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How many concurrent diagnoses can there be on an insurance form?
3 (4 diagnoses altogether)
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What is first volume of ICD-9 codes? Where is it used?
numerical index; used in doctor's office
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What does ICD-9 stand for?
Int'l Classification of Diseases, 9th Edition
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Where is volume 3 of the ICD-9 book used?
in hospitals only
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What did the US originally use ICD-9 codes for?
Reporting causes of disease, prepping mortality stats
-
Where and when did the ICD system begin?
1700s in England
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How many supplements and appendices are there to volume 1 of the ICD-9 book?
2 supplements, 5 appendices
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Who uses this book for reporting mortalities?
State Health Depts and US Public Health
-
What are the 5 appendices of the ICD-9 book?
- 1. M codes
- 2. Glossary of Mental Disorders
- 3. Classification of drugs by American Hospital Formulatory Service and the IDC-9 equivalents
- 4. Classification of Industrial Accidents according to agency
- 5. List of 3-digit categories
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When did coding become a requirement for all federally sponsored insurance programs?
1989
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Who updates the ICD-9 annually?
NCHS-- National Center for Health Stats
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How many Volumes are are in the ICD-9 book?
3
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What kind of supplemental classification would you use for an annual physical exam?
V code
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When does Medicare require you to start using the newest ICD-9?
January 1st
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A working diagnosis that has not been proven and includes words like, "suspected", "rule out", "possible", "questionable":
qualified diagnosis
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What is an 'M' code?
- Morphology code (tumor tissue type) of neoplasms
- *** appear on hospital reports
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What is a 'V' code?
Codes that are used when a definitive Dx cannot be stated, but there is a valid reason for the patient to seek medical care
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Give a couple examples of a V code
- Well baby check
- Annual physical exam
- Family history of cancer
- Evaluation by cardiologist before surgery
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What is an E code?
Code for external causes of injury and poisoning (also criminal activity)
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What is a disorder that does not always affect prognosis of primary condition?
Secondary diagnosis
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Dx listed first on the claim form:
Primary Dx
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When can new editions of the ICD book be used? (What start date)
October 1st
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disorder that coexists with primary condition that complicates treatment of primary condition
concurrent Dx
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When are new ICD books issued?
September, annually
-
Instead of coding the qualified diagnosis, what would you code?
The symptoms
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Do E codes expedite the processing of injury claims?
yes
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For PRIVATE INSURANCE COMPANIES, when must you begin using the newest ICD-9 book?
March 1st
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Where is the only place M codes will appear?
Hospital reports
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Can you code a qualified Dx?
no, just the symptoms
-
Do E codes affect 3rd party payment?
No
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Codes used when there is no definitive Dx but the patient has a valid reason to be seen...
V codes
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Two supplemental classifications of Vol I of ICD-9 book:
V and E codes
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What is the first step in using the index of the ICD-9 book?
locate the main term in volume 2
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What should you do if you cannot find the condition listed (first)?
Try a broader condition (syndrome, disease, disorder)
-
What is another name for a modifier?
subterm
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Which volume do you look to first when trying to locate a disease?
Vol II
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How do you make a code more specific after the first 3 digits?
add a decimal and one or two additional digits
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Would you ever code the PRE-OP Dx instead of the POST-OP Dx?
No, always Post-op
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What are nonessential modifiers?
Qualifying words that do not have to be included in the Dx statement for the code # to apply
-
Where is a subterm located?
Indented two spaces beneath main term
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Where do you look after finding the disease in Vol II?
Vol I, numerical index
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Where would you look if you couldn't find a code using major terms and after trying to find a broader condition?
Appendix E
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Vol I is organized in how many digits?
3
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When do you code using only Vol II?
NEVER
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Do you need to wait for pathology/lab reports before coding on an insurance form?
Yes, to make sure you have an accurate Dx
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Is there a need for proofreading when coding?
YES
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Define subterm:
Term that qualifies the main terms or conditions by describing differences in site or etiology
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Is the doctor usually aware of coding changes?
No.
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What do the two digits after a decimal point do?
