Term
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Definition
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Definition
| Medicare Severity Diagnosis Related Group |
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Definition
Balanced Budget Act of 1997
Public Law 105-33
Signed by Clinton
Changes to Medicare and Medicaid
Expanded Services for CMS programs including SCHIP
Extended MCare Trust Fund to fight fraud & abuse
Increased HC for seniors |
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Definition
| Healthcare Procedure Coding System |
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Definition
| Current Procedural Terminology 4th Ed. |
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Definition
| Advanced Beneficiary Notice |
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Definition
| Aid to Families with Dependent Children |
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Definition
| American Hospital Association |
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Definition
| Agency for Health Care Administration |
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Definition
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Definition
Against Medical Advice
OR
American Medical Association |
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Definition
| American National Standards Institute |
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Definition
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Definition
| Ambulatory Surgical Center |
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Definition
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Definition
National Correct Coding Initiative
Jan 1st 1996 |
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Definition
| Benficiary Notices Initative |
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Definition
| Crippled Children's Services |
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Term
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Definition
| Current Dental Terminology |
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Term
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Definition
| Comprehensive Error Rate Testing |
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Term
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Definition
| Continued Health Care Benefit Program |
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Term
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Definition
| Clinical Laboratory Improvement AMENDMENT |
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Term
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Definition
| Community Mental Health Clinic |
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Term
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Definition
| Comprehensive Outpatient Rehabilitation Facility |
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Definition
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Term
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Definition
| Federal Employees' Compensation Act |
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Definition
| Governmen Printing Office |
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Term
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Definition
| Health Provider Shortage Area |
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Term
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Definition
| Intermediate Care Facility |
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Term
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Definition
| Investigational Device Exemption |
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Term
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Definition
| Initial Enrollment Questionnaire |
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Term
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Definition
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Term
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Definition
| Inpatient Prospective Payment System |
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Term
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Definition
| Local Medical Review Policies |
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Term
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Definition
| Maximum Allowable Actual Charge |
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Term
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Definition
| Medicare Administrative Contractor |
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Term
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Definition
| Major Diagnostic Categories |
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Term
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Definition
| Medicare Hospital Insurance |
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Term
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Definition
| Medicaid Integrity Contractors |
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Term
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Definition
| Medicaid Integrity Program |
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Term
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Definition
| Medicare Modernization Act |
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Definition
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Term
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Definition
| National Association of Insurance Commissioners |
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Term
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Definition
| Medicare Volume Performance Standard |
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Term
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Definition
| National Uniform Billing Committee |
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Term
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Definition
| National Uniform Claim Committee |
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Term
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Definition
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Term
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Definition
| Parallel Operating Environment |
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Term
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Definition
| Patient Self Determination Act |
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Term
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Definition
| Resource-Based Relative Value Scale |
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Term
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Definition
| Residental Treatment Centers |
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Term
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Definition
| State Uniform Billing Committee |
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Term
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Definition
| Treatment Authorization Number |
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Term
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Definition
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Term
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Definition
| Usual Customary and reasonable |
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Definition
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Term
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Definition
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Term
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Definition
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Term
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Definition
| Military Treatment Facility |
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Term
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Definition
| Emergency Medical Treatment and Active Labor Act |
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Term
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Definition
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Term
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Definition
Hill Burton
Financial Allowance |
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Term
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Definition
Relative Value Unit
Foundation for the Fee Schedule
Work Required
Practice Expense
Malpractice Insurance Expense |
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Term
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Definition
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Term
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Definition
| Professional Standards Review Organization |
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Term
| Medicare Types of Charges |
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Definition
Actual-actual charges for service rendered
Approved-Medicare ceiling within geographical area
Global-summ or pro and technical provided and billed by same physician
Prevailing-going rate within an area
UCR-charge consistent within an area |
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Term
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Definition
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Term
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Definition
Acute Inpatient-illness or trauma (generally short term
Observation (OBS)- use of bed and periodic monitoring by nursing staff
Long-term care-chronically ill or disabled in nursing facility
Respite Care-short term and temporary
Custodial Care-NOT COVERED by Medicare, in-house by family
Home Health Care-approved by Medicare only is signed off by physician (gatekeeper) and provided by trained caregiver |
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Term
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Definition
Prime-MTF is primary source
Extra-PPO
Standard-FFS Option (old Champus)
Tricare for Life-Medicare supplemental
Active Military in Prime |
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Term
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Definition
