| What are other items? Part b helps pay for? | show 🗑
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| Who qualifies for an annual wellness visit? | show 🗑
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| What does AWV stand for? | show 🗑
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| What does IPPE stand for? | show 🗑
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| What is the beneficiary obligation in the original Medicare plan for an annual wellness visit? | show 🗑
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| How often is a bone mass measurement covered? | show 🗑
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| show | Certain beneficiaries at risk for losing bull mass or developing osteoporosis.
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| show | Topayment, coinsurance, and deductible or waived
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| How often is cardiovascular disease screening covered? | show 🗑
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| What is included in a cardiovascular disease screening? | show 🗑
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| show | All asymptomatic Medicare beneficiaries
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| What is the beneficiary obligation in the original Medicare plan for cardiovascular disease screening? | show 🗑
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| How often can a beneficiary get a colorectal cancer screening? | show 🗑
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| What beneficiary is eligible for colorectal cancer screening? | show 🗑
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| show | For FOBT , flexig, colonoscopy- copayment coinsurance and deductible waived. Barium enema coinsurance applies, deductible waved. For a multi-target stool DNA test. If polyp found and removed, 20% copayment applies.
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| show | Two screening test per year if diagnosed with pre-diabetes or one screening test per year if previously tested but not diagnosed with diabetes or if never tested.
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| Who qualifies for diabetes screening test? | show 🗑
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| show | Copayment, coinsurance, and deductible are waived.
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| What is the coverage for diabetes self-management training? | show 🗑
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| show | Copayment, coinsurance, and deductible applies
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| show | Once every 12 months. Must be done or supervised by an eye doctor who is legally allowed to do the service and the beneficiary state of residence.
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| Who is eligible for glaucoma screening? | show 🗑
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| show | Copayment, coinsurance, and deductible apply
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| How often is hepatitis b vaccine covered? | show 🗑
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| show | Beneficiaries who are intermediate or high risk for contracting Hep b. But beneficiaries who are currently positive for hepatitis be antibodies are not eligible for this benefit.
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| show | Co-payment, coinsurance, and deductible are waived
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| Who is eligible for hepatitis c virus screening? | show 🗑
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| show | Annually for high risk beneficiaries with continued illicit drug use with injection, or who had a blood transfusion before 1992. Once in a lifetime if born between 1945 and 1965 and not at high risk.
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| show | Copayment, coinsurance, and deductible or waived.
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| show | Annually for high-risk cases and three times per pregnancy (one screening per trimester) for those beneficiaries who are pregnant.
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| show | Beneficiaries who are at an increased risk for HIV, who may be pregnant, or who are between ages 15 through 65 and ask for the test
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| show | Copayment, coinsurance, and deductible are waived
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| How often is an initial preventative physical exam covered? | show 🗑
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| show | Initial preventative physical examination
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| show | All new Medicare beneficiaries who are within the first 12 months of the first Medicare part b coverage.
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| show | For an IPPE without EKG- copayment and coinsurance apply; deductible waved.
For an IPPE with EKG- copayment, coinsurance, and deductible apply
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| show | 1 CVD risk reduction visit annually
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| show | Intensive behavioral therapy
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| show | Cardiovascular disease
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| Who is eligible for intensive behavioral therapy for cardiovascular disease? | show 🗑
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| show | Copayment, coinsurance, and deductible or waived
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| show | Annually for all beneficiaries; frequency of coverage includes one visit every week for month one; one visit every other week for months two through six; in one visit every month for months 7 through 12.
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| show | Beneficiaries with a BMI of greater than 30, who are competent and alert at the time that counseling is provided and who's counseling is furnished by qualified primary care physician or other primary care practitioner in a primary care setting
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| What is the beneficiary obligation in the original Medicare plan for intensive behavioral therapy for obesity? | show 🗑
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| show | Annually for beneficiaries between ages 55 through 77
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| show | Beneficiaries who show no signs or symptoms of lung cancer and you have a history of smoking at least 30 packs, a year; who are current smokers or have quit smoking within the past 15 years. There also must be a written order for the service that criteria
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| show | Car insurance and deductible waived. If all criteria are meant, there is a written order, and the physician accepts assignment.
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| How often is mammogram screening covered? | show 🗑
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| show | Modifier GG
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| Who qualifies for screening mammogram? | show 🗑
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| show | Coinsurance, copayment and deductible waived
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| How often is diagnostic mammograms covered? | show 🗑
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| Who is covered for diagnostic mammograms? | show 🗑
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| show | Coinsurance and deductible apply
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| show | Medical nutrition therapy
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| How often is medical nutrition therapy covered? | show 🗑
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| show | Copayment, coinsurance in deductible waived. Note- if the patient is receiving dialysis in a dialysis facility, Medicare will cover MNT as part of the overall dialysis care.
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| show | Beneficiaries diagnosed with diabetes or a renal disease or who have received a kidney transplant within the last 3 years
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| How often is a pap smear and pelvic exam covered, including a clinical breast exam? | show 🗑
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| Who is covered for a pap smear and pelvic exam? | show 🗑
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| show | Copayment, coinsurance, and deductible or waived
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| How often is a prostate cancer screening covered? | show 🗑
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| show | Male beneficiaries age 50 in order- beginning the day after the 50th birthday
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| show | Digital rectal exam- co. Payment, coinsurance, and deductible apply
PSA test- co-payment, coinsurance, and deductible waived
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| show |
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| How often is screening and behavioral counseling to reduce alcohol misuse covered? | show 🗑
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| Who is eligible for screening and behavioral counseling to reduce alcohol misuse? | show 🗑
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| show | Copayment, coinsurance, and deductible or waived
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| show | Once every 5 years
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| Who is eligible for screening for cervical cancer with human papilloma virus or HPV test? | show 🗑
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| What is the beneficiary obligation in the original Medicare plan for screening for cervical cancer with human papilloma virus or HPV? | show 🗑
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| show | Annually for all beneficiaries
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| Who is eligible for screening for depression? | show 🗑
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| What is the beneficiary obligation in the original Medicare plan for screening for depression? | show 🗑
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| show | Annually for all beneficiaries; frequency of coverage depends on the type of STI's being treated.
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| Who is eligible for sexually transmitted infection screenings and high intensity behavioral counseling to prevent STIs? | show 🗑
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| What is the beneficiary obligation in the original Medicare plan for sexually transmitted infection screenings and high intensity behavioral counseling to prevent STIs? | show 🗑
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| show | Two sensation attempts per year; each attempt includes a maximum of four intermediate or intensive sessions; up to eight sessions within a 12-month.
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| Who is covered for smoking and tobacco use sensation counseling? | show 🗑
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| show | Copayment, coinsurance, and deductible waived
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| show | Once in a lifetime
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| show | Beneficiaries with certain risk factors for AAA to receive a referral from their physician, physician assistant, nurse practitioner, or clinical nurse specialist
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| What is the beneficiary obligation in the original Medicare plan for ultrasound screening for abdominal aortic aneurysm? | show 🗑
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| show | Once a year per flu season
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| show | One shot can be followed by a second, different shot one year later
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| show | All beneficiaries with part b coverage
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| What is the beneficiary obligation in the original Medicare plan for vaccinations? | show 🗑
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| show | Acupuncture, routine dental services, cosmetic surgery, hearing aids and exams, orthopedic shoes, outpatient prescription drugs, routine foot care, routine. Eye care, routine. Physical exams, care while traveling outside the u.s, custodial care
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| show | Medicare advantage or a replacement plan from the traditional Medicare plan.
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| Do Medicare advantage plans need to follow the minimal rules set by Medicare? | show 🗑
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| What are the five types of Medicare advantage plans? | show 🗑
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| show | Health maintenance organization
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| show | These are plans in which members must generally get health care from providers in the plans network
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| What does PPO stand for? | show 🗑
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| show | Plans which are similar to HMOs, but members can see any doctor or provider that accepts Medicare and they don't need a referral to see a specialist
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| Private fee for service plans | show 🗑
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| show | These are plans which limit all or most of their membership to people in some long-term care facilities such as nursing homes, and who are eligible for Medicare and Medicaid. These plans are available in limited areas only
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| What does MSAs stand for? | show 🗑
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| show | Plans which have two parts: one part is a Medicare advantage hot deductible plan and the other part is a medical savings account into which Medicare deposits money that people can use to pay health care cost
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| show | The period when a patient enrolls or disenrolls in a Medicare advantage organization during a period of service.
