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Flashcards in Fitz professional issues Deck (25)
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1
Q

Dual eligible

A

Receives Medicaid and Medicare

2
Q

Medicaid definition

A

publicly financed health and long term care coverage for low-income people

3
Q

Prospective payment system

A

-Pays the provider a set amount based on the applicable Diagnosis Related Group

4
Q

Four elements of malpractice

A

duty of care
breach of standard of care
injury
proximal cause

5
Q

Standard of care

A

care that a reasonable, similarly situated professional would have provided for an individual

6
Q

CPT stands for

A

Current Procedural Terminology

7
Q

ICD stands for

A

International Classification of Diseases

8
Q

When billing Medicaid, NP’s authority to bill comes from

A

state and federal law

9
Q

When billing commercial insurance, NP’s authority to bill comes from

A

state law and/or the commercial payers

10
Q

Are capitated rates negotiable

A

yes

11
Q

When billing Medicare, NP’s authority to bill comes from

A

state law

12
Q

Components of evaluation and care

A
  • taking history
  • physical exam
  • medical decision making
  • counseling
  • coordination of care
13
Q

Fee-for-service

A

-every procedure performed has an associated payment

14
Q

Capitated system of reimbursement

A

-agency recieves set amount per month for all services needed by the patient and covered under a contract between payer and practice company

15
Q

What are capitation rates based on

A

-profit projections and actuarial data

16
Q

T/F when payment is capitated, practices want to take care of as much as possible through calls, electornic, mailings, or visit with other staff other than MD, NP, PA

A

True

17
Q

How many levels of evaluation in CPT

A

5

18
Q

Most frequently billed level of visit for Medicare established patients

A

level 3

99213

19
Q

What is composed of a level 3 visit

A
  • need 2/3
  • at least one element of HPI and at least one positive or negative response to ROS
  • at least 6 elements of PE
  • Low complexity
20
Q

What is composed of a level 4 visit (99214)

A
  • need 2/3
  • at least 4 elements of HPI, positive or negative responses to at least 2 ROS and at least one notation about past history, FMH, or social history
  • at least 12 elements on PE
  • medical decision making of moderate complexity
21
Q

What is “incident-to”

A
  • an integral, although incidental, part of the physician’s personal professional services in the course of diagnosis or treatment of an injury or disease
  • allow physician to bill for services provided by an assistant or delegate in the office
  • Ex: return visit for BP check
  • can bill Medicare for CPT 99211 (level 1)
  • physician must be in the office a the time of visit, must have documented the plan of care, must employ the nurse, and must remain involved in the care of the patient.
22
Q

What does HIPAA stand for

A

Health Insurance Portability and Accountability Act

23
Q

Major purpose of privacy rule

A

-define and limit the circumstances in which an individual’s protected health information can be used or disclosed by covered entities

24
Q

De-identified

A

-when specific identifiers have been removed from protected health information so that it no longer can be used to identify an individual

25
Q

What is a covered entity

A

-every healthcare provider who electronically transmits health information in connection with certain transactions