Shared Flashcard Set

Details

CPAT test
Certified Patient Accounting Tech exam
241
Health Care
Professional
01/12/2011

Additional Health Care Flashcards

 


 

Cards

Term
CAH
Definition
Critical Access Hospital
Term
MS-DRG
Definition
Medicare Severity Diagnosis Related Group
Term
BBA
Definition

Balanced Budget Act of 1997

 

Public Law 105-33

 

Signed by Clinton

 

Changes to Medicare and Medicaid

Expanded Services for CMS programs including SCHIP

Extended MCare Trust Fund to fight fraud & abuse

Increased HC for seniors

Term
HCPCS
Definition
Healthcare Procedure Coding System
Term
CPT-4
Definition
Current Procedural Terminology 4th Ed.
Term
ABN
Definition
Advanced Beneficiary Notice
Term
AFDC
Definition
Aid to Families with Dependent Children
Term
AHA
Definition
American Hospital Association
Term
AHCA
Definition
Agency for Health Care Administration
Term
ALOS
Definition
Average Length of Stay
Term
AMA
Definition
Against Medical Advice
OR
American Medical Association
Term
ANSI
Definition
American National Standards Institute
Term
APR
Definition
Annual Percentage Rate
Term
ASC
Definition
Ambulatory Surgical Center
Term
ATB
Definition
Aged Trial Balance
Term
CCI
Definition
National Correct Coding Initiative
Jan 1st 1996
Term
BNI
Definition
Benficiary Notices Initative
Term
CCS
Definition
Crippled Children's Services
Term
CDT
Definition
Current Dental Terminology
Term
CERT
Definition
Comprehensive Error Rate Testing
Term
CHCBP
Definition
Continued Health Care Benefit Program
Term
CLIA
Definition
Clinical Laboratory Improvement AMENDMENT
Term
CMHC
Definition
Community Mental Health Clinic
Term
CORF
Definition
Comprehensive Outpatient Rehabilitation Facility
Term
DRA
Definition
Deficit Reduction Act
Term
FECA
Definition
Federal Employees' Compensation Act
Term
GPO
Definition
Governmen Printing Office
Term
HPSA
Definition
Health Provider Shortage Area
Term
ICF
Definition
Intermediate Care Facility
Term
IDE
Definition
Investigational Device Exemption
Term
IEQ
Definition
Initial Enrollment Questionnaire
Term
IG
Definition
Implementation Guide
Term
IPPS
Definition
Inpatient Prospective Payment System
Term
LMRP
Definition
Local Medical Review Policies
Term
MAAC
Definition
Maximum Allowable Actual Charge
Term
MAC
Definition
Medicare Administrative Contractor
Term
MDC
Definition
Major Diagnostic Categories
Term
MHI
Definition
Medicare Hospital Insurance
Term
MIC
Definition
Medicaid Integrity Contractors
Term
MIP
Definition
Medicaid Integrity Program
Term
MMA
Definition
Medicare Modernization Act
Term
MUE
Definition
Medically Unlikely Edit
Term
NAIC
Definition
National Association of Insurance Commissioners
Term
MVPS
Definition
Medicare Volume Performance Standard
Term
NUBC
Definition
National Uniform Billing Committee
Term
NUCC
Definition
National Uniform Claim Committee
Term
PIP
Definition
Periodic Interim Payment
Term
POE
Definition
Parallel Operating Environment
Term
PSDA
Definition
Patient Self Determination Act
Term
RBRVS
Definition
Resource-Based Relative Value Scale
Term
RTC
Definition
Residental Treatment Centers
Term
SUBC
Definition
State Uniform Billing Committee
Term
TAN
Definition
Treatment Authorization Number
Term
TOB
Definition
Type of Bill
Term
UCR
Definition
Usual Customary and reasonable
Term
USPHS
Definition
US Public Health Service
Term
NPP
Definition
Non Physician Practioner
Term
MSN
Definition
Medicare Summary Notice
Term
MTF
Definition
Military Treatment Facility
Term
EMTALA
Definition
Emergency Medical Treatment and Active Labor Act
Term
ESRD
Definition
End Stage Renal Disease
Term
Title I
Definition
Hill Burton
Financial Allowance
Term
3 Components of RVU
Definition
Relative Value Unit
Foundation for the Fee Schedule

