Midterm Exam - Chapters 1-6
medical insurance - ANS>>-also known as health insurance
jj jj jj jj jj jj jj
-medical insurance: a written policy stating terms of an agreement between a policyholder
jj jj jj jj jj jj jj jj jj jj jj jj
and a health plan
jj jj jj jj
-health plans are often referred to as payers
jj jj jj jj jj jj jj
covered services - ANS>>may include primary care, emergency care, medical specialists'
jj jj jj jj jj jj jj jj jj jj
services, and surgery
jj jj jj
preventive medical services - ANS>>include physical exams, pediatric and adolescentjj jj jj jj jj jj jj jj jj
immunizations, prenatal care, and routine screening procedures
jj jj jj jj jj jj jj
excluded services - ANS>>-include dental services, eye care, employment related injuries,
jj jj jj jj jj jj jj jj jj jj
cosmetic procedures, or experimental/investigational procedures
jj jj jj jj jj
-preexisting condition: medical condition diagnoses before the policy took effect jj jj jj jj jj jj jj jj jj
managed care organizations (MCO) - ANS>>-managed care offers a more restricted
jj jj jj jj jj jj jj jj jj jj
choice of providers and treatments in exchange for lower premiums, deductibles, and
jj jj jj jj jj jj jj jj jj jj jj jj
other changes
jj jj
-MCOs establish links between provider, patient, and payer
jj jj jj jj jj jj jj
health maintenance organization (HMO) - ANS>>-combines coverage of medical costs
jj jj jj jj jj jj jj jj jj
and delivery of healthcare for prepaid premium
jj jj jj jj jj jj jj
-often require networks which is a group of providers having participation agreements with
jj jj jj jj jj jj jj jj jj jj jj jj
a health plan
jj jj jj
-HMO members may be required to choose a primary care physician
jj jj jj jj jj jj jj jj jj jj
preferred provider organization (PPO) - ANS>>-an MCO where a network of providers
jj jj jj jj jj jj jj jj jj jj jj
supply discounted treatment for plan members
jj jj jj jj jj jj
-most popular type of health plan
jj jj jj jj jj
-creates a network of physicians, hospitals, and other providers with negotiated discounts
jj jj jj jj jj jj jj jj jj jj jj
consumer driven health plan (CDHP) - ANS>>-combines a high deductible health plan with
jj jj jj jj jj jj jj jj jj jj jj jj
a medical savings plan
jj jj jj jj
-usually a PPO with high deductible and low premiums
jj jj jj jj jj jj jj jj
3 types of medical insurance payers - ANS>>-private payers: dominated by large
jj jj jj jj jj jj jj jj jj jj jj
insurance companies
jj jj
-self funded (self insured) health plans: organizations paying for health insurance directly
jj jj jj jj jj jj jj jj jj jj jj
by setting up a fund from which to pay
jj jj jj jj jj jj jj jj jj
-government sponsored healthcare programs: includes Medicare, Medicaid, TRICARE, jj jj jj jj jj jj jj
and CHAMPVA
jj jj
,medical billing cycle - ANS>>-10 step cycle that consists of series of steps leading to
jj jj jj jj jj jj jj jj jj jj jj jj jj jj
maximum, appropriate, and timely payment
jj jj jj jj jj
-steps
--1. preregister patients
jj jj jj
-- 2. establish financial responsibility
jj jj jj jj jj
--3. check in patients
jj jj jj jj
--4. review coding compliance
jj jj jj jj
--5. review billing compliance
jj jj jj jj
--6. check out patients
jj jj jj jj
--7. prepare and transmit claims
jj jj jj jj jj
--8. monitor payer adjudication
jj jj jj jj
--9. generate patient statements
jj jj jj jj
--10. follow up payments and collections
jj jj jj jj jj jj
medical record documentation - ANS>>-encounter: visit between patient and medical
jj jj jj jj jj jj jj jj jj
professional
jj
-evaluation and management (E/M): providers evaluation of a patient's condition, and jj jj jj jj jj jj jj jj jj jj
decision on a course of treatment
jj jj jj jj jj jj
HIPAA - ANS>>-federal act with guidelines for standardizing the electronic data
jj jj jj jj jj jj jj jj jj jj
interchange of administrative and financial healthcare transactions, exposing fraud and
jj jj jj jj jj jj jj jj jj jj
abuse, and protecting and securing PHI
jj jj jj jj jj jj
-protects private health information, ensures coverage, uncovers fraud and abuse, and
jj jj jj jj jj jj jj jj jj jj
creates industry standards
jj jj jj
-privacy rule jj
--law regulating use and disclosure of patients protected health information
jj jj jj jj jj jj jj jj jj jj
