nomenclature, classification systems
Providers and third party payers use _____ and _____ to collect, store, and process data.
payment systems, fee schedules, exclusions
Typically, third party payers adopt ____, _____, and _____ after Medicare has implemented them.
medical nomenclature
Vocabulary of clinical and medical terms.
coding system
Organizes medical nomenclature according to similar conditions, diseases, procedures, and services.
codes
Numeric and alphanumeric characters.
reimbursement, data collection, education, research
Codes are reported for _____, _____, _____ and _____.
diagnosis, procedure
Administrative simplification provisions of HIPAA required adoption of two types of code sets: _____ and _____ codes.
diseases, injuries, impairments, causes, actions
Large code sets include: (1) _____, _____, or _____; (2) ____ of the previous; (3) _____ taken to prevent, diagnose, treat or manage the previous.
race/ethnicity, type of facility, type of unit
Small code sets include: ______, _____, and ____.
ICD 9 CM, CPT, HCPCS II, CDT, NDC
Codes sets proposed by HIPAA and already in use by most health plans, clearinghouses, and provider include: _____, _____, _____, _____, and _____.
simplify, claims submission, third party payers, data quality
The intent of standard coding guidelines is to ______ _________ for health care providers who deal with multiple _____ and to improve _____
modify, system, valid codes, clearinghouse
Payers that do not follow official coding guidelines will be required to ______ their _______ to accept all _____ or contract with a ______ to process transactions.
clearinghouse
A public or private entity (billing service, repricing company) that processes or facilitates the processing of health information received from another entity.
basale nomina anatomica
Nomenclature developed in late 1800s by the Anatomical Society.
1929, New York Academy of Medicine, SND
Developed in ______ by the _____, this was the first medical nomenclature to be universally accepted in the U.S.
standardized nomenclature of disease
SND
SND
This nomenclature system introduced the concept of multi-axial coding.
Standardized nomenclature of diseases and operations
SNDO
1936, AMA, SNDO
Developed in _____ by the _____, this was based on SND and added an axis for operations
Systematized Nomenclature of Pathology
SNOP
1965, College of American Pathologists, SNOP
Published in _____ by the _____, this nomenclature consisted of a four axis system of terms and related codes used by pathologists interested in storage and retrieval of medical data.
Systematized Nomenclature of Medicine
SNOMED
1974, College of American Pathologists, SNOMED
Developed in _____ by _____, this nomenclature codifies all activities within the patient record including medical diagnoses and procedures, nursing diagnoses and procedures, patient signs and symptoms, occupational history, and many causes of disease.
Logical Observation Identifiers Names and Codes
LOINC
LOINC, SNOMED RT
This is a universal standard medical vocabulary for identifying laboratory and clinical observations. It is integrated into ______.
Unified Medical Language System
UMLS
Current Medical Information Terminology
CMIT
1981, AMA, CMIT
Developed in _____ by _____, this nomenclature is used for naming and describing diseases and conditions in practice and in areas related to medicine.
National Library of Medicine, 1986, UMLS
Developed by the ________ beginning in _____, the purpose of this system is to aid in the development of systems to help health professionals and researcher retrieve and integrate electronic biomedical information from a variety of sources and make it eas
16th Century, London Bills of Morality
Developed in _____, this is considered the first classification system.
world health organization
What organization is responsible for reviewing and revising the International Classification of Diseases Manual every 10 years?
1975
ICD 9 came out in _____.
1989, 1994
ICD 10 came out in _____ with WHO member states adopting it in _____.
detailed, 8000, 4000, alphanumeric, numeric, three, three, two, cause of death titles, conditions, coding rules
ICD 10 differs from ICD 9 in the following ways: (1) more ______ (______ categories vs _____); (2) uses three digit _____ codes (vs. three-digit _____ codes); (3) contains _____ additional chapters; (4) published in _____ volumes (vs. _____ volumes); (5)
diagnostic and statistical manual of mental disorders
DSM
DSM
Published by the _________, this is the standard classification system of mental disorders used by mental health professionals
five
DSM III has ____ axes.
current procedural terminology
CPT
AMA, 1966, CPT
Originally published by the _____ in _____, this is the national standard code set for physician services.
procedures, services, physicians, ambulatory care
CPT classifies _____ and _____, _____ and _____ settings use CPT to report procedures and services.