| Health Insurance Coverage Number or Claim Number |
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Term
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Definition
International Classification of Diseases, Volume 9
-CM: Clinical Modification
I: Diagnostic Tabular Listing
II:Diagnostic Index
III:Procedure (for use on IP claims) |
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Term
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Definition
Resource Utilization Group
53 RUGS used to assess payments for SNF patients |
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Term
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Definition
| Omnibus Budget Reconciliation Act of 1986 |
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Term
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Definition
| Consolidated Omnibus Budget Reconciliation Act of 1985 |
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Term
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Definition
| Tax Equity and Fiscal Responsibility Act of 1982 |
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Term
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Definition
| Deficit Equity and Reduction Act of 1984 |
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Term
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Definition
| State Children Health Insurance Program |
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Term
| Division of Access Services |
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Definition
Scheduling
Pre-reg
Pre-deposit
Inpt Admitting
Outpatient Reg
Pre-certification |
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Term
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Definition
Base for 2010:$1100.00
Part A Ded Days 1-60 100%
Co-ins per DAY 61-90 25%
Co-ins per DAY 91-150 (Lifetime Reserve) 50%
SNF Days 1-20 $0.00
SNF Days 21-100 12.5%
Part B: $155.00 |
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Term
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Definition
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Term
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Definition
| Patients protected from liability if they did not know the services would not be covered |
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Term
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Definition
| Pre-admit testing on OP basis needs to be bundled with IP claim if DX code are the same |
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Term
| Exceptions to 72-hour rule |
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Definition
But have 24-hour rule:
Psych hospitals
Rehab hosp
Children's hosp
LT Care hosp
Cancer hosp |
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Term
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Definition
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Term
| MS-DRG created on 3 tiers of payments |
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Definition
A major complication or comorbidity (mcc)
A complication or comorbidity (cc)
No compliacation or comorbidity |
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Term
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Definition
| Health Insurance Portability and Accountability Act of 1996 |
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Term
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Definition
Related to something other than disease
Chronic illness or routine exam
Revisit on chronic illness |
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Term
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Definition
Evaluation and Management
3 key components:
history
exam
decision making
Contributary:
Counseling
Coordination of Care
Nature of presenting problem |
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Term
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Definition
1: 5-digit number code (CPT)
2: Alphanumeric codes assigned by CMS
3: Alphanumeric assigned by MCare as "temp CPT" |
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Term
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Definition
| Unique Physician Identification Number |
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Term
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Definition
| Office of Inspector General |
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Term
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Definition
| Freedom of Information Act |
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Term
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Definition
| Railroad Retirement Board |
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Term
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Definition
Non-Availability Statement
Issued by commander when something can't be done at a MTF
Good for 30 days |
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Definition
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Term
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Definition
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Definition
| Joint Commission on Accreditation of Healthcare Organizations |
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Term
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Definition
| Civilian Health and Medical Program of the Veterans Administration |
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Term
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Definition
| NO PAY CLAIM to Medicare based on UR and Admitting Physician disagreement (from an inpatient hospital bill) |
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Term
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Definition
| Voice Case Information System (confirm bankruptcy) |
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Term
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Definition
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Term
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Definition
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Term
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Definition
| Operation Restore Trust of 1995 |
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Term
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Definition
| Uniform Billing Form 2004 |
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Term
| Who developed the Patient Bill of Right? When? |
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Definition
American Medical Association
1975 |
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Term
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Definition
| Health Care Financing Administration (old name of CMS) |
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Term
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Definition
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Term
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Definition
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Term
| Largest Health Insurer in US |
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Definition
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Term
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Definition
| Parent whose birthday occurs first during in the year is primary for children when covered by both parents (except in specified court directives) |
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Term
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Definition
IDs the conditions related to the bill that may affect payer processing
ex: -02 Employment Related
-21 Billing for Denial
-40 Same Day Transfer
FL 18-28 |
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Term
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Definition
IDs the specific date defining a significant event related to the bill
-01 auto accident
-11 date of onset
-18 patient/bene retirement
FL 31-34 |
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Term
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Definition
IDs monetary values
-01 Most Common Semi-Private Rate
-12 Working Aged with EGHP
-13 ESRD in coordination with EGHP
FL 39-41 |
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Term
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Definition
IDs specific accomodation, ancilary service or billing calc
-250 Pharm
-300 Lab
-450 ED
FL 42-49 |
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Term
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Definition
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Term
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Definition
1st-Type of Facility (1=Hospital)
2nd-Bill Classication (1=Inpatient Part A, 3=OP)
3rd: Frequency (0=NonPayment/Zero claim) |
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Term
| # of FI, Carriers and MACS |
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Definition
| 25 FI, 18 Carriers will be replaced by 15 MACS by 2011 |
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Term
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Definition
Individuals and business
Assets auctioned to cover liabilities
Debt totally discharged
70% |
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Term
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Definition
| Reorganization...for distressed businesses |
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Term
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Definition
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Term
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Definition
| Individuals on repayment schedule over 3 years |
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Term
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Definition
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Term
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Definition
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Term
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Definition
| Medicare Moderization Act |
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Term
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Definition
Who are you speaking with?