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| What are the two factors that determine whether the Medicare advantage organization is liable for the payment? | show 🗑
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| If a patient changes Medicare advantage status druing a inpatient hospital admission what determines who is responsible for the bill? | show 🗑
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| If the provider is not a PPS provider, is the Medicare advantage organization responsible for payment for services one in after the day of enrollment up through the day that the disenrollment is effective? | show 🗑
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| show | Medicare prescription drug plan
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| show | Yes, an annual deductible
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| show | Formulary
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| show | Yes they are categorized into tears in each tier. Can have a different cost
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| What does MAC stand for? | show 🗑
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| What are Medicare administrative contractors? | show 🗑
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| show | Currently there are 12 part a/ part b. 4 DME
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| show | Under the program, the providers sign a participation agreement, buying them to accept assignment for all services provided to Medicare patients for the following year.
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| show | Normally acquired at registration or admission
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| show | No but must be got in prior to discharge
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| If a provider accepts assignment, what are they agreeing to? | show 🗑
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| show | No
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| If they provider does not accept assignment, what can they do? | show 🗑
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| show | Maximum of 115% of the Medicare approved amount
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| What are advantages of participating in the Medicare physician program? | show 🗑
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| show | 80%
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| What does government imprimatur mean? | show 🗑
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| When submitting a claim to Medicare, does the name on the claim have to match the name on the card exactly? | show 🗑
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| What did the Medicare access and chip reauthorization act of 2015 require? | show 🗑
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| What is the identification number on the Medicare card called | show 🗑
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| What are the parameters for an MBI? | show 🗑
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| show | Medigap is a health insurance sold to fill the gaps of coverage like deductibles, coinsurance and copayments under the original Medicare plan
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| show | Medicare supplemental insurance
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| show | Only beneficiaries with the original Medicare plan. It's a beneficiary with a Medicare advantage plan joins. It will not pay for any deductibles, co-payments or other cost sharing amounts
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| What is Medicaid? | show 🗑
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| Who is responsible for the funding of Medicaid programs? | show 🗑
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| show | Paying for the care of patience residing in custodial care facilities
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| show | Establish eligibility standards, determine what benefits and services to cover, set payment rates
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| show | Dual eligible benefits are individuals who are entitled to Medicare part A/ part B and are also eligible for some form of Medicaid benefit
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| What is workers compensation? | show 🗑
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| show | Gather as much information as possible regarding the patient's coverage, including any group health insurance, secure a worker's compensation claim number for the case
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| show | Tricare covers active duty service numbers, their spouses, dependence, and retirees unless they are eligible for Medicare.
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| show | Sponsor
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| show | For the sponsor, it starts on the first day of active orders. Other members are eligible after the sponsor has been on active duty for 30 days
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| show | This is a program for qualified service. Retirees that acts as a supplement to Medicare
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| What is a non--availability statement? | show 🗑
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| Who issues the NAS? | show 🗑
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| How long is an NAS good for? | show 🗑
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| show | It is a military treatment facility established for the purpose of furnishing medical/ dental care to eligible individuals. There is a 40 mi catchment area in which active duty personnel should go to the MTF to receive their treatment
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| What is children's health insurance program or CHIP? | show 🗑
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| show | Wear a company will put premium payments into a fun to cover services and pay a third party to administer benefits from the fund
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| Are self-insured health plans regulated under federal law? | show 🗑
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| Does self insured health plans have to follow the state timely payment regulations | show 🗑
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| show | This refers to health insurance that covers individuals. Most people dolph obtain this a type of insurance as a benefit of employment.
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| show | This is insurance for someone who is injured to a non-work-related accident. This may be covered through property and casualty or auto insurance.