--protected health information: individually identifiable health information transmitted or
jj jj jj jj jj jj jj jj jj
maintained by electronic media
jj jj jj jj
-security rule jj
--requires CEs to establish safeguards to protect PHI
jj jj jj jj jj jj jj jj
--security measures
jj jj
---secure internet connections
jj jj jj
---access control, password, and log files
jj jj jj jj jj jj
---backups
jj
---security policies
jj jj
-HIPAA created the Health Care Fraud and Abuse control program to uncover and
jj jj jj jj jj jj jj jj jj jj jj jj
prosecute fraud and abuse in federal healthcare programs
jj jj jj jj jj jj jj jj
American Recovery and reinvestment act (ARRA) 2009 - ANS>>-law with provisions
jj jj jj jj jj jj jj jj jj jj
concerning standards for electronic transmission of healthcare data
jj jj jj jj jj jj jj jj
-contains the HITECH act: law promoting the adoption and meaningful use of health
jj jj jj jj jj jj jj jj jj jj jj jj
information technology
jj jj
new patients - ANS>>-patient who has not seen a particular provider within the past three
jj jj jj jj jj jj jj jj jj jj jj jj jj jj
years
jj
, -5 types of imformation are important
jj jj jj jj jj
--preregistration and scheduling information
jj jj jj jj
--medical history
jj jj
--patient/guarantor and insurance data
jj jj jj jj
--assignment of benefits
jj jj jj
-- acknowledgment of receipt of notice of privacy practices
jj jj jj jj jj jj jj jj jj
---form accompanying a covered entity's notice of privacy practices for the patient's
jj jj jj jj jj jj jj jj jj jj jj jj
signature, indicating the NPP has been read
jj jj jj jj jj jj jj
determining the primary insurance - ANS>>-primary insurance: health plan that pays jj jj jj jj jj jj jj jj jj jj
benefits first
jj jj
-secondary insurance: second payer on a claim jj jj jj jj jj jj
-tertiary insurance: third payer on a claim jj jj jj jj jj jj
-supplemental insurance: health plan that covers services not normally covered by a jj jj jj jj jj jj jj jj jj jj jj
primary insurance plan
jj jj jj
-coordination of benefits: explains how an insurance policy will pay if more than one policy jj jj jj jj jj jj jj jj jj jj jj jj jj jj
applies
jj
-birthday rule: guideline stating that the parent whose day of birth is earlier in the calendar
jj jj jj jj jj jj jj jj jj jj jj jj jj jj jj
year holds the primary policy
jj jj jj jj jj
-gender rule: guideline stating that when a child is covered by two health plans, the father's
jj jj jj jj jj jj jj jj jj jj jj jj jj jj jj
plan is the primary policy
jj jj jj jj jj
ICD-10-CM - ANS>>-used to code and classify morbidity (disease) data jj jj jj jj jj jj jj jj jj
-mandated for diagnoses under HIPAA electronic health care transactions and code sets jj jj jj jj jj jj jj jj jj jj jj
standards beginning October 1, 2015
jj jj jj jj jj
-code makeup jj
--code: three to seven character alphanumeric representation of a disease or condition
jj jj jj jj jj jj jj jj jj jj jj jj
---category: 3 character code
jj jj jj jj
---subcategory: 4 or 5 character code
jj jj jj jj jj jj
---when available, 6th and 7ths characters are required
jj jj jj jj jj jj jj jj
-updates are called addendas jj jj jj
-organization
--find main reason
jj jj jj
--find description of condition in alphabetic index
jj jj jj jj jj jj jj
--look up code found in alphabetic index, in the tabular list
jj jj jj jj jj jj jj jj jj jj jj
ICD-10-CM alphabetic index - ANS>>-organized by condition not body part jj jj jj jj jj jj jj jj jj
-main term: word that identifies a disease or condition in the alphabetic index
jj jj jj jj jj jj jj jj jj jj jj jj
-default code: code listed next to the main term in the alphabetic index that is most often
jj jj jj jj jj jj jj jj jj jj jj jj jj jj jj jj
associated with a particular disease or condition
jj jj jj jj jj jj jj
-subterm: word or phrase that describes a main term in the alphabetic index
jj jj jj jj jj jj jj jj jj jj jj jj
-etiology: cause or origin of disease or condition jj jj jj jj jj jj jj
-nonessential modifier: supplementary word or phrase that helps define a code jj jj jj jj jj jj jj jj jj jj
-not elsewhere classifiable (NEC): abbreviation indicating the code to use when a disease
jj jj jj jj jj jj jj jj jj jj jj jj
or condition cannot be placed in any other category
