Podcast
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.
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___________ 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.
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Medicare ______ is a prescription drug benefit.
Medicare ______ is a prescription drug benefit.
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Which group does the Medicare program not cover?
Which group does the Medicare program not cover?
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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?
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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)?
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The CPT coding system was developed by the _____.
The CPT coding system was developed by the _____.
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Outpatient services are reported on claim form ____.
Outpatient services are reported on claim form ____.
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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 ______.
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The first chapter in the CPT is the _______.
The first chapter in the CPT is the _______.
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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 ______.
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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 ______.
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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.
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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.
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Category III codes are used to document use of _____
Category III codes are used to document use of _____
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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 __________.
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What does HCPCS stand for?
What does HCPCS stand for?
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Which temporary codes are used for durable medical equipment?
Which temporary codes are used for durable medical equipment?
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Which temporary codes are used for procedures and professional services?
Which temporary codes are used for procedures and professional services?
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What do J codes refer to?
What do J codes refer to?
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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?
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Words that follow the code are called?
Words that follow the code are called?
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What does stand alone mean in coding?
What does stand alone mean in coding?
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What does (MCO) Managed Care Organization refer to?
What does (MCO) Managed Care Organization refer to?
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What does (PPO) Preferred Provider Organization mean?
What does (PPO) Preferred Provider Organization mean?
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What does (HMO) Health Maintenance Organization stand for?
What does (HMO) Health Maintenance Organization stand for?
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What is the purpose of the Federal Register?
What is the purpose of the Federal Register?
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What does (EDI) Electronic Data Interchange refer to?
What does (EDI) Electronic Data Interchange refer to?
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What are Code Sets?
What are Code Sets?
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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.
