Glossary D-M

What is Durable Medical Equipment



Equipment that can withstand repeated use, is primarily and usually used to serve a medical purpose, is generally not useful to a person in the absence of illness or injury, and is appropriate for use in the home. To be covered, durable medical equipment must be medically necessary and prescribed by a contracting physician for use in the home. Examples are oxygen equipment, wheelchairs, hospital beds, and other items that the insurance company determines are medically necessary, in accordance with Medicare laws, regulations and guidelines.


E Codes:


E Codes are supplementary classification of coding in which you look for external causes of injury rather than disease. The use of an E code after the primary or secondary diagnosis tells the insurance carrier what caused the injury.

V Codes:


V codes are used when a person who is not currently sick encounters health services for some specific purpose, such as to act as a donor of an organ, receive vaccination, seek consultation regarding family planning, allergies etc.,

•V codes are also a supplementary classification of coding.


End-stage renal disease (ESRD)

A chronic kidney disorder that requires long-term hemo dialysis or kidney transplantation because the patient's filtration system in the kidneys has been destroyed. Workers who have paid into the Social Security/ Medicare Fund and their dependents with ESRD who meet specific ESRD requirements are covered by Medicare.


Fee-for-service (a medical office bookkeeping and insurance term):

A method whereby the physician or other health care provider bills for each visit or service rendered rather than on an all-inclusive or prepaid fee basis.


Gatekeeper

Primary physician or other health care professional assigned by the insurer to review the medical management of plan enrollees.


Global fee

The fee for total care of a surgical case including all pre/postoperative care. This applies to surgical cases listed in the CPT code book which do not have an asterisk (*) at the end of the code number.

Global surgery:

A Medicare billing term that requires an all-inclusive fee for the following services: preoperative services performed by the surgeon within 24 hours of surgery, all interoperative procedures, treatment of surgical complications not requiring a return to the operating room, and 90 days of surgery related postoperative care.


Home healthcare


If a patient is confined to his/her home and requires skilled care for an illness or injury, Medicare can pay for care provided by a home health agency. Your physician should provide the home health agency with a plan of treatment. The services may be provided either on part-time or intermittent bases, not full time.


Hospice

A hospice is a public agency or private organization that is primarily engaged in providing pain relief, symptom management, and supportive services to terminally ill people and their families.

Medical Necessity Denials.

In simple terms is whenever a carrier determines that the service rendered was not necessary, or unreasonable. They feel that this particular service was not needed since it comprises as being part of the major procedure.


Two Ways to Deny Services as Medically Unnecessary.

For example, John sees Dr. Humphries because she has a sore throat. Dr.Humphries looks at her throat and ears, takes a throat culture, tells her to get some rest and prescribes an antibiotic. Dr.Humphries spends quite a bit of time talking with the lonely patient and therefore charges for a Level 4 office visit. The carrier subsequently reduces the visit level to a Level2 and pays based on the level2 office visit, because a level 4 visit (according to the definitions in CPT) was not reasonable or necessary to diagnose and treat a sore throat. This is termed a medical necessity reduction.


Medicare

A federal health insurance program for people 65 years of age or over and retired on Social Security, Railroad Retirement, or federal government retirement programs, individuals who have been legally disabled for more than 2 years, and persons with end-stage renal disease.

Medicare Fee Schedule (MFS)

Schedule of Medicare fees based on RBRVS factors. Non PARs are restricted to the limiting fees on this schedule.

Medicare/Medicaid Crossover Program (MCD

A combination of the Medicare and Medicaid/MediCal Programs that is available to Medicare-eligible persons with income below the federal poverty level.

*Medicare Part A: Benefits covering inpatient hospital and skilled nursing facility services, hospice care, home health care, and blood transfusions.

*Medicare Part B: Benefits covering outpatient hospital and health care provider services.

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