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| show | It is quite limited but will pick quickly
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| What is no fault coverage? | show 🗑
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| show | This is a common term for patients who have no insurance.
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| What should any discounting of South Bay accounts be vetted through? | show 🗑
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| What is health savings accounts or HSAs? | show 🗑
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| P who can put money into an HSA account? | show 🗑
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| show | A program that determines which plan or insurance policy will pay first. If two health plans or insurance policies cover the same benefits. If one of the plans is a Medicare health plan, federal law may decide who pays first.
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| If a person has Medicare and and a commercial insurance. When is Medicare the secondary pair? | show 🗑
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| show | Employer group health plan
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| show | Insurance that pays medical expenses related to an injury resulting from an accident regardless of who may be at fault.
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| show | Homeowners insurance, commercial insurance, auto insurance.
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| show | Any source that provides payment on a claim based on a legal liability for illnesses, damages to properties, or injuries.
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| show | Malpractice, wrongful death, product liability, and uninsured motorist.
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| Can a veteran choose whether to receive services covered under the VA or Medicare? | show 🗑
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| If a patient chooses the VA over Medicare, how does billing work? | show 🗑
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| If the patient chooses Medicare over the VA, how does billing work? | show 🗑
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| What are other COB determining factors? | show 🗑
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| When wouldn't Tricare be the last pair? | show 🗑
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| show | Yes
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| show | They will only pay for Tricare covered services and the maximum allowed Tricare amounts, and all Tricare policies and procedures must still be followed.
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| If a person has a liability, property and casualty insurance along with other insurance who was primary and who is secondary? | show 🗑
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| If a person is covered by two commercial insurances, what is used to determine who primary coverage depends on? | show 🗑
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| show | If married, the birthday rule dictates that the parent with the first birthday in the counter year will provide the primary coverage. Not the birth year. Just the birthday. For example, mom has 6/1/1970 and dad has of 1/16/70. Dad would be primary
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| What is the birthday rule if parents are divorced for separated? | show 🗑
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| What is conditional payment? | show 🗑
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| show | Attempt at administrative simplification to use standard transaction to aid an electronic claim transmission.
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| Did HIPAA require standard transaction code sets? | show 🗑
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| show | 270, 271, 276, 277, 278, 354, 834, 835, 837D, 837I, 847P
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| show | Healthcare eligibility. 270 is inquiry and 271 is the response.
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| show | Healthcare claim status. 276 is inquiry and 277 is the response.
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| show | Referral certification and authorization
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| What does transaction code 354 relate to? | show 🗑
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| show | Enrollment and disenrollment in a health plan
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| What does transaction code 835 relate to? | show 🗑
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| show | Dental claim
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| What does transaction code 837i relate to? | show 🗑
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| What does transaction code 837P relate to? | show 🗑
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| Is it important to maintain a provider's coding master files on an annual basis? | show 🗑
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| show | ICD, present on admission indicators, CPT, HCPCS, NPI, taxonomy code,
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| What does ICD-10 stand for? | show 🗑
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| show | Present one admission indicators
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| show | Healthcare Common procedure Coding system
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| What does CPT -4 stand for? | show 🗑
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| What does NPI stand for? | show 🗑
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| What is ICD-10? | show 🗑
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| show | Inpatient claims
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| show | Outpatient procedures
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| What are HCPCS codes used for? | show 🗑
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| show | Provider identification, as directed by CMS's administrative simplification identifier standards
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| What are taxonomy codes? | show 🗑
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| What do ICD-10 codes set consist of? | show 🗑
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| show | 68,000 codes to allow for great specificity and identifying and tracking services offered in the medical field
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| show | Code the primary diagnosis 1st, followed by 2nd, 3rs and so forth. Code any coexisting cond that affect the visit or pro c as supp, code the principal in disch dx to the highest level of specificity, code any coexisting dx to the lowest level of specif.
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| show | CMS mandated the use of POA indicators for most inpatient claims. The indicator is paired with each dike nurses code in the medical record. They are used to identify non-payable complications such as hospital acquired conditions.