What are they doing with the claim?
When is the claim going to be paid?
Where is the claim in their process and shere are they going to send the payment?
Why hasn't the claim been paid yet? |
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Term
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Definition
| misuse of a person, substance service or finaicial matter such that harm is caused |
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Term
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Definition
| The intentional or illegal descption or misrepresentation made for the purpose of personal gain, or to harm or manipulate another person or organization |
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Term
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Definition
| A person who moves of changes their residency, but fails to motify creditors. A forwarding address is normally on file. |
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Term
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Definition
| A debtor who can not be located by the creditor. |
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Term
| Recommended % of pre-registered inpatients |
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Definition
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Term
| 5 collection control points |
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Definition
Pre-Admission
Admission
In-house
At Discharge
After Discharge |
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Term
| Who qualifies for CHAMPVA? |
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Definition
| Injured vets and dependents |
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Term
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Definition
| Anyone that participates in MEDICARE |
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Term
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Definition
Acitve Duty Service Members
Eligible family of Active Duty
Miliary retirees and family
Surviving family members
Wards and legally adopted children
Some former spouses who meet length of marriage rules |
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Term
| Who's not eligible for TRICARE? |
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Definition
| Eligible for Medicare and over 65 , unless still active |
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Term
| Can you have CHAMPVA and TRICARE at same time? |
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Definition
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Term
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Definition
18-36 months after seperation from service or loss of eligiblity
Cobra for Tricare
Must enroll within 60 days |
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Term
| TRICARE Standard pays by DRG for IP in all states except |
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Definition
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Term
| NAS is good for how long? |
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Definition
30 days from issuance
42 days after pregnancy
15 days after mother's discharge if newborn still in-house |
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Term
| Exceptions to NAS requirement |
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Definition
Has other health insurance
Medical or psych emerg admit or op emerg
Benefits under Program for the Person with Disabilities
More than 40 mile catchment area
SNF or RTC admits
Student Infirmaries |
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Term
| Filing period for TRICARE claims |
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Definition
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Term
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Definition
Medicaid
Indian Halth Servies
Supplemental insurance |
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Term
| When is Tricare secondary? |
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Definition
Workman's Comp
Auto policy
Student Insurance
HMO
PPO |
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Term
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Definition
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Term
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Definition
"Benefit Period"
60 consecutive days after discharge |
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Term
| Inpatient Hosp Benefit Days |
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Definition
30 "full days" " covered days"
60 "co-insurance"
30 "lifetime reserve"
Hosp MUST notify pt when only have 5 days left on their co-insurance |
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Term
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Definition
| 3 days in hospital PLUS discharge day |
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Term
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Definition
Preferably before admission
Authorization for ALOS
NOt guarantee of payment |
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Term
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Definition
Advanced Beneficiary Notice
April 1 1998 |
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Term
| Which services' coverage is limited by ABN? |
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Definition
Labs
Radiology
Cardiovascular Testing |
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Term
| Options patient can take on an ABN: |
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Definition
1. Want the test, but bill Medicare for official decision
2.Want test, but don't bill Medicare
3. I don't want the test |
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Term
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Definition
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Term
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Definition
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Term
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Definition
| Medicare's eligibility system |
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Term
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Definition
Pass all front-end claim edits
Processed electronically
If investigated, won't require contact
If reviewed, all medicare evidence is attached
Not developed on a post-payment basis (not a denial appeal claim) |
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Term
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Definition
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Term
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Definition
| Type of patient and procedure covered? |
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Term
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Definition
| procedure and diagnostic info clinically consistent? |
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Term
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Definition
| 3 months before patient becomes eligible for Medicare |
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Term
| Medicare is secondary to: |
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Definition
Worker's Comp
Auto
Federal Black Lung
ESRD only for first 30-months |
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Term
| How long on Medicare for ESRD? |
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Definition
12 months post dialysis
36 months post kidney transplant |
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Term
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Definition
| Employer Group Health Plan |
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Term
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Definition
When Medciare isn't sure who is primary
120 days |
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Term