international classification of diseases for oncology
ICD-O
ICD O 3, 2001
_____ was implemented in _____ and uses ten digit codes to describe tumor's primary site, topography code, histology, behavior, and aggression
international classification of injuries, disabilities, and handicaps
ICIDH
1980, ICIDH
Published in _____, this classified health and health related domains that describe body functions, structures, activities, and participation
CMS, HCPCS Level II, public domain
Published by a variety of vendors, this is the coding system is managed by _____ and classifies medical equipment, injectable drugs, transportation services and other services not classified in CPT. The coding system is in the _____.
current dental terminology
CDT
ADA, CDT
Published by the _____, this classifies dental procedures and services.
National Drug Codes
NDC
FDA, NDC, public domain
Published by a variety of vendors and managed by the _____, this serves as a universal product identifier for human drugs. The coding system is in the_____.
Alternative Billing Codes
ABCodes
ABCodes
This classifies services not included in the CPT manual to describe the service, supply, or therapy provided. They may also be assigned to report nursing services and alternative medicine.
third party payer
An organization that processes claims for reimbursement covered by a health care plan.
B
Claims processed by Medicare for physician services fall under Medicare Part _____.
A
Claims processed by Medicare for health care facilities fall under Medicare Part _____.
Medicare Administrative Contractors
Payers may serve as ________ by processing both Medicare Part A and B claims.
carriers, fiscal intermediaries
Payers serve as _____ and _______ for Medicare by processing claims.
Blue Cross and Blue Shield
This third party payer covers the costs of full range of hospital and physician services.
blue cross, blue shield
With regard to BCBS, _____ initially covered just hospital care, and _____ covered just physicians' services.
commercial payers
This type of payer includes private health insurance and employer based group health insurance.
indemnity, reimburses, premiums
Private health insurance usually consists of an ______ plan which covers individuals for ____ health care expenses. The insurance company ____ the patient or the provider and individuals pay annual _____.
benefit, 80 percent, commercial health insurance plan
Employer based group health insurance is often provided as an employee ____ in which the employer pays _____ of insurance premiums and contracts with a ________.
employer self insurance plans
Type of payer. An employer accepts direct responsibility for paying employee's health care without purchasing health insurance .
third party administrator, TPA
An employer self insurance plan usually contracts with a ________ or _____.
third party administrator
An organization that provides benefit design, claims administration and utilization review to employers who use a self insurance plan.
benefit design
Medical services covered by the plan.
claims administration
Processing claims to reimburse services.
utilization review
Reviewing medical care for appropriateness, necessity, and quality.
Civilian Health and Medical Program of the Department of Veterans Affairs
CHAMPVA
CHAMPVA
Provides health care benefits to dependents of veterans rated as 100 percent permanently and totally disabled as a result of service connected conditions, veterans who died as a result of service connected conditions, and veterans who died on duty with le
Federal Employee Health Benefits Program
FEHBP
FEHBP
Voluntary health care program that covers federal employees, retirees, and their dependents and survivors.
Indian Health Service
DHHS agency that provides federal health care services to American Indians and Alaska Natives
Medicaid
A joint federal and state program that provides health care coverage to low-income populations and certain aged and disabled individuals.
Medicare
Provides health care coverage to elderly and disabled persons.
Military Health System
MHS
MHS
Provides and maintains readiness to provide health care services and support to members of the Uniformed Services during military operations and to members of Uniformed Services, family members, and other entitled to DoD health care.
TRICARE, military health care resources, civilian health care professionals
Military health plan that covers active duty and retired members of the uniformed services and their dependents. Combines _____and networks of _____.
Programs of All Inclusive Care for the Elderly
PACE
PACE
Community based Medicare and Medicaid programs that provide integrated health care and long term care services to elderly persons who require a nursing facility level of care.
State Children's Health Insurance Plan
SCHIP
SCHIP
Established to provide health assistance to uninsured, low income children either through separate programs or through expanded eligibility under state Medicaid programs.