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| How many levels are HCPCS codes divided into? | show 🗑
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| What is level one of the HCPCS codes? | show 🗑
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| show | 5 digit numeric codes with alphabetic prefixes a. Through v, assigned by CMS to identify products, supplies, and services not included in the CPT codes, such as ambulance, DME, orthotics and dmepos.
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| show | Codes that are used at the state level by Medicaid and other pairs to designate additional services. They are often referred to as local codes and our prohibited under HIPAA but still required by some state programs.
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| show | P a range of CPT codes applies to e&m and this is determined on the process and the charge for examining a patient and formulating treatment. The code is assigned a level based on seven components.
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| show | History, examination, medical decision making, counseling, coordination of care, nature presenting problem, time spent
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| show | Yes, except emergency department where there is no distinction.
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| What are HCPCS in CPT? Modifiers? | show 🗑
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| What is an NPI? | show 🗑
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| show | Administrative codes to identify practitioner type and specialty for healthcare practitioners. It is a hierarchical code that consists of codes, descriptions and definitions.
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| show | A unique 11 digit three segment numeric identifier that is assigned to each medication listed under the FDA.
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| show | The first identifies the labeler, second is type of product, third identifies the size and type of the package
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| What are payment methodologies? | show 🗑
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| What are the different methods of payment methodologies ? | show 🗑
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| What is Medicare severity diagnosis- related group or MS-DRG? | show 🗑
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| show | 25
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| How many days does a hospital have to file subsequent inpatient DRG adjustments from the date of the remittance advice for Medicare patients? | show 🗑
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| Who gets paid under the ambulatory payment classification or APC? | show 🗑
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| show | Services in each APC are similarly clinically and in terms of the resources they require. A payment rate is established for each group.
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| show | Yes
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| show | HCPCS/ CPT codes, e and m codes, diagnosis code, site of service.
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| show | When the patient dies before admission. They would need to add the CPT code for the inpatient only procedure and then add a CA modifier indicating that the patient died prior to admission as an inpatient.
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| Who is exempt from APCs? | show 🗑
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| Is the OPPS and APC the same type of payment methodology? | show 🗑
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| show | Acute care hospital outpatient services, hospital and distinct part hospital units exempt from inpatient PPS, partial hospitalization programs associated with community mental health centers.
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| show | A fee associated with the CPT and HCPTC codes that Medicare will allow. These are used for outpatient services including lab, screening, mammogram, and outpatient PT. Similar to how physician services are paid..
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| show | How Medicare pays for physician services. Not based on charges but based on three major elements.
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| show | Reschedule based on RVU's, MVPS, and limits on the amount non-participating physicians can charge beneficiaries.
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| show | Work required or work RVU, practice expense or PE, malpractice insurance expense or MP
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| What is usual, customary, and reasonable or UCR payment mythology? | show 🗑
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| What is skilled nursing facility perspective payment or SNF PPS? | show 🗑
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| show | A three-digit classification code assigned to each RUG, and a two-digit assessment indicator that specifies the type of assessment used to support the billing of the claim.
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| show | Hospital that serves rural communities. may not have any more than 25 inpt beds that may be used for swing bed services. They may op as a distinct part. Rehab/ psych unit with up to 10 beds. Have an alos of 96 hours or less per patient for acute care.
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|
||||
| Do critical access hospitals have to have a 24-hour emergency care service 7 days a week? | show 🗑
|
||||
| show | Must be located more than 35 mi drive from any hospital or CAH in an area with mountainous train or only secondary roads.
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|
||||
| Are critical access hospital subject to the IPPS or OPPS payment mythologies? | show 🗑
|
||||
| What are critical access hospitals paid? | show 🗑
|
||||
| Are critical access hospitals subject to Medicare Part A and Part B deductible and Co insurancees? | show 🗑
|
||||
| What is capitation payment mythology? | show 🗑
|
||||
| What is per diem payment mythology? | show 🗑
|
||||
| show | Percent of charges means that the claim is paid at a predetermined percentage discount rates
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|
||||
| show | It is the oldest method of payment. It is the mythology providers are paid for each medical service rendered to a patient.
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|
||||
| show | Electronic file that resides in the providers information system and that contains charges that can be posted to a patient's account.
