Fitz professional issues

Question 1

Dual eligible

Answer 1

Receives Medicaid and Medicare

Question 2

Medicaid definition

Answer 2

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

Question 3

Prospective payment system

Answer 3

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

Question 4

Four elements of malpractice

Answer 4

duty of care
breach of standard of care
injury
proximal cause

Question 5

Standard of care

Answer 5

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

Question 6

CPT stands for

Answer 6

Current Procedural Terminology

Question 7

ICD stands for

Answer 7

International Classification of Diseases

Question 8

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

Answer 8

state and federal law

Question 9

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

Answer 9

state law and/or the commercial payers

Question 10

Are capitated rates negotiable

Answer 10

yes

Question 11

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

Answer 11

state law

Question 12

Components of evaluation and care

Answer 12

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

Question 13

Fee-for-service

Answer 13

-every procedure performed has an associated payment

Question 14

Capitated system of reimbursement

Answer 14

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

Question 15

What are capitation rates based on

Answer 15

-profit projections and actuarial data

Question 16

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

Answer 16

True

Question 17

How many levels of evaluation in CPT

Answer 17

5

Question 18

Most frequently billed level of visit for Medicare established patients

Answer 18

level 3

99213

Question 19

What is composed of a level 3 visit

Answer 19

• 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

Question 20

What is composed of a level 4 visit (99214)

Answer 20

• 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

Question 21

What is “incident-to”

Answer 21

• 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.

Question 22

What does HIPAA stand for

Answer 22

Health Insurance Portability and Accountability Act

Question 23

Major purpose of privacy rule

Answer 23

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

Question 24

De-identified

Answer 24

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

Question 25

What is a covered entity

Answer 25

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