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other

"other" or "other specified" codes (usually with 4th digit 8 or 5th digit 9 are used when the information in the medical record provides detail for which a specific code does not exist.

The amount on an ABN should be within how much of the cost to the patient?

$100 or 25% of cost RATIONALE: CMS instructions stipulate, "Notifires msut make a good faith effort to insert a reasonable estimate....the estimate should be within $100 or 25% of the actual costs, whichever is greater.

CY 2013 Conversion Factor

$25.0008

Published conversion factor for CY 2011

$33.9764

Published Conversion factor for CY 2012

$34.0376

IF: Work RVUs = 0.48 Work GPCI = 1.000 Practice Expense CPCI = 0.943 MP GPCI = 0.572 transitioned non-facility practice RVUs = 0.70 Calculate non-facility pricing amount for cpt code 99212 using 2011 CF of $33.9764

$39.51 Non-facility pricing amount (physician office, private practice)

ChampVA

(Civilian Health and Medical Program of the Veteran Affairs)- was created to provide medical benefits to spouses and children of veterans w/ total, permanent service related disabilities or for surviving spouses and children of a veteran who died as a result of service related disability. It is a service benefit therefore no premiums. Members who receive TRICARE do not qualify for CHAMPVA

OIG Compliance Program for Individual and Small Group Physician Practices include the following key actions

* Implement compliance and practice standards through the development of written standards and procedures. * designate a compliance officer or contac to monitor compliance efforts and enforce practice standards * conduct appropriate training and education of practice standards and procedures * conduct internal monitoring and auditing through the performance of periodic audits * respond appropriately to detected violations through the investigation of allegations through the investigation of allegations and the disclosure of incidents to appropriate government entitities * Develop open lines of communication * Enforce disciplinary standards through well-publicized guidelines

LCDs give guidance when

* a given service is indicated or necessary, * give guidance on coverage limitations * describe the specific CPT codes to which the policy applies * lists IICD-9-CM codes that support medical necessity for the given service or procedure

Under the Privacy rule, the minimum necessary standard of HIPAA does not apply to

* disclosures to or requests by a health care provider for treatment purposes * disclosures to the individual who is the subject of the information * uses or disclosures made pursuant to an individual's authorization * uses or disclosures required for compliance with the HIPAA Administrative Simplification Rules * Disclosures to the US Dept of Health and Human Services when disclosure of info is required under the Privacy Rule for enforcement purposes. * Uses or disclosures that are required by other law

"hold harmless clause"

* found in some non-Medicare health plan contracts * prohibits billing to patient for anything beyond deductibles and co-pays.

A compliance plan may offer several benefits, including:

* more accurate payment of claims * fewer billing mistakes * improved documentation and more accurate coding * less chance of violating self-referral and anti-kickback status

A suffix that means resection is

-ectomy

A suffix meaning "inflammation" is

-itis

Which suffix means breathing?

-pnea

Toenails grow at approximate rate

1 mm per month

What are some of the common suffixes for diseases and meaning

1. -itis-inflammation 2. -oma-tumor 3. -pathy- disease of

Hair on the scalp grows approximately how much per day and per year

1. .3 to .4 mm/day 2. @ 6 inches per year

What are the requirement for a PA and what

1. 26 1/2 month to complete 2. Lincense to practice medicine with physician supervision

When and who can a covered entity disclose health information to

1. A covered entity may use or disclose protected health infromation for its own treatment,payment or health care operations 2. A covered entity may disclose protected health information for treatment activities of a health care provider 3. A covered entity may disclose protected health information to another covered entity or a health care provider for the payment activities of the entity that recieves the information 4 A covered entity may disclose to another covered entity for health care operation activities of the entity that recieves the infromation, if each entiity either has or had a relationship with the individual who is the subject of the protected health information 5. A covered entity that participates in an organized health care arrangement may disclose protected health information about an individual to another covered entity tath participates in the organized health care arrangement for any health care operations activites of the organized health care arrangement

What must be done BEFORE the patient signs the ABN

1. ABN must be verbally recived with beneficiary or his/her represenative 2. Any questions raised during that review must be answered

What are the characteristics of synovial joints

1. Articular cartilage that covers the bone ends 2. Joint cavity lined with synovial membrane 3. Joint capsule of fibrous connective tissue that surrounds and provides stability of the joint 4. Accessory ligament that give reinforcement

The human skeleton is divided in which 2 parts

1. Axial 2. Appendicular

What does the nail bed contain

1. Blood vessels 2. nerves 3. Melanocytes (melanin-producing cells)

What are the categories of the human body

1. Cells 2. Tissues 3. Organs 4. Systems

What must the provider must complete (in regards to ABN)

1. Complete one-page form in full 2. giveing the patient an explanation as to why Medicare is likely to refuse vocerage for proposed procedure or service

What are the Key actions of this programs

1. Conduct internal monitorind and auditing throught the performance of periodic audits 2. implement compliance and pratice standards through the development of written standards and procedures 3. designate a compliance officer or contact (s) to monitor compliance efforts and enforce practice standards 4. Conduct appropriate training and education on practice standards and procedures 5. Respond appropriately to detected violation through the investigation of allegations and the disclosure of incidents to appropriate government entities 6. Develop open lines of communication 7.Enforce diciplinary standards through well-publicized guidelines

What must go to the patient and to the provider

1. Copy of completed signed form must be given to beneficiary or representative 2. The provider must retain the original notice on file

What do Excepted benefits include

1. Coverage only for a ccident, or disability income insurance, or any combination thereof 2. Coverage issued as a supplement to liability insurance 3. Liability insurance, including general liability insurance and automobile liability insurance 4. Worker's compensation or similar insurance 5. Credit-only insurance 6. Coverage for on-site medical clinics 7. Other similar insurance coverage, specified in regulation, under which benefits for medical care are secondary or incidental to other insurance benefits

What is the difference between Covered and Non-covered items

1. Covered items-services and procedures are covered only when linked to designated, approved diagnosis 2. Non-covered items are deemed "not reasonable or necessary

what are some of things that operative header note might include?

1. Date and time of procedure 2. Name of surgeon, co-surgeon, assistant surgeon 3. Typer of anethesia and anestheiology provider name 4. Pre-operative and post-operative diagnoses 5. Procedures performed 6. Complications

What 2 layers make up the human skin

1. Dermis 2. Epidermis

What are the 5 most important Coding Tips for operative reports for a coders

1. Diagnosis code reporting 2. Start with the procedures listed 3. Look for key words 4. Highlight unfamiliar words 5. Read the body

Under the Privacy rulem the minimum necessary standards does not apply to the following

1. Disclosures to or requests by a health care provider for treatment of purposes 2. Disclosures to the individual who is the subject of the information 3. Uses or disclosures made pursuant to an individual's authorization 4. Uses or disclosures required for compliance with the HIPAA Administrative Simplification Rules 5. Disclosures to the U.S. Department of Health and Human Services when disclosure of the information is required under the Privacy Rule for enforcement purposes 6. Uses or disclosures that are required by other laws

Who is under the "health care providers covered entity"

1. Doctors 2. Clinics 3. Psychologists 4. Nursing Home 5. Pharmacies

Medical coders assign a code to what

1. Each diagnosis 2. service/procedure 3. Supply, using the classification system when applicable

When is a ABN never required and WHY

1. Emergency and urgent care situation 2. CMS prohibits given an ABN to a patient who is "under duress," including patient who need Emergency Department service before stabilization

What does the acroymn EIN and who uses it

1. Employer Indentification Number 2. Issued to employers by the Internal Revenue Services (IRS)

What are several benefits that a compliance plan can offer

1. Faster, more accurate payment of claims 2. Fewer billing mistakes 3. Diminished chances of a payer audit 4. Last chance of running a foul of self-referral and anti-kickback statutes.

Bones provide what functions

1. Form the skeleton 2. Provide the chief means of support for the body 3. Provide the mechanism for motion 4. Protect vital organs 5. Serve as a production factory for blood cells 6. Store calicum, phosphorus, and magnesium salts

What are the Code sets that within the transactions, code sets have been designated for standard use?

1. HCPCS 2. CPT 3. CDT 4. ICD-9-CM 5. NDC

Who is under the "Health plan covered entity

1. Health Insurance Companies 2. HMO 3. Company Health Plans 4. Governement programs that pay for health care, such as Medicare, Medicaid, and the military, and veterans health care programs

What transactions are used in National Standard for Electronic care transaction and code set

1. Health claims and equivalent encounter information 2. Enrollment and disenrollment in a health plan 3. Eligibility for a health plan 4. Health care payment and remittance advice 5. Health plan premium payments 6. Health claim status 7. Referral certification and authorization 8. Coordination of benefits

Techicians who speciallize in coding inpatient hospital services are referred as

1. Health information coders 2. medical record coders 3. Coder/abstractors 4. Coding Specialist

What are 2 types of Granules

1. Keratohyaline granules 2. lamellated granules

What is LCD and What is it

1. Local Coverage Determinations 2. MAC is responsible for interpreting national policies into regional policies. The LCDs further define what codes are needs and when an item or service will be coved . LCD have jurisdiction only with their regional area

What are the seven classifications of bones

1. Long 2. Tubular 3. Short 4. seasmoid 5. Cuboidal 6. Flat 7. irregular

HITECH lowers what for what constitutes a voliation but provides what during which any violation not due to willful neglect may be corrected without a penalty

1. Lowers the Bar 2. 30-Day window

What is MS-DRGs and what is it

1. Medicare Severity-Diagnosis Related Groups 2. Determines the amt the hospital will be reimbursed if the PT is covered by Medicare or other insurance programs

After the ABN is signed, What are choices the patient has

1. Medicare beneficiary may choose to proceed with procedure/service and assume financial responsiblity. If the patient chooses to proceed, he may request the charge be submitted to Medicare for consideration (with the understanding that it will probably be denied 2. may elect to forego the procedure or service

What are some of the common reason why Medicare may deny a procedure and service

1. Medicare does not pay for the procedure/service for the patient's condition 2. Medicare does not pay for the procedure/service as frequently as proposed 3. Medicare dod not pay for experimental procedure/services

What is a mid-level providers and who

1. Mid-level providers are know as physician extenders 2. Physician assistants (PA) and Nurse Practitioners (NP)

what are 5 types of membranes in the human body?

1. Mucous Membrane 2. Serous Membrane 3. Synovial Membrane 4. Meninges

What are 4 types of tissue and what do they do

1. Muscle tissue- produces movement 2. Nerve tissue- conducts impluses to and from the brain 3. Connective tissue - connects and supports various body structures: Adipose (fat) and osseous (bone) 4. Epithelial tissue- found in the skin, lining of the blood vessels, respiratory, intestinal, urinary tracts, and other body systems

What is NCD and what does it do

1. National Coverage Determinations 2. Explains when Medicare will pay for items or services

What does the acroymn NPI and who used it

1. National Provider Indentifier 2. indentifier for providers required on the transactions

Administration Simplification (HIPPA) address the need for

1. National standards for electronic health care tranaction and code sets 2. National unique indentifiers for providers, health plans and employers 3. Privacy and Security of health data

What is the difference between Hospital and Physican Services

1. Outpatient coding (physician services)- learning CPT, HCPCS, LEVEL II, ICD-9 CM codes Volume 1 and 2 2. Inpatient coding (Hospital services)- Learning CPT, ICD-9 CM codes Volumes 1,2,3 and MS-DRGS

These structure work together to provide what functions within the body

1. Protection from injury, fluid loss, and microorganism 2. Temperature regulation 3. Fluid balance-excretion 4. Sensation

What does the acroymn RNA means and what does it do

1. Ribonucleic acid 2. Contained within the nucleus, is transcribed from DNA by enzymes and plays a crucial role in protein synthesis

What are the 2 layers of strata of the dermis

1. Stratum Papillare 2. Stratum Reticulare

The dermis contains many important structures nourishing and innervating the skin, what are they

1. Vessels carrying blood and lymph 2. Nerves and nerve endings 3. Glands 4. Hair follicles

Nails grow all the time but the rate of growth slow with

1. age 2. poor circulation

What is the standard body postion and what is it

1. anatomical position 2. an upright, face-forward position with the arms by the side and palms facing forward. The feet are parallel and slightly apart

what are 3 things that Coder must master

1. anatomy 2. medical terminology 3. must be detail-oriented

What are 4 components of a cell and what do they do

1. cell membrane- forms the boundary of the cell 2. cytoplasm- make up the body of the cell 3. Nucleus- the small, round structure in the center of the cell 4. Chromonsomes- located in the nucleus of the cell; they contain genes determining hereditary characteristics

A coder must evaluate the medical record for

1. completeness and accuracy 2. communicate regularly with physicians and othe health care professional to clarify DX or obtain additonal PT info.

What are the four general group of connective tissue

1. connective tissue proper 2. cartilage 3. bone 4. blood

What are the 5 types of body cavities and what is in the space

1. cranial cavity- inside the skull, or cranium, containing the brain 2. Spinal (Vertebral canal)- inside the spinal column containing the spinal cord 3. Thoraci or chest cavity- the space containing the heart, lungs, esophagus, trachea, bronchi, and thymus 4. Abdominal cavity- the space containing the lower portion of the esophagus, the stomach, intestines (excluding the sigmoid colon and rectum) kidneys, liver, gallbladder, pancreas, splean and ureters 5. Pelvic cavity- the space containing the urinary bladder, certain reproductive organs, part of the large intestine, and the rectum

What are the 3 types of joints

1. fibrous 2. cartilaginous 3. Synovial

what are 2 structures of hair

1. follicle 2. shaft

Who is under the covered entity

1. health care providers 2. Health plans 3. Health care Clearinghouse

What are some of things that operative body note might include

1. indication for surgery 2. details of the procedure (s) 3. Findings

Information required by payers to determine the need for care

1. knowledge of the emergent nature or severity of the patient's complaint or condition 2. All signs, symptoms, complaints, or background facts describing the reason for care, such as required follow-up care.

the shaft is compoosed of keratin in what 3 layers

1. medulla 2 cortex 3. cuticle

Stratum lucidum layer is normally found only on what

1. palms of the hands 2. soles of the feet

The hypodermis serves to

1. protect the underlying structures 2. prevent loss of the body heat 3. anchor the skin to the underlying musculature

what does is the purpose of Keratin on the fingernail

1. protective plate 2. counterforce to the finger tip to increase sensory input of touch

Non-participating Providers are

1. providers not contracted with the insurance carriers 2. not required to make the adjustment

HITECH allows patients to do what

1. request an audit trail showing all disclosures of their health information made through an electronic record 2. requires an individual to be notified if there is an unauthorized disclosure or use of his or her health information

What are the 6 specific parts of the nail

1. root 2. nail bed 3. nail plate 4. eponychium (cuticle) 5. perionychium 6. hyponychium

what does synovial membrane do

1. secrete synovial fluid into the joint cavity 2. lubricates the ends of of bones so they move freely

What are 3 types of muscles found in the body

1. skeletal Muscle 2. Cardiac Muscle 3. Smooth Muscle

The largest organ system in the body is comprised of what 3 structures

1. skin 2. hair 3. Nail

What are the 5 strata of the epidermis

1. stratum Corneum 2. Stratum Lucidum 3. Stratum Granulosum 4. Stratum Spinosum 5. Stratum Basale

What does the term "suffix"mean and where does come from

1. to fasten underneath 2. Latin word subfigure

second trimester

14 weeks 0 days to less than 28 weeks 0 days

How many payers in the most simplest form?