Work Required
Practice Expense
Malpractice Insurance Expense
Term
SNF
Definition
Skilled Nursing Facility
Term
PSRO
Definition
Professional Standards Review Organization
Term
Medicare Types of Charges
Definition
Actual-actual charges for service rendered
Approved-Medicare ceiling within geographical area
Global-summ or pro and technical provided and billed by same physician
Prevailing-going rate within an area
UCR-charge consistent within an area
Term
EOB
Definition
Explanation of Benefits
Term
Levels of Care
Definition
Acute Inpatient-illness or trauma (generally short term
Observation (OBS)- use of bed and periodic monitoring by nursing staff
Long-term care-chronically ill or disabled in nursing facility
Respite Care-short term and temporary
Custodial Care-NOT COVERED by Medicare, in-house by family
Home Health Care-approved by Medicare only is signed off by physician (gatekeeper) and provided by trained caregiver
Term
Tricare Plans
Definition
Prime-MTF is primary source
Extra-PPO
Standard-FFS Option (old Champus)
Tricare for Life-Medicare supplemental

Active Military in Prime
Term
HICN
Definition
Health Insurance Coverage Number or Claim Number
Term
ICD-9 Volumes
Definition
International Classification of Diseases, Volume 9
-CM: Clinical Modification

I: Diagnostic Tabular Listing
II:Diagnostic Index
III:Procedure (for use on IP claims)
Term
RUG
Definition
Resource Utilization Group

53 RUGS used to assess payments for SNF patients
Term
OBRA
Definition
Omnibus Budget Reconciliation Act of 1986
Term
COBRA
Definition
Consolidated Omnibus Budget Reconciliation Act of 1985
Term
TEFRA
Definition
Tax Equity and Fiscal Responsibility Act of 1982
Term
DEFRA
Definition
Deficit Equity and Reduction Act of 1984
Term
SCHIP
Definition
State Children Health Insurance Program
Term
Division of Access Services
Definition
Scheduling
Pre-reg
Pre-deposit
Inpt Admitting
Outpatient Reg
Pre-certification
Term
Medicare Deductibles
Definition
Base for 2010:$1100.00

Part A Ded Days 1-60 100%
Co-ins per DAY 61-90 25%
Co-ins per DAY 91-150 (Lifetime Reserve) 50%

SNF Days 1-20 $0.00
SNF Days 21-100 12.5%

Part B: $155.00
Term
Blood Deductible
Definition
3 pints per year
Term
Waiver of Liability
Definition
Patients protected from liability if they did not know the services would not be covered
Term
72-hour rule
Definition
Pre-admit testing on OP basis needs to be bundled with IP claim if DX code are the same
Term
Exceptions to 72-hour rule
Definition
But have 24-hour rule:
Psych hospitals
Rehab hosp
Children's hosp
LT Care hosp
Cancer hosp
Term
# of DRG
Definition
745
Term
MS-DRG created on 3 tiers of payments
Definition
A major complication or comorbidity (mcc)
A complication or comorbidity (cc)
No compliacation or comorbidity
Term
HIPPA
Definition
Health Insurance Portability and Accountability Act of 1996
Term
V Codes (ICD)
Definition
Related to something other than disease

Chronic illness or routine exam
Revisit on chronic illness
Term
E/M
Definition
Evaluation and Management
3 key components:
history
exam
decision making

Contributary:
Counseling
Coordination of Care
Nature of presenting problem
Term
HCPCS Levels
Definition
1: 5-digit number code (CPT)
2: Alphanumeric codes assigned by CMS
3: Alphanumeric assigned by MCare as "temp CPT"
Term
UPIN
Definition
Unique Physician Identification Number
Term
OIG
Definition
Office of Inspector General
Term
FOIA
Definition
Freedom of Information Act
Term
RRB
Definition
Railroad Retirement Board
Term
NAS
Definition
Non-Availability Statement

