The Three Key Components of E

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Bossier Parish Community College *

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Oct 30, 2023

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1 The Three Key Components of E&M (Evaluation & Management) CODES History, examination, and medical decision-making complexity The levels of E/M services are based on documentation located in patient's medical record and are based on KEY COMPONENTS (history/Hx, examination, & medical decision-making complexity) and CONTRIBUTORY FACTORS (counseling, coordination of care, nature of presenting problem & time) History is the subjective information the patient tells the physician Four elements of a history are chief complaint (CC) history of present illness (HPI) review of systems (ROS) and past, family, and social history (PFSH) Invalid claim is one that is submitted with a transposed member ID number According to CLIA (Clinical Laboratory Improvement Amendments) when billing Medicare for a waived laboratory test what modifier should be QW

2 used What take precedence over ICD-9-CM chapter specific guidelines Coding conventions and instructions what action should be taken when a claim is billed for a level 4 office visit and paid at a level 3 submit an appeal with supporting documentation On a patient's remittance advice, a deductible of $100 has been applied. The provider has requested the patient account personnel to write it off. What describes this scenario FRAUD Patient presents for an incision & drainage of Pilonidal Cyst. what part of the body is it referring to Coccyx (tail bone) Which is a valid ICD-9-CM principal? Code signs and symptoms in the absence of an established diagnosis A patient calls your office and is upset about bill received. Her Insurance company denied claim, You should inform the patient the reason for denial

3 what should you do A billing and coding specialist should understand that the financial record source that is generated by a provider’s office is called a Patient Ledger Account A claim can be denied or rejected for Block 24D containing a diagnosis code? True block 24D is for CPT codes (diagnosis codes go in Block 21) This scenario is most appropriate to submit an electronic claim Claim submitted contains an outpatient procedure What component of an EOB (explanation of benefits) expedites the process of a phone appeal Claim Control Number An example of a diagnostic category code is 541 (3 digits/no decimal point) In managed care organizations PPO (preferred provider option) help control a patient's insurance cost by offering low-cost deductibles

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4 Which describes an "implied contract" A patient schedules an appointment with a new provider's office An insurance claims register (aged insurance report) facilitates which follow-up insurance claims by date How does a third-party payer determine timely filing for claims Contract with the provider A woman in her 3rd trimester of pregnancy present to her Dr.’s office with a diagnosis of a sprained wrist w/ swelling due to falling on a wet floor. Dr. documented no relationship between the sprain & pregnancy. What is appropriate coding sequencing Sprained wrist, pregnancy, fall on floor ambulatory surgery centers, home healthcare and hospice organizations, inpatient a non-allowed charge goes in? the adjustment column of the credits Claim to be correctly use 12 pitch (PICA)

5 processed via optical character recognition (OCR) billing & coding specialist should characters What transports oxygenated blood from the Heart Aorta What is the valve that controls opening between the right atrium and right ventricle Tricuspid valve What valve is located between the left atrium and left ventricle Bicuspid valve AKA mitral valve Nocturia is excessive urination at night the duodenum is the first section of the small intestine the ileum is the last section of the small intestine V-codes are used as the 1st listed diagnosis to indicate family history How many behavior classifications are included in Table of neoplasms 6

6 What is the form that contains DOS (date of service), CPT codes, ICD- 9-CM, fees, and copayment info an Encounter form What is the medical term that describes the body's inability to compensate for position change orthostatic hypotension what font is the standard font for the CMS 1500 paper claim 10 pitch (PICA) An integral part of an autopsy is what type of examination gross examination A paper claim should be submitted if a claim contains unlisted procedure codes What organization accepts electronic claims MAC - Medicare Administrative Contractors Because of Medicare NCCI (National Correct Coding Initiative) edits improper code combinations are in what type of claim claim rejection What type of insurance coverage is offered to Medigap coverage

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7 Medicare beneficiaries by private third-party payers What is the accrediting agency for laboratories CLIA (Clinical Laboratory Improvement amendments What is it called when an insurance claim is overdue for payment delinquent claim What is a fixed dollar amount for office, pharmacy, and emergency department services co-payment What is a percentage of the costs for covered services that is approved by the insurance company co-insurance what is the condition in which the urethral opening is on the lateral aspect of the penis paraspadias What is the standard form for professional outpatient services and procedures CMS-1500 What can never be reported as a stand alone code an add-on code