2 Private insurance plans and government insurance plans

What is the approximate percentage of an operative report contains words less important to a coder?

20 %

By which week does a developing fetus has its lifetime supply of hair follicles

22 weeks

third trimester

28 weeks to delivery

282.42 Sickle-cell thalassemia with crisis ** Sickle-cell thalassemia with vaso-occlusive pain ** Thalassemia Hb-S disease with crisis Use additional code for the type of crisis, such as: ** acute chest syndrome (517.3) **splenic sequestration (289.52) correct sequence for sickle-cell thalassemia crisis with acute chest syndrome in correct sequence are:

282.42, 517.3

ICD-9CM is published in ___ volumes

3

What is meninges composed of

3 connective tissue membrane

Tertiary

3rd insurance plan that covers what 1st and 2nd

The structure of the human body falls into how many categories

4

qid

4 times per day

The epidermis is composed of what

4 to 5 layers called stratum

What is a physican degree of education

4 years of college, 4 years of medical school plus 3 to 5 years of residency.

How many Act are under HIPPA

5

How many body cavities does the body have

5

How many types of Membranes are there in the human body

5

Morphology codes consist of ___ digits

5

On average a human body have how many follicles

5 million

The ___ is used after an incomplete term which requires one or more of the descriptions that follow to make it assignable to a given category

:, colon

NP must have

A Master Degree in Nursing

What is a cell

A basic unit of all living things

arterial line

A catheter inserted into an artery, used most commonly to measure real-time blood pressure and obtain samples for arterial blood gas.

nonselective catheterization

A catheter is placed in the main trunk; contrast may be injected and images may be taken, but the catheter is not moved into any other branches.

non-tunneled catheter

A catheter that is inserted through the skin directly into a central vessel.

croup

A common, high-pitched, barking cough found in infants and children with nasal-type symptoms.

Fee Schedule

A complete listing of fees used by the health plan to pay

acute

A condition with a rapid onset with a short course.

CVP (central venous pressure)

A direct measurement of the blood pressure in the right atrium and vena cava. CVP reflects the amount of blood returning to the heart and the ability of the heart to pump blood from the right heart into the pulmonary system.

PAC-Pulmonary Artery Catheter (eg, Swan-Ganz)

A flow directed catheter inserted into the pulmonary artery. PACs are used to measure pressures and flows within the cardiovascular system.

What is Medicaid

A health insurance assistance program for some low income people (especially children and pregnant women) sponsored by federal and state governments

Anesthesiologist Assistant

A health professional who has completed an accredited anesthesia assistant training program.

Covered Benefit

A health service or item that is included in the health plan and paid for partially or in full.

Consolidated Omnibus Budget Recondiliation Act (COBRA)

A law that helps keep people covered by employer groups after coverage ended due to death of a spouse, losing a job, reduced hours, leaving voluntarily, or getting a divorce. The beneficiary may have to pay the premium however there is no administrative fee.

Splenoportography

A method of using X-ray imaging to view the portal system via the spleen.

Physical Status Modifier

A modifier used to report the physical status assigned to each patient undergoing anesthesia. Patients are ranked by their individual health status.

Advance Beneficiary Notification (ABN)

A notice from provider to patient that Medicare may deny payment. Patient must sign before services are provider, otherwise patient is not responsible if Medicare does not cover.

Medicare Part B is considered what

A optional benefit for which the patient must pay a premium and which generally requires a yearly copay

Conditional Payment

A payment made by Medicare in which another payer is responsible. Ex,, Auto is in litigation, if they pay, then Medicare will be reimbursed

Coordination Period

A period of time where the employer group health will pay first on the bill and Medicare will pay 2nd.

Fiscal Intermediary

A private company that contracts with Medicare to pay Part A and some Part B claims. (Also called Intermediary)

Durable Medical Equipment Regional Carrier (DMERC)

A private company that contracts with Medicare to pay bills for durable medical equipment (DME)

-Gram

A record of data

EDI Translator

A software tool for accepting an EDI transmission and converting data into another format

What is ABN

A standardized form that explains to the patient why medicare may deny the particular service or procedure.

controlled hypotension

A technique used in general anesthesia to reduce blood pressure to control bleeding during surgery. Watch anesthesia record for notes regarding deliberate or controlled hypotension.

CMS-R-131

ABN form or Advance Beneficiary Notice which explains to the patient why Medicare may deny the particular service or procedure.

HITECH was enacted as part of What

ARRA

Define Lordosis

Abnormal anterior curvature of spine usually lumbar

Lordosis

Abnormal anterior curvature usually lumbar

Kyphosis

Abnormal curvature of spine humpback

Superior (cranial)

Above toward the lower end of the spine

Why is there a need for National Standard for Electronic Health care transaction and code set

According to CMS " transactions are electronic excahanges involving transfer of information between two parties for a specific purpose. National standards for electronic health care transaction are designeed to improve the effciency and effectiveness of the health care system by standardizing the formats used for electronic transactions.

-graphy

Act of recording data

Health Care Code Maintenance Committee

Administered by Blue Cross Blue Shield Association (BCBSA) maintains coding schemes used in X12 transactions and elsewhere. They include claim adjustment reason codes, claims status category codes and claim status codes.

Department of Health and Human Services (DHHS)

Administers many of the social programs at the federal level dealing with the health and welfare of citizens of the United States. (Parent of CMS)

What is Title II of HIPPA known as

Administration Simplification

Adrenocortic/o

Adrenal cortex

Adren/o adrenal/o

Adrenal gland epinephrine

If a sevice fails to support medical necessity requirements per the LCD, and the service is not covered, the practice would be responsible for obtaining a(n)

Advance Beneficiarly Notice of NonCoverage (Advance Benefiary Notice, or ABN)

What does ABN stand for

Advance Beneficiary Notice of Noncoverage, or Advance Beneficiary Notice

ABN

Advanced Beneficiary Notice

Post

After behind

Assignment

Agreeing to acccept Medicare fees as payment in full

Pneum/o pneumat/o

Air, gas, desperation lung

Ambulatory Care

All types of health services that do not require an overnight stay.

Volume 3 of the ICD-9-CM

Alphabetic Index and Tabular List of Procedures: Procedures performed in the inpatient setting

modifier 92

Alternative Laboratory Platform Testing

APC

Ambulatory Payment Classification

What is APC and who uses it

Ambulatory Payment Classification- outpatient facility coders (physician services

ASC

Ambulatory Surgical Center

ASC

Ambulatory Surgical Centers

Apc

Ambulatory payment clasification

AMA

American Medical Association

ARRA

American Recovery and Reinvestment Act (of 2009)

ARRA

American Recovery and Reinvestment Act of 2009

What does the acroymn ARRA stand for

American Recovery and refinvestment act of 2009

ASHIM

American Society of Health Informatics Managers, Inc. is a non-profit group of computer professionals that specialize in health information technology (HIT). They are certified through Certified Health Informatics System Professionals (CHISP)

Benefit Payment

Amount paid by insurance after the deductible and coinsurance have been deducted

False Claims Act

An act that allows employees to sue employers on behalf of the federal government for fraud against the government. The employee retains a share of the recovery as a reward for his or her efforts.

Deductible

An annual amount or out of pocket expense the subscriber must pay either individually or per family.

sequela

An inactive, residual effect or condition produced after the acute portion of an injury or illness has passed.

surgical field avoidance

Anesthesia provider avoids an area where the surgeon is working (usually on procedures around the head, neck, or shoulder girdle).

Protected Health Information (PHI)

Any information about health status, provision of health care, or payment for health care that can be linked to an individual. This is interpreted rather broadly and includes any part of a patient's medical record or payment history.

Aort/o

Aorta

__________ _________ provides an alternative view of the contents of ICD-9-CM and contains the _____ _____ ______ _____ _______

Appendix E; 3 digit categories in ICD-9-CM

Arteriol/o

Arteriole

Arter/o

Artery

colostomy

Artificial opening between colon and abdominal wall

What is the definition of A of SOAP

Assessment-Evaluation and conclusion made by the provider. This is usually where the diagnosis(es) for the services are found

modifier 82

Assistant surgeon (when qualified resident surgeon not available)

Atri/o

Atrium

Ab

Away from

Ante

Before forward

Pre

Before in front

Pro

Before in front of

Indentify the following prefix of time : Pre-

Before, in front of

Indentify the following prefix of time : Pro-

Before, in front of

anesthesia time

Begins when the anesthesiologist (or anesthesia provider) begins to prepare the patient for the induction of anesthesia and ends when the anesthesiologist (or anesthesia provider) is no longer in personal attendance.

Inferior ( caudal)

Below towards the lower end of the spine

The prefix sub- means beneath. Based on word parts, what is the definition of subfascial?

Beneath the fascia.

cholesteatoma

Benign growth of skin in the middle ear; usually caused by chronic otitis media.

Cholangi/o

Bile duct

Chol/e chol/o

Bile gall

-desis

Binding fusion

Hem/ o hemat/ o

Blood

Thromb/o

Blood clot

Ecchymosis

Blood seeping into skin causing discoloration

Oste/o

Bone

Osteoblasts

Bone forming cell

Define Classification Irregular of bone

Bones in the body not fitting into the above classifications mentioned.

Define Phalangeal

Bones of fingers and toes

Define Metacarpal

Bones of hand

[]

Brackets are used to enclose synonyms, alternate wording, or explanatory phrases

Enchephal/0

Brain

Transverse fracture

Break in shaft of bone across longitudinal axis

Define Transverse Fracture

Breaks shaft of a bone across the longitudinal axis

Mast/o

Breast mammary gland

Spir / o

Breathing

Bronch/o

Bronchus

Burs/o

Bursa sac of fluid near joint

official coding and reporting guidelines are provided by

CMS and NCHS

CMS will accept the ____________ for either a "potentially non=covered" service or for a statutorily excluded service

CMS-R-131

nephrotomography

CT image of the kidneys

Cali/o calic/o

Calyx

Define Osteocarcinoma

Cancerous tumor of bone

Short bones cuboidal

Carpal bones of the wrist tarsal bones of the ankle

veins

Carry deoxygenated blood back to the heart

Chondr/o

Cartilage

Ventricul/o

Cavity ventricle

Upon leaving the last portion of the small intestine, nutrients move through the large intestine in what order

Cecum, ascending colon, transverse colon, descending colon, sigmoid colon, rectum, anus

Mitosis

Cells divide and multiply to form two cells

what is mitosis

Cells divide and multipy to form two cells

What is CMS and what does it provide

Center for Medicare & Medicaid Services (CMS) provides coverage for people over the age of 65, blind, or disabled individuals, people with end -stage renal disease

What is the CMS-HCC

Center for Medicare & Medicaid Services-Hierarchical condition category

Cms-hcc

Center for medicare and medicaid hierarchical condition catagory

CMS

Centers for Medicare and Medicaid

Cortic/o

Cerebral cortex outer portion

Cerebr/o

Cerebrum

Enrollment Period

Certain period of time when a subscriber can join a health plan.

Episode of Care

Charging a lump of sum for all services

Bucc/o

Cheek

CHIP

Children's Health Insurance Program, joint federal and state, can not be eligible for medicaid

UB-04

Claim form used by hospitals and facilities for billing procedures and services.

CMS1500

Claim form used for billing physiicans and other services, ex physical therapy.

Automated Claim Review

Claim review and etermination via system edits and don't require human intervention

Assigned Claim

Claim submittted by a provider who accepts Medicare

Appendix C

Classification of Drugs by American Hospital Formulary Service List Number and Their ICD-9-CM equivalents

Appendix D

Classification of Industrial Accidents According to Agency.

Diagnosis Related Groups (DRG's)

Classification system that groups patients according to diagnosis, type of treatment, age and other relevant criteria. Under the prospective payment system (PPS), hospitals are paid a set fee for treating patient's in a DRG category.

Stratum lucidum

Clear layer sole feet and hand palms

An entity that processes nonstandard health information they receive from another entity into a standard format is considered what?

Clearinghouse

Deep ( internal)

Closer to the center of the body

What does Deep (internal)

Closer to the center of the body

Superficial ( external)

Closer to the surface of the body

what does Superficial (external)

Closer to the surface of the body

Cochle/o

Cochlea of inner ear

Diagnosis Code

Code within the ICD-9 that explains the reason for the medical encounter and for underlying conditions that contribute to the patient's care and effect treatment receive or length of stay.

What is Medicare Part C

Combines the benefits of Medicare Part A, Part B, and sometimes Part D.

What is acroymn CDT stand for

Common Dental Terminology

Choledoch/o

Common bile duct

Appeal

Complaint by hospital or patient about a health care payment

What should all physician's office and health care facilities should have and actively use

Compliance plan

Which of the following conditions results from an injury to the head? The symptoms include headache, dizziness, and vomiting

Concussion

Define Ecchymosis

Condition in which blood seepss into the skin causing discoloration

Define Ankylosis

Condition of stiffening of joint

Define Osteoporosis

Condition resulting in reduction of bone mass

purkinje fibers

Conduction myofibers branching off of the right and left bundle branches into the cells of the myocardium.

horseshoe kidney

Congenital anomaly in which the kidneys are fused together at the lower end during fetal development, resulting in one large, horseshoe-shaped kidney, often associated with cardiovascular, central nervous system, or genitourinary anomalies.

extrophy of bladder

Congenital anomaly occurring when the bladder everts itself, or turns inside out, through an absent part of the lower abdominal and anterior bladder walls with incomplete closure of the pubic bone.

Define the classification of FLAT of bone

Consists of a layer of spongy bone between two thin layers of compact bones; Cross-section is flat not round.

incarcerated

Constricted, irreducible hernia that may cause obstruction of the organ contained within the hernia.

crystalline lens

Convex disc suspended on threads just behind the iris.