Issued by commander when something can't be done at a MTF
Good for 30 days
Term
CWF
Definition
Common Working File
Term
CPU
Definition
Central Processing Unit
Term
JCAHO
Definition
Joint Commission on Accreditation of Healthcare Organizations
Term
CHAMPVA
Definition
Civilian Health and Medical Program of the Veterans Administration
Term
Bill type 110
Definition
NO PAY CLAIM to Medicare based on UR and Admitting Physician disagreement (from an inpatient hospital bill)
Term
VCIS
Definition
Voice Case Information System (confirm bankruptcy)
Term
Title XIX
Definition
Medicaid
Term
Title XVIII
Definition
Medicare
Term
ORT
Definition
Operation Restore Trust of 1995
Term
UB04
Definition
Uniform Billing Form 2004
Term
Who developed the Patient Bill of Right? When?
Definition
American Medical Association
1975
Term
HCFA
Definition
Health Care Financing Administration (old name of CMS)
Term
Kennedy-Kassenbaum
Definition
another name for HIPPA
Term
# of DHHS Divisions
Definition
11
Term
Largest Health Insurer in US
Definition
Medicare
Term
Birthday Rule
Definition
Parent whose birthday occurs first during in the year is primary for children when covered by both parents (except in specified court directives)
Term
Condition Code
Definition
IDs the conditions related to the bill that may affect payer processing
ex: -02 Employment Related
-21 Billing for Denial
-40 Same Day Transfer

FL 18-28
Term
Occurence Code
Definition
IDs the specific date defining a significant event related to the bill
-01 auto accident
-11 date of onset
-18 patient/bene retirement

FL 31-34
Term
Value Code
Definition
IDs monetary values
-01 Most Common Semi-Private Rate
-12 Working Aged with EGHP
-13 ESRD in coordination with EGHP

FL 39-41
Term
Revenue Code
Definition
IDs specific accomodation, ancilary service or billing calc

-250 Pharm
-300 Lab
-450 ED

FL 42-49
Term
CMS 1450
Definition
another name for UB04
Term
Type of Bill
Definition
1st-Type of Facility (1=Hospital)
2nd-Bill Classication (1=Inpatient Part A, 3=OP)
3rd: Frequency (0=NonPayment/Zero claim)
Term
# of FI, Carriers and MACS
Definition
25 FI, 18 Carriers will be replaced by 15 MACS by 2011
Term
Chapter 7
Definition
Individuals and business
Assets auctioned to cover liabilities
Debt totally discharged
70%
Term
Chapter 11
Definition
Reorganization...for distressed businesses
Term
Chapter 12
Definition
Farmers
Term
Chapter 13
Definition
Individuals on repayment schedule over 3 years
Term
QuiTam Statute
Definition
False Claim Act
Term
Lincoln Act
Definition
False Claim Act
Term
Section 1011
Definition
Medicare Moderization Act
Term
5 W of Collecting Claims
Definition
Who are you speaking with?
What are they doing with the claim?
When is the claim going to be paid?
Where is the claim in their process and shere are they going to send the payment?
Why hasn't the claim been paid yet?
Term
Abuse
Definition
misuse of a person, substance service or finaicial matter such that harm is caused
Term
Fraud
Definition
The intentional or illegal descption or misrepresentation made for the purpose of personal gain, or to harm or manipulate another person or organization
Term
Un-Intentional Skip
Definition
A person who moves of changes their residency, but fails to motify creditors. A forwarding address is normally on file.
Term
Skip
Definition
A debtor who can not be located by the creditor.
Term
Recommended % of pre-registered inpatients
Definition
70-90% within 24 hours
Term
5 collection control points
Definition
Pre-Admission
Admission
In-house
At Discharge
After Discharge
Term
Who qualifies for CHAMPVA?
Definition
Injured vets and dependents
Term
Who has to take TRICARE?
Definition
Anyone that participates in MEDICARE
Term
Tricare Eligible
Definition
Acitve Duty Service Members
Eligible family of Active Duty
Miliary retirees and family
Surviving family members
Wards and legally adopted children
Some former spouses who meet length of marriage rules
Term
Who's not eligible for TRICARE?
Definition
Eligible for Medicare and over 65 , unless still active
Term
Can you have CHAMPVA and TRICARE at same time?
Definition
NO
Term
CHCBP
Definition
18-36 months after seperation from service or loss of eligiblity
Cobra for Tricare