Managed Care, capitation
Type of payer. Provider accepts a predetermined payment for each subscriber for a specific period of time. Appropriate care must be provided to subscriber even if costs exceed _____.
closed panel staff, PPOs
Managed care plans range from structured _____ model HMOs to less structured ______.
consumer directed health plans
Define employer contributions and ask employees to be more responsible for health are decisions and cost sharing.
customized sub capitation plan, flexible spending account, health savings account, health care reimbursement account, health reimbursement arrangement
Consumer Directed Health Plans include: (1) _____; (2) _____; (3) _____, (4) ______, (5) _____.
workers compensation
State mandated insurance program that reimburses health care costs and lost wages if an employee suffers a work related disease or injury.
inpatient prospective payment system
TEFRA of 1983 legislated the _________.
diagnosis related groups, predetermined, Medicare
The prospective payment system uses _____ to reimburse short term hospitals at a _______ rate for _____ inpatient services.
grouper
DRG ______ software is used to assign each DRG according to data input for each inpatient stay.
Medical Severity DRG
This was implemented by CMS in 2007 to classify inpatient hospital cases into groups according to similar resource utilization.
cost outlier
Inpatient cases that qualify for additional reimbursement is categorized as a _____
high costs
Cost outliers adjust the DRG rate when a case results in unusually ______ when compared with other cases in the same DRG
outpatient preadmission, diagnostic, therapeutic
IPPS three day payment window requires that _____ services provided by a hospital up to three days prior to a patient's inpatient admission be covered by PPS DRG payment for ______ and _____ services.
balanced budget act, 1997, resource utilization groups
______ of _____ legislated the implementation of a Skilled Nursing Facility PPS which is called ______.
RUGs, per diem, case mix
_____ reimburse Medicare SNF services according to a ________ prospective rate adjusted for _____.
OCESAA, 1999, home health resource groups
________ of _____ called for the implementation of a Home Health Prospective Payment System for Medicare home health services called ______.
HHRGs, prospectively determined, 60 days
_____ reimburse Medicare home health care services according to a ______ rates and require recertification every _____ by the physician who reviews the plan of care.
ambulatory payment classifications
______ of _____ legislated implementation of an outpatient prospective payment system (OPPS) called _____.
APCs, payment rate, more than one
_____ organize similar outpatient health care services clinically and according to resources required. A _____ is established for each, and depending on the services provided, hospitals can be paid for _____ per encounter.
inpatient rehabilitation facility prospective payment system
______ of _____ authorized implementation of a per discharge ______ for rehabilitative services.
IRFPPS
______ utilizes information from a patient assessment instrument to classify patients into distinct groups based on _____ and expected _____ needs for rehabilitative services.
Balanced Budget Refinement Act, 1999 long term care DRGs
_____ of _____ mandates implementation of a LTC PPS which uses information from long term care hospital patient records to classify patients into distinct _______ based on clinical characteristics and resource needs.
deficit reduction act, 1984, clinical laboratory fee schedule, national limitation amount
The _____ of _____ established the _____ as a methodology for determining fees for existing tests. One year later COBRA established a _____ which serves as a payment ceiling or cap on amount Medicare will pay for each test.
durable medical equipment, prosthetics/orthotics, and supplies fee schedule
_____ is a payment methodology mandated by OBRA of 1987, It was implemented to set fees for medical equipment and supplies.
OBRA, 1989, resource based relative value scale system, Medicare physician fee schedule
_____ of _____ implemented _____ which is used to reimburse physician services covered by Medicare Part B. It is now commonly called the _____.
OBRA, 1980, conditions, prospective, APCs, OPPs, relative payment weights
_____ of _____ mandated that an ambulatory surgical center could participate in Medicare if certain _____ were met and stated that the ASC payment rate is expected be calculated on a ______ basis. In 2008, Medicare implemented use of _____, _____, and ___
balanced budget act, 1997, ambulance fee schedule, relative value, deductible, 20%
_____ of _____ required implementation of an _____ which reimburses ambulance service providers a pre-established fee for each service provided. Payment for each category is based on the ______ assigned to the service. Ambulance providers will not be allo
MMA, 2003, end stage renal disease composite payment rate system, case mix adjusted composite, vary.