Corne/o

Cornea

anterior segment

Cornea up to the vitreous body, including the aqueous humor, iris, and lens.

What must the provider present to the patient on the ABN for a proposed procedure or service

Cost Estimate

What is Medicare Part B

Covered Medically necessary doctors' services, outpatient care, other medical services (including some preventive service not covered under Medicare Part A

What is Medicare Part A

Covers inpatient hospital care, as well as care provided in skilled nursing facilites, hospice care, and home health care

Fair Debt Collection Act

Covers what debt collectors/agencies are allowed/not allowed to do for collecting payments, prohibited practices may result in civil penalty for collectors

CF

Coversion Factor - fixed dollar amount used to translate the RVUs into fees

cholecystoenterostomy

Creation of a connection between the gallbladder and intestine

-tripsy

Crushing

CPT

Current Procedural Terminology

What is acroymn CPT stand for

Current Procedural Terminology

Cdt

Current dental terminology

Frontal ( coronal)

Cuts a a right angle to the midline cut from side to side and divides the body into front anterior and back section

Transverse (horizontal) axial

Cuts horizontally through the body and separates the body into upper and lower section

Saggital

Cuts through the midline of the body from front to back and divides the body into right and left sections

Federal Register

Daily publication for rules of federal agencies and organizations as well as executive orders and other presidential documents.

Melan/o

Dark black melanin

Stratum basle

Deepest of five layers made of basle cells

What is Stratum basale composed of

Deepest of the 5 layers, made of basal cells

Appendix B

Deleted 10/1/2004 - contained Glossary of Mental Disorders.

Total Body Hypothermia

Deliberate reduction of a patient's total body temperature, reducing the general metabolism of the tissues. Watch anesthesia record for notes regarding total body total body hypothermia. Generally, temperature is reduced 20 percent to 30 percent below a patient's normal temperature. This may not be reported separately when the code indicates it is included.

DNA

Deoxyribonuclic acid

What does the acroymn HHS

Department of Health & Human Services

HHS

Department of Health and Human Services

Demographic Data

Describes the characteristics of the enrollee populations within a managed care entity, age, sex, race, etc

What is the National Coverage Determinations Manual

Describes whether specific medical items, services, treatment procedures or technologies can be paid under Medicare

Fully Accredited

Designation that all standards have been met and approved by Center for Medicare and Medicaid Services (CMS) without any other actions.

Encounter Data

Detailed data about the patients services provided by a managed care entity. Similiar to that of a claim form. Sometimes called "shadow claims"

Guidelines

Developed by appropriate groups to assist providers with decisions in specific clinical situations.

DRG

Diagnosis Related Group

Admitting Diagnosis

Diagnosis code indicating patient's diagnosis at admission

What does the first coding tip mean for the operative report for a coder ?

Diagnosis code reporting- Use the post-operative diagnosis for coding unless there are further defined diagnoses or additional diagnoses found in the body or finding of the operative report.

Phren/o

Diaphragm

Diagnosis

Disease, signs, or symptoms that indicate the patient's condition and support medical necessity for services provided.

Modifier 59

Distinct procedural service

modifier 59

Distinct procedural service

Case Mix

Distribution of patients into categories reflecting severity of illness or resource uses.

Board Certified

Doctor specializing in certain area of medicine and who passes an advanced exam. Primary care and specialists can both be board certified

Notice of Privacy Practices

Document informing a patient of when and how their PHI can be used.

What is a medical record

Documentation is the recording of pertinent facts and observation about an individual's health history, including past and present illness, tests, treatments and outcomes

Closed fracture

Does not involve a break in skin

Define Closed fracture

Does not involve a break in the skin

Ot/o

Ear

Salping/o

Ear tube rust schism tube

Where are the Bartholin's glands found?

Either side of the introitus in the female

EHR

Electronic Health Record

Charge Description Master (CDM)

Electronic billing table where charge amounts are kept in a centralized place.

What is EHR

Electronic health record

Endocrin/o

Endocrine glands or system

concha bullosa

Enlargement of the nasal turbinate

what is included in the Health care clearinghouse covered enitity

Entities that process nonstandard health information they receive from another entity into standard format or vice vesa

Health Plan

Entity that assumes the risk of paying for medical treatment.

Epididym/o

Epididymis

Benefit Period

Episode of care within hospitals & skilled nursing facilities (SNF). Begins on admission and ends 60 days after care has ended

What is the Mucous Membrane Composed of

Epithelium overlaying a layer of connective tissue called Lamina Propria

Adjusted Average Per Capita Cost (AAPCC)

Estimate of how much Medicare will spend in a year for an average beneficiary

E/M

Evaluation and Management

E/M OR E&M

Evaluation and Management

What are some different types of services documented in medical record

Evaluation and management Operative reports X-Rays

-scopy

Examination of

Electronic Data Interchange (EDI)

Exchange of transactions from one computer to another in a standard format

epiglottidectomy

Excising the covering of the larynx.

-ectomy

Excision surgical removal

Explanation of Benefits EOB(Remittance Advise (RA)- Medicare)

Explanation from insurance with details of payment, denials, etc.

exteriorization

Exposing an internal structure outside the body for observation, surgery, or experimentation, such as creating a passage from the bladder to the abdominal wall.

What is the coder role in a physician's office

Extremely important to proper reimbursement and the livelihood of the physican

Blephar/o

Eyelid

Community Mental Health Services

Facility provides outpatient services for children, elderly, chronically ill, & residents discharged from inpatient treatment at a mental health facility. 24 hour day emergency care, partial hospitalization or psychosocial rehab, & screening for admission to inpatient facility.

CMS rules require the provider to present the ABN to patient when

Far enough in advance that the beneficiary or representative have time to consider the options and make an informed choice.

Distal

Farther to the point of attachment or given reference point

Fasci/o

Fascia

Medicare

Federal health insurance company, 65 or older, or people w/ certain disabilities or ESRD

What is Medicare

Federal health insurance program- Administerd by the Center for Medicare &Medicaid Services (CMS)

Long bones/ tubular

Femur humerus,

apheresis

Filtering of blood to remove stem cells.

Dactylic

Finger or toe

Copayment

Fixed amount patient pays upfront

after-cataract

Following cataract removal, the physician opts to retain the posterior outermost shell, so an organic separation remains between the posterior and anterior chambers. This remaining shell later may develop opacities called "after-cataract."

brachytherapy

Form of radiation therapy in which radioactive pellets or seeds are implanted directly into the tissue being treated to deliver their dose of radiation in a more directed fashion.

What is Smooth muscle

Found in the walls of all the hollow organs of the body except the heart. It condtraction reduces the size of these structures; movement generally is considered Involunatry

HITECH has how many categories of violation

Four

Indentify the following prefix of number : Quadri-

Four

Quadri

Four

Epidermis

Four to five layers call stratum

Fraud and Abuse

Fraud is to purposely bill services not given or for higher reimbursement than give. Abuse is payment for services billed by mistake but should not have been paid for.

Cholecyst/ o

Gallbladder

Gangli/o ganglion/o

Ganglion

bariatric surgery

Gastric restrictive procedures that are used to treat morbid obesity.

conduction system

Generates and distributes electrical impulses over the heart and along the septum to stimulate contraction, allowing blood to move throughout the body

allogenic

Genetically different, but obtained from the same species.

GPCI

Geographic Practice Cost Index

Glomerul/ o

Glomerulus

What is stratum Granulosum composed of

Granular layer of cells

Stratum granulosum

Granules layer of cells accumulate two types of granules kerathoyLine and lamelated granules

Trich/o

Hair

Accredited

Having seal of approval after being evaluated and demonstrating quality standards

What will most operative notes have

Header and Body

What does the acroymn HITECH stand for

Health Information Technology for Economic and Clinical Health Act

HICN

Health Insurance Claim Number

Adjudication

Health Insurance Claims process at the insurance company

HIPAA stands for

Health Insurance Portability and Accountability Act of 1996

What is HIPAA

Health Insurance Portability and Accountability Act of 1996

What is HMO

Health Maintenace Organizations

HMO

Health Maintenence Organization

Episode of Care

Health care services given during a certain period of time, usually during a hospital stay.

Additional Benefits

Health care services not covered by Medicare and are offered through the Medicare Advantage Organization for no additional premium. The benefits must equal the ACR (Adjusted Community Rating)

Administrative Data

Health insurance information stored in automated information system about enrollment, eligibility, claims, etc.

Group Health Plan

Health plan providing coverage to employees & families and supported by employer.

HCPCS

Healthcare Common Procedure Coding System

What is acroymn HCPCS stand for

Healthcare Common Procedure Coding System

Cardi/o

Heart

Hippa

Heath information portability and accountability act

rectocele

Herniation of the rectal wall through the posterior wall of the vagina

What does the fourth coding tip mean for the operative report for a coder?

Highlight unfamiliar words- Words you are not familiar with should be highlighted and researched for understanding

Stratum corneum

Horny layer

Metabolism

How drug breaks down in preparation to leave body

Ex ix yx

Ices : index indices

Claim Adjustment Reason Codes

Identifies the reason for any difference in charge and payment. This code set is used in the X12 835 Claim Payment & Remittance Advice and the X12 837 Claim transactions and is maintained by Health Care Code Maintenance Committee

Claim Status Code

Identifies the status of a claim. This code set is used in the X12N 277 Claim Status Inquiry and Response transactions and is mainted by the Health Care Code Maintenance Committee

Immun / o

Immunity, immune system

implantable defibrillator

Implantable device that delivers an electrical shock to restore a normal heart rhythm.

Hypothermic Circulatory Arrest

Implies a temperature of 20 degrees centigrade or less.

Smooth muscle

In the walls of all hollow organs except the heart contracts and is involuntary

en bloc

In total or in full; as a single piece.

End/o

In with in

Disability

Inability to engage in activity for medical reasons expected to last more than 12 months

-tomy

Incision cutting

Basic Benefit

Includes Medicare covered benefits (except hospice) and additional benefits

modifier 22

Increased procedural services

Never code directly from the

Index to Disease

Volume 2 of the ICD-9-CM

Index to Diseases: Diagnosis codes organized in an alphabetic index

Allowed Charge

Individual charge determination by carrier for a covered service or supply.

condyloma

Infectious tumor-like growth caused by the human papilloma virus, with a branding connective tissue core and epithelial covering that occurs on the skin and mucous membranes of the perianal region and external genitalia.

Pediculosis

Infestation of lice

Define Pediculosis

Infestation with lice

balanoposthitis

Inflammation and/or infection of the glans penis and prepuce.

Define Osteochondritis

Inflammation of bone and cartilage

Osteochondritis

Inflammation of bone and cartilage

Define Bursitis

Inflammation of bursa

Define Onchitis

Inflammation of nail matrix

Onychitis

Inflammation of nail matrix

Define Tendonitis

Inflammation of tendon

cystitis cystica

Inflammation of the bladder characterized by the formation of multiple cysts.

Comprehensive Inpatient Rehabilitation Facility

Inpatient rehabilitation to patient's with physical disabilities.

-tome

Instrument for incising

indentify the following suffix: -tome

Instrument for incising (cutting)

-meter

Instrument for measuring

-graph

Instrument for recording data

-scope

Instrument for viewing or examination

Indentify the following suffix: -meter

Instrument of measuring

Facility Charge

Insurance companies pay less and charge a cost for the facility where services where rendered.

Sebacious glands are a part of which anatomic system?

Integumentary

Cardiac muscle

Interlocking involuntary striated muscle and smooth muscle allow the passage of electrical impulses

ICD-9-CM

International Classification of Disease, 9th Clinical Modification

Enter/0

Intestines

What is the function of the thyroid gland

It secretes hormones regulation body metabolism and blood calcium

Which of the following is true about the tympanic membrane

It separates the external ear from the middle ear

Arth/o

Joint

Arthropathy

Joint disease

Kerat/o

Keratin/ horny layer of skin

Nephr/o

Kidney

Ren/o

Kidney

The loop of Henle is locate in which structure

Kidney

Hair papilla

Knob like indentation at bottom of hair follicle containing blood supply to hair root

Define Hair Papilla

Knoblike indentation at bottom of hair follicle containing the bloody supply to hair root

What is an NCD interpreted at the MAC level considered?

LCD Each MAC (Medicare Adminstrative Contractor) is responsible for interpreting national policies into regional policies, or Local Coverage Determinations

Which structure of the ear is considered the inner ear?

Labyrinth

Dacryocyst/o

Lacrimal sac

Disproportionate Share Hospital

Large share of low income patients. States subside under Medicaid and Medicare inpatient payments are higher.

Laryng/o

Larynx

CMS regulations often serves as ____ word in coding requirement for Medicare and Non-Medicare payers alike

Last

Define Scoliosis

Lateral Curvature of spine

Freedom of Information Act (FOIA)

Law requiring US government to give information to the public when it receives a written request, only records of executive branch. NOT congress, federal courts, state or local governments or private groups.

HIPAA Privacy Rule

Law that regulates the use and disclosure of patients' protected health information (PHI).

Flat bones

Layer of spongy bones between two thin layers of compact bone skull, ribs

The heart circulates blood through the lungs and is sent back into the left atrium of the heart via which vessel(s)?

Left and right pulmonary veins

Which chamber of the heart is considered the one working the hardest?

Left ventricle

A patient sustaining an injury to her great saphenous vein would have sustained injury to which of anatomical site?

Leg

Act/ Law/ Statute

Legislation passed through Congress and signed by President or passed over his veto

Phak/o phac/o

Lens

Attending Physician

Licensed physician who certifies the patient services via medical necessity and is primarily responsible for the patient's medical care and treatment.

What is limiting charge

Limits set on what can be charged for each CPT code, no matter if the physican is Par or Non-Par

Chromosome

Linear strand made of dna carrying genetic information

Where is Mucous Membrane Lined

Lined the interior walls of the organs and tubes opening to the outside of the body

Labi/o

Lip

Appendix E

List of 3 digit categories

Formulary Drugs

Listing of prescription medications that are approved for use and/or covered by plans

Lunula

Little moon area of nail

Hepat/o

Liver

LCD

Local Coverage Determinations

Prefixes often (not always) indicate what

Location, Time, number

Edit

Logic within Standard Claims Processing System that selects claim data and determines the payment

What does the third coding tip mean for the operative report for a coder?

Look for key words- Key words may include locations ana anatomical structures involved, surgicial approach, procedure method, procedure type, siiz and number and the surgical instruments used during the procedure

Define Alopecia

Loss of hair

Define Osteopenia

Lower than average bone density, can be a precursor to osteporosis

En: Ina

Lumen: lumina

Pneumon/o

Lung

Pulm/ o

Lungs

Lymph/o

Lympatic

Lymphaden/o

Lymph node

Lymphangi/ o

Lymph vessel

If an NCD doesn't exist for a particular item, its up to the ______ to determine coverage.