Must enroll within 60 days
Term
TRICARE Standard pays by DRG for IP in all states except
Definition
Maryland
Term
NAS is good for how long?
Definition
30 days from issuance
42 days after pregnancy
15 days after mother's discharge if newborn still in-house
Term
Exceptions to NAS requirement
Definition
Has other health insurance
Medical or psych emerg admit or op emerg
Benefits under Program for the Person with Disabilities
More than 40 mile catchment area
SNF or RTC admits
Student Infirmaries
Term
Filing period for TRICARE claims
Definition
1 year from DOS
Term
When is TRICARE primary?
Definition
Medicaid
Indian Halth Servies
Supplemental insurance
Term
When is Tricare secondary?
Definition
Workman's Comp
Auto policy
Student Insurance
HMO
PPO
Term
TRICARE appeal period?
Definition
90 days
Term
Medical Spell of Illness
Definition
"Benefit Period"
60 consecutive days after discharge
Term
Inpatient Hosp Benefit Days
Definition
30 "full days" " covered days"
60 "co-insurance"
30 "lifetime reserve"

Hosp MUST notify pt when only have 5 days left on their co-insurance
Term
Medicare SNF requirement
Definition
3 days in hospital PLUS discharge day
Term
Pre-Cert includes:
Definition
Preferably before admission
Authorization for ALOS
NOt guarantee of payment
Term
BBA Section 4317
Definition
Advanced Beneficiary Notice
April 1 1998
Term
Which services' coverage is limited by ABN?
Definition
Labs
Radiology
Cardiovascular Testing
Term
Options patient can take on an ABN:
Definition
1. Want the test, but bill Medicare for official decision
2.Want test, but don't bill Medicare
3. I don't want the test
Term
# of elements on UB04
Definition
81
Term
Who developed the UB04?
Definition
NUBC and AHA
Term
Common Working File
Definition
Medicare's eligibility system
Term
What is a Clean Claim?
Definition
Pass all front-end claim edits
Processed electronically
If investigated, won't require contact
If reviewed, all medicare evidence is attached
Not developed on a post-payment basis (not a denial appeal claim)
Term
Code Edit
Definition
correct use of ICD9?
Term
Coverage Edit
Definition
Type of patient and procedure covered?
Term
Clinical Edits
Definition
procedure and diagnostic info clinically consistent?
Term
When is IEQ mailed?
Definition
3 months before patient becomes eligible for Medicare
Term
Medicare is secondary to:
Definition
Worker's Comp
Auto
Federal Black Lung
ESRD only for first 30-months
Term
How long on Medicare for ESRD?
Definition
12 months post dialysis
36 months post kidney transplant
Term
EGHP
Definition
Employer Group Health Plan
Term
Conditional Payment
Definition
When Medciare isn't sure who is primary
120 days
Term
If provider doesn't accept Medicare assignment:
Definition
1. Can charge up to 115% Medicare amount
2. Ask for entire payment up front
3. Still submit claim to Medicare
Term
Revenue Codes are reviewed by who? When?
Definition
CMS, NUBC, and SUBCs

