CPC COMPLIANCE AND REGULATORY ELABOARATIONS

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outpatient coding - focuses on physician professional services and outpatient facility coding. coders should learn cpt, hcpcs level 2 and icd-10-cm hospital inpatient coding - focuses on a different subset of skills, where coders will work with icd-10-cm and icd-10-pcs. coders assign medical severity diagnosis related groups (ms-drgs) types of providers - 1. primary care provider (pcp) 2. physician extenders 3. participating providers 4. non participating providers pcp - primary care provider (gate keeper) physician extenders - mid-level provider, advanced practice registered nurse (arpn), nurse practitioner (np), physician assistant (pa), clinical nurse specialist (cns) participating providers - par provider or in network provider (inn) - is one contracted with the health insurance company to provide service to plan members for specific prenegotiated rates. non participating providers - non par provider or out of network provider (oon) - is one not contracted with the health insurance plan 2 primary types of insurers - private insurance plans government insurance plans commercial insurance or non federal insurance - are private payers that may offer both group and individual plans. contracts they provide may include hospitalization, basic and major medical coverage government insurance or federal insurance - the most significant insurance is medicare medicare - is a federal health insurance program administered by the centers for medicare and medicaid services (cms) Centers for Medicare and Medicaid Services (CMS) - provides coverage for people over the age 65, blind or disabled individuals, and people with permanent kidney failure or esrdcms regulations - determine the coding requirements for medicare and non-medicare payers alike medicare program is made up of several parts - medicare part a medicare part b medicare part c medicare part d medicare part a - cover inpatient hospital care, as well as care provided in skilled nursing facilities, hospice care, and home healthcare medicare part b - covers medically necessary physicians' services, outpatient care and other medical services (including some preventive services). medicare part b is an optional benefit for which the patient must pay a premium and which generally require a yearly deductible and co-insurance medicare part c (medicare advantage) - combines benefits of part a and part b and sometimes part d. plans are managed by private insurers approved by medicare. the plans may charge different co-payments, co-insurance, or deductibles for services medicare part d (prescription drug coverage program) - available to all medicare beneficiaries. private company approved by medicare provide coverage medicaid - is a health insurance assistance program for some low income people, children and pregnant women sponsored by federal state and state government. state-funded insurance programs - providing coverage for children up to 21 years of age may include crippled children's services, children's medical services, children's indigent disability services and children with special health care needs CHAMPUS or TRICARE - -civilian health and medical program of the uniformed services -insurance linked to military services also known as TriCare -benefits program for active duty and retired members of the military CHAMPVA (civilian health and medical program of the department of veterans affairs) - is a health care benefits program for permanently disabled veterans and their dep

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