MAC

epispadias

Male anomaly in which the urethral opening is abnormally located on the dorsum of the penis, appearing as a groove with no upper urethral wall covering.

MP

Malpractice

Health Care Prepayment Plan (HCPPP)

Managed care organization that pays for all in network services after a monthly premium, deductible and copayment. Out of network services are payable by the patient.

Poly-

Many much

Indentify the following prefix of number : Poly-

Many, much

what is MAC

Medical Administrative Contractor

Durable Medical Equipment (DME)

Medical Equipment ordered by a doctor for use in the home. Must be reusable, ex. walker, wheelchair.

MS-DRG

Medical Severity-Diagnosis Related Group

Current Dental Terminology (CDT)

Medical code set of dental procedures maintained and copyrighted by American Dental Association (ADA) and adopted by the secretary of Health and Human Services (HHS) as a standard for reporting dental services and transactions

Current Procedural Terminology (CPT)

Medical code set of physician and other services, maintained and copyrighted by American Medical Association (AMA) and adopted as a standard for reporting physician and other services.

Designated Code Set

Medical code set or administrative code set required to be used by the adopted implementation specification for standard transaction

Health Common Procedural Coding System (HCPCS)

Medical code set that identifies health care procedures, equipment and supplies for claim submission purposes. Level I is Current Procedural Terminology (CPT) maintained by the AMA. Level II is alpha numeric identifying items not found in CPT and maintained by Center for Medicare and Medicaid Services (CMS) and Blue Cross Blue Shield Association (BCBSA) and the Health Insurance Association of American (HIAA)

Ambulatory Care Sensitive Conditions (ACSC)

Medical condtions that if treated immediatly and managed properly should not require hospitalization.

Indian Health Services

Medical services are provided free of charge to American Indians & Alaska Natives who are members of federally recognized tribes

What is the most significant government insurer

Medicare

What are the parts of Medicare

Medicare A Medicare B Medicare C Medicare D

MAC

Medicare Administrative Contractor

Medicare Part C is also called

Medicare Advantage

What is Medicare Part C also called

Medicare Advantage

Which plan covers PPO and HMO

Medicare Part C

Mac

Medicare administrative contractor

Ms-drg

Medicare severity diagnostic related group

Ambulatory Payment Classification (APC)

Medicare's outpatient prospective payment system in which services are grouped based on the resources needed and payment is fixed within each group

Administrative Costs

Medicare, Medicaid, CMS refer to this as their expenses to have the program, operating expenses, program management, etc.

Medull/o

Medulla oblaengata inner section middle soft marrow

Mening/o meninge/o

Meninges

Men/o mens

Menstruation

Mes/o

Middle

Psych/o

Mind

Comminuted fracture

More that two separate bones components segmental fracture bony fragments

Appendix A

Morphology of Neoplasms

Or/0

Mouth

Stoma stomat/o

Mouth

Kin/o kinesi/o

Movement

coronary circulation

Movement of blood through the tissues of the heart

antegrade

Moving forward or with the usual direction of flow.

In order, starting with the innermost layer, what are the four walls of digestive tract?

Mucosa, submucosa, muscle, serosa

Modifier 51

Multiple procedures

Muscul/o

Muscle

My/o

Muscle

Myle/o

Muscle

papillary muscles

Muscles attached to the lower portion of the interior wall of the ventricles and connected to the chordae tendineae.

diaphragm

Muscular wall separating the abdominal and thoracic cavities.

The ICD-9-CM Coordination and Maintenance Committee, which is co-chaired by the

NCHS (National Centers for Health Statistics) and the CMS (Centers for Medicare & Medicaid Services)

Onych/o

Nail

NCD

National Coverage Determination

NCD

National Coverage Determinations

What does the acroymn NDC stand for

National Drug codes

Procimal

Nearer to the point of attachment or given reference point

Which of the following is a renal calculus? * Pyelectasia * Hydroureter * Nephrolithiasis * Pyonephrosis

Nephrolithiasis

Neur/o

Nervous system,nervous tissue

Gli/o

Neuroglia cells

Administrative Code Sets

Non medical code sets that characterize a general business situation rather than a medical condition.

Custodial Care

Non-skilled personal care attendance (PCA) to help with Activities of Daily Living (ADL) like eating, bathing, etc.

Rhin / o

Nose

Exclusions

Not covered by insurance carrier, ex. prescriptions, eye care

NEC

Not elsewhere classifiable

NOS

Not otherwise specified

excludes2

Note in the Tabular List to indicate the terms listed are to be reported from another category and may be reported with the current selected code if both conditions exist.

excludes1

Note in the Tabular List to indicate the terms listed are to be reported with a code from another category and are not to be reported with the current selected code

What is CMS instruction stipulate on Cost estimate

Notifiers must make a good faith effort to insert a reasonalble estimate...the estimate should be within $100 or 25% of the actual costs, whichever is greated.

Health Insurance Claim Number (HICN)

Number assigned to insurance carrier/ beneficiary identifying them as the insurance subscriber.

NP

Nurse Practitioner

Who enforces HIPAA privacy rule

OCR (Office of Civil Rights)

What OIG document should a provider review for potential problem areas that will receive special scrutiny in the upcoming year?

OIG work plan

autologous

Obtained from the patient

medical supervision

Occurs when an anesthesiologist is involved in five or more concurrent anesthesia procedures, or fails to meet required medical direction criteria.

Epiphyseal fracture

Occurs when matrix is calcifying and chondrocytes are dying seen in children

Define Epiphyseal fracture

Occurs when matrix is calcifying and chondrocytes are dying. Common in Children

What month of each year does the OIG release a work plan outlining its priorities for the fiscal year ahead?

October

When does the OIG release a work plan outlining its priorities for the fiscal year ahead?

October

When will ICD-10-CM be effective

October 1, 2013

OCR

Office for Civil Rights

Ocr

Office for civil rights

OCR

Office of Civil Rights

What does the acroymn OCR stand for

Office of Civil Rights

OIG

Office of Inspector General

What does the acroymn OIG stand for

Office of Inspector General

OIG

Office of the Inspector General

Code of Federal Regulations

Official compiliation of federal rules and requirements

Mon/o

One single

Green stick

Only one side of shaft is broken other is bent

Define Greenstick Fracture

Only one side of the shaft is broken, and other is bent. Common in children

what is the HIPPA Minimum necessary requirement

Only the minimum necessary protected health information should d to satisfy a particular purpose. if the information is not required to satisfy a particular purpose, it must be withheld.

Center for Disease Control and Prevention (CDC)

Organization that protects public health through monitoring disease trends, investigation outbreaks, implementing illness, and injury control.

What term is used for pus draining from the ear?

Otopyorrhea

Ec ecto

Out outside

Indentify the following prefix of location: Ec-, Ecto-

Out; outside

Comprehensive Outpatient Rehabilitation Facility (CORF)

Outpatient rehabilitation

Ambulatory Surgery Center (ASC)

Outpatient surgery center not located in the hospital. Patient's may stay a few hours up to 1 night.

Oophor/o

Ovary

Salping/o

Oviduct tube

O/o

Ovum egg cell

Ov/o ovul/o

Ovum egg cell

Define Chondralgia

Pain around and in the cartilage

Insul/o

Pancreatic islets

Parathyr/o parathyroid

Parathyroid gland

Medicare Part C combines the benefits of

Part A and Part B and sometimes Part D

If an inbuilding pharmacy delivers medication (for home use) to an individual receiving outpatient chemotherapy, which part of Medicare should be billed for the pain medication by the pharmacy?

Part D

Administrative Simplification

Part of HIPAA authorizing HHS (Health and Human Services) to 1. adopt standards for transactions & code sets; 2. adopt standard identifiers for health plans; 3. adopt standards to protect security & privacy of personally identifiable health information.

Emergency Room (Hospital)

Part of hospital where emergency diagnosis and treatment of illness is provided 24 hours a day

What is the largest Sesamoid bone

Patella

Exceptions to Privacy Rule

Patient authorization is not required to use and disclose PHI for treatment, payment, & healthcare operations (TPO)

Ppaca

Patient protection and affordable care act

Independent Practice association

Patients contract with many different providers

Sesamoid bones

Pattela made of cartilage in early life becomes Osseous in adults

Coinsurance

Percentage of medical bill the beneficiary is responsible for paying.

Health Care Provider

Person trained and licensed to give health care and has a licensed place to treat patients. Doctors, nurses, or hospitals are examples.

Dual Eligibility

Persons covered under Medicare and Medicaid

Define Subcutaneous

Pertaining to below the skin

Chondral

Pertaining to cartilage

Define Chondral

Pertaining to cartilage

Define Coccygeal

Pertaining to coccyx

Define Femoral

Pertaining to femur or thigh bone

Define Dactylic

Pertaining to finger or toe

Define Patellar

Pertaining to patella

Define Iliac

Pertaining to the ilium

Define cutaneous

Pertaining to the skin

Define Hypodermic

Pertaining to under the skin

Define Intradermal

Pertaining to within the skin

Define Carpal

Petaining to the wrist bones

Pharyng/o

Pharynx

On: a

Phenomenon phenomena

Phrenic/o

Phrenic nerve

PA

Physician Assistant

PE

Physician Expense

PFS

Physician Fee Schedule

Where is Medicare Part B usually used

Physician offices (Outpatient Facility)

Define dermatologist

Physician specializing in diseases of the skin and subcutaneous tissue

Case Management

Physician, nurse, or other person tracks use of facilities and resources of a patient to be sure they are receiving the care they need.

Define Melanin

Pigment giving color to the skin

Define Melanoma

Pigmented tumor of the skin

Pituitar/o

Pituitary gland

Hypophys/o

Pituitary gland hypophysis

What is the definition of P of SOAP

Plan-Course of Action. Here, the provider will list eh next steps for the patient, whether it is ordering additional test, or taking over the counter medication

-plasty

Plastic repair plastic surgery reconstruction

Thrombocyt/o

Platelet, thrombocytes

Pluer/o

Pleura

What is PPO

Preferred Provider Organizations

What is Medicare Part D

Prescription drug coverage program available to all Medicare beneficiaries. Private companies approved by Medicare provide the coverage.

Decubitus

Pressure ulcer

Define Decubitus

Pressure ulcer/bedsore

Stratum spinosum

Prickle cells

Commerical carriers are considered what

Private payers that offer both group and individual plans.

modifier 63

Procedure Performed on Infants Less than 4 kg

angioplasty

Procedure to open narrow or blocked vessels

add-on codes

Procedures commonly carried out in addition to the primary procedure performed. Add-on codes may not be reported alone, and are identified with a + sign.

Discharge Planning

Process of deciding what a patient needs to move smoothly from one level of care to another, ex. hospital to nursing home.

PLI

Professional Liability Insurance

American Medical Association (AMA)

Professional organization maintains CPT code sets, secretariat to National Uniform Claim Committee (NUCC) which consults under HIPAA. ASC payment group rate.

Ancillary Services

Professional services by a hospital or inpatient facility. Xrays, drugs, labs, etc.

Is :Es

Prognosis : prognoses

Demonstrations

Projects and contracts that CMS has signed with various health care organizations. Used to evaluate the effects and impact of various health care initiatives and the cost of implications to the public.

Compound fracture

Projects through skin w/ possible infection

Define Compound fracture

Projects throught the skin with a possibility of infection

Prostat/o

Prostate

What is the acroymn PHI stand for

Protected health infomation

What is the Patient Safety Rule according to the OCR

Protects indentifiable information being used to analyze patient safety event and improve patient safety

What does the OCR do

Protects the privacy of individually indentifiable health information; HIPAA Security Rule Patient Safety Rule

diverticulum

Protrusion of the intestinal wall

Custodial Care Facility

Provides room and board, and other personal assistance on a long term basis but does not include medical care.

Health Care Clearinghouse

Public or private entity that processes data from nonstandard to standard and/or receives standard transactions from another entity to convert

-centesis

Puncture tap

How often do Practices should check policies to maintain compliance

Quarterly

cholangiopancreatography

Radiographic recording of the biliary system and pancreas.

duodenography

Radiographic recording of the duodenum, or the first part of the small intestine.

cineradiography

Radiography of an organ in motion (for example, a beating heart)

Cost Rate

Ratio of cost of the program on an incurrerd basis during a year to the taxable payroll for the year.

What does the fifth coding tip mean for the operative report for a coder?

Ready the body- All procedure reported should be documented with the body of the report. The body may indicate a procedure was abandoned or complicated, possibly indicating the need for a different procedure code or reporting of a modifier

reanastomosis

Reconnecting a previous connection between two places organs or spaces

Proct/o

Rectum

Erythr /o erythrocyt/ o

Red blood cell

Downcode

Reduce the value and code of a claim when documentation does not support the level of service billed by provider.

modifier 90

Reference (outside) laboratory

monitored anesthesia care

Refers to a continuum a technique for many surgical procedures that do not require deep sedation or a general anesthetic. The anesthesia provider must be prepared to convert to general anesthesia, if necessary.

epicardial

Relating to the innermost layer of the heart wall.

RUC

Relative Value Update Committee

Pyel/o

Renal pelvis

modifier 91

Repeat clinical diagnostic laboratory test

modifier 77

Repeat procedure by another physician or other qualified health care professional

modifier 76

Repeat procedure or service by same physician or other qualified health care professional

Cost Report

Report required from providers on an annual basis in order to make proper determination of amounts payable under Medicare program.

American Hospital Association (AHA)

Represents concerns of instituitional providers. They host the National Uniform Billing Committee (NUBC) which consults under HIPAA

Health Insurance Association of America (HIAA)

Represents the interest of commercial health care insurers. Participates in HCPCS Level II code data sets.

Claim

Request for payment for services or benefits received. Claims are called bills through Medicare Part A

Emergency Medical Treatment and Active Labor Act (EMTALA)

Requires Medicare participating hospitals provide appropriate screening examination to any patient that requests such an exam. The patient must be stabilized before transferring care.

RBRVS

Resource Based Relative Value System

Retin/o

Retina

The ABN form is entitled

Revised ABN CMS-R-131 and is available with instructions as a free download on the CMS website.