On-going basis
Term
Elements of a Charge Master
Definition
Department Numbers/Cost Centers
Revenue Codes
Charge Master numbers
Charge Description Charge Amounts
CPT/HCPCS
Modifiers
General Ledger Numbers
Term
Where would you find the Charge info on the UB04?
Definition
FL 42-49
Term
DEERS
Definition
Defense Enrollment Eligibility Reporting System
Term
When can V-codes be primary?
Definition
Only when ancillary services are provided
Term
ICD-9 is updated when?
Definition
Annually, going into effect January 1st
Term
Date NCCI went into effect?
Definition
Jan 1 1996
Term
Purpose of NCCI
Definition
Establish standareds of medical billing
Identify codes that may be a potential for fraud and abuse
Identify codes that are componenets of another code and shouldn't be undundled or billed at the same time
Term
MUE implemented on
Definition
January 1 2007
Term
APC
Definition
Ambulatory Payment Classifications
Term
How many Never Events are there?
Definition
28
Term
Capitation payments
Definition
paid fixed per capita amount for each person served, regardless of services
"per member per month"
Term
Fee-for-Service payments
Definition
payment based on straight charges (often contractually discounted)
Term
Fee Schedule
Definition
Payor determines set payment amount for each service...typically adjusted annually
Term
Per Diem payment
Definition
Set rate per day in hospital regardless of actual charges or costs
Term
ABN contains what information?
Definition
Listing ot test(s)
Estimated cost of the tests
Reason denial is likely
Statement that that patient is responsible for charges
Area for patient to sign
Term
MSN covers what period of time?
Definition
3-months worth of Medicare billed services
Term
CMS-R-131
Definition
another name for the ABN
Term
Can an admitting clerk decline admitting a patient?
Definition
NO
Term
Who can admit a patient to a hospital?
Definition
Members of medical staff ONLY; not administrators
Term
The Privacy Act of 1974 protect who from whom?
Definition
The patient from misuse of records by FEDERAL agencies only; generally doesn't cover States or private organizations!
Term
Who is covered under the Privacy Act?
Definition
US Citizens and aliens lawfully admitted for permanent residence ONLY
Term
Criteria for Relase of Medical Records:
Definition
1. Nothing released without patient's consent, unless
2. Furnished in civil or criminal action upon issuance of a subpoena
3. Records can be faxed
4. Need specific (detailed) authorization for HIV/AIDS, psych, alcohol and drug dependency
Term
Who is authorized to make entries in medical records?
Definition
1. Treating or attending physician
2. Physician extenders (PA, NP)
3. Licensed RN
4. Health profession students (under supervision)
Term
Verbal/teephone orders can be accepted by:
Definition
1. Physician Extenders (PA,NP)
2. Licensed/Registered Nurses
Term
Advanced Medical Directives are also known as:
Definition
Patient Self Determination Act
Term
Advanced Directives do what 2 main things:
Definition
1. Give medical power of attorney to someone else if the patient becomes incapacitated
2. give direction about future medical care
Term
Advanced Directives were the result of what legistation?
Definition
OBRA
Term
Living Will
Definition
another name for Advanced Directive
Term
How can an advanced directive by revoked?
Definition
Destroying ALL copies
Term
Agencies are usually the _____ payor.
Definition
last (secondary)
Term
Liability insurance (Work comp, auto, etc) are usually the _______ payor.
Definition
Primary
Term
How many employees must an employer have for it's 65+ employees to be considered Working Aged?
Definition
20
Term
General consent forms cover:
Definition
Routing Lab testing
Diagnostic Imaging
Medical Treatment
Term
Special consent forms are required for:
Definition
HIV Positive testing
Surgery (major and minor)
Anesthesia
Non-surgical procedures with more than a slight risk
Cobalt or radiation therapy
Electroshock or psych treatment
Experimental procedures
Drug/alcohol treatment
Term
Actual consent is when:
Definition
Patient gives either written or oral consent.
Term
Implied consent "in fact" vs. "by law"
Definition
In fact: patient doesn't object (but is able to)
By law: patient is unconscious and pt is taken to the ER
Term
How is Informed consent different from Actual/expressed consent?
Definition
Patient understand their condition and what will be performed
Term
When is a minor consider emancipated (by court of law)?
Definition
1. no longer requires parental guidance or financial support
2. fathered or gave birth to a child
3. reached age or majority (18 to 21, depending on state)
Term
Gatekeeper
Definition
Primary Care physician in Managed Care Plans that directs patient care to specialists and facilities.
Term
How often can JCAHO conduct audits?
Definition
Typically every 3 years, but as soon as 9 months and as late as 30 months...unannounced!!!
Term
3 phases of emergency planning:
Definition
1. Response
2. Back-up
3. Recovery
Term
When is census most often taken?
Definition
Midnight (0000 hours)
Term
Avg Daily Census calculation
Definition
sum of total patient days in month/total number of days
Term
% of occupancy calculations
Definition
census/total beds
Term
bad debt
Definition
uncollecible account resulting from the extension of credit
Term
charity care
Definition
services provided where it is never expected to result in cash flow
Term
indigent
Definition
patient that has no means of paying for medical services and is not eligible under Medicaid or other assistance program
Term
judgement
Definition
a legally verifiable claim against a debtor
Term
Medigap
Definition
health insurance/benfit plan offered by private entity to supplement Medicare beneficiaries that are also on Medicaid
Term
OBRA impacts employers with how many employees?
Definition
100
Term
TEFRA, DEFRA and COBRA impact employers with how many employees?
Definition
20
Term
What are the two governing bodies effecting healthcare charge?
Definition
DHHS and CMS
Term
How many agencies are there under DHHS?
Definition
300
Term
# of DHHS Operating Division