8 What is a pre-existing condition An illness or condition present before insurance coverage begins What insurance policy is NEVER primary when the insured has more than one policy medicaid (payer of last resort) A triangle in front of a code in the updated CPT manual means the description of the code has been changed a CPT coding system is service and procedure based A respirator used by a Medicare patient is an example of Durable medical equipment (DME) Medical ethics are Standards of conduct the way to correct an error on a patient's medical record is to cross out the incorrect data with a single line, write in correct information, followed by initials and date A patient was diagnosed with cardiomegaly, what does this mean enlargement of heart What is the ICD-9-CM subclassification code 5 digits (282.60)

9 What is the ICD-9-CM subcategory code 4 digits (255.0) Ann Smith had a biopsy take from a lump found in her left breast. 3 days after procedure she was informed that the biopsy is positive for carcinoma. 5 days later she undergoes radical mastectomy. what modifier can be attached to primary code modifier -58 (staged or related procedure or service by the same physician during the same post-operative period A document that contains dates of service (DOS), list of detail charges, co- payments & deductibles paid, date insurance was filed, adjustments and account balance is called an Itemized statement What people DO NOT qualify for Medicaid High income earners ICD-9-CM is the International Classification of Diseases, 9th Revision, Clinical Modification An established patient is defined as one who has received professional services from the 3 years

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10 physician or another physician of the same specialty in the same group within the past how many years A patient is diagnosed with metastatic bone neoplasm. The neoplasm will be coded as Secondary malignant Under the RBRVS (Resource-based relative value scale) method of reimbursement, "conversion factor" is a dollar amount An organization that initiated the development of ICD codes is WHO (World Health Organization) The patient's birth date on the CMS-1500 form is entered in which of these formats MM/DD/CCYY (month/date/century & year)(8 digits) A patient has contracture of the right hand due to a third degree burn suffered a year ago. Code for the third-degree burn from a year ago will be referenced from the alphabetic index under late, effects of burn

11 which main term and subterm The term used to describe of the five long bones of the midfoot is Metatarsal bones A service that is rarely provided, unusual, variable, or new may require a ______ (blank) in determining medical appropriateness of the service Special report A new patient is one who has not visited a physicians office in more than 3 years Category I CPT codes health care providers report for reimbursement for the procedures & services rendered Category II codes HCPCS (Healthcare Common Procedure Coding System) for performance measure Category III codes HCPCS (Heathcare Common Procedure Coding System) temporary codes/emerging technologies

12 Triangle means change in wording Sideways Triangles means change of wording between the triangles/contains new or revised text Bullet (solid circle)/RED means new procedure code Plus sign (+) means add-on code Circle with line through it represents modifier 51 exempt code circle means recycled or reinstated code Circle with a dot in center (bulls-eye) means moderate sedation Brackets [] means enclose synonyms, alternative wording or explanatory phrases/found in the tabular list (volume 1) Slanted brackets means used in the alphabetic index, volume 2,used to enclose the manifestation of the underlying condition. Sequence code inside slanted brackets after underlying condition code

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13 parentheses () means used in both the index and tabular to enclose supplementary words. (nonessential modifiers) that may be present or absent in the statement of a disease or procedure without effecting the code number to which it is assigned colon : means located in tabular list after an incomplete term that needs one or more of the modifiers that follow in order to make the condition assignable to a given category Six sections of the CPT manual are Evaluation & Management (E&M), Anesthesia, Surgery, Radiology, Pathology, Medicine Evaluation & Management (E&M) are numbered 99201-99499 Anesthesia is numbered 00100-01999 Surgery is numbered 10021-19499 Radiology is numbered 70010-79999 Pathology is numbered 80048-89398

14 Medicine is numbered 90281-99607 Where are Modifiers found in the CPT book Front cover and Appendix A What modifier is used for "unrelated evaluation & management (E&M) services by the same physician or other qualified healthcare professional during a post operative period" Modifier 24 What modifier is used for "significant, separately identifiable evaluation & management (E&M) service by the same physician or other qualified healthcare professional on the same day of the procedure or other service" Modifier 25 What modifier is for the "professional component" Modifier 26 What modifier is for "bilateral procedure" Modifier 50 What modifier is for "multiple procedures" Modifier 51

