CPC COMPLIANCE AND REGULATORY Elaborations 2022/2023, RATED A

CPC COMPLIANCE AND REGULATORY Elaborations 2022/2023 outpatient coding - focuses on physician professional services and outpatient facility coding. coders should learn cpt, hcpcs level 2 and icd-10-cm hospital inpati ...

CPC COMPLIANCE AND REGULATORY Elaborations 2022/2023 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 dependents MEDIGAP Insurance - - privately purchased individual or group health insurance policies designed to supplement medicare coverage - benefits may include payment of medicare deductibles co-insurance and balance bills, as well as payment for service not covered by medicare workers compensation - insurance provided by employers to cover employees injured on the jobmanaged care organization (mco) - includes hmo, ppo, and pos plans HMO - health maintenance organization PPO - preferred provider organization POS - point of service plan Medical Physician Fee Schedule (MPFS) - look up tool, provides information on each procedure code including the global surgery indicator resource based relative value scale (rbrvs) - - to determine how much money medical provider should be paid - assigns procedures performed by a physician and other medical provider a relative value which is adjusted by geographic region resource costs are divided into 3 components - 1. physician work 2. practice expence 3. professional liability insurance (pli) physician work - - accounts for just over half (52%) of a procedure/service total relative value. - is measured by the time it takes to perform the service practice expence - - accounts 44% of the total relative value for each service - its relative values are reasource based and differ by site of service professional liability insurance (pli) - accounts for 4% of the total relative value for each service physician fee schedule (pfs) - cms annually publishes pfs information on its website PE - physician expence MP - malpractice GPCI (geographic cost index) - used to realized the varying cost based on geographic location CF (conversion factor) - this is a fixed dollar amount used to translate the RVU's into fees medical necessity - refers to whether a procedure or service is considered appropriate in a given circumstanceNational Coverage Determination, (NCD) - explain when medicare will pay for items or service Medicare Administrative Contractor (MAC) - is responsible for interpreting national policies into regional policies, called Local Coverage Determination (LCD) Local Coverage Determination (LCD) - explain when a given service is indicated or necessary, give guidance on coverage limitations, describe the specific CPT codes to which the policy applies, and list ICD-10-CM codes that support medical necessity for the given service or procedure Advance Beneficiary Notice (ABN) - is a written beneficiary notification to the beneficiary indicating that the insurer may not reimburse the cost of the procedure and therefore the patient may be liable to pay types of claims - 1. paper claims 2. electronic claims types of paper claims - HCFA UB04 Health Care Financing Administration (HCFA) - - also called CMS-1500 - standard medical claim form used form used for submitting Medicare Part B (outpatient billing) Uniformed Bill (UB 04) - - also called as CMS 150 - paper claim for Medicare Part A (inpatient billing) types of electronic claims - 1. NSF 2. ANSI NSF - national standard format - limited byte carrying capacity ANSI - american national standard institute - flexible format medical records - chronologically documents patients care between providers, facilitate claims receive and payments and can serve as legal documents. all services provided to the patient must be supported and documented EOB (explanation of benefits) - - documents are protected health info