🗑
|
||||
| What are other names for a chargemaster? | show 🗑
|
||||
| show | Department numbers, revenue codes, chargemaster numbers, charge descriptions, charge amounts, CPT/ HCPCS codes, modifiers, general ledger numbers.
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|
||||
| How often should I charge master be reviewed? | show 🗑
|
||||
| show | When insurance payer contracts with providers to receive discounts off Normally build charges.
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|
||||
| What are some elements of a pair contract? | show 🗑
|
||||
| show | A temporary substitute, especially for a doctor or a member of the clergy. Situation like weekends and when they provider is on vacation or absent. A substitute provider can be paid for services provided to a Medicare patient.
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|
||||
| show | The regular physician is unable to provide the services, the patient had a previously scheduled appointment or treatment with the regular physician, the substitute doesn't provide services to the patient for more than 60 days.
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|
||||
| show | UB-04 and 837i, super Bill, CMS-1500 and 837 p, itemist statement, statement, MSN, EOB, RA, and 835.
🗑
|
||||
| What does MSN stand for? | show 🗑
|
||||
| show | Remittance advice
🗑
|
||||
| What does EOB stand for? | show 🗑
|
||||
| show | The UB-04 refers to the hard copy version of the hospital claim form in the 837i refers to the electronic data set to submit claims to a payer.
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|
||||
| show | UB formats have distinct SL numbers and names assigned to each data element reported , UB formats do not distinctly different between patient data and subscriber data, UB contains 81 data elements and reports info about treat and con of PT.
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|
||||
| show | National uniform, billing committee or NUBC
🗑
|
||||
| show | Did UBO or paper format is divided into 81 boxes called field locators. The electronic version is divided into loops in segments
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|
||||
| show | CMS-1450
🗑
|
||||
| show | A two-digit code that clarifies an event or condition related to the bill that may affect payer processing
🗑
|
||||
| What are some common condition codes? | show 🗑
|
||||
| What are some common occurrence codes? | show 🗑
|
||||
| show | A two-digit code and a date that together clarify a significant event or condition related to a claim
🗑
|
||||
| show | A two-digit code followed by two dates that identify a span of time relevant to claim processing
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|
||||
| show | 70- non-utilization days, day for which the beneficiary has exhausted all regular coin days. 74 -9. Level of care, period non-cover level of care in a covered stay, 76- Pt liability , period non-covered care for which the hosp is perm to charge the pt
🗑
|
||||
| show | P a two-digit code and it's related amount of value that together clarifying an event or condition related to a claim
🗑
|
||||
| show | 08- lifetime reserve amount in the first calendar year in billing. 48- latest hemoglobin reading , A0- 5 digit zip code of location where the patient is initially placed on board the ambulance.
🗑
|
||||
| What is a revenue code? | show 🗑
|
||||
| What are common revenue codes? | show 🗑
|
||||
| What is a type of bill code? | show 🗑
|
||||
| show | Type of facility
🗑
|
||||
| show | 1 - hospital, 2- skilled nursing, 3- home health, 4-religious non-medical hospital, 5- religious non -medical extended care, 7- clinic, 8- special facility, ACS.
🗑
|
||||
| What is the second digit for type of bill code mean for Bill classification except clinics and special facilities , the first digit is 1-5? | show 🗑
|
||||
| What is the second digit for type of bill code mean for Bill classification clinics only, first digit is a 7? | show 🗑
|
||||
| What is the second digit for type of build code mean for Bill classification special facilities only, first digit is an 8? | show 🗑
|
||||
| What does the third digit for type of bill code relate to? | show 🗑
|
||||
| show | A, B, C, D, E, F, G, H, I, J, K, M, P. 0, 1, 2, 3, 4, 5, 7, 8, 9
🗑
|
||||
| What does the third digit type of bill code digit A mean? | show 🗑
|
||||
| What does the third digit for type of bill code digit B mean? | show 🗑
|
||||
| What does the third digit C Mean for type of bill code? | show 🗑
|
||||
| What does the third digit D type of bill code mean? | show 🗑
|
||||
| What does the third digit E for type of bill code mean? | show 🗑
|
||||
| What does the third digit F for type of bill code mean? | show 🗑
|
||||
| What does the third digit G for type of bill code mean? | show 🗑
|
||||
| show | CMS initiated adjustment claim- used to identify adjustments initiated by CMS. For FI use only.