RNA

Ribonucleic acid Transcribed from DNA by enzymes and plays a crucial role in protein synthesis

Dextr/o

Right

Bones are composed of what

Rigid connective tissue

Tinea

Ringworm

Define Tinea

Ringworm; a fungal infection of the skin

What does the CMS-HCC provide

Risk adjument model provides adjusted payment based on a patient's disease and demographic factors.

define the classification SHORT of bone

Roughly cube shaped bones

Civilian Health and Medical Program (CHAMPUS)

Run by department of defense. Used to give medical care to active duty but now this is called TRICARE

What is SOAP

S- Subjective O-Objective A- Asssessment P-Plan

Evaluation and Management services are provided in what standard format

SOAP

Define Hair Follicles

Sacs holding the root of hair fibers

Sail/o

Saliva, salivary glands

Scler/o

Sclera

Osche/o

Scrotum

Seb/o

Sebum sebaceous gland

Sperm/0 spermat/o

Seman spermatozoa

Semin/o

Semin

Vesicul/o

Seminal vesicle

decortication

Separating the pleura adhering to lungs to assist with expansion of the lungs.

Catastrophic Illness

Serious and costly health problem that could be life-threatening or cause disability. Costs can cause patient financial hardship.

Um a

Serum sera

Covered Services

Services for which a carrier pays as defined and limited by coverage or statute. physician care, outpatient hospitals, diagnostic tests, DME, ambulance, and other health services.

Covered Charges

Services or benefits for which a health plan makes either partial or full payment.

Code Set

Set of codes used to encode data elements terms, codes, concepts, required under HIPAA

Health Employer Data and Information Set (HEDIS)

Set of standard performance measures that give you information about the quality of a health plan. Center for Medicare and Medicaid Services (CMS) collects HEDIS data for Medicare patients.

What is the HIPPA Security Rule according to the OCR

Sets national standards for the security of electronic protected health information and the confidentiality provision of the patient Safety Rule

Define Comminuted Fracture

Shatter affected part into bony fragments

Administrative Simplification Act

Signed 12/17/01 allows HHS (Health & Human Services) to exclude providers from Medicare for HIPAA non-compliance of electronic claims and prohibit paper claims except in certain situations

modifier 25

Significant Separately Identifiable E/M Service by the Same Physician on the Same Day of the Procedure or Other Service

ipsilateral

Situated on the same side

Derm/o

Skin

Dermat/o

Skin

What does the axial skeleton consist of

Skull, hyoid/cervical spine, ribs, sternum, vertebrae, sacrum

Somn/o Somn/i

Sleep

Critical Access Hospital

Small facility that gives limited outpatient and inpatient hospital services in rural areas

Nucleus

Small round structure within the cell containing chromosomes and nucleoplasm DNA and RNA

CMS developed polices regarding medical necessity are based on regulations found in title XVIII, $1862(a) of the

Social Security Act

Business Associate

Someone performs a function on behalf of a covered entity but is not part of the covered entity's workforce, outside business manager.

Caregiver

Someone who cares for a patient who is ill, disabled, or aged. Can be relatives, friends or someone who is paid.

Define Follicles

Specialized structures required for hair growth

Genev

Specific segment of base pairs in chromosomes functional unit. Of heredity

What is a gene

Specific segment of base pairs in chromosomes; functional unit of heredity

Capitation

Specified amount of money is paid to a health plan or doctor regardless of the services rendered in that period. One lump sum.

Myle/o

Spinal cord

Radical/o

Spinal nerve root

Splen/ o

Spleen

What procedure is performed when the spleen is removed?

Splenectomy

Define Spiral Fracture

Spread along length of bone and produced by twisting stress

Spinal fracture

Spread along length of bone and produced by twisting stress

4 HMO models

Staff, Group, Independent practice association, Network

modifier 58

Staged or Related Procedure or Service by the Same Physician During the Postoperative Period

Soap

Standard format for EM services subjective objective assessment plan

What does the second coding tip mean for the operative report for a coder?

Start with the procedures listed- For the coder who is new to coding a procedure , one way of quickly starting the research process is by focusing on the procedures listed in the header. Read the note in its entirety to verify the procedures performed. Procedures listed in the header may not be listed correctly and procedures documented with the body of the report may not be listed in the header at all. It will help a coder with a place to start

CMS Agent

State survey agency who participates in Medicare surveys and certification process. ex. private physician consulting with the State Agency (SA) or CMS regional office.

Advanced Directive

Statement written by patient on how they want medical decisions to be made. May include a Living Will or Durable Power of Attorney for healthcare.

embezzlement

Stealing money that has been entrusted to your care

Gastr/0

Stomach

Skeletal muscle

Striated muscle , voluntary control

Cytology

Study of cells

What is cytology

Study of cells including the formation, structure and function of cells

Narc/o

Stupor numbness sleep

The lymphatic ducts empty their contents into what structure?

Subclavian veins

turbinates

Superior, middle, and inferior bony structures found in each right and left nasal cavity to assist with air movement.

Health Care Quality Improvement Program (HCQIP)

Supports mission of CMS to assure health security for beneficiaries and improving quality of care.

-stomy

Surgical creation of an opening

-Pexy

Surgical fixation

Athrodesis

Surgical fixation of a joint

dacryocystorhinostomy

Surgical procedure that restores the flow of tears into the nose from the lacrimal sac when the nasolacrimal duct does not function.

annuloplasty

Surgical reconstruction of the ring (annulus) of the heart valve.

sialolithotomy

Surgical removal of a stone located in the salivary gland or duct.

Cell membrane

Surround and protects the individual cell

Osteorrhaphy

Suture of bone

Hird/o

Sweat/perspiration

Synov/i

Synovial fluid, joint or membrane

Volume 1 of the ICD-9-CM

Tabular List: Diagnosis codes organized in order by code

foley catheter

Temporary indwelling urethral catheter held in place in the bladder by an inflated balloon containing fluid or air.

Ten/o tendin/o

Tendon

Pump Oxygenator

Term used when a cardiopulmonary bypass (CPB) machine is used to function as the heart and lungs during heart surgery.

Orchi/o orchid/0

Testis

Test/o

Testis testicle

HITECH

The Health Information Technology for Economic and Clinical Health Act

Center for Medicare & Medicaid Services (CMS)

The Heath & Human Services (HHS) agency responsible for Medicare & parts of Medicaid. Maintains UB-04, oversight of HIPAA and maintains HCPCS code set & Medicare remittance advice (RA) remark codes. They promote higher quality care

DRG Coding

The MS-DRG categories used by hospitals on discharge billing.

What was published in the Federal Register on October 5, 2000

The OIG Compliance Program for Individual and Small Group Physician Practice

Date of Service

The actual date a particular service was performed

Deductible (Medicare)

The amount a beneficiary must pay for health care before Medicare begins to pay, either Part A or Part B. These amounts vary every year.

Actual Charge

The amount the provider charges for medical services or supplies. Not always paid in full.

Case Mix Index

The average Diagnostic Related Groups (DRG) relative weight for all Medicare admissions

Medical Records

The complete history and current assessment, providing continuity of care, documenting med. necessity, defense against malpractice, used for billing

Cost Sharing

The cost of medical care the patient must pay, coinsurance, deductible, etc.

Admission Date

The date the patient was admitted for inpatient care, outpatient, or start of care.For hospice, enter effective date of election of hospice benefits.

Admitting Physician

The doctor responsible for admitting a patient to the hospital or other inpatient health facility

Approved Amount

The fee Medicare sets as reasonable and pays to the provider.

Catastrophic Limit

The highest amount a beneficiary is required to pay out of pocket during a certain period of time for certain covered charges.

Vital Capacity (VC)

The maximum volume of air a person can exhale after maximum inhalation. The measure is used in diagnostic pulmonary testing.

Benefits

The money or services provided through an insurance policy

Beneficiary

The name of a person who has health care insurance through the insurance program

Fixed Capital Assets

The net worth of facilities and other resources

Coordination of Benefits

The process of determining which policy is first when a patient has 2 health care plans.

What does ABN protect

The provider's financial interest by creating a paper trail that CMS requires before a provider can bill the patient for payment if Medicare denies coverage for the stated service or procedure

Work RVUs reflect

The relative levels of time and intensity associated with furnishing a Medicare PFS service and account for ~50% of the total payment associated with a service.

Descriptor

The text defining a code in a code set

cardioversion

The use of defibrillator paddles to restore normal rhythm of the heart by electrical shock.

What does purpose of connective tissue

They support and connect tissue of the body

Stratum reticulare

Thick layer dense irregular connective tissue

Stratum papillare

Thin superficial layer interlocked with the epidermis

Indentify the following prefix of number :Tri-

Three

Tri

Three

Us I

Thrombus thrombi

Indentify the following prefix of location : Per-

Through

Per

Through

Trans

Through across

Dia

Through complete

Indentifiy the following prefix of location : Dia-

Through; complete

Thym/o

Thymus gland

Thyr/o thyroid/o

Thyroid gland

Define Connective

Tissue connecting or binding together

What is the important title concerning the position of a medical coder

Title II-Preventing Health care Fraud and Abuse; Administrative Simplication; Medical Liability Reform

Under what regulations is medically necessity found under

Title XVIII 1862 (a) (1) of the Social Security Act

Ton/o

Tone; pressure

Gloss/0

Tongue

Lingu/o

Tongue

Tonsil/o

Tonsil

Ad

Toward near

Lateral

Toward the Side of the body

Posterior (dorsal)

Toward the back

Anterior (ventral)

Toward the front

Medial

Toward the midline of the body

What does Lateral mean

Toward the side of the body

What does Medial mean

Towards the midline of the body

Trache/ o

Trachea

What does acroymn TPO stand for

Treatment Payment and Health Care Operations

Tpo

Treatment Payment and healthcare operations

True or Fale Cartilage is nonvascular or has no blood vessels

True

Bi

Two twice

Tympan/o

Tympanic cavity middle ear tympanic membrane

Myring/o

Tympanic membrane

Covered Entity

Under HIPAA, this is a health plan, clearninghouse, or provider who transmits any health information in electronic format in connection with HIPAA transaction.

Relative Value Unit (RVU)

Unit of measure assigned to a medical procedure based on the time required to perform it. This system is composed of three elements: work, practice expense, and liability insurance.

Modifier 78

Unplanned Return to the Operating/Procedure Room by the Same Physician Following Initial Procedure for a Related Procedure During the postoperative Period

modifier 78

Unplanned Return to the Operating/Procedure Room by the Same Physician Following Initial Procedure for a Related Procedure During the postoperative Period

Modifier 79

Unrelated procedure or service by the same physician during the postoperative period

Ureter/0

Ureter

Urethr/o

Urethra

Which anatomical structure in the urinary system differs in position and length between male and female, but serves the same function with regard to urine, and is often treated the same?

Urethra

Cyst/o

Urinary bladder

Vesic/o

Urinary bladder

Urin/o

Urine

Ur/o

Urine urinary tract

What is the result of a ureteral blockage?

Urine will not be able to flow from the kidney to the bladder

direct endoscopy

Use of an endoscope to look directly at the larynx.

indirect endoscopy

Use of mirrors with a rigid laryngoscope to view the larynx.

Off label

Used for a purpose for which the drug has not been FDA approved

Hyster/o

Uterus

Metr/o metr/o

Uterus

Uvul/o

Uvula

Colp/o

Vagina

Valv/o valvul/o

Valve

Private Payers contracts may

Vary but may include hospitalization, basic and major medical coverage.

The structure of the male anatomy carrying sperm out of the epididymis is called

Vas Deferens

Vas/o

Vas deferens ductus deferens also vessel duct

Phleb/o

Vein

Ven/o ven/i

Vein

chordee

Ventral (downward) curvature of the penis due to a fibrous band along the corpus spongiosum seen congenitally with hypospadias, or a downward curvature seen on erection in disease conditions causing a lack of distensibility in the tissues.

Define Compression Fracture

Vertebra Collapse due to trauma, tumor or osteoporosis

Compression fracture

Vertebra collapse

A ae

Vertebra: vertebrae

Irregular bones

Vertebrae facial

Angi/o

Vessel

Vas/o vascul/o

Vessel

peritoneoscopy

Visualization of the abdominal cavity using a scope placed through a small incision in the abdominal wall.

Episi/0

Vulva

When should an ABN be signed?

When a service is not expecgted to be covered by Medicare. RATIONALE: This form explains to the patient why a service MAY be denied by Medicare. The ABN form should be completed for services potentially con-covered by Medicare to advise the patient of potential financial responsibility.

When is a physican considered a "participating physician"

When contracted with a insurance carrier whether that be a private insurance company or a governmental.

Emergency Care

When patient's health is in serious danger and every second counts

When seeing the instruction to use additional code, which code goes first?

When sequencing codes, the codes listed under the "use additional code" are secondary

if a NCD does not exist what are CMS guidelines

Where coverage of an item or service is provided for specified indications or circumstances but is not explicitly excluded for others, or where the item or service is not mentioned at all in the CMS Manual System, the Medicare contractor is to make the coverage decision, in consultation with its medical staff and with CMS when appropriate, based on the laws, regulations, ruling and general program instructions.

Leuk/ o leukocyt/ o

White blood cell

Gym/o gynec/0

Woman

Erg/o

Work

Colles fracture

Wrist effects distal radius bone

Care Plan

Written plan of services patient will receive to ensure the patient's best care physically, mentally & socially

portography

X-ray visualization of the portal circulation using radiopaque material

Can a Medical record serve as legal document

YES

Define Jaundice

Yellowness of skin

Formula for Calculating Facility Payment amounts

[(Work RVU * Work GPCI) + (Transitioned Facility PE RVU * PE GPCI) + (MP RVU * MP GPCI)] * CF

Formula for Non-Facility Pricing Amount

[(Work RVU * Work GPCI) + (Transitioned Non-Facility PE RVU * PE GPCI) + (MP RVU * MP GPCI)] * (CF)

arterial line

a catheter inserted into an artery, used most commonly to measure real-time blood pressure, and obtain samples for arterial blood gas

Which of the following best describes psoriasis

a chronic condition characterized by red, dry elevated lesions covered by silvery scales

chronic

a condition that develops slowly and persists over a period of time

Joint and articulating surfaces provide what

a connection between two or more parts of skeleton

conscious sedation

a decreased level of consciousness in which the patient is not completely asleep

Pre-existing Condition

a diagnosed condition that a person had before the health insurance policy

What is a operative report

a document the detail of a fprocedure performed on a patient

Controlled substance

a drug that contains a narcotic and has potential for addiction

What is the OIG

a government agency tasked to protected the integrity of Department of Health & Human Services programs, as well as the health and welfare of the beneficiaries of those programs

What are systems

a group of rogans working together to perform a complex body function

panel

a group of tests performed together and listed in the code description

Medicaid is a

a health insurance assistance program for some low-income people

anesthesiologist assistant

a health professional who has completed an accredited anesthesia assistant training program

what is the serous membrane composed of

a layer of simple squamous epithelium overlaying a layer of loose connective tissue.

subcutaneous layer is not considered

a layer of skin.

