CMS Flashcards Chapter 1 & 13

Questions and Answers

What is the largest third-party payer in the United States?

CMS or Medicare

A ______, usually an insurance company, handles the daily operations for Medicare, including paperwork claims payments.

MACs (Medicare Administrative Contractors)

A medical coder's responsibility is a code and ___.

Accurately and Completely

The _________ is the fastest growing segment of the population.

Elderly Signup and view all the answers

___________ assignment is when a provider does not bill the patient for the difference between the service cost and Medicare allowed.

Accepting Signup and view all the answers

Medicare ______ is a prescription drug benefit.

Part D Signup and view all the answers

Which group does the Medicare program not cover?

Prisoners Signup and view all the answers

In which issue of the Federal Register are updates to Medicare outpatient reimbursement NOT published?

October Signup and view all the answers

Which is not a component that is taken into account with a Relative Value Unit (RVU)?

Overhead, Work and Malpractice Signup and view all the answers

The CPT coding system was developed by the _____.

AMA (American Medical Association) Signup and view all the answers

Outpatient services are reported on claim form ____.

CMS (Health Insurance Claim Form 1500) Signup and view all the answers

Codes for services and procedures that include conscious sedation are identified in the CPT by an ______.

Bullseye Signup and view all the answers

The first chapter in the CPT is the _______.

Evaluation and Management Signup and view all the answers

Codes in the CPT whose descriptions include information from a preceding code are called ______.

Indented Codes Signup and view all the answers

Additional numbers or letters used with CPT codes to provide greater specificity about the delivery of services or procedure are called ______.

Modifiers Signup and view all the answers

When no code exists for a procedure or service, the appropriate __________ code should be used.

Unlisted Procedure Signup and view all the answers

When a written report is required to document a procedure or service, it must include a description of the nature, extent, and need for the procedure and the _____, _, _____ required to deliver it.

TIME, EFFORT, EQUIPMENT Signup and view all the answers

Category III codes are used to document use of _____

Emerging technology Signup and view all the answers

The three main ways to find information in the CPT index are by service or procedure, by anatomic site, or by _ or __.

Condition, Disease Signup and view all the answers

What does HCPCS stand for?

Healthcare Common Procedural Coding System Signup and view all the answers

Which temporary codes are used for durable medical equipment?

K codes Signup and view all the answers

Which temporary codes are used for procedures and professional services?

G codes Signup and view all the answers

What do J codes refer to?

Generic Drugs Signup and view all the answers

Which is an example of a discount that would be permitted as a 'safe harbor' from fraud and abuse regulations?

An HMO contracts with a laboratory for all laboratory services and receives a discounted price. Signup and view all the answers

Words that follow the code are called?

Procedure and service description Signup and view all the answers

What does stand alone mean in coding?

Have all the words full description Signup and view all the answers

What does (MCO) Managed Care Organization refer to?

Is a group that is responsible for the healthcare services offered to an enrolled group or person. Signup and view all the answers

What does (PPO) Preferred Provider Organization mean?

A group of providers who form a network and who have agreed to provide services to enrollees at a discounted rate. Signup and view all the answers

What does (HMO) Health Maintenance Organization stand for?

Delivery system that allows the enrollee access to all healthcare services. Signup and view all the answers

What is the purpose of the Federal Register?

Is the official publications for all 'Presidential Documents', 'Rules and Regulations,' 'Proposed Rules,' and 'notices.' Signup and view all the answers

What does (EDI) Electronic Data Interchange refer to?

Send claims electronically to a payer Signup and view all the answers

What are Code Sets?

Are composed of numbers and/or letters that identify specific diagnosis and clinical procedures on claims. Signup and view all the answers

Study Notes

CMS and Medicare Overview

CMS (Centers for Medicare & Medicaid Services) is the largest third-party payer in the United States.
Medicare Administrative Contractors (MACs) manage daily operations for Medicare, including claims processing and payments.
Elderly individuals represent the fastest-growing segment of the population and are primarily served by Medicare.

Medicare Features and Codes

Accepting assignment allows providers to bill Medicare directly, foregoing additional charges to patients.
Medicare Part D provides prescription drug benefits.
Certain groups, such as prisoners, are not covered by the Medicare program.

Documentation and Coding

Medical coders are tasked with coding services accurately and completely.
Outpatient services are reported using the CMS Health Insurance Claim Form 1500.
Codes related to conscious sedation in the CPT system are marked with a bullseye.

CPT Coding System

The CPT (Current Procedural Terminology) coding system, developed by the American Medical Association (AMA), includes codes for services and procedures.
The first chapter in the CPT is Evaluation and Management.
Indented codes refer to those whose descriptions include information from preceding codes.
Modifiers are additional identifiers used with CPT codes to specify details about services delivered.

Unlisted and Category III Codes

When no appropriate code exists, an unlisted procedure code should be used.
Category III codes document the use of emerging technologies.
There are three main methods to search the CPT index: by service or procedure, anatomic site, or condition/disease.

HCPCS and Temporary Codes

HCPCS stands for Healthcare Common Procedural Coding System, which includes codes not found in CPT.
K codes are temporary codes for durable medical equipment.
G codes are used for procedures and professional services.
J codes refer to generic drugs.

Managed Care Organizations

Managed Care Organization (MCO) refers to a group responsible for healthcare services offered to a defined population.
Preferred Provider Organization (PPO) consists of providers who offer discounted services within a network.
Health Maintenance Organization (HMO) provides a system where a primary care physician acts as a gatekeeper for healthcare services.

Regulatory and Electronic Processes

The Federal Register publishes official documents, including rules and proposed regulations.
Electronic Data Interchange (EDI) allows claims to be submitted electronically to payers.
Code sets are composed of numbers and letters identifying specific diagnoses and procedures on claims forms.

Studying That Suits You

Use AI to generate personalized quizzes and flashcards to suit your learning preferences.

Description

Test your knowledge of Chapter 1 and 13 related to CMS with these flashcards. The questions cover key terms and concepts related to Medicare, its administration, and medical coding responsibilities. Use these flashcards for a clear understanding of the CMS processes.