Payment Policy

Question 1

Medical Coders Purpose:
1. Code____and______
2. To Effectively_________.

Answer 1

1. Code Diagnoses and Services
2. To Effectively Bill Health Insurance for the Costs of Services

Question 2

1. Some patients pay for their medical expenses_____.
2. Most patients will have ______or______(under____categories).

Answer 2

1. Some patients pay for their: medical expenses out of pocket with their own money
2. Most: patients will have one or more health plans (under 3 categories)

Question 3

3 Categories of Payers:
1. Commercial Carriers

1._______Company
2.Offer Medical ______for______and______.
3. Include Organizations______ , _____
4. Include Other________Providers
5. Contracts Cover________of________
6. Contracts Cover________of________

Answer 3

1.Commercial Carriers:

1. Private Insurance Company
2. Offer Medical Insurance for Groups and Individuals
3. Include Organizations: Blue Cross Blue Shield, Aetna
4. Include Other Major Service Providers
5. Contracts Cover a Wide Variety of Services
6. Contracts Cover a Wide Variety of Individual Plans

Question 4

3 Categories of Payers:
2. Medicare

1.United States Primary__________Insurance.
2.Paid for by_________.
3. Administered by__________(CMS)
4. Made up of _____ Parts (____Parts: ___,___,___,___)
5. Available to _____.
(1) Older than____
(2)____Blind Disabled
(3)
(4)

Answer 4

2. Medicare
3. United States Primary Government-Funded Insurance
4. Paid for by Federal Government
5. Administered by Centers for Medicare & Medicaid Services (CMS)
6. Made up of Multiple Parts (Medicare Parts: A, B, C, D)
7. Available to Individuals:
   (1) Older than 65
   (2) Blind Disabled
   (3) Suffering from Permanent Kidney Failure or:
   (4) Suffering from End-Stage Renal Disease (ESRD)

Question 5

3 Categories of Payers:
3. Medicaid

1.________Program
2.Sponsored at the___________
3.For ____-_____ Individuals
4.Especially _______ ______ and _______
5.Varies from _____ to _____
6.Must_____to____ ____ ____

Answer 5

3. Medicaid
4. Insurance Assistance Program
5. Sponsored at the Federal and State level
6. For Low-Income Individuals
7. Especially Pregnant Women and Children
8. Varies from State to State
9. Must Adhere to Certain Federal Guidelines

Question 6

Merit-Based Incentive Payment Solution (MIPS)

1. ____of____programs
2. Part of: ________ Access and ______ _____ Insurance Program _______ _____ Act.
3. Established: ____.
4. Determines ______in order to:

5.________and_______in_______.

Answer 6

1. One of Two Programs
2. Part of: Medicare Access and Children’s Health Insurance Program Reauthorization Act
3. Established: 2015
4. Determines Medicare Payments In Order to:
5. Promote Improvement and Innovation in Clinical Activities

Question 7

Merit-Based Incentive Payment Solution (MIPS):
1. Measures: ________ ________ Providers (referred to as eligible _______) Performance Based On:
(1) ________: of performance

(2) Promoting _______________(by using ________ ________ ________ technology)

(3) Improvement _________:
1.Care___________
2.________Safety
3.________ ___ care;

2. Combined __________ Score Determines Whether: Participating ______ ______ Receive:
   an Adjustment (_______, _______, ______) to Their _________ ___________

Answer 7

1. Measures: Participating Providers (referred to as eligible clinicians) Performance Based On:
   (1) Quality: of performance

(2) Promoting Interoperability (by using Electronic Health Record Technology)

(3) Improvement Activities:
1.Care Coordination,
2.Patient Safety
3.Cost of care;

2. Combined Aggregate Score Determines Whether: Participating Eligible Clinicians Receive:
   an Adjustment (Positive, Negative, Neutral] to Their Medicare Reimbursement

Question 8

Alternative Payment Models (APMs)

1. ______ of ______ Tracks
2. Determine ________ Payments for _________ Rendered (provided)*
3. Established: ______
4. Part of: Medicare Access and Children’s Health Insurance Reauthorization Act
5. Meant to Ensure ________ (Especially _______ Suffering From ___________ __________) Receive ______ While ________:
   Unnecessary ________ or ______ of _______.