Cartilage is made of

a matrix of chondrocytes, collagen, cells called proteoglycans depending on the type of cartilage

physical status modifier

a modifier used to report the physical status assigned to each patient undergoing anesthesia. patients are ranked by their individual health status.

diaphragm

a muscle that separates the chest from the abdominal cavity

velocity flow mapping

a non-invasive method to image blood flow through the heart by displaying flow data on the two-dimensional echocardiographic image

What is connective tissue

a number of different tissues with common feauture.

chronic obstructive pulmonary disease (COPD)

a progressive lung disease restricting air flow, which makes breathing difficult. Chronic bronchitis and emphysema are the two main components of COPD. Most COPD is a result of cigarette smoking.

indentify the following suffix :-gram

a record of data

SRNA (student registered nurse anesthetist)

a registered nurse training in an accredited nurse anesthesia program

carina

a ridge of cartilage in the trachea that occurs between the division of the two main bronchi

define the classification SESAMOID of bone

a short bone formed within tendons; cartilaginous in early life and osseous in adult.

a combination code indicates

a single code is used to classify 2 diagnoses, a diagnosis with an associated secondary process (manifestation), or a diagnosis with an associated complication

Medicaid administed on

a state-by-state basis and coverage varies- although each of the state programs adheres to certain federal guidelines

anastomosis

a surgical connection between two hollow or tubular structures

The musculoskeletal system is

a systems of muscles, joints, tendons, ligament

cardiopulmonary bypass (CPB)

a technique used during heart surgery to take over temporarily the function of the heart and lungs

controlled gypotension

a technique used in general anesthesia to reduce blood pressure to control bleeding during surgery. watch anesthesia record for notes regarding deliberate or controlled hypotension

modality

a therapeutic agent or application

what does the cutaneous membrane consist of

a thin outer layer of stratified squamous epithelium attached to a thicker underlying layer of connective tissue.

What is cartilage

a type of flexible connective tisssue

doppler

a type of ultrasound, especially useful for imaging blood flow. The doppler can create images either in shades of gray or, when processed by a computer, in color.

conversion factor

a unit multiplier to convert anesthesia units into a dollar amount for anesthesia services. CMS annually reviews conversion factors. conversion factors also may be negotiated with insurance companies

What is a compliance plan

a written set of instructions outlining the process for coding and submitting accurate claims and what to do if mistakes are found.

compliance plan

a written set of instructions outlining the process for coding and submitting accurate claims, and what to do if mistakes are found.

reducible

able to be corrected or put back into a normal position

Leukocytosis is

abnormal condition of WBC

Define Kyphosis

abnormal curvature of thoracic spine (humpback)

hydroureter

abnormal enlargement or distention of the ureter with water or urine caused by an obstruction

Barrett's esophagus

abnormal growth of stomach or intestinal cells at the distal end of the esophagus.

fistula

abnormal opening from one area to another area in the body or outside fo the body

hyperplasia

abnormal proliferation in the number of normal cells in regular tissue arrangement

What does Superior (cranial) mean

above; toward the head

indentify the following suffix: -graphy

act of recording data

Healthcare operations

activities necessary for a covered entity to run its business.

Major Medical

addition insurance for unusually large medical expenses

If a coder does not include all pertinent diagnoses and co-morbidities, the provider may lose out on what

additional reimbursement for which he/she is entitled.

Portions of HITECH strengthen HIPAA rules by

addressing the privacy and security concerns assoicated with the electronic transmission of health information

Tumor of a gland

adenoma

The difference between the physican's fee and the insurance carriers allowed amount is

adjusted by the participating provider

Endocrine glands that are above each kidney

adrenal

ICD-10 accommodates

advancements in medical knowledge of disease and disease processes, where ICD-9_CM has become outdated and insufficient.

Physician specialist

advances training in a particular area of medicine. (neuro., derm.)

bipolar disorder

affective disorder with alternating mood swings from euphoria to depression

p.c

after meal

Indentify the following prefix of time :Post-

after, behind

Medicare Part D is available to

all Medicare beneficiaries.

What is Cardiac muscle

also called heart muscle, it contains interlocking involuntary striated muscles as wellas smooth muscle, which allow the electrical impulses to pass quickly across the muscle fibers

What is skeletal muscle

also called striated muscle, it is attached to the skeleton by tendons; contraction of skeletal muscule is under voluntary control

Deductible

amount paid annually, insurance pays after it is met, higher deductible and lower premium,

HITECH allows patients to request

an audit trail showing all disclosures of their health information made through an electronic record.

Accreditation

an examination process the healthcare facility goes through to evaluate the facilities policies, procedures, and performance to meet higher standards.

The term episiotomy best describes a procedure of what type

an incision made in the perineum to enlarge the passage for the fetus during delivery

esophagitis

an inflammation of the lining of the esophagus

modifier 47

anesthesia by surgeon

surgical field avoidance

anesthesia provider avoids an area where the surgeon is working

Policy holder

another name for patient

immune globulin

antibodies derived from blood plasma providing short term protection against certain infections

The definition of a Health plan in the HIPPA regulations excludes

any policy, plan or program that provides or pays for the cost of excepted benefits

includes

appears immediately after a three-digit code title to further define or clarify the category

Topical

applied directly to skin or mucous membrane

Coordination of Benefits

applies when an individual is covered by more than one insurance policy

The meaning of atherosclerosis is

artery plaque

The combining form meaning "joint" is

arthro

prosthetic

artificial body part

PRN

as needed

Appendix C is available to

assist in coding of adverse effects

modifier 80

assistant surgeon

h.s

at bed time

orientation

awareness; ability to comprehend and to adjust in an environment

Indentify the following prefix of location : Ab-

away from

trachoma

bacterial infection of the eyes

flat fee

based on the physician fee schedule. Payments are made under the relative value unit. Time is not a consideration for payment.

a.c

before meal

Indentify the following prefix of time : Ante-

before; forward

The fifth digit in a morphology code indicates

behavior of the neoplasm

What does Inferior (caudal) mean

below; toward the lower end of the spine

vestibular schwannoma

benign tumor arising from nerve cells of the auditory nerve, also called acoustic neuroma

acoustic neuroma

benign tumor on the auditory nerve (8th cranial nerve) that causes vertigo, tinnitus, and hearing loss

The prefix meta means

beyond

modifier 50

bilateral procedure

-desis

binding, fusion

indentify the following suffix: -desis

binding, fusion

The study of life is

biology

The term "hemic" specifically refers to what bodily fluid?

blood

hematospermia

blood in seminal fluid

Flat bones have marrow but lack what

bone marrow cavity

Define Osteoblast

bone-forming cell

define the classification LONG of bones

bones longer than they are wide and found in the limbs. The bones are named for their elongated shape, not their size.

septum

bony structure that separates the left nasal cavity from the right nasal cavity

bronchi

bottom portion of the trachea that splits into airways to the right and left lung; the right is shorter and wider than the left.

Slow heartbeat

bradycardia

atherosclerosis

buildup of plaque or fatty paste inside arterial walls

po

by mouth

dacryolith

calculus on the lacrima

Enlargement of the heart

cardiomegaly

critical care

care provided for a critical illness or injury which acutely impairs one or more vital organ systems and is an imminent or life-threatening condition

arteries

carry oxygenated blood away from the heart

what does the serous membrane line

cavities including the thracic cavity and internal organs

Which term relates to the brain

cerebral

If a woman has a PAP smear performed by her gynecologist, what part of the female anatomy is involved?

cervix

Treatment using drugs

chemotherapy

aqueous humor

clear fluid filling the area behind the cornea, in front of the iris

what is stratum lucidum composed of

clear layer

occlusion

closure

Abuse

coding practices that lead to improper reimbursement by error because they do not meet medical necessity, ex. changing diagnosis to be covered by insurance

epididymis

coiled tube on the back of the testis that is the site of sperm maturation and storage and where spermatozoa are propelled into the vas deferent toward the ejaculatory duct by contraction of smooth muscle

pneumothorax

collapsed lung

empyema

collection of pus between the lung and the lining of the lung (pleural space)

:

colon is used in Volume I (tabular list) after an incomplete term requiring one or more of the descriptions that follow to make it assignable to a given category

Group policy

company offered insurance policy to employees

What is stratum Spinosum composed of

composed of prickle cells

exstrophy

condition in which an organ is turned inside out

NIH (national institute of health)

conducts research, trains research scientist, and distributes health info. to the public

microtia

congenital deformity of the ear

what is synovial membrane composed of

connective tissue

tenon's capsule

connective tissue surrounding the posterior eyeball

Larynx

connects the nasopharynx to the trachea, covered by the epiglottis during swallowing to prevent aspiration

Skill coders may become

consulatants, educators or medical auditors

Proper code assignment is determined by

content of the medical record and by the unique rules that governs each code set

Participating provider

contracts with health insurance companies to provide services to members at agreed upon rate

Section I of the official guidelines includes

conventions, general coding guidelines, and chapter specific guidelines

Pigment cells are in what layer of the shaft

cortex

Health Insurance

cover some or all medical/ surgical cost

Incision of the skull

craniotomy

Managed care organziations

created to manage cost of healthcare, in-network providers into agreement w/ MCO, Five models: HMO,PPO,EPO,IDS,POS

An ABN protects the provider's financial interest by

creating a paper trail that CMS requires before a provider can bill the patient for payment if Medicare denies coverage for the stated service or procedure.

percussion

creating sounds form the body by tapping

jejunostomy

creation of an artificial opening between the jejunum and the abdominal wall

gastrostomy

creation of an artificial opening into the stomach

xeroradiography

creation of radiographs by photoelectric process using metal plates coated with a semiconductor

Release of information

critical for continuity of care, federal and state law governed, greater protection for HIV, AIDS, Mental Health, and Substance abuse

-tripsy

crushing

Indentify the following suffix: - tripsy

crushing

orthotic

custom made mechanical appliance used in orthopedics

What does Frontal (coronal) plane mean

cuts at a right angle to the midline cut , from side to side and divides the body into front (anterior) and Back (posterior) sections

What does Transverse (horizontal) plane mean

cuts horizontally through the body and separates the body into upper (superior) and lower (inferior) sections

What does Sagittal plane mean

cuts through the midline of the body from the front to back and divides the body into right and left sections

qd

daily

infarction

death of tissue

modifier 57

decision for surgery

Intramuscular

delivered deep into muscle

burns are classified by

depth, extent, agent

fulguration

destruction of living tissue with an electric spark

decompensation

deterioration; exacerbation fo an illness or condition

Preauthorization

determines coverage and medical necessity

Birthday Rule

determines which insurance is primary and which is secondary when child is covered by both parents. Which ever parents b-day is earlier

A word that means "complete separation" and is the process of separating wastes from blood.

dialysis

Referring Physician

directs patient to another physician for diagnosis and treatment

modifier 53

discontinued procedure

arrhythmia

disorder of the heart rate or rhythm

DAW

dispense as written

hydronephrosis

distention of the kidney caused by an accumulation of urine that cannot flow out due to an obstruction. it may be caused by conditions such as kidney stones or vesicoureteral relflux

The transverse plan

divides the body into upper and lower portions

bifurcation

division into two

Medical record chronologically

documents patient care to assist in continuity of care between providers, facilitate claims review and payment

Drug classification

drugs are grouped by therapeutic use, body system they treat, and chemical structure

neurogenic baldder

dysfunctional bladder due to a central or peripheral nervous system lesion that may result in incontinence, residual urine retention, infection, stones, and renal failure.

Who is responsible for interpreting national policies into regional polices, called LCDs?

each MAC (Medicare Administrative Contractor)

A record of electricity in the brain is

electroencephalogram

parentheses are used to

enclose supplementary words that may be present or absent in the statement of a disease or procedure without affecting the code number to which it is assigned

Brackets are used in tabular list to

enclose synonyms, alternate wording, or explanatory phrases

Which of the following does not circulate fluids throughout the body

endocrine system

anoscopy

endoscopic examination of the anus

proctosigmoidoscopy

endoscopic examination of the sigmoid colon and rectum

Increased accuracy of physician documentation in result of a compliance program actually may assist what

enhancing patient care

A healthcare clearing house is a

entity that processes nonstandard health information they receive from another entity into a standard format

An abnormal collection of blood above the membrane covering the brain

epidural hematoma

Pertaining to skin cells

epithelial

Abuse

errors are not deliberate, 3 categories: inadvertent billing and coding errors, excessive charges, insufficient documentation, penalties are meant to educate.

modifiers

essential modifiers are subterms listed below the main term in alphabetical order, and are indented 2 spaces

The first step in 3rd party reimbursement is

establishing medical necessity

Medical underwritting

evaluating a persons health to decide whether or not to insure them

By statute, all work RVUs, must be examined no less often than

every 5 years

q4h

every four hours

qod

every other day

necropsy

examination fo a dead body to determine cause of death (autopsy)

indentify the following suffix: -scopy

examination of

autopsy

examination of a dead body to determine the cause of death

gross

examination of the entire specimen without sectioning of the specimen into thin slides to be examined without the use of a microscope

indentify the following suffix: -ectomy

excision, surgical removal

EPO

exclusive provider organization, similar to PPO, no OON Benefits

side effects

expected in some people, beneficial or harmful

Exclusions

expenses not covered by insurance company

The ABN is a standardized form that

explains to the patient why Medicare may deny the particular service or procedure.

laparoscopy

exploring the abdomen and pelvic cavities using a scope placed through a small incision in the abdominal wall

esophageal varices

extremely dilated sub-mucosal veins in the lower third of the esophagus

Volume 3 of the ICD-9-CM includes procedure codes and is typically used by

facilities for inpatient services.

azoospermia

failure of the development of sperm or the absence of sperm in semen

hypospadias

fairly common birth defect in males in which the meatus, or urinary opening, is abnormally positioned on the underside of the penile shaft or in the perineum, requiring early surgical correction

prolapse

falling or dropping down of an organ or internal part

hallucination

false sense of perception or reality

Dependent

family member of a health plan member

what does Distal mean

farther from the point of attachment or from a given reference point

Subcutaneous tissue is mostly composed of

fatty or adipose tissue plue some areolar tissue

bone marrow

flexible tissue in the interior of bones

PERILYMPH

fluid in the cochlea that vibrates and creates nerve impulses to the cochlear nerve

injection

fluid introduced into tissue, cavity, or vessel, usually by needle

hysterosalpingography

fluoroscopic imaging of the uterus and Fallopian tubes.

hysterosalpingography

fluoroscopic imaging with contrast of the uterus and Fallopian tubes

refraction

focus and direction of light

loosening of association

frequent change of subject, often with minimal relationship

Anterior means

front

vitreous humor

gel-like mass that fills the large posterior chamber of the eye

Which doctor specializes in treating older patients

geriatrician

The root lies beneath the skin behind the fingernail and extends several millimeters into the finger is also known as

germinal matrix

g

gram

Power of Attorney

grants power to a representative of your choosing to legally act and make decisions on your behalf.