jj jj jj jj jj jj jj jj jj
medical insurance - ANS>>-also known as health insurance
jj jj jj jj jj jj jj
-medical insurance: a written policy stating terms of an agreement between a policyholder
jj jj jj jj jj jj jj jj jj jj jj jj
and a health plan
jj jj jj jj
-health plans are often referred to as payers
jj jj jj jj jj jj jj
covered services - ANS>>may include primary care, emergency care, medical specialists'
jj jj jj jj jj jj jj jj jj jj
services, and surgery
jj jj jj
preventive medical services - ANS>>include physical exams, pediatric and adolescentjj jj jj jj jj jj jj jj jj
immunizations, prenatal care, and routine screening procedures
jj jj jj jj jj jj jj
excluded services - ANS>>-include dental services, eye care, employment related injuries,
jj jj jj jj jj jj jj jj jj jj
cosmetic procedures, or experimental/investigational procedures
jj jj jj jj jj
-preexisting condition: medical condition diagnoses before the policy took effect jj jj jj jj jj jj jj jj jj
managed care organizations (MCO) - ANS>>-managed care offers a more restricted
jj jj jj jj jj jj jj jj jj jj
choice of providers and treatments in exchange for lower premiums, deductibles, and
jj jj jj jj jj jj jj jj jj jj jj jj
other changes
jj jj
-MCOs establish links between provider, patient, and payer
jj jj jj jj jj jj jj
health maintenance organization (HMO) - ANS>>-combines coverage of medical costs
jj jj jj jj jj jj jj jj jj
and delivery of healthcare for prepaid premium
jj jj jj jj jj jj jj
-often require networks which is a group of providers having participation agreements with
jj jj jj jj jj jj jj jj jj jj jj jj
a health plan
jj jj jj
-HMO members may be required to choose a primary care physician
jj jj jj jj jj jj jj jj jj jj
preferred provider organization (PPO) - ANS>>-an MCO where a network of providers
jj jj jj jj jj jj jj jj jj jj jj
supply discounted treatment for plan members
jj jj jj jj jj jj
-most popular type of health plan
jj jj jj jj jj
-creates a network of physicians, hospitals, and other providers with negotiated discounts
jj jj jj jj jj jj jj jj jj jj jj
consumer driven health plan (CDHP) - ANS>>-combines a high deductible health plan with
jj jj jj jj jj jj jj jj jj jj jj jj
a medical savings plan
jj jj jj jj
-usually a PPO with high deductible and low premiums
jj jj jj jj jj jj jj jj
3 types of medical insurance payers - ANS>>-private payers: dominated by large
jj jj jj jj jj jj jj jj jj jj jj
insurance companies
jj jj
-self funded (self insured) health plans: organizations paying for health insurance directly
jj jj jj jj jj jj jj jj jj jj jj
by setting up a fund from which to pay
jj jj jj jj jj jj jj jj jj
-government sponsored healthcare programs: includes Medicare, Medicaid, TRICARE, jj jj jj jj jj jj jj
and CHAMPVA
jj jj
,medical billing cycle - ANS>>-10 step cycle that consists of series of steps leading to
jj jj jj jj jj jj jj jj jj jj jj jj jj jj
maximum, appropriate, and timely payment
jj jj jj jj jj
-steps
--1. preregister patients
jj jj jj
-- 2. establish financial responsibility
jj jj jj jj jj
--3. check in patients
jj jj jj jj
--4. review coding compliance
jj jj jj jj
--5. review billing compliance
jj jj jj jj
--6. check out patients
jj jj jj jj
--7. prepare and transmit claims
jj jj jj jj jj
--8. monitor payer adjudication
jj jj jj jj
--9. generate patient statements
jj jj jj jj
--10. follow up payments and collections
jj jj jj jj jj jj
medical record documentation - ANS>>-encounter: visit between patient and medical
jj jj jj jj jj jj jj jj jj
professional
jj
-evaluation and management (E/M): providers evaluation of a patient's condition, and jj jj jj jj jj jj jj jj jj jj
decision on a course of treatment
jj jj jj jj jj jj
HIPAA - ANS>>-federal act with guidelines for standardizing the electronic data
jj jj jj jj jj jj jj jj jj jj
interchange of administrative and financial healthcare transactions, exposing fraud and
jj jj jj jj jj jj jj jj jj jj
abuse, and protecting and securing PHI
jj jj jj jj jj jj
-protects private health information, ensures coverage, uncovers fraud and abuse, and
jj jj jj jj jj jj jj jj jj jj
creates industry standards
jj jj jj
-privacy rule jj
--law regulating use and disclosure of patients protected health information
jj jj jj jj jj jj jj jj jj jj
