The symbol “O” in the Current Procedural Terminology reference is used to indicate what?
Reinstated or recycled code
In the anesthesia section of the CPT manual, what are considered qualifying circumstances?
Add-on codes
As of April 1, 2014 what is the maximum number of diagnoses that can be reported on the CMS-1500 claim form before a further claim is required?
12
What is considered proper supportive documentation for reporting CPT and ICD codes for surgical procedures?
Operative report
What action should be taken first when reviewing a delinquent claim?
Verify the age of the account
A claim can be denied or rejected for which of the following reasons?
Block 24D contains the diagnosis code
A coroner’s autopsy is comprised of what examinations?
Gross Examination
Medigap coverage is offered to Medicare beneficiaries by whom?
Private third-party payers
What part of Medicare covers prescriptions?
Part C
What plane divides the body into left and right?
Sagittal
Where can unlisted codes be found in the CPT manual?
Guidelines prior to each section
Ambulatory surgery centers, home health care, and hospice organizations use which form to submit claims?
UB-04 Claim Form
What color format is acceptable on the CMS-1500 claim form?
Red
Who is responsible to pay the deductible?
Patient
A patient’s health plan is referred to as the “payer of last resort.” What is the name of that health plan?
Medicaid
Informed Consent
Providers explain medical or diagnostic procedures, surgical interventions, and the benefits and risks involved, giving patients an opportunity to ask questions before medical intervention is provided.
Implied Consent
A patient presents for treatment, such as extending an arm to allow a venipuncture to be performed.
Clearinghouse
Agency that converts claims into standardized electronic format, looks for errors, and formats them according to HIPAA and insurance standards.
Individually Identifiable
Documents that identify the person or provide enough information so that the person can be identified.
De-identified Information
Information that does not identify an individual because unique and personal characteristics have been removed.
Consent
A patient’s permission evidenced by signature.
Authorizations
Permission granted by the patient or the patient’s representative to release information for reasons other than treatment, payment, or health care operations.
Reimbursement
Payment for services rendered from a third-party payer.
Auditing
Review of claims for accuracy and completeness.
Fraud
Making false statements of representations of material facts to obtain some benefit or payment for which no entitlement would otherwise exist.
Upcoding
Assigning a diagnosis or procedure code at a higher level than the documentation supports, such as coding bronchitis as pneumonia.
Unbundling
Using multiple codes that describe different components of a treatment instead of using a single code that describes all steps of the procedure.
Abuse
Practices that directly or indirectly result in unnecessary costs to the Medicare program.
Business Associate (BA)
Individuals, groups, or organizations who are not members of a covered entity’s workforce that perform functions or activities on behalf of or for a covered entity.
What is the main job of the Office of the Inspector General (OIG)?
The OIG protects Medicare and other HHS programs from fraud and abuse by conducting audits, investigations , and inspections.
Medicare
Federally funded health insurance provided to people age 65 or older, and people 65 and younger with certain disabilities.
Medicaid
A government-based health insurance option that pays for medical assistance for individuals who have low incomes and limited financial resources.
Timely Filing Requirements
Within 1 calendar year of a claim’s date of service.
Electronic Data Interchange (EDI)
The transfer of electronic information in a standard form.
Coordination of Benefits Rules
Determines which insurance plan is primary and which is secondary.
Conditional Payment
Medicare payment that is recovered after primary insurance pays.
Crossover Claim
Claim submitted by people covered by a primary and secondary insurance plan.
Assignment of Benefits
Contract in which the provider directly bills the payer and accepts the allowable charge.
Allowable Charge
The amount an insurer will accept as full payment, minus applicable cost sharing.
Clean Claim
Claim that is accurate and complete. They have all the information needed for processing, which is done in a timely fashion.
Dirty Claim
Claim that is inaccurate, incomplete, or contains other errors.
Medicare Administrative Contractor (MAC)
Processes Medicare Parts A and B claims from hospitals, physicians, and other providers.
Remittance Advice (RA)
The report sent from the third-party payer to the provider that reflects any changes made to the original billing.
Explanation of Benefits (EOB)
Describes the services rendered, payment covered, and benefit limits and denials.
National Provider Identifier (NPI)
Unique 10-digit code fro providers required by HIPAA.
Heath Maintenance Organization (HMO)
Plan that allows patients to only go to physicians, other health care professionals, or hospitals on a list of approved providers, except in an emergency.
Modifier
Additional information about types of services, and part of valid CPT or HCPCS codes.
By signing block 12 of CMS-1500 form, a patient is doing what?
Authorizes the release of medical information.
Claim
Complete record of the services provided by the health care professional, along with appropriate insurance information.
Where does the NPI number go on the CMS-1500 form?