Name them
Definition
11
1. National Institites of Health (NIH)
2. Food and Drug Admin (FDA)
3. Centers for Disease Control and Prevention (CDC)
4. Agency for Toxic Substances and Disease Registry (ATSDR)
5. Indian Health Services (IHS)
6. Health Resources and Services Admin (HRSA)
7. Substance Abuse and Mental Health Services Admin (SAMHSA)
8. Agency for Health CAre Research and Quality (AHRQ)
9. Centers for Medicare and Medicaid Services (CMS)
10. Admin for Children and Family (ACF)
11. Admin on Aging (AOA)
Term
What year did The Social Security Admin seperate from DHHS?
Definition
1995
Term
3 Divisions of CMS
Definition
Center for Medicare Management
Center for Beneficiary Choices
Center for Medicaid and State Operations
Term
To CMS, healthcare security means:
Definition
Access to affordable and quality healthcare services
Protection of the rights and dignity of beneficiaries
Provision of clear and useful information
Term
What president signed Medicare into law?
Definition
Lyndon Johnson 1965
Term
Dual eligibility means:
Definition
Individual is entitled to Medicare Part A and/or B and is also eligible to Medicaid
Term
When was SCHIP extended?
Definition
2009 by Obama in the Children's Health Insurance Program Reauthorization Act
Term
Health Savings Accounts were part of which legislation?
Definition
HIPPA
Term
Fraud and Abuse Control is coordinated by:
Definition
OIG and DOJ
Term
What is the Fraud Reporting Hotline #:
Definition
1-800-HHS-TIPS
Term
Once notified of a Ch 7 bankruptsy, you must:
Definition
Flag the patient account
Suspend all collection activity (pending final disposition)
Cease all contact with patient
Notify any third pary collection agencies
Forward a copy of the Notice to all third pary collection agency
Notify all parties if any payments are received
Term
What are the "usual times" for collection calls outlined in the FDPCA?
Definition
8am to 9pm
Term
How many days does a patient have to notify the hospital of statement errors
Definition
60
Term
How many days does the hospital have to respond to a patient complaints of statement errors?
Definition
30
Term
How long does the hospital have to legitimate statement errors?
Definition
2 billing cycles or a max of 90 days
Term
What should you do when you find out a patient is deceased?
Definition
Check if legitimate estate exists
Change the mailing address to "The Estate of ..."
If no estate exists and another party has not assumed financial responsiblity, write off the balance
Check register of wills for estate information
Term
Statutes of limitations are greatest for what?
Definition
Judgements
Term
What might extend statutes of limitations?
Definition
Obtain a written "promise to pay"
Obtain a partial payment on the principal account
Reduce the account to judgement immediately
Execute a new contract
Term
Lien
Definition
Recorded claim against real or personal property, generally arising out of a debt
Term
Tort liability
Definition
liability for an injury or wrongdoing done by one person to another resulting from a breach of legal duty
Term
Average Daily Revenue Calculation
Definition
Total Charges or Recue for x # of days/total # of days
Term
Average Days in A/R Calculation
Definition
Accounts Receivable at specific time/Average Daily Revenue
Term
What are the levels # of creditors/ $ for involuntary bankruptsy
Definition
12 of more creditors, 3 with more than $5k

OR

Fewer than 12, but one must be $10,775
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