_____ of _____ established the _____ for services related to dialysis. The system for dialysis services is based on a _____ rate, which is a ______ rate that does not _____ according to characteristics of the beneficiary
fee for service
Most payers initially reimbursed providers according to _________.
retrospective, after, per diem
Fee for service is a _____ payment system that billed payers _____ health care services were provided to the patient. Hospital reimbursement was generated as _____ a payment system based on daily charges.
increased, prospective payment systems
Health care costs ____ dramatically with implementation of government sponsored health programs leading to the creation of _______.
prospective payment systems
______ pre-establish reimbursement rates for health care services.
case mix
Types and categories of patients
case mix analysis
When facilities analyze types and categories of patients to forecast health care trends in their facilities, ensure appropriate services are provided, and recognize different resource needs for patients.
health care trends, appropriate services, resource needs
Facilities conduct case mix analysis to forecast _____, in their facilities, ensure _______ are provided, and recognize different ______ for patients.
case mix data
Medicare and other payers review _____ because they recognize that some facilities may serve caseloads that include disproportionate shares of patients with above or below average needs.
case mix adjustment
This involves decreasing the average difference between the pre-established payment and each patient's actual cost to the facility.
average difference, pre established payment, actual cost
Multiple possible payment rates based on patients' anticipated care needs allow payment systems to decrease the _____ between _____ and each patient's ______.
high resource, low cost, low need
Case mix adjustment results in encouraging facilities to admit _____ cases and discouraging admission of _____, _____ patients.
severity of illness
The physiologic complexity that comprises the extent and interactions of a patient's disease as presented to medical personnel.
physiologic measures, signs, symptoms
Severity of illness scores are based on _____ of the degree of abnormality of individual _____ and _____ of a patient's disease.
case mix data, severity of illness scores
_____ and _____ are calculated to analyze and measure standards of patient care and assess quality.
critical pathways
Interdisciplinary guidelines developed by hospitals to facilitate management and delivery of quality clinical care in a time of restrained resources.
clinical services, time frames, resources, diagnoses, procedures
Critical pathways allow for the planning of provision of _____ that have expected _____ and ____ targeted to specific _____ and _____.
high in volume, resource use, costly
With clinical pathways, targeted clinical services are frequently those that are _____ and _____ and therefore _____.
chargemaster
This lists all of the procedures, services, and supplies provided to patients by a hospital (charges may also appear).
encounter form, superbill
An _______ (or _____) list procedures and services and supplies provided to patients by a physician (charges may also appear).
accounting code, CPT/HCPCS code number, narrative description
On chargemaster and encounter forms, each item includes _____, _____, and brief _____.
chargemasters
______ play a crucial role in data capture for hospital billing purposes.
cms 1450
Standard institutional claim form submitted by hospitals, skilled nursing facilities, and other institutional based providers to payers to obtain reimbursement for health care services provided to patients.
ub 04
Form otherwise known as CMS 1450
revenue codes
_____ classify hospital categories of service by revenue cost center (ICU, ED, etc).
cms 1500
A universal claim form developed by CMS and used by providers of services to bill professional fees to health carriers.
IRS federal tax employer identification number
The National Employer Identifier is the _______.
national provider identifier, electronic claims, 10
The _____ is a number assigned to hospitals, doctors, nursing homes and other providers in order to file _____ with insurance programs. It is a unique identifier consisting of ____ numeric digits.
national health plan identifier, 10
The _____ is assigned to third party payers, and it contains _____ numeric digits.
electronic data interchange
The computer to computer transfer of data between provider and payer via a data format agreed upon by the sending and receiving parties.
national electronic standards, payers, plans, providers
Administrative simplification provisions of HIPAA direct the federal government to adopt _____ for automated transfer of certain health care data between health care _____, _____, and _____.
hipaa format
After 2003, electronic claims will not be processed if they are in format other than the _____.
fraud
Act that represents a crime against payers or other health care programs, or attempts or conspiracies to commit those crimes.
abuse, unnecessary costs, medically necessary, recognized standards
_______ is the pattern of practice that is inconsistent with sound business, fiscal, or health service practices. It results in _____ to payers and government programs, reimbursement for services not _____, or failure to meet professionally _____ health s
documentation, proper, needed, diagnosis, direct care, treatment, good medical practice, convenience
Medical necessity requires the _____ of services or supplies that are _____ and _____ for the diagnosis or treatment of medical condition; are provided for ____, _____, and _____ of the medical condition; meet the standards of _______ in the local area; a
10000, 3, government programs
The civil monetary penalties act imposes a maximum of up to _____ dollars plus a maximum assessment of up to ____ times the amount claimed by providers who knew the procedure was not rendered and submitted on the claim. Violators can also be excluded from
compliance guidelines
The DHHS OIG developed a series of provider specific _____ which identify risk areas and offer concrete suggestions to improve and enhance an organization's internal controls to billing practices and business arrangement are in order.
