what does acting within ethical behavior boundaries mean
what does acting within ethical behav
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CBCS Exam Study Guide
Medical Billing & Coding as a Career - ANSWER *Claims assistant professional or
claims manager, *Coding Specialist, * Collection Manager, *Electronic Claims
Processor, *Insurance Billing Specialist, * Insurance Coordinator, *Insurance Counselor,
*Medical Biller, *Medical & Financial Records Manager, * Billing & Coding Specialist
What are Medical Ethics? - ANSWER Standards of conduct based on moral principle.
They are generally accepted as a guide for behavior towards pt's, dr's, co-workers, the
gov, and ins co's.
What does acting within ethical behavior boundaries mean? - ANSWER carrying out
one's responsibilities w/ integrity, dignity, respect, honesty, competence, fairness, &
trust.
Legal Aspects of of Medical Billing & Coding: - ANSWER ...
Compliance regulations: - ANSWER Most billing-related cases are based on HIPPA and
False Claims Act
Health Insurance Portability & Accountability Act (HIPPA) - ANSWER Enacted in 1996,
created by the Health Care Fraud & Abuse Control Program-enacted to check for fraud
and abuse in the Medicare/Medicaid Programs and private payers
What are the 2 provisions of HIPPA? - ANSWER Title I: Insurance Reform
Title II: Administrative Simplification
What is Title I of HIPPA? - ANSWER Insurance Reform-primary purpose is to provide
continuous ins coverage for worker & their dependents when they change or lose jobs.
Also *Limits the use of preexisting conditions exclusions *Prohibits discrimination from
past or present poor health *Guarantees certain employees/indv the right to purchase
new health ins coverage after losing job *Allows renewal of health ins cov regardless of
an indv's health cond. that is covered under the particular policy.
What is Title II of HIPPA? - ANSWER Administrative Simplification-goal is to focus on
the health care practice setting to reduce administrative cost & burdens. Has 2 parts- 1)
development and implementation of standardized health-related financial &
administrative activities electronically 2) Implementation of privacy & security
procedures to prevent the misuse of health info by ensuring confidentiality
What is the False Claims Act (FCA)? - ANSWER Federal law that prohibits submitting a
fraudulent claim or making a false statement or representation in connection w/ a claim.
Also protects & rewards whistle-blowers.
What is the National Correct Coding Initiative (NCCI)? - ANSWER Developed by CMS
to promote the national correct coding methodologies & to control improper coding that
lead to inappropriate payment of Part B health ins claims.
,CBCS Exam Study Guide
How many edits does NCCI include? - ANSWER 2: 1)Column 1/Column 2 (prev called
Comprehensive/Component) Edits
2) Mutually Exclusive Edits
Column 1/Column 2 edits (NCCI) - ANSWER Identifies code pairs that should not be
billed together b/c 1 code (Column 1) includes all the services described by another
code (Column 2)
Mutually Exclusive Edits (NCCI) - ANSWER ID's code pairs that, for clinical reasons,
are unlikely to be performed on the same pt on the same day
What are the possible consequences of inaccurate coding and incorrect billing? -
ANSWER *delayed processing & payment of claims *reduced payments, denied claims
*fine and/or imprisonment *exclusion from payer's programs, loss of dr's license to
practice med
Who has the task of investigate and prosecuting health care fraud & abuse? - ANSWER
The Office of Inspector General (OIG)
Fraud - ANSWER knowingly & intentionally deceiving or misrepresenting info that may
result in unauthorized benefits. It is a felony and can result in fines and/or prison.
Who audits claims? - ANSWER State & federal agencies as well as private ins co's
What are common forms of fraud? - ANSWER billing for services not furnished,
unbundling, & misrepresenting diagnosis to justify payment
Abuse - ANSWER incidences or practices, not usually considered fraudulent, that are
inconsistent w/ the accepted medical business or fiscal practices in the industry.
What are examples of Abuse? - ANSWER submitting a claim for services/procedures
performed that is not medically necessary, and excessive charges for services,
equipment or supplies.
What is a method use to minimize danger, hazards, & liabilities associated w/ abuse? -
ANSWER Risk Management
Patient Confidentiality - ANSWER All pt's have right to privacy & all info should remain
privileged. Only discuss pt info when necessary to do job. Obtain a signed consent form
to release medical info to ins co or other individual.
When may providers use PHI (Protected Health Information) w/o specific authorization
under the HIPPA Privacy Rule? - ANSWER When using for TPO, Treatment (primarily
for the purpose of discussion of pt's case w/ other dr's) Payment (providers submit
claims on behalf of pt's) & Operations (for purposes such as training staff & quality
improvement)
,CBCS Exam Study Guide
What is Employer Liability? - ANSWER Means physicians are legally responsible for
their own conduct and any actions of their employees (designee) performed w/in the
context of their employment. Referred to as "vicarious liability. A.K.A "respondent
superior"-"let the master answer". Means employee can be sued & brought to trial
What is Employee Liability? - ANSWER "Errors & Omissions Insurance"-protection
against loss of monies caused by failure through error or unintentional omission on the
part of the indv or service submitting the claim. ****Some dr's contract w/ a billing
service (clearinghouse) to handle claims submission, & some agreements contain a
clause stating that the dr will hold the co harmless from "liability resulting from claims
submitted by the service for any account", means dr is responsible for mistakes made
by billing service, errors & omissions is not needed in the instance. ******However, if dr
ever asks the ins biller to do the least bit questionable, such as write of pt's balances for
certain pt's automatically, make sure you have a legal document or signed waiver of
liability relieving you of responsibility for such actions.
What is a Medical Record & what is it comprised of? - ANSWER documentation of the
pt's social & medical history, family history, physical exam findings, progress notes,
radiology & lab results, consultation reports and correspondence to pt- Is the foremost
tool of clinical care and communication.
What is a medical report? - ANSWER part of the medical record & is a permanent legal
document that formally states the consequences of the pt's exam or treatment in letter
or report form. IT IS THIS RECORD THAT PROVIDES INFO NEEDED TO COMPLETE
THE INS CLAIM FORM.
Reasons for Documentation - ANSWER Important that every pt seen by dr has
comprehensive legible documentation about pt's illness, treatment, & plans for following
reasons:
*Avoidance of denied or delayed payment by ins co investigating the medical necessity
of services
*Enforcement of medical record-keeping rules by ins co requiring accurate
documentation that supports procedure & diagnosis codes.
*Subpoena of medical records by state investigators or the court for review
*Defense of professional liability claim
Retention Of Medical Records - ANSWER Is governed by state & local laws & may vary
from state-to-state. Most dr are required to retain records indefinitely, deceased pt
records should be kept for @ least 5 years
Med Term - ANSWER ...
Diagnosis suffixes: - ANSWER ...
-algia - ANSWER pain
, CBCS Exam Study Guide
-emia - ANSWER blood condition
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