17b
What are two pieces of information that need to be collected from patients?
Full name and date of birth.
Deductible
The amount of money a patient m just pay out of pocket before the insurance company will start to pay for covered benefits.
Coinsurance
the pre-established percentage of expenses paid by the insurance company after the deductible has been met.
Copayment
A fixed dollar amount that must be paid each time a patient visits a provider.
Medicare Part A
Provides hospitalization insurance to eligible individuals.
Medicare Part B
Voluntary supplemental medical insurance to help pay for physicians’ and other medical professionals’ services, medical services, and medical-surgical supplies not covered by Medicare Part A.
Medicare Advantage (MA)
Combined package of benefits under Medicare Parts A and B that may offer extra coverage for services such as vision, hearing, dental, health and wellness, or prescription drug coverage.
Medicare Part D
A p.an run by private insurance companies and other vendors approved by Medicare.
Medigap
A private health insurance that pays for most of the charges not covered by Parts A and B.
What are the three major kinds of government insurance plans?
Medicare, Medicaid, and State Children’s Health Insurance Program (SCHIP)
Referral
Written recommendation to a specialist.
Precertification
A review that looks at whether the procedure could be performed safely but less expensively in an out patient setting.
Predetermination
A written request for a verification of benefits.
Who is usually the gatekeeper?
Primary care physician
Preauthorization
Approval from the health plan for an inpatient hospital stay or surgery.
Formulary
A list of prescription drugs covered by an insurance plan.
Tier 1
Providers and facilities in a PPO’s network.
Tier 2
Providers and facilities within a broader, contracted network of the insurance company.
Tier 3
Providers and facilities out of the network.
Tier 4
Providers and facilities not on the formulary
Preferred Provider
Tier 2 provider
What’s the difference between a copayment and coinsurance?
Copayment is a flat fee that a patient pays; Coinsurance is a percentage of the covered benefits paid by both the insurance company and the patient.
What is the advantage of employer-based self-insured health plans?
Due to economies of scale, employer-based self-insured health plans are more reasonably priced than private insurance.
What is the coinsurance percentage?
Amount the provider is allowed for the service and the amount he was paid. The patient has coinsurance responsibility to what provider was allowed.
What is a common coinsurance percentage split?
80% for the insurance carrier and 20% for the patient.
Accounts Receivable Department
Department that keeps track of what third-party payers the provider is waiting to hear from and what patients are due to make a payment.
Aging Report
Measures the outstanding balances in each account.
Charge description Master (CDM)
Information about health care services that patients have received and financial transactions that have taken place.
Account Number
Number that identifies specific episode of care, date of service, or patient.
Health Record Number
Number the provider uses to identify an individual patient’s record.
Medicare Summary Notice (MSN)
Document that outlines the amounts billed by the provider and what the patient must pay the provider.
Subscriber
Purchaser of the insurance or the member of group for which an employer or association as purchased insurance.
Subscriber Number
Unique code used to identify a subscriber’s policy.
Cost Sharing
The balance the policyholder must pay the provider.
Batch
A group of submitted claims.
Balance Billing
Billing patients for charges in excess of the Medicare fee schedule.
Notice of Exclusions from Medicare Benefits
Notification by the physician to a patient that a service will not be paid.
Advance Beneficiary Notice of Noncoverage
Form provided if a provider believes that a service may be declined because Medicare might consider it unnecessary.
What does the term reconciliation mean?
Refers to the process the billing office goes through to determine what payments have come in from the third-party payer and what the patient owes the provider.
Write-off
The difference between the provider’s actual charge and the allowable charge.
Medical Necessity
The documented need for a particular medical intervention.
What are two reasons why a claim may be denied?
An invalid subscriber name was given or a coding error was made.
What is the role of the accounts receivable department?
Manages follow-up to the billing process for a provider’s office.
What are two kinds of information the CDM stores?
Description of services and revenue code.
What are the four types of nonmusical codes used by Medicare to explain claims?
Group codes, claims adjustment reason codes (CARCs), remittance advice remark codes (RARCs) and provider-level adjustment reason codes.
Who benefits from the new appeals process, and why?
The patient; the new process lays out steps the insurance company must follow and makes sure that tasks get done in a timely fashion.
When can a patient request an external independent review?
After an internal appeal has been denied.
V Codes
Codes used to classify visits when circumstances other than disease or injury are the reason for the appointment.
E Codes
Codes used to classify environmental events, circumstances, and conditions, such as the cause of injury, poisoning, and other adverse events.
Encounter
A direct, professional meeting between a patient and a health care professional who is licensed to provide medical services.
Mortality
The incidence of death in a specific population.
Morbidity
The number of cases of disease in a specific population.
Category I CPT Code
Code that covers physicians’ services and hospital outpatient coding.