national correct coding initiative
Developed by CMS to promote national correct coding methodologies and to eliminate improper coding.
false claims act
Imposes civil liability on those who submit false claims to government for payment and can exclude violators from participating in government programs.
qui tam
Provisions of federal False Claims Act that encourages and rewards private individuals who are aware of fraud being committed against government.
federal antikickback statute, 25000, 5
Prohibits the offer, payment, or solicitation of compensation for referring Medicare/Medicaid patients. Imposes a ______ dollar fine per violation, plus imprisonment for up to ____ years.
safe harbor regulations
Specifies various payment and business practices that, although potentially capable of inducing referrals of business reimbursement under federal health care programs, would not be treated as criminal offenses under the antikickback statute.
subtitle A
______ of HIPAA authorized implementation of a fraud and abuse control program, which coordinates federal, state, and local law enforcement programs to control fraud and abuse with health plans and health care delivery.
payment error and prevention program
Identifies and reduces improper Medicare payments resulting in a reduction in the Medicare payment error rate. Participates in overpayment recovery.
stark I physician self referral law
Prohibits a physician from referring Medicare patients to clinical laboratory services where they or a member of their family have a financial interest.
stark II physician self referral law
Prohibits a physician from referring Medicare patients to clinical laboratory services or other services (e.g., home health, outpatient prescription drugs, radiation therapy) where they or a member of their family have a financial interest.
physicians at teaching hospitals
Requires a national review of teaching hospitals compliance with reimbursement rules and training of physician who provide services at teaching hospitals. Danger of some organizations billing Medicare part B for services paid under part A.
recovery audit contractor program, overpayments, underpayments
Mandated by MMA to find and correct improper Medicare payments paid to providers participating in fee for service Medicare. Goal is to identify _______ and _______.
overpayments
Occurs when health care providers submit claims that do not meet Medicare's NCCI or medical necessity policies.
underpayments
Occur when health care providers submit claims for a simple procedure but upon review of the record a more complicated procedure was documented as being done.
clinical circumstances, correctly coded, correct claims
LCDs and NCDs specify under what _____ a service is covered and _____. They assist providers in submitting _____ for payment.
LCDs
These outline how contractors will review claims to ensure that they meet Medicare coverage requirements. They are published to provide guidance within a specified geographic area.
local coverage determinations, national coverage determinations
LCDs, NCDs
CMS
Who publishes NCDs?
NCDs
LCDs need to be consistent with ______.
never events
Errors in medical care that are clearly identifiable, preventable, and serious in their consequences for patients.
never events
These indicate a real problem in the safety and credibility of a health care facility.
never events
Surgery on the wrong body part, foreign body left in the patient, mismatched blood transfusion are all examples of _____ .
provider groups
In recent years, CMS began working with ______ to identify quality standards that can serve as a basis for public reporting and payment.
reimbursement, quality measures
Federal legislation provides increased _____to hospitals that publicly report _____.
not consistent, preventing
Paying for never events is _____ with goals of Medicare payment reforms. Eliminating payments for never events will result in resources being directed toward _____ such events.
deficit reduction act
This allows CMS to adjust payments for hospital acquired infections.
hospital acquired conditions
The Deficit Reduction Act resulted in a quality adjustment in MS DRG payments to hospitals eligible for reimbursement under IPPS for certain _____.
hospital acquired conditions
Catheter associated urinary tract infections, air embolism, falls and trauma are examples of _____.
high cost, high volume, higher payment, secondary diagnosis, prevented
HACs include those that are (1) ____ or _____; (2) result in the assignment of case to MS DRG that has a _____ when present as ______; (3) could reasonably have been _____.
not reimbursed, secondary diagnosis
IPPS hospitals are ______ additional amounts in the case of HACs as if the reported _______ was not present.
present on admission
CMS also requires hospitals to report _____ indicators for principal and secondary diagnoses.
POA
______ conditions are present at the time the order for inpatient admission occurs. Include those conditions that develop during an outpatient encounter, including emergency department, observation, or outpatient surgery.