--protected health information: individually identifiable health information transmitted or
jj jj jj jj jj jj jj jj jj
maintained by electronic media
jj jj jj jj
-security rule jj
--requires CEs to establish safeguards to protect PHI
jj jj jj jj jj jj jj jj
--security measures
jj jj
---secure internet connections
jj jj jj
---access control, password, and log files
jj jj jj jj jj jj
---backups
jj
---security policies
jj jj
-HIPAA created the Health Care Fraud and Abuse control program to uncover and
jj jj jj jj jj jj jj jj jj jj jj jj
prosecute fraud and abuse in federal healthcare programs
jj jj jj jj jj jj jj jj
American Recovery and reinvestment act (ARRA) 2009 - ANS>>-law with provisions
jj jj jj jj jj jj jj jj jj jj
concerning standards for electronic transmission of healthcare data
jj jj jj jj jj jj jj jj
-contains the HITECH act: law promoting the adoption and meaningful use of health
jj jj jj jj jj jj jj jj jj jj jj jj
information technology
jj jj
new patients - ANS>>-patient who has not seen a particular provider within the past three
jj jj jj jj jj jj jj jj jj jj jj jj jj jj
years
jj
, -5 types of imformation are important
jj jj jj jj jj
--preregistration and scheduling information
jj jj jj jj
--medical history
jj jj
--patient/guarantor and insurance data
jj jj jj jj
--assignment of benefits
jj jj jj
-- acknowledgment of receipt of notice of privacy practices
jj jj jj jj jj jj jj jj jj
---form accompanying a covered entity's notice of privacy practices for the patient's
jj jj jj jj jj jj jj jj jj jj jj jj
signature, indicating the NPP has been read
jj jj jj jj jj jj jj
determining the primary insurance - ANS>>-primary insurance: health plan that pays jj jj jj jj jj jj jj jj jj jj
benefits first
jj jj
-secondary insurance: second payer on a claim jj jj jj jj jj jj
-tertiary insurance: third payer on a claim jj jj jj jj jj jj
-supplemental insurance: health plan that covers services not normally covered by a jj jj jj jj jj jj jj jj jj jj jj
primary insurance plan
jj jj jj
-coordination of benefits: explains how an insurance policy will pay if more than one policy jj jj jj jj jj jj jj jj jj jj jj jj jj jj
applies
jj
-birthday rule: guideline stating that the parent whose day of birth is earlier in the calendar
jj jj jj jj jj jj jj jj jj jj jj jj jj jj jj
year holds the primary policy
jj jj jj jj jj
-gender rule: guideline stating that when a child is covered by two health plans, the father's
jj jj jj jj jj jj jj jj jj jj jj jj jj jj jj
plan is the primary policy
jj jj jj jj jj
ICD-10-CM - ANS>>-used to code and classify morbidity (disease) data jj jj jj jj jj jj jj jj jj
-mandated for diagnoses under HIPAA electronic health care transactions and code sets jj jj jj jj jj jj jj jj jj jj jj
standards beginning October 1, 2015
jj jj jj jj jj
-code makeup jj
--code: three to seven character alphanumeric representation of a disease or condition
jj jj jj jj jj jj jj jj jj jj jj jj
---category: 3 character code
jj jj jj jj
---subcategory: 4 or 5 character code
jj jj jj jj jj jj
---when available, 6th and 7ths characters are required
jj jj jj jj jj jj jj jj
-updates are called addendas jj jj jj
-organization
--find main reason
jj jj jj
--find description of condition in alphabetic index
jj jj jj jj jj jj jj
--look up code found in alphabetic index, in the tabular list
jj jj jj jj jj jj jj jj jj jj jj
ICD-10-CM alphabetic index - ANS>>-organized by condition not body part jj jj jj jj jj jj jj jj jj
-main term: word that identifies a disease or condition in the alphabetic index
jj jj jj jj jj jj jj jj jj jj jj jj
-default code: code listed next to the main term in the alphabetic index that is most often
jj jj jj jj jj jj jj jj jj jj jj jj jj jj jj jj
associated with a particular disease or condition
jj jj jj jj jj jj jj
-subterm: word or phrase that describes a main term in the alphabetic index
jj jj jj jj jj jj jj jj jj jj jj jj
-etiology: cause or origin of disease or condition jj jj jj jj jj jj jj
-nonessential modifier: supplementary word or phrase that helps define a code jj jj jj jj jj jj jj jj jj jj
-not elsewhere classifiable (NEC): abbreviation indicating the code to use when a disease
jj jj jj jj jj jj jj jj jj jj jj jj
or condition cannot be placed in any other category
jj jj jj jj jj jj jj jj jj