Category II CPT Code
Code designed to serve as supplemental tracking codes that can be used for performance measurement.
Category III CPT Code
Code used for temporary coding for new technology and services that have not met the requirements needed to be added to the main section of the CPT book.
How many CPT code category sections are listed in the CPT manual?
Six
Encounter Form
Form that includes information about past history, current history, inpatient record, discharge information and insurance information.
Abstracting
The extraction of specific data from a medical record, often for use in an external database, such as a cancer registry.
Encoder
Software that suggests codes based on documentation or other input.
MS-DRG Grouper
Software that helps coders assign the appropriate Medicare severity diagnosis-related group based on the level of services provided, severity of the illness or injury, and other factors.
APC Grouper
Helps coders determine the appropriate ambulatory payment classification (APC) for an outpatient encounter.
Computer-assisted Coding (CAC)
Software that scans the entire patient’s electronic record and codes the encounter based on the documentation in the record.
What is abstracting?
It involves reviewing the health record and/or encounter form and translating the medical documentation into the specific code sets.
What are three purposes of ICD-9-CM?
Classifying morbidity and mortality, indexing hospital records by disease and operations and reporting diagnoses by physicians.
How does ICD-10-CM improve upon ICD-9-CM?
ICD-10-CM provides more detailed clinical information, updated medical terminology and classification of diseases.
What are the goals of ICD-10-PCS?
Improve accuracy and efficiency of coding, reduce training effort, and improve communication with physicians.
What character of ICD-10-PCS for medical or surgical procedure would identify the body part?
Character 4
CPT codes are used to describe what?
Services rendered by the provider.
What doe modifiers provide?
The means to report or indicate a service or procedure that has been altered by some specific circumstance but not changed in its definition or code.
What are HCPCS Level II codes used for?
They were established to report services, supplies, and procedures not represented in CPT.
What part of the medical record is used to determine the correct E/M code used for billing & coding?
History and physical
Which block on the CMS-1500 claim form is used to bill ICD codes?
21
Which block should the billing and coding specialist fill out on the CMS-1500 claim form when billing a secondary insurance company?
9a
What happens after a third-party payer validates a claim?
Claim adjudication
What is the purpose of running an aging report each month?
It indicates which claims are outstanding.
What are Z codes used to identify?
Immunizations
What type of insurance is considered the payer of last resort?
Medicaid
What modifier should be used to indicate a professional service has been discontinued prior to completion?
-53
What form is used as a financial report of all services provided to patients?
Patient account record
What block on the CMS-1500 form should you enter the prior authorization number?
23
Block 17b on the CMS-1500 claim form should list what information?
Referring physician’s national provider identifier number.
What is modifier -50 used for?
A bilateral procedure
What information is recorded in Block 33a of the CMS-1500 form?
National Provider Identification Number
What block on the CMS-1500 claim form is required to indicate a workers’ compensation claim?
10a
When submitting claims, what is the outcome if block 13 is left blank?
The third-party payer reimburses the patient and the patient is responsible for reimbursing the provider.
What was developed to reduce Medicare program expenditures by detecting inappropriate codes and eliminating improper coding practices?
NCCI
What policy determines if a particular item or service is covered by Medicare?
National Coverage Determination (NCD)
What is an example of Medicare abuse?
Charging excessive fees.
What notice explains why Medicare will deny a particular service or procedure?
Advance Beneficiary Notice (ABN)
In the anesthesia section of the CPT manual what is considered qualifying circumstances?
Add-on codes
A billing and coding specialist can ensure appropriate insurance coverage for an outpatient procedure by obtaining what?
Precertification
What symbol indicates a revised code?
Triangle
What standardized formats are used in the electronic filing of claims?
HIPAA standard transactions
What formats are used to submit electronic claims to a third-party payer?
837
The billing and coding specialist should follow the guidelines in the CPT manual for which of the following reasons?
The guidelines define items that are necessary to accurately code.
What is a HIPAA compliance guideline affecting electronic health records?
The electronic transmission and code set standards require every provider to use the healthcare transactions, code sets, and identifiers.
What block on the CMS-1500 claim form is used to accept assignment of benefit?
27
What is an example of a remark code from an explanation of benefits document?
Contractual allowance
What describes the term “crossover” as it relates to Medicare?
When an insurance company transfers data to allow coordination of benefits of a claim.
Stark Law
Prohibits a provider from referring Medicare patients to a clinical laboratory service in which the provider has a financial interest.
At what percentage should a front torso burn be coded?
18%
What block on the CMS-1500 claim form should be completed for procedures, services and supplies?
24D
What national provider identifiers (NPIs) is required in Block 33a of a CMS-1500 claim form?
Billing provider