15 What modifier is use for "decision made for surgery" Modifier 57 What modifier is for "unplanned return to the operating/procedure room by the same physician following the initial procedure for a relative procedure during the post operative period" Modifier 78 What modifier is for "unrelated procedure or service by the same physician during the post operative period" Modifier 79 Types of Government health insurance include Medicare (A,B,C,D), Medicaid (categorically needy, medically needy), Tricare (Standard, Extra, Prime), CHAMPVA Types of private health insurance include Private payers/commercial carries,Group Health Plans, Indemnity Insurance, HMO (Health Maintenance Organization), PPO (Preferred Provider Option), Point of Service, Disability, Workers Compensation.

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16 Medicare part "A" covers Hospital stay Medicare Part "B" covers physician office Medicare Part "C" covers combination of both "A & B" Medigap (MG)/Medifill is a type of policy designed to supplement coverage under a fee for service Medicare plan. May cover prescription costs and the deductible & co-payment (20% of the Medicare allowed amount) Tricare Health Insurance is Military insurance that covers uniformed military men and woman and their families Tricare standard beneficiaries to see any doctor Tricare EXTRA (PPO- preferred provider organization) Yearly deductable, provide services at discounted rate, healthcare delivered by a network of civilian healthcare providers who accept payments from CHAMPUS Tricare PRIME HMO type of plan that receive healthcare through military facilities such as

17 VA clinic and or Hospitals CHAMPVA healthcare plan for military, where the VA share costs of supplies and services with eligible beneficiaries Private Payers/Commercial carriers people who are responsible for securing there own health insurance Group Health Plans are insurance plans that provide insurance for a group offered by employers to all employees Indemnity Insurance (fee for service) is a fee for service when a person is between health plans. covers somethings but not everything HMO Health Maintenance Organization PPO (preferred provider organization) Care is paid for as received instead of in advance Point of Service Choose to get TRICARE covered non-emergency services outside the prime network of providers

18 without a referral Disability insurance for people who can not work due to a disability Workers Compensation insurance for people who are injured on the job, can get medical information without consent Clean Claim is a claim that all information is correct Dirty Claim is claim submitted with errors - manual processing, can be resubmitted An ABN (Advanced Beneficiary Notice) is a notice given by doctor or supplier to the patient when they believe Medicare will deny payment (patient will have to pay if denied) Basic Billing & Reimbursement Steps are Collect patient information, verify insurance, prepare encounter form, code diagnosis and CPT, review Linkage Protocal, Calculate physician charges, prepare claim, transmit claim, follow-up on reimbursement

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19 Review Linkage Protocal is appropriateness of codes, payers rules about the linkage, documentation to support the codes,& compliance with regulations & guidelines through HIPPA Life cycle of a claim is 1)submission 2)processing 3)adjudication 4)non- covered 5)unauthorized 6)medical necessity checks 7) payment/RA/ERA (remittance advice/electronic remittance advice) E-codes are for durable medical equipment(DME) used in home (medicare Part "C") E-codes are also used for Environmental, external cause of injury, poisoning, & other adverse effects as well as reactions to medications ROS (Review of Symptoms) is inventory of the constitutional symptoms regarding the varies body systems What action should be taken if an insurance Appeal decision with a providers report

20 company denies a service as not medically necessary What is the appropriate code selection for the removal of a malignant lesion on the arms Subsection of Integumentary system (located in the CPT manual in the surgery subsection) Which Block(s) requires the patient's authorization to release medical information to process a claim Block 12 (also acts as assignment of benefits for Medicare) Under which circumstances should a paper claim be submitted to the Insurance carrier A claim containing unlisted procedure codes Health care clearinghouses are covered entities affected by HIPAA security rules. They are the middle men between the provider & the payer The provision of health insurance policies that specifies which coverage is considered primary or secondary is called Coordination of Benefits Eligibility verification is the process of checking & confirming that a patient is covered under

21 an insurance plan The purpose of precertification is the Verification of Benefits What expedites the process of a phone appeal Claim control number -tomy a surgical incision -stomy a new artificial opening Can employees (billing specialist) of a physician be held liable of malpractice for billing errors (whether intentional or not) and what is it called Yes and it is referred to as "vicarious liability" AKA "Respondent superior"

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