Answer 8

1. One of Two Tracks
2. Determine Medicare Payments for Services Rendered (provided)*
3. Established: 2015
4. Part of: Medicare Access and Children’s Health Insurance Reauthorization Act
5. Meant to Ensure Patients (Especially Patients Suffering From Chronic Conditions) Receive Care While Avoiding:
   Unnecessary Errors or Duplication of Services.

Question 9

Alternative Payment Models (APMs)

(Overtime)
________Who Receive:
A ___________ Percentage of Their __________ Part __ _______ or
A ___________ Percentage of Their ________ through an ____
Can ___:
A _% Yearly _______ _______.

(Unlike MIPs)
Their Are a ________ ______ of _____ Available,
Depending On the ___________ and ______ of ________.

Answer 9

(Overtime)
Providers Who Receive:
A Substantial Percentage of Their Medicare Part B Payments or
A Substantial Percentage of Their Patients through an APM
Can Earn:
A 5% Yearly Incentive Payment.

(Unlike MIPs)
Their Are a Wide Variety of APMs Available,
Depending On the Specialty and Type of Provider.

Question 10

Place of Services Codes:

1. _____ Digit Code
2. Use on _________Professional’s _____ ______Document
3. Show What ________ the________ ________Was_______In.
4. Codes _____ by:
   _____for______&______ _______ (____)

Answer 10

Place of Services Codes:

1. Two Digit Code
2. Used on Healthcare Professional’s Service Claim Document
3. Show What Setting the Professional’s Services Was Provided In
4. Codes Maintained by:
   Centers for Medicare & Medicaid Services (CMS)

Question 11

Place of Services Codes

1. Can______ ______the __________ _______of The_______ ______ __:

(1) The Code_____When_____: ______, ______, ______ _______

2. _____Into_____Based On ______ ____ _______ in a:
   (1)
   (2)
3. _____ from _____ ______for_________and_________ _________ and ________ _______ _______ them.

Answer 11

Place of Services Codes

1. Can Greatly Affect the Reimbursement Rate of The Professional Depending on:

(1) The Code Used When Billing: Medicare, Medicaid, Private Insurance

2. Divided Into Categories Based On Whether Treatment Takes Place In a:
   (1) Medical Facility
   (2) Or Not
3. Separate from Codes Used for Diagnosis and Procedure Identification and Not Coded Alongside them

Question 12

Place of Service Codes: Facility & Non-Facility Codes

1. Place of Service Codes:
   Divided into ______ and ___-_____Codes

2._________Codes Cover Services By:
(1)
(2)
(3)

3. _______Codes cover services:
   (1)_____ _____ _______

Answer 12

Place of Service Codes

1. Place of Service Codes:
   Divided into Facility and Non-Facility Codes
2. Facility Codes Cover Services By:
   (1) Hospitals
   (2) Skilled Nursing Facilities
   (3) Ambulatory Surgical Centers
3. Non-Facility:
   (1) All Other Locations

Question 13

Fraud

Medical Coding Fraud

Answer 13

1. Fraud: the criminal deception of an individual organization for financial gain.
2. Medical Coding Fraud: intentionally overcharging insurance companies or false reporting services that were not provided.

Question 14

Types of Medical Coding Fraud:

Answer 14

1. Upcoding: apply a higher-paying billing code to a professional service
2. Unbundling: billing the components of a bundled code separately

3.Split Billing: billing a treatment that was performed during a single encounter as if it occurred over multiple days

4. Billing services provided or performed by nurses, residents, and staff under codes that are used only for a physicians duties
5. Reporting a higher number of units than what was provided