| If provider doesn't accept Medicare assignment: |
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Definition
1. Can charge up to 115% Medicare amount
2. Ask for entire payment up front
3. Still submit claim to Medicare |
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Term
| Revenue Codes are reviewed by who? When? |
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Definition
CMS, NUBC, and SUBCs
On-going basis |
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Term
| Elements of a Charge Master |
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Definition
Department Numbers/Cost Centers
Revenue Codes
Charge Master numbers
Charge Description Charge Amounts
CPT/HCPCS
Modifiers
General Ledger Numbers |
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Term
| Where would you find the Charge info on the UB04? |
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Definition
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Term
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Definition
| Defense Enrollment Eligibility Reporting System |
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Term
| When can V-codes be primary? |
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Definition
| Only when ancillary services are provided |
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Term
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Definition
| Annually, going into effect January 1st |
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Term
| Date NCCI went into effect? |
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Definition
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Term
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Definition
Establish standareds of medical billing
Identify codes that may be a potential for fraud and abuse
Identify codes that are componenets of another code and shouldn't be undundled or billed at the same time |
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Term
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Definition
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Term
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Definition
| Ambulatory Payment Classifications |
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Term
| How many Never Events are there? |
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Definition
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Term
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Definition
paid fixed per capita amount for each person served, regardless of services
"per member per month" |
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Term
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Definition
| payment based on straight charges (often contractually discounted) |
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Term
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Definition
| Payor determines set payment amount for each service...typically adjusted annually |
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Term
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Definition
| Set rate per day in hospital regardless of actual charges or costs |
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Term
| ABN contains what information? |
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Definition
Listing ot test(s)
Estimated cost of the tests
Reason denial is likely
Statement that that patient is responsible for charges
Area for patient to sign |
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Term
| MSN covers what period of time? |
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Definition
| 3-months worth of Medicare billed services |
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Term
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Definition
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Term
| Can an admitting clerk decline admitting a patient? |
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Definition
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Term
| Who can admit a patient to a hospital? |
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Definition
| Members of medical staff ONLY; not administrators |
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Term
| The Privacy Act of 1974 protect who from whom? |
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Definition
| The patient from misuse of records by FEDERAL agencies only; generally doesn't cover States or private organizations! |
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Term
| Who is covered under the Privacy Act? |
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Definition
| US Citizens and aliens lawfully admitted for permanent residence ONLY |
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Term
| Criteria for Relase of Medical Records: |
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Definition
1. Nothing released without patient's consent, unless
2. Furnished in civil or criminal action upon issuance of a subpoena
3. Records can be faxed
4. Need specific (detailed) authorization for HIV/AIDS, psych, alcohol and drug dependency |
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Term
| Who is authorized to make entries in medical records? |
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Definition
1. Treating or attending physician
2. Physician extenders (PA, NP)
3. Licensed RN
4. Health profession students (under supervision) |
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Term
| Verbal/teephone orders can be accepted by: |
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Definition
1. Physician Extenders (PA,NP)
2. Licensed/Registered Nurses |
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Term
| Advanced Medical Directives are also known as: |
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Definition
| Patient Self Determination Act |
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Term
| Advanced Directives do what 2 main things: |
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Definition
1. Give medical power of attorney to someone else if the patient becomes incapacitated
2. give direction about future medical care |
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Term
| Advanced Directives were the result of what legistation? |
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Definition
|
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Term
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Definition
| another name for Advanced Directive |
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Term
| How can an advanced directive by revoked? |
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Definition
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Term
| Agencies are usually the _____ payor. |
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Definition
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Term
| Liability insurance (Work comp, auto, etc) are usually the _______ payor. |
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Definition
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Term
| How many employees must an employer have for it's 65+ employees to be considered Working Aged? |
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Definition
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Term
| General consent forms cover: |
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Definition
Routing Lab testing
Diagnostic Imaging
Medical Treatment |
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Term
| Special consent forms are required for: |
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Definition
HIV Positive testing
Surgery (major and minor)
Anesthesia
Non-surgical procedures with more than a slight risk
Cobalt or radiation therapy
Electroshock or psych treatment
Experimental procedures
Drug/alcohol treatment |
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Term