What is the great toe called

hallux

arteriosclerosis

hardening of the arteries

Therapeutic concentration

having enough medication in system to be considered therapeutic

where is greatest concentration of follicles

head

HMO

health maintenance organization, PCP selected, only responsible for Copay, must stay in network

Administrative Law Judge (ALJ)

hearing officer who presides over appeal conflicts between providers or beneficiaries, and Medicare contractors (MAC's)

A myocardial infarction is a

heart attack

A condition in which blood is held back

hematuria

Blood protein found in red blood cells

hemoglobin

diaphragmatic hernia

hernia of the diaphragm

cystocele

herniation of the urinary bladder into the vagina

Schedule 2

high potential for abuse, dangerous, 30 signed prescription with no refills, opiods, dilaudid

The first 4 digits of a morphology code identify the

histological type of the neoplasm

hyoid bone

horseshoe-shaped bone situated in the anterior midline of the neck between the chin and the thyroid cartilage

Abstractor

hospital employee who converts documented procedurs and diangoses into medical codes

Pharmokinetics

how a drug moves through your body, absorption, distribution, metabolism, excretion

E codes are used to report

how an injury occurred and where the injury occurred.

absorption

how drug enters blood stream

Excretion

how drug leaves body

Distribution

how drug travels to target site

Pharmocodynamics

how drugs work on the body, 3 main effects: therapeutic, side effects, adverse reaction

Excessive amount of sugar in the blood is

hyperglycemia

allergy

hypersensitivity caused by exposure to an antigen

What is another name for subcutaneous layer

hypodermis

Which later is not considered part of the skin

hypodermis

presumptive identification

identification of a microorganism based on the growth patterns, color, and success in culturing the specimen in certain media

definitive identification

identification of the genus and species of the microorganism

what action can the provider take if the patient refuses to sign the ABN

if the patient still request the procedures and services but refuses to sign a properly-presented ABN, the provider should cocument the patient's refusal. The provider and a witness should then sign the form.

ductogram

imaging of the ducts in the breast

epidurography

imaging of the epidural space in the spine

hypothermic circulatory arrest

implies a temperature of 20 degrees c or less

strabismus

improper alignment of the eyes

Enteral

in mouth or GI tract (orally or rectally)

Indentify the following prefix of location: End/o-

in; within

disorientation

inability to estimate direction or location

indentify the following suffix: -tomy

incision, cutting

modifier 22

increased procedural services

slanted brackets

indicate multiple codes are required

brackets are used in the alphabetic index to

indicate multiple codes are worried

Define Arthritis

inflammation of joint

endocarditis

inflammation of the inner lining of the heart

epididymo-orchitis

inflammation of the testicles and epididymis

cystitis

inflammation of the urinary bladder

Medicare part A helps to cover:

inpatient hospital care care provided in skilled nursing facilities hospice care home health care

Medication admin Records

inpatient recordss

catheterization

insertion of a catheter into a body structure

Code first

instruction used in categories not intended to be the principal diagnosis. These codes are written in italics with a note. The note requires the underlying disease (etiology) be recorded first and the particular manifestation be recorded second. This note only appears in the tabular index

indentify the following suffix: -graph

instrument for recording data

Indentify the following suffix: -scope

instrument for viewing or examining

Secondary

insurance covering patient as dependent

Primary

insurance covering the patient as policy holder

formularies

insurance plans drug list, updated by committee and pharmacist

IDS

integrated delivery system, MCO coordinates all aspects of patient care, can include medical, vision, dental, and prescription, claims processing and workers comp.

What is largest organ system called

integumentary system

panic attack

intense anxiety; feels like a loss of control

As a part of Health Care Reform, the Affordable Care Act of 2010 amended the definition of fraud to remove the __________ requirement

intent

Fraud

intent is deliberate, federal offense, targets medicare, penalties are meant to punish

what does the serous membrane support

internal organs

eventuation of intestines

intestinal protrusion of the intestines through the abdominal wall

autonomic

involuntary, relating to the autonomic nervous system

what is the job of epithelium in mucous membranes

involved in absorption and secretion

Vertebrae are considered what

irregular bones

Office of the Inspector General (OIG)

issues antifraud compliance programs to help providers eliminate billing/coding errors, protects integrity of medicare and Medicaid programs

Which of the following is not true of the thoracic diaphragm

it is a frequent site of a spigelian (lateral ventral) hernia

In order for a V code to be listed first,

it must meet the definition of a principle or first-listed diagnosis code

Fee for Service

itemize and bill every item and service separately

anastomosis

joining of two blood vessels to allow flow from one to the other

Network HMO

joins together any number of staff models

what does synovial membrane line

joint cavities

Define Arthropathy

joint disease

Medicaid

joint federal and state program, people with limited income and resources, eligibility differs between states

What is a fingernail made of

keratin

Reno and nephro both mean

kidney

Visual examination of the abdomen by make a small incision near the navel is called?

laparoscopy

HIPAA Security Rule

law requiring covered entities to establish safeguards to protect health information, focuses on ePHI

minimum necessary standard

least amount of info required

A medically necessary service is the

least radical service/procedure that allows for effective treatment of the patients' complaint or condition

Indentify the following prefix of location: Sinister/o

left

modifier F1

left hand, second digit

modifier LT

left side

The myocardium is thickest around which chamber of the heart?

left ventricle

Policy

legal contract between a person or group and insurance company

Federal Registration

legal newspaper published every business day by the National Archives and records admin.

Which of the following has a refraction function in the eye? macula retina lens iris

lens

first trimester

less than 14 weeks

desensitize

lessening of sensitivity by administration of a specific antigen in low doses

auscultation

listening to body organs

What is areolar tissue

loose connective tissue consisting of a meshwork of collagen, elastic tissue and reticular fibers.

Schedule 4

low potential for abuse and dependency ex: Ativan, valium

Schedule 5

low potential for abuse, contain limited amount of certain narcotics, ex: Lyrica, lomotil

modifier E2

lower left eyelid

The mediastinum contains all of the following except

lungs

What is the nail and the nail bed and its edges called

lunula

Which of the following does not contribute to refraction in the eye?

macula

exenteration

major operation during which an organ and its adjacent structures are removed

The tunica vaginalis is part of which system?

male reproductive

Incus, stapes, _____

malleus

modifier 32

mandated services

molecular diagnostics

measurement of DNA, RNA, proteins, or metabolites to detect genotypes, mutations, or biochemical changes

pachymetry

measurement of corneal thickness

pelvimetry

measurement of the dimensions and capacity of the pelvis

Benefits

medical expenses that insurance company covers

Volumes 1 and 2 are used to assign diagnosis codes that establish

medical necessity for services rendered.

on call

medical personnel with special training and skills available to provide services when summoned

Medicare Part B helps to cover

medically necessary physicians' services ouptatient care other medical services (including some preventative services) not covered under Part A

What layer give hair its charactertistic color

medulla

Which part of the brain controls blood pressure, heart rate and respiration

medulla

oval window

membrane covered window from the inner ear to the middle ear

gait trainig

method of restoration of balance, extremity swings, stance

psychotherapy

method of treating mental disorders. treatment may involve education, pharmacology, suggestion, psychoanalysis

cilia

microscopic, hair-like projections that propel mucus toward the upper airway so that it can be expectorated

Indentify the following prefix of location : Mes/o

middle

choroid

middle layer between the retina and the sclera in the eye's posterior segment. nourishes the retina

Tricare

military health plan that provides services for active duty personnel and their families, survivors of military personnel and retired military personnel and their families

mg

milligram

modifier 81

minimum assistant surgeon

Schedule 3

moderate to low potential for abuse, high psychological dependency, ex: suboxone, Tylenol with codeine

Toenails grow what

more slowly

the root produces of what of the nail

most of volume

What does the muscloskeletal system provide

movement, form, strength and protection

modifier 99

multiple modifiers

modifier 51

multiple procedures

bundle of his

muscle fibers in the heart's conduction system that branch off to the right and left sides of the heart

Court order

must be responded to or provider may be fined

A benign tumor of muscle is

myoma

onych/o

nail

What does Proximal mean

nearer to the point of attachment or to the given reference point

Hemiplegia is a disorder caused by a defect in which anatomic system?

nervous

What is affected by myasthenia gravis

neuromuscular junction

modifier NU

new equipment

ileostomy

new opening of the ileum to the outside of the body

Non- Participating Provider

no agreement with insurance company to provide service and does not accept fee

Schedule 1

no current accepted use, high potential for abuse, most dangerous, es: heroin, LSD

uninsured

no insurance

NEC

not elsewhere classifiable

Medicare and many insurance plan may deny payment for a service that is

not reasonable or necessary according to the Medicare reimbursement rules.

npo

nothing by mouth

parenteral nutrition

nutrients delivered intravenously to patients who are postoperative, in shock, or otherwise unresponsive

enteral nutrition

nutrients for patients with impaired ability to chew/swallow or ingest food, typically delivered by gastric or nasogastric tube

What is the definition of O of SOAP

objective-The provider assesses and documents the patient's illness using observation, palpation, auscultation and percussion. Test and other services performed may be documented here as well

Mallory-Weiss syndrome

occurs in the mucous membrane of the esophagus, where it connects to the stomach; usually caused by forceful or long-term vomiting, coughing, or epileptic convulsions

Define Colles' Fracture

occurs in wrisit and affects the distal radius bone

Fingernail grow at an approximate rate

of 3mm per month

Generic name

official name of drug, simpler than chemical name, not copyrighted

Guardianship

one individual can legally act on the behalf of a minor or incompetent adult.

Indentify the following prefix of number : Mon/o

one; single

A key provision in HIPAA is the Minimum Necessary requirement. this means

only the minimum necessary protected health information should be shared to satisfy a particular purpose.

meatus

opening or passage into the body

Modifier BO

orally administered nutrition, not by feeding tube

oz

ounce

medication list

outpatient records

Parenteral

outside GI tract (injection)

extracranial

outside the skull

extraspinal

outside the spine

Define Arthralgia

pain in joint

orthopantogram

panoramic, radiographic image of the entire dentition, alveolar bone, and other adjacent structures on a single film; taken extra-orally

Stark law

part of social security act, applies to physician's who refer medicare/ Medicaid patients to facilities they have a financial interest in, addresses potential for overutilization, applies to referrals deemed medically unnecessary

hiatal hernia

part of the stomach pushes through wall into the diaphragm, into the chest

A doctor who perform autopsies and examines biopsy samples is a

pathologist

Staff HMO

patient employs their own physician

Consent

patient gives permission

Group HMO

patient is in contract with physician group

subpoena

patient must be notified so they can object to the disclosure

coinsurance

patient pays a percentage of the cost of the service

Assignment of Benefits

patient signs authorization form to allow insurance to pay benefits directly to provider rather to than to patient.

new patient

patient who has not been seen by a provider of the same specialty, in the same group, within the past three years

established patient

patient who has seen a provider of the same specialty, in the same group, within the past three years

observation status

patient's condition requires monitoring, but the decision to admit to inpatient status has not been made

Reimbursement

pay for service rendered

Abuse consists of

payment for items or services that are billed by providers in error that should not be paid for by Medicare.

omentum

peritoneal connection between the stomach and other internal organs

chronic intersitial cystitis

persistently inflamed lesion of the bladder wall, usually accompanied by urinary frequency, pain, nocturne, and a distended bladder

Policy holder

person insurance policy is issued to

Anaphylactic shock

person loses ability to breath, most severe allergic reaction

Individual

person purchased insurance on their own

HIPAA provides federal protections for

personal health information when held by covered entities.

hemic

pertaining to blood

atrioventricular

pertaining to the atria and the ventricles

gastrointestinal

pertaining to the stomach and the intestine

Resource costs for RBRVS are divided into three componentes:

physican work practice expense professional liability insurance

clinical laboratory

place where tests are performed on clinical specimens to get information about the health of a patient as pertaining to the diagnosis, treatment and prevention of disease

clinical laboratory

place where tests are performed on clinical specimens to get information about the health of a patient as pertaining to the diagnosis, treatment, and prevention of diseae

shuntogram

placement of a radioactive isotope in the shunt reservoir in the head to measure the speed with which it moves to the abdomen. shuntogram is the term used for angiography of an a/v fistula for renal dialysis

nephrostomy

placement of a stent, tube, or catheter to form a passage from the exterior of the body into the renal pelvis or calyx, often for drainage of urine or an abscess, for exploration, or calculus extraction

indentify the following suffix: -plasty

plastic repair, plastic surgery, reconstruction

POS

point of service, Combination of HMO and PPO, receive in and OON benefits at different level of cost

Guaranteed Issue

policy issued to a person regardless of age or pre-existing condition

Modifier 58

post operative-planned prospectively at the time of the original procedure, more extensive than the original procedure, for therapy following a diagnostic procedure

modifier 55

postoperative management only

PPO

preferred provider organization, MCO contracts with providers, patients do not have to have PCP, can see any provider, cost are lower for in network

modifier 56

preoperative management only

home care

prescribed medical care provided in a patient's home

Medicare Part D is a

prescription drug coverage program

hematuria

presence of blood in the urine

comorbidity

presence of two or more illnesses the same time. there may be an association between the illnesses

PCP

primary care physician, provides comprehensive care

Medicare Part D is a coverage provided by

private companies approved by Medicare

Commercial (non-Medicare) may develop their own medical policies which do not follow Medicare guidelines and are specified in

private contracts between the payer and practice or provider

Medicare Part C plans are managed by

private insurers approved by Medicare.

fluoroscopy

procedure for viewing the interior of the body using x-rays and projecting the image onto a television screen

goniotomy

procedure where an opening is made in the trabecular meshwork of the front part of the eye. The provider uses a goniolens during the procedure

Modifier 26 & TC

professional component

modifier 26

professional component

Prediction about the outcome of treatment

prognosis

If an organ slides or falls forward, the condition is

prolapse

A part of the male genital system sitting below the urnary bladder and surrounding the urethra is called the

prostate

PHI

protected health information

CDC (center disease control and protection)

protects public health of the nation and responds to public health emergencies

Claim

providers request of medical payment from insurance company

CMS (center for medicare/Medicaid services)

provides oversight of the medicare program and federal portion of Medicaid program