🗑
|
||||
| show | FI adjustment claim other than qio or provider- used to identify adjustments initiated by the FI. For FI use only.
🗑
|
||||
| What does the third digit j mean for type of Bill code? | show 🗑
|
||||
| show | OIG initiated adjustment. Claim- used to identify adjustments initiated by OIG. For FI use only.
🗑
|
||||
| show | MSP initiated adjustment claim- used to identify adjustments initiated by MSP. For FI use only. Note: MSP takes precedence over other adjustment sources.
🗑
|
||||
| What does the third digit P mean for type of bill code? | show 🗑
|
||||
| show | Non-payment/zero claims- used when it does not anticipate payment from the payer for the bill, but is informing the pair about a period of non-payable confinement or termination of care.
🗑
|
||||
| show | Admit through discharge claim- used for a bill and compensating an entire inpt confinement or course of outpatient treatment for which it expects pmt from the payer or which it will update ded or inp t or Part B claims when Medicare is secondary to EGHP
🗑
|
||||
| show | Interim- first claim- used for the first of an expected series of bills for which utilization is chargeable or which will update inpt ded for the same confinement of course of treatment. For HHAs, used for the submission of org or replacement are RAPs.
🗑
|
||||
| What does the third digit 3 mean for type of bill code? | show 🗑
|
||||
| show | Interim- last claim- used for a bill for which utilization is chargeable and which is the last of a series for this confinements or course of treatments.
🗑
|
||||
| What does the third digit 5 mean for type of bill code? | show 🗑
|
||||
| What does the third digit 7 mean for type of bill code? | show 🗑
|
||||
| What does the third digit 8 mean for type of bill code? | show 🗑
|
||||
| show | Final claim for a home health PPS episode- used to indicate the HH bill should be processed as a debit or credit adjustment to the request of anticipated payment.
🗑
|
||||
| What is a super bill or encounter form? | show 🗑
|
||||
| show | No
🗑
|
||||
| What billing form is used to submit physician and professional services? | show 🗑
|
||||
| show | CMS- 1500
🗑
|
||||
| Should all Medicare claims be submitted electronically according to the administrative simplification compliance act? | show 🗑
|
||||
| show | A complete listing or detailed account of every service posted to a patient account to include the data, service, description, service code, charge amount, estimated insurance amounts, patient payment, and totals.
🗑
|
||||
| What is another name for itemized statement? | show 🗑
|
||||
| What is a data mailer or a statement? | show 🗑
|
||||
| What is a Medicare summary notice or MSN? | show 🗑
|
||||
| show | Remittance advice and was formerly known as the Medicare explanation of benefits.
🗑
|
||||
| show | Yes
🗑
|
||||
| show | It is a statement sent by the health insurance company to covered individuals explaining what medical treatments/ services were paid for when they're behalf. The RA is the same information but to the provider.
🗑
|
||||
| What are the only distinct differences between EOB and an RA? | show 🗑
|
||||
| show | EDI 835 files
🗑
|
||||
| Do EOBs contain protected health information? | show 🗑
|
||||
| show | The payer, the payee, patient name, dos, service performed, total charges, allowed amount, amount patient is responsible for, contractual adjustments, a brief explanation why claim was denied if denied.
🗑
|
||||
| show | Generally they only pay the amount the primary EOB says was the members responsibility.
🗑
|
||||
| What is the role of EOB's in identifying healthcare fraud and abuse? | show 🗑
|
||||
| For Medicare, if a covered service was furnished to a Medicare beneficiary, is it required to submit a claim for the services provided? | show 🗑
|
||||
| show | No
🗑
|
||||
| What is the penalty if he provider does not comply with filing a claim to Medicare if it is mandatory? | show 🗑
|
||||
| show | Medicare is listed as secondary payer, payment from the primary insurance sent directly to beneficiary, beneficiary. Not provide the primary insurance information, services were provided outside of United States, services excluded for Medicare, beneficiary signed. An ABN for services in indicated that they didn't want Medicare to be billed, the provider opted out of the Medicare program in.
