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Questions and Answers
What is the largest third-party payer in the United States?
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.
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 _________.
A medical coder's responsibility is a code______ and _________.
Accurately and Completely
The _________ is the fastest growing segment of the population.
The _________ is the fastest growing segment of the population.
___________ assignment is when a provider does not bill the patient for the difference between the service cost and Medicare allowed.
___________ assignment is when a provider does not bill the patient for the difference between the service cost and Medicare allowed.
Medicare ______ is a prescription drug benefit.
Medicare ______ is a prescription drug benefit.
Which group does the Medicare program not cover?
Which group does the Medicare program not cover?
In which issue of the Federal Register are updates to Medicare outpatient reimbursement NOT published?
In which issue of the Federal Register are updates to Medicare outpatient reimbursement NOT published?
Which is not a component that is taken into account with a Relative Value Unit (RVU)?
Which is not a component that is taken into account with a Relative Value Unit (RVU)?
The CPT coding system was developed by the _____.
The CPT coding system was developed by the _____.
Outpatient services are reported on claim form ____.
Outpatient services are reported on claim form ____.
Codes for services and procedures that include conscious sedation are identified in the CPT by an ______.
Codes for services and procedures that include conscious sedation are identified in the CPT by an ______.
The first chapter in the CPT is the _______.
The first chapter in the CPT is the _______.
Codes in the CPT whose descriptions include information from a preceding code are called ______.
Codes in the CPT whose descriptions include information from a preceding code are called ______.
Additional numbers or letters used with CPT codes to provide greater specificity about the delivery of services or procedure are called ______.
Additional numbers or letters used with CPT codes to provide greater specificity about the delivery of services or procedure are called ______.
When no code exists for a procedure or service, the appropriate __________ code should be used.
When no code exists for a procedure or service, the appropriate __________ code should be used.
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.
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.
Category III codes are used to document use of _____
Category III codes are used to document use of _____
The three main ways to find information in the CPT index are by service or procedure, by anatomic site, or by _________ or __________.
The three main ways to find information in the CPT index are by service or procedure, by anatomic site, or by _________ or __________.
What does HCPCS stand for?
What does HCPCS stand for?
Which temporary codes are used for durable medical equipment?
Which temporary codes are used for durable medical equipment?
Which temporary codes are used for procedures and professional services?
Which temporary codes are used for procedures and professional services?
What do J codes refer to?
What do J codes refer to?
Which is an example of a discount that would be permitted as a 'safe harbor' from fraud and abuse regulations?
Which is an example of a discount that would be permitted as a 'safe harbor' from fraud and abuse regulations?
Words that follow the code are called?
Words that follow the code are called?
What does stand alone mean in coding?
What does stand alone mean in coding?
What does (MCO) Managed Care Organization refer to?
What does (MCO) Managed Care Organization refer to?
What does (PPO) Preferred Provider Organization mean?
What does (PPO) Preferred Provider Organization mean?
What does (HMO) Health Maintenance Organization stand for?
What does (HMO) Health Maintenance Organization stand for?
What is the purpose of the Federal Register?
What is the purpose of the Federal Register?
What does (EDI) Electronic Data Interchange refer to?
What does (EDI) Electronic Data Interchange refer to?
What are Code Sets?
What are Code Sets?
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.
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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.