Federal Employees Compensation Act

provides workers compensation insurance for civilian employees of the federal government

Treatment

provision coordination and management of healthcare (consults and referrals)

evisceration

pulling the viscera outside of the body through the incision

through which vessel is oxygenated blood returned to the heart from the lungs

pulmonary vein

-centesis

puncture, tap

indentify the following suffix: -centesis

puncture, tap

clinical laboratory improvement amendments (CLIA)

quality standards for all laboratory testing to ensure the accuracy, reliability, and timeliness of patient test results, CLIA waived tests-simple tests that may be performed in non laboratory settings

barium enema

radiographic examination of the rectum and colon after administration of barium sulfate into the rectum

aortography

radiographic image of the aorta and branches using contrast material

cholangiography

radiographic image of the bile duct

bronchography

radiographic image of the bronchi of the lungs using contrast material

corpora cavernosography

radiographic image of the corpora cavernous and draining veins using contrast medium

discography

radiographic image of the dic of the spine

cephalogram

radiographic image of the head

dacryocystography

radiographic image of the lacrimal drainage system

sialography

radiographic image of the salivary ducts and glands

myelography

radiographic image of the spinal cord

vasography

radiographic image of the vas deferent and ejaculatory duct following dye injection

angiography

radiographic imaging of blood vessels

pyelography

radiographic imaging of the renal pelvis of a kidney following injection of a radiopaque substance through the ureter or into a vein

cholangiography

radiographic recording of the bile ducts

cholecystography

radiographic recording of the gallbladder

hepatography

radiographic recording of the liver

splenoportography

radiography of the splenic and portal veins; includes injection of a radiopaque medium

urethrocystography

radiography of the urethra and bladder using a radiopaque substance

Adverse Effects

rare, always harmful, should inform FDA

therapeutic index

ratio or window between therapeutic and toxic

onset of action

reaching the peak effect, takes time

GPCI is used to

realize the varying cost based on geographic location

medical necessity

reasonable and necessary services to bring a cure or a change in the condition for which the patient is being seen.

modifier 52

reduced services

define the classification TUBULAR of bone

referred to as long bones

Define the classification CUBOIDAL of bone

referred to as short bones

monitored anesthesia care

refers to a continuum a technique for many surgical procedures that do not require deep sedation or a general anesthetic. the anesthesia provider must be prepared to convert to general anesthesia, if necessary

nystagmus

reflexive jerky eye movements as a response to the messages of the inner ear

Chron's disease

regional enteritis

payment

reimbursing healthcare providers for service

myocardial

relating to the myocardium

enterolysis

releasing of adhesions of intestine

exenteration

removal of a complete structure

pneumonectomy

removal of a lung

debridement

removal of dead or damaged tissue to promote healing

dialysis

removal of toxins from the blood by diffusion over a membrane or filter in patients with renal impairment or failure

fundoplasty

repair of the bottom of an organ or muscle

Modifier 76 & 77

repeat procedures

compulsion

repetitive behavior with ritualistic characteristics; uncontrolled impulse

hydration

replenishment of fluids

HIPAA Title II

requires written consent and permission from the patient to share information

Medicare payments for physician services are standardized using a

resource-based relative value scale (RBRVS)

Confidentiality

responsibility to protect patient information from unauthorized use or disclosure. Legal and ethical concept

retinal detachment

retina is freed from the blood-rich choroid at the back of the eye. when the retinal layer floats away, it loses its supply of nutrients. nutrients must me returned, or vision is lost

Discharge of fluid from the nose

rhinorrhea

Indentify the following prefix of location : Dextr/o

right

limbus

ring where the cornea meets the sclera; also known as the sclerocorneal junction

HIPAA (Health Insurance Portability and Accountability Act)

safe guards PHI, allows patient the right to control the use and disclosure of personal health info.

Removal of a fallopian tube

salpingectomy

examples of common reasons to report V codes:

screening tests routine physicals personal or family history of a disease or disorder

review of systems

series fo questions regarding signs and symptoms that are associated with the patient's chief complaint

what are does the meninges do

serve as a protective covering

modifier Q6

service finished by a locus tennis physician

What does the appendicular skeleton consist of

shoulder girdle, pelvic girdle, extremities

use additional code

signals the coder an additional code should be used, if the information is available, to provide a more complete picture of the diagnosis.

contralateral

situated on or affecting the opposite side of the body

what is another for the cutaneous membrane

skin

intussusception

slipping of one part of intestine into another part

capillaries

smallest branches of the coronary arteries and veins

retrobulbar

space behind the eye

pleural cavity

space between the folds of the pleura

Which of the following are auditory ossicles

stapes and incus

Medicaid is adminisitered on a

state by state basis adhering to certain federal guidelines.

Workers Compensation

state mandated insurance program, statutes vary by state, employers required to compensate employees who were injured on job

Appendix D is used primarily for

statistical purposes. It provides information about employment injuries.

what is another name for the nail bed

sterile matrix

Authorization

stipulates which PHI to disclose and to whom

chord tendineae

string-like attachments connected to the AV valves

in vivo

studies performed within the living body

forensics

studies used or applied in the investigation and establishment fo facts or evidence in a court of law

neuro psychology

study and treatment of psychiatric and neurological disorders

psychology

study of behavior, thoughts, feelings

cytopathology

study of cellular changes in disease

mycology

study of fungi

cytogenetics

study of genes to determine whether disease has inherited components and to identify the specific genetic components of certain disease and processes, so they can be better treated

genetics

study of heredity

Pharmacology

study of how drugs work, are made, interact, etc

parasitology

study of parasites

cytopathy

study of the cellular changes in disease

hematology

study of the components and behavior of blood

immunology

study of the immune system, its components, and function

gastroenterology

study of the stomach, intestine, esophagus, liver, gallbladder, and pancreas

virology

study of viruses

what lies underneath the dermis

subcutaneous layer

What is the definition of S of SOAP

subjective- The patient's statment about his or her health, including symptoms

What is the fibrous connective tissue that is included in this layer

superficial fascia

Which of the following is a function of the pancreas? * supplies digestive enzymes manufactures melatonin * stimulates growth * secretes vasopressin

supplies digestive enzymes

All services provided to a patient is

supported and documented in the medical record

anuria

suppression, cessation, or failure fo the kinds to secrete urine

modifier 54

surgical care only

indentify the following suffix: -stomy

surgical creation of an opening

Define arthrodesis

surgical fixation of a joint

Define Sternotomy

surgical incision of sternum

marsupialization

surgical procedure that creates an exterior pouch from an internal abscess

atherectomy

surgical removal of plaque buildup from the interior of an artery

enucleation

surgical removal of the eyeball

cholecystectomy

surgical removal of the gallbladder

blepharoplasty

surgical repair of the eyelid

indentify the following suffix: -rraphy

surgical repair, suture

pneumonolysis

surgical separation of the lung from the chest wall to allow the lung to collapse

modifier 66

surgical team

indentify the following suffix: -pexy

surgicial fixation

Define Osterrhaphy

suture of bone

modifier 95

synchronous telemedicine service rendered via a real-time interactive audio and video telecommunications system

ICD-10-C

table of drug

modifier TC

technical component

pump oxygenator

term used when a cardiopulmonary bypass (CPB) machine is used to function as the heart and lungs during heart surgery.

excludes

terms following "excludes" notes are to be reported with a code from another category.

qualitative

test determining the presence or absence of a drug

quantitative

test identifying the amount of an analyze within a specified range but does not identify a specific quantity

pulmonary function tests

tests to diagnostic breathing problems

HITECH was enacted as part of

the American Recovery and Reinvestment Act of 2009 (ARRA)

Maintenance of hte ICD-9-CM is performed by

the Coordination and Maintenance Committee

NEC is used when

the ICD-9-CM system does not provide a code specific for the patient's condition.

What was ARRA and HITECH promote

the adoption and meaningful use of health information technology

Participating Providers (Par Providers are required to accept

the allowed payment amount determined by the insurance carrier as the fee for payment and follow all other guidelines stipulated by the contract

The classification system determines what

the amount health care providers will be reimbursed if the patient is covered by Medicare, Medicaid, or other insurance programs using the system

trachea

the cartilaginous and membranous tube that descends from the larynx and branches into the right and left main bronchi

use addtional code, if applicable

the causal condition note indicates this code may be assigned as a diagnosis when the causal condtion is unknown or not applicable. If a causal condition is known, the code should be sequenced as the principal diagnosis.

NOS is used only when

the coder lacks the information necessary to code to a more specific 4th or 5th digit subcategory

What are the categories depending on

the covered entity's level of culpability for releasing protected information and minimum and maximum penalties.

Where does nail bed extend to

the edge of the lunula to the hyponychium

The OIG is mandated by public law to engage in activities to test

the efficiency and economy of government programs to include investigation of suspected health care fraud or abuse.

Whose responsibility is it to develop and implement policies, best suited to its particular circumstances, to meet HIPAA requirements.

the entity covered by HIPAA

What is stratum corneum composed of

the horny layers, outermost layer

Certification

the hospital passed a survey done by a state government agency. Medicare only covers hospital stays in hospitals that are certified or accredited.

Administration Simplification speaks to what

the increasing use of technology in the health care industry

what does the serous membrane companrtmentalize

the large vavities to hinder spread of infection

Generally what a medically-necessary service is

the least radical service/procedure that allows for effective treatment of the patient's complaint or condition

What does the cutaneous membrane forms

the outer covering of the body

Medicare Part B premiums are paid by

the patient

V codes are commonly used when

the patient presents for treatment with no complaints.

mediastinum

the portion of the thoracic cavity between the lungs containing the heart, aorta, esophagus, trachea, and thymus gland, as well as blood vessels and nerves

alveoli

the primary units for the exchange of oxygen and carbon dioxide in the lungs

Coding is

the process of translating this written or dictated fmedical record into a series of numeric or alpha-numeric codes

Selecting a code with the NEC classification means

the provider documented more specific information regarding the patient's condition, but there is not a code in ICD-9-CM that reports the condition accurately

chief complaint

the reason the patient presents for an encounter

pleura

the serous membrane covering the lungs and lining the thoracic cavity

Define dermatology

the study of the skin

Joints are classified accord to what

the type of connective tissue at the articulating surfaces

glottis

the vocal cords and the opening between them

LCDs have jurisdiction only within

their regional area

infusion

therapeutic agent introduced into the body by a vein

HITECH requires that an individual be notified if

there is an unauthorized disclosure or use of his or her health information.

what is stratum reticulare composed of

thick layer of dense, irregular connective tissue

what is stratum papillare composed of

thin superficial layer interlocked with epidermis

eponym

this term indicates the code describes a disease or syndrome named after a person

cognitive

thoughts or thinking, learning, or memory processes

How many lobes make up the right lung

three

tid

three times a day

ossicles

three tiny bones of the middle ear

Indentify the following prefix of location : Trans-

through; across

manipulation

thrusting movement to achieve realignment of joints or spine

stapes

tiny bone (ossicle) in the middle ear

What is the tasked for a coder with an operative report

to break down the information and applying the correct code.

instill

to introduce gradually in order to establish securely

fraud

to purposely bill for srevices that were never given or to bill for a service that has a higher reimbursement than the service provided.

What is the coders required to with the medical records

to read and understand the documentation in the medical record in order to accurately code the services rendered.

atherectomy

to remove plaque from an artery

palpation

touching the body

What does Posterior or Dorsal mean

toward the back of the body

What does Anterior or Ventral mean

toward the front of the body

Indentify the following prefix of location: Ad-

toward; near

brand name

trade mark protected by drug manufacturer or pharmaceutical company.

biofeedback

training technique for development fo a person's ability to control his or her autonomic nervous system

chemotherapy

treatment of disease by means fo chemical substances or drugs; usually cancers

chiropractic

treatment predominately using manipulation of spinal and musculoskeletal structures and recuperative powers of the body

polyp

tumor on a pedicle that bleeds easily and may become malignant

bid

twice daily

volvulus

twisting of the intestine on itself

What are Organs

two or more kinds of tissue together performing special body functions

modifier 62

two surgeons

Indentify the following prefix of number : Bi-

two, twice

Capitation

type of reimbursement paid per number of patients on the membership roster. Paid regardless of services rendered

echoencephalography

ultrasound image of the brain

sonohysterography

ultrasound imaging of the uterus

Emancipation of Minors

under age child is granted decision making rights and financial responsibility of themselves

Where is the dermis located

under the epidermis

Sub Q

underskin, for meds the body needs to absorb slowly

relative value unit

unit measure used to assign a value to services. determined by assigning weight to factors such as physician work, practice expense and malpractice expense.

gradiosity

unrealistic concept of self-importance

modifier 24

unrelated e/m by the same physician or other qualified healthcare professional during a postoperative period

NOS is the equivalent of

unspecified

modifier 23

unusual anesthesia

atria

upper chambers of the heart

The tube leading from the bladder to the outside of the body is

urethra

doppler study

use of a n ultrasound prove to determine blood flow

video-assisted thoracoscopic surgery (VATS)

use of endoscope and video to perform diagnostic and surgical procedures on the thoracic cavity

boldface type

used for all codes and titles in the Tabular list

Italicized type

used for all exclusion notes and to identify codes that should not be used for describing the primary diagnosis

code first

used in categories not intended to be the principal diagnosis

An ectopic pregnancy is a complication n which the fertilized ovum is implanted in a any tissue other than the

uterine wall

phleb/o

vein

artery

vessel carrying blood from the heart to the tissues

modifier GA

waiver of liability statement issued as required by payer policy, individual case

modifier GU

waiver of liability statement issued as required by payer policy, routine notice

lavage

washing out an organ

Premium

what a person pays for their policy

NCD explain

when Medicare will pay for items or services.

combination code

when a single code is used to classify two diagnoses

The number of stratum varies based on what

where the epidermis is located

what is medical necessity relates to

whether a procedure or service is considered appropriate in a given circumstance

The term "medical necessity refers to

whether a procedure or service is considered appropriate in a given circumstance.

duration of action

whole time drug is effective in body

where are meninges found

with the dorsal cavity

Intravenous

within a vein directly in blood stream, fastest but most dangerous

intracoronary

within the heart

peritoneal

within the lining of the abdominal cavity

Subpoena Duces Tecum

written document directing individuals or organizations to also furnish relevant documentation and records

What is the meaning of xantho

yellow

Does Medicare Part B generally require a yearly deductable and copayment?

yes


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