Contract with the beneficiary, the provider has been barred or excluded from the Medicare program.
🗑
|
||||
| show | 365 days
For outpatients, the date is determined on the line items and for inpatient claim should have a span of dates and they use the "from" date to determine timely filing.
🗑
|
||||
| show | No, the claim must be written off
🗑
|
||||
| What is a late charge for facility billing? | show 🗑
|
||||
| What are some reasons late charges occur? | show 🗑
|
||||
| show | Late charges often have to be rebuild, causing delays and account resolution. Sometimes the late charges will just be credited from the account or written off instead of being rebuild.
🗑
|
||||
| Our late charges costly? | show 🗑
|
||||
| What is the 3-day payment window rule? | show 🗑
|
||||
| show | Similar to the 3 day payment window rule but for inpt psych hospitals, inpt rehab facilities,, long term care facilities, and children's and cancer hospitals.
🗑
|
||||
| How can electronic claims be generated? | show 🗑
|
||||
| show | Faster entry into payer system, less paper, faster sub to payer, proof of receipt, less clerical intervention, greater interest, fewer staffing resources, more reports, better follow-up capabilities.
🗑
|
||||
| show | Challenges with payer acceptance, inability to send attachments, inflexible vendor reporting, upload and download issues, challenges with backward integration.
🗑
|
||||
| show | NCCI, Outpatient Code Editor, Medicare Code Editor, MUE
🗑
|
||||
| show | National Correct Coding Initiative
🗑
|
||||
| What are NCCI edits? | show 🗑
|
||||
| show | It promotes correct coding methodologies and strives to eliminate improper coding.
🗑
|
||||
| show | Establish standards of medical billing, identify codes that may be potential for fraud and abuse, identify codes that are components of another code, and should not be unbundled and billed on the same encounter by the same provider.
🗑
|
||||
| show | Before the claim is paid. The processing system tests every pair of codes reported on the same DOS, for the same pt, and same provider.
🗑
|
||||
| show | An appropriate modifier.
🗑
|
||||
| What does OCE stand for? | show 🗑
|
||||
| show | Similar to the NCCI edits but apply to hospital outpatient services under the hospital OPPS.
🗑
|
||||
| show | - Determine whether a specific code is payable under the hospital OPPS
- Include many of the CCI edits
- Determine if the ASC limit applies to each bill
🗑
|
||||
| show | It is software that can detect incorrect billing data that is being submitted.
🗑
|
||||
| What are the 3 things that the MCE address to support the assignment of an MS-DRG. | show 🗑
|
||||
| What does MUE stand for? | show 🗑
|
||||
| show | prepayment
🗑
|
||||
| What is a MUE? | show 🗑
|
||||
| What are MUEs designed to do? | show 🗑
|
||||
| show | Sometimes
🗑
|
||||
| show | Not in most cases.
🗑
|
||||
| show | Correct Coding Solutions, the contractor who developed the program.
🗑
|
||||
| What is a "clean" claim? | show 🗑
|
||||
| What are "non-standard claims"? | show 🗑
|
||||
| What is an "incomplete" claim? | show 🗑
|
||||
| What is an "invalid" claim" | show 🗑
|
||||
| What happens if a claim is found to be incomplete or invalid? | show 🗑
|
||||
| show | Any claim that is considered incomplete or invalid.
🗑
|
||||
| How many days does Medicare allow for invalid or incomplete claims to be corrected? | show 🗑
|
||||
| show | To stay current on requirements and submitting accurate claims.
🗑
|
||||
| What could happen if errors go uncorrected and claims are paid inappropriately? | show 🗑
|
||||
| show | 1. Written policies and procedures
2. Have a Compliance officer and committee
3. Training and education
4. Lines of communication
5. Enforced standards and disciplinary procedures
6. Auditing and monitoring.
7. Responding to offenses and developing corrective action plans.
🗑
|
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larae711
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