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Definition
| Patient gives either written or oral consent. |
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Term
| Implied consent "in fact" vs. "by law" |
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Definition
In fact: patient doesn't object (but is able to)
By law: patient is unconscious and pt is taken to the ER |
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Term
| How is Informed consent different from Actual/expressed consent? |
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Definition
| Patient understand their condition and what will be performed |
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Term
| When is a minor consider emancipated (by court of law)? |
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Definition
1. no longer requires parental guidance or financial support
2. fathered or gave birth to a child
3. reached age or majority (18 to 21, depending on state) |
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Term
|
Definition
| Primary Care physician in Managed Care Plans that directs patient care to specialists and facilities. |
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Term
| How often can JCAHO conduct audits? |
|
Definition
| Typically every 3 years, but as soon as 9 months and as late as 30 months...unannounced!!! |
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Term
| 3 phases of emergency planning: |
|
Definition
1. Response
2. Back-up
3. Recovery |
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Term
| When is census most often taken? |
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Definition
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Term
| Avg Daily Census calculation |
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Definition
| sum of total patient days in month/total number of days |
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Term
| % of occupancy calculations |
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Definition
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Term
|
Definition
| uncollecible account resulting from the extension of credit |
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Term
|
Definition
| services provided where it is never expected to result in cash flow |
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Term
|
Definition
| patient that has no means of paying for medical services and is not eligible under Medicaid or other assistance program |
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Term
|
Definition
| a legally verifiable claim against a debtor |
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Term
|
Definition
| health insurance/benfit plan offered by private entity to supplement Medicare beneficiaries that are also on Medicaid |
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Term
| OBRA impacts employers with how many employees? |
|
Definition
|
|
Term
| TEFRA, DEFRA and COBRA impact employers with how many employees? |
|
Definition
|
|
Term
| What are the two governing bodies effecting healthcare charge? |
|
Definition
|
|
Term
| How many agencies are there under DHHS? |
|
Definition
|
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Term
# of DHHS Operating Division
Name them |
|
Definition
11
1. National Institites of Health (NIH)
2. Food and Drug Admin (FDA)
3. Centers for Disease Control and Prevention (CDC)
4. Agency for Toxic Substances and Disease Registry (ATSDR)
5. Indian Health Services (IHS)
6. Health Resources and Services Admin (HRSA)
7. Substance Abuse and Mental Health Services Admin (SAMHSA)
8. Agency for Health CAre Research and Quality (AHRQ)
9. Centers for Medicare and Medicaid Services (CMS)
10. Admin for Children and Family (ACF)
11. Admin on Aging (AOA) |
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Term
| What year did The Social Security Admin seperate from DHHS? |
|
Definition
|
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Term
|
Definition
Center for Medicare Management
Center for Beneficiary Choices
Center for Medicaid and State Operations |
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Term
| To CMS, healthcare security means: |
|
Definition
Access to affordable and quality healthcare services
Protection of the rights and dignity of beneficiaries
Provision of clear and useful information |
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Term
| What president signed Medicare into law? |
|
Definition
|
|
Term
|
Definition
| Individual is entitled to Medicare Part A and/or B and is also eligible to Medicaid |
|
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Term
|
Definition
| 2009 by Obama in the Children's Health Insurance Program Reauthorization Act |
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Term
| Health Savings Accounts were part of which legislation? |
|
Definition
|
|
Term
| Fraud and Abuse Control is coordinated by: |
|
Definition
|
|
Term
| What is the Fraud Reporting Hotline #: |
|
Definition
|
|
Term
| Once notified of a Ch 7 bankruptsy, you must: |
|
Definition
Flag the patient account
Suspend all collection activity (pending final disposition)
Cease all contact with patient
Notify any third pary collection agencies
Forward a copy of the Notice to all third pary collection agency
Notify all parties if any payments are received |
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Term
| What are the "usual times" for collection calls outlined in the FDPCA? |
|
Definition
|
|
Term
| How many days does a patient have to notify the hospital of statement errors |
|
Definition
|
|
Term
| How many days does the hospital have to respond to a patient complaints of statement errors? |
|
Definition
|
|
Term
| How long does the hospital have to legitimate statement errors? |
|
Definition
| 2 billing cycles or a max of 90 days |
|
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Term
| What should you do when you find out a patient is deceased? |
|
Definition
Check if legitimate estate exists
Change the mailing address to "The Estate of ..."
If no estate exists and another party has not assumed financial responsiblity, write off the balance
Check register of wills for estate information |
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Term
| Statutes of limitations are greatest for what? |
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Definition
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Term
| What might extend statutes of limitations? |
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Definition
Obtain a written "promise to pay"
Obtain a partial payment on the principal account
Reduce the account to judgement immediately
Execute a new contract |
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Term
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Definition
| Recorded claim against real or personal property, generally arising out of a debt |
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Term
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Definition
| liability for an injury or wrongdoing done by one person to another resulting from a breach of legal duty |
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Term
| Average Daily Revenue Calculation |
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Definition
| Total Charges or Recue for x # of days/total # of days |
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Term
| Average Days in A/R Calculation |
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Definition
| Accounts Receivable at specific time/Average Daily Revenue |
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Term
| What are the levels # of creditors/ $ for involuntary bankruptsy |
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Definition
12 of more creditors, 3 with more than $5k
OR
Fewer than 12, but one must be $10,775 |
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