They define the disease more specifically
-
How are the main terms of ICD-9 codes printed?
In boldface type
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Define comorbidity.
Either the presence of one or more disorders (or diseases) in addition to a primary disease or disorder, or the effect of such additional disorders or diseases.
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Which coding book has V codes?
ICD-9 book
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Which coding book has E codes?
ICD-9 book
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Name the 6 sections of the CPT book
- Pathology
- Radiology
- Medicine
- Anesthesia
- Surgery
- E/M
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What are the two types of coding?
- CPT and ICD-9
- *CPT= procedures
- *ICD-9= Dx
-
Define fiscal intermediary/agent.
- A fiscal Intermediary (FI) refers to an entity or a private company that
- has a contract with the center for medicare and medicaid services to determine and to pay part A and some part B bills
-
What is meant when you say "spreading the risk"?
- Spreading the risk: The selling of insurance in multiple areas to multiple policyholders to
- minimize the danger that all policyholders will have losses at the same
- time.
-
Define Insurance Claims Register.
A log that allows you to see at a glance if a claim has been filed and also if it has been paid.
-
When should you follow up on a claim?
30-45 days on all claims if they have not been paid
-
Authorization to release information form is used when?
To show Medicare/Medicaid the person or persons you have designated to access your health information
-
Four reasons why CPT codes were developed
- *To track disease processes
- *Research
- *For insurance processing (faster)
- *To classify medical procedures
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Define UCR.
Usual, customary, reasonable
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What do HMOs place a strong emphasis on?
well-care and early detection to reduce later cost
-
Three uses for ICD-9 code book?
- *used to code, store, computerize, and retrieve large volumes of information from a pt record
- *lengthy terminology is reduced to 3-5 digits
- *Used for participation in Medicare, Medicaid, all other insurance programs
-
3 key components of E/m codes
- *History
- *Examination
- *Medical decision making
-
Define assignment of benefits.
- The doctor agrees to accept payment from an insurance company first and then bill the patient for any after-insurance
- balances. (SO INSURANCE PAYMENT GOES DIRECTLY TO DOCTOR)
-
Define utilization review.
A utilization review is when a health insurance company reviews a request for medical treatment.
-
Define gatekeeper.
Person who provides health care services at the lowest possible cost and avoiding nonessential care
-
Define non-duplication of benefits.
A provision in some types of health insurance policies which specifies that the insurer will not pay benefits for any amount that is reimbursed by others.
-
Dates on insurance forms are recorded using how many digits?
8
-
Information contained in an authorization letter (when a patient is referred to a specialist):
- *Auth #
- *Date received by UR, date approved, and exp date
- *Dx code
- *Name, address, phone of specialist
- *# of authorized visits
-
What is catastrophic coverage?
Catastrophic coverage is insurance coverage that is designed to protect the consumer from financial disaster in the case of a serious medical emergency.
-
What is the standard insurance form called?
CMS 1500
-
A system of payment in which providers are paid a fixed per capita fee for each enrolled patient is known as:
capitation
-
Employer ID # is also referred to as:
Tax ID #, IRS ID
-
Reference initials on the CMS 1500 should be where on the form?
Lower left hand corner
-
HMO stands for:
Health Maintenance Organization
-
Who revises the CPT-4 book?
AMA (published annually)
-
Define preadmission certification.
Approval by a case manager or insurance company representative (usually a nurse) for a person to be admitted to a hospital or in-patient facility, granted prior to the admittance.
-
Define Quality Assurance.
assesses the quality of care provided in a health care setting
-
Coordination of benefits is also called:
non-duplication of benefits
-
What does worker's compensation insurance cover?
Work related injuries or illnesses
-
Define upcoding.
Coding deliberately to be able to receive a higher reimbursement
-
Describe the concept of RBRVS. (Resource-Based Relative Value Scale)
It is used to determine how much providers should be paid. It works by assigning units. It is needed to standardize payment (provide national uniform payments)
-
Define DRGs (Diagnostic Related Groups)
This system classifies patients into groups based on the principal Dx, type of surgical procedure, presence or absence of significant comorbidities/complications, and other relevant criteria.
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