• found in some non-Medicare health plan contracts
• prohibits billing to patient for anything beyond deductivles and copays.

• more accurate payment of claims
• fewer billing mistakes
• improved documentation and more accurate coding
• less chance of violating self-referral and anti-kickback status

ABN form 

or

Advance Beneficiary Notice which explains to the patient why Medicare may deny the particular service or procedure.

IF:          

Work RVUs = 0.48

Work GPCI = 1.000

Practice Expense CPCI = 0.943

MP GPCI = 0.572

transitioned non-facility practice RVUs = 0.70

Calculate non-facility pricing amount for cpt code 99212 using 2011 CF of $33.9764

$39.51 Non-facility pricing amount

(physician office, private practice)

Advance Beneficiarly Notice of NonCoverage (Advance Benefiary Notice, or ABN)

• a given service is indicated or necessary, 
• give guidance on coverage limitations
• describe the specific CPT codes to which the policy applies
• lists IICD-9-CM codes that support medical necessity for the given service or procedure

medically necessary physicians' services

ouptatient care

other medical services (including some preventative services) not covered under Part A

inpatient hospital care

care provided in skilled nursing facilities

hospice care

home health care

resource-based relative value scale

(RBRVS)

• Implement compliance and practice standards through the development of written standards and procedures.
• designate a compliance officer or contac to monitor compliance efforts and enforce practice standards
• conduct appropriate training and education of practice standards and procedures
• conduct internal monitoring and auditing through the performance of periodic audits
• respond appropriately to detected violations through the investigation of allegations through the investigation of allegations and the disclosure of incidents to appropriate government entitities
• Develop open lines of communication
• Enforce disciplinary standards through well-publicized guidelines

physican work

practice expense

professional liability insurance

Sebacious glands are a part of which anatomic system?

$100 or 25% of cost

RATIONALE: CMS instructions stipulate, "Notifires msut make a good faith effort to insert a reasonable estimate....the estimate should be within $100 or 25% of the actual costs, whichever is greater.

• disclosures to or requests by a health care provider for treatment purposes
• disclosures to the individual who is the subject of the information
• uses or disclosures made pursuant to an individual's authorization
• uses or disclosures required for compliance with the HIPAA Administrative Simplification Rules
• Disclosures to the US Dept of Health and Human Services when disclosure of info is required under the Privacy Rule for enforcement purposes.
• Uses or disclosures that are required by other law

LCD

Each MAC (Medicare Adminstrative Contractor) is responsible for interpreting national policies into regional policies, or Local Coverage Determinations

When a service is not expecgted to be covered by Medicare.

RATIONALE: This form explains to the patient why a service MAY be denied by Medicare. The ABN form should be completed for services potentially con-covered by Medicare to advise the patient of potential financial responsibility.

Which of the following has a refraction function in the eye?

• macula
• retina
• lens
• iris

Which of the following is a function of the pancreas?

• supplies digestive enzymes
  manufactures melatonin
• stimulates growth
• secretes vasopressin 

Which of the following is a renal calculus?

• Pyelectasia
• Hydroureter
• Nephrolithiasis
• Pyonephrosis

each MAC

(Medicare Administrative Contractor)

NCHS (National Centers for Health Statistics) and the

CMS (Centers for Medicare & Medicaid Services)

When sequencing codes, the codes listed under the "use additional code" are secondary

282.42 Sickle-cell thalassemia with crisis

Sickle-cell thalassemia with vaso-occlusive pain

Thalassemia Hb-S disease with crisis

Use additional code for the type of crisis, such as:

acute chest syndrome (517.3)

splenic sequestration (289.52)

correct sequence for sickle-cell thalassemia crisis with acute chest syndrome in correct sequence are: