AAPC CPB FINAL EXAM 2023-2024 REAL EXAM 170 QUESTIONS AND ANSWERS (VERIFIED ANSWERS)|ARGADE

Health plan, clearinghouses, and any entity transmitting health information is considered by the Privacy Rule to be a:
covered entity

Which of the following is not a covered entity in the Privacy Rule
healthcare consulting firm

A request for medical records is received for a specific date of service from patient’s insurance company with regards to a submitted claim. No authorization for release of information is provided. What action should be taken?
release reqt to ins co

How many national priority purposes under the Privacy Rules for disclosure of specific PHI without an individual’s authorization or permission?
12

A health plan sends a request for medical records in order to adjudicate a claim. Does the office have to notify the patient or have them sign a release to send the information?
no

A practice sets up a payment plan with a patient. If more than four installments are extended to the patient, what regulation is the practice subject to that makes the practice a creditor?
Truth in Lending Act

Which of the following situations allows release of PHI without authorization from the patient?
workers comp

misusing any information on the claim, charging excessively for services or supplies, billing for services not medically necessary, failure to maintain adequate medical or financial records, improper billing practices, or billing Medicare patients at a higher fee scale that non-Medicare patients.
abuse

A claim is submitted for a patient on Medicare with a higher fee than a patient on Insurance ABC. What is this considered by CMS?
abuse

According to the Privacy Rule, what health information may not be de-identified?
phys provider number

making false statements or misrepresenting facts to obtain an undeserved benefit or payment from a federal healthcare program
fraud

All the following are considered Fraud, EXCEPT:
inadequate med recd

A hospital records transporter is moving medical records from the hospital to an off-site building. During the transport, a chart falls from the box on to the street. It is discovered when the transporter arrives at the off-site building and the number of charts is not correct. What type of violation is this?
breach

impermissible release or disclosure of information is discovered
breach

What standard transactions is NOT included in EDI and adopted under HIPAA?
waiver of liability

The Federal False Claim Act allows for claims to be reviewed for a standard of how many years after an incident?
7

A new radiology company opens in town. The manager calls your practice and offers to pay $20 for every Medicare patient you send to them for radiology services. What does this offer violate?
anti kickback laws

A private practice hires a consultant to come in and audit some medical records. Under the Privacy Rule, what is this consultant considered?
biz associate

Medicare overpayments should be returned within _ days after the overpayment has been identified
60

HIPAA mandated what entity to adopt national standards for electronic transactions and code sets?
HHS

Entities that have been identified as having improper billing practices is defined by CMS as a violation of what standard?
abuse

In addition to the standardization of the codes (ICD-10, CPT, HCPCS, and NDC) used to request payment for medical services, what must be used on all transactions for employers and providers?
unique id

A person that files a claim for a Medicare beneficiary knowing that the service is not correctly reported is in violation of what statute?
False Claims Act

Medicare was passed into law under the title XVIII of what Act?
SS Act

While working in a large practice, Medicare overpayments are found in several patient accounts. The manager states that the practice will keep the money until Medicare asks for it back. What does this action constitute?
fraud

A practice agrees to pay $250,000 to settle a lawsuit alleging that the practice used X-rays of one patient to justify services on multiple other patients’ claims. The manager of the office brought the civil suit. What type of case is this?
qui tam

OIG, CMS, and Department of Justice are the government agencies enforcing __.
fed abuse and fraud laws

A practice allows patients to pay large balances over a six month time period with a finance charge applied. The patient receives a statement every month that only shows the unpaid balance. What does this violate?
TILA

An insurance plan that provides a gatekeeper to manage the patient’s health care is known as a/an
HMO

a corporate umbrella for management of diversified healthcare delivery systems
IPO

An employee has signed up for a program through her employer. It allows her to put pre-tax money away from her paycheck in order to pay for out-of-pocket healthcare expenses. She may contribute up to $2650 (2018) per year. If she does not use all of the money during the current year, she forfeits it. What is this?
FSA

Which option is not considered an MCO?
HSA

A Medicare patient presents after slipping and falling in a neighbor’s walkway. The cement had a large crack, which caused the pavement to raise and be unsteady. The neighbor has contacted his homeowner’s insurance and they are accepting liability and have initiated a claim. How should the visit be billed?
Homeowners, then Medicare

Insurance coverage provided by an organization that is not an employer (such as a membership organization or credit card company that offer benefits to its members) is what kind of group insurance?
association group

office bills Medicare, but the patient receives the payment and the office must collect their fee from the patient. The office, by state law, can charge the patient a limiting charge that is 10 percent above the Medicare fee schedule amount. What type of Medicare provider is this physician?
non par

A patient presenting for care does not have an insurance card and is billed CPT 99213 for $100. The patient pays $100 to the provider. A week later, the patient presents verification of coverage through Medicaid for this date of service. What process should be followed?
file a claim to Medicaid w EOB

Medicare part without a monthly charge if worked for 10+ years
A

Managed Care Organizations (MCOs) place the physician at financial risk for the care of the patient and are reimbursed by
capitation

Which of the following is NOT evaluated in the credentialing process?
phys req for priviledges

HSA is ________ to employees
tax free income

What type of plan allows an insurer to administer straight indemnity insurance, an HMO, or a PPO insurance plans to its members?
triple option

We have an expert-written solution to this problem!
A healthcare organization with 2 hospitals, 20 clinics, and 3 urgent care centers belongs to an ACO program. They have been in the shared savings program for two years and are now eligible to move large payments to a population-based model as they have been successful in keeping costs down and have met all the CMS benchmarks set for them. What type of ACO is this?
Pioneer

What is the largest health program in the United States?
Medicare

a unique 10-digit identification number required by HIPAA
NPI

Medicaid plans provide for low-income families. Which statement regarding Medicaid is NOT correct?
All plans offer HMOs

A new physician comes in to the practice that is just out of medical school. He will need to be able to see patients in the office and at the hospital. What process will he need to undergo in order to be able to participate with Medicare and other health plans?
credentialling

NPI numbers have two types of entities – identify the two types:
group and sole proprietor

NPI
National Provider Identifier

Which of the following services is NOT covered under Medicare Part B?
Home Health

ACOs are formed with _ lives
5000

HMOs are formed with _ lives
100,000 +

When insurance coverage is being verified, which of the following is NOT a method on which to rely?
patient

When a fee ticket (encounter form) is not completed, what procedure would NOT be acceptable?
no charge

Information about deductibles, copays, eligibility dates, and benefit plans is completed during what step?
verify benefits

determine primary and secondary coverage
birthday rule

Which of the following is NOT considered a part of the authorized process when the patient signs the consent for payment?
auth for treatment

Patient types help to classify the patients based on
payer, ins type

Life Cycle of a Claim
submission
processing
adjudication
payment/denial

What authorizes information to be sent to the insurance payer so payment of medical benefits can be processed?
consent for payment

Amount of expenses that must be paid before any payment is made by the insurance company
deductible

BCBS member #:
3 letters then 9 numbers

When charges are entered and all required components are verified by the claims editing system, what would this be considered as?
clean claim

When does the processing of an insurance claim for a patient begin?
when appt scheduled

When a patient is seen for evaluation and the decision is made for a minor procedure that is performed on the same day, which modifier is appended to the claim to allow reimbursement for the E/M and the procedure?
25

A 68-year-old Medicare patient presented for an annual examination and had no complaints. Her claim, billed as 99387, was denied. Was this billed correctly? If not, how is this encounter correctly billed?
it depends on doc

If a procedure is performed on a 72-year-old Medicare patient which code category is preferred for reporting?
G code HCPCS

The NCCI policy manual is updated:
annually

The part of National Correct Coding Initiative (NCCI) that places frequency limitations on codes that can be billed on a single date of service by a single provider is called:
MUE

provide limitations of frequency on codes that can be billed in a single day by a single provider for a beneficiary.
MUE

NCCI edits are updated by CMS and released
quarterly

When using the Practitioner PTP Edits table, an NCCI tool, the modifier indicator of 0 (zero) tells the user:
mod not allowed

Indicates specific CPT code pairs that can be reported on the same day for the same beneficiary by the same provider.
NCCI file

The Medicaid NCCI program consists of six methodologies. Each methodology is composed of _ components
4

Medicare states that reporting bundled codes in addition to the major procedural code is considered to be unbundling, and if repeated with frequency it is considered to be:
fraud

When looking at the NCCI Edit tables, Column 1 codes are indicated as payable. Column 2 codes contain the codes that are:
not payable without mod

What modifier is required when a procedure is performed on the same day as an E/M service and both should be paid and not considered bundled?
25

What modifier is used to indicate two procedures are performed on the same day and should not be bundled?
59

NCDs are released by which of the following entities:
CMS

Reporting a service based on an LCD requires the CPB to look at coverage guidance for the procedure being performed. Coverage guidance would NOT include:
experimental procedures

Which of the following modifiers are not used to bypass NCCI edits?
76, 77

Services that are performed for treatment or diagnosis of an injury, illness, or disease in accordance with generally accepted standards of medical practice defines:
medical necessity

Codes that are considered to be bundled are based on Centers for Medicare & Medicaid (CMS) standards called:
NCCI

An E/M service that is performed during a post-operative period, but is not related to the surgical procedure that was performed, can be billed with which modifier?
24

Medicare provides a list of questions to ask beneficiaries that helps determine if Medicare is primary or secondary. Where can this information be found?
MSP Manual

What type of code reports the event(s) related to the billing period on the UB-04 claim form?
occurrence codes

What is the purpose of the standard CMS-1500 claim form?
pro services for phys

FL 35 and FL 36 are used on the UB-04 claim form to identify occurrence span code and dates. When is this section completed?
inpt services

When entering the patient’s name on the CMS-1500 claim form, what punctuation should be used?
comma

A _ is used to indicate an inpatient service is reported on an outpatient claim.
condition code

The UB-04 claim form is also called:
CMS 1450

Determination of the insurer’s payment amount after the member’s insurance benefits have been applied.
adjudication

_ provider with overall responsibility for the patient’s medical care during hospitalization.
attending

Identify the correct format to enter the date of birth on a paper CMS-1500 claim form
MMDDCCYY

On the UB-04 claim form, the type of bill is identified by a four-digit numerical code. The first digit is a leading zero, what does the second digit represent?
facility type

Medicare refers to the insured’s ID as the:
health ins claim number

The provider accepts a contractual write-off of the difference between the charged amount and the allowed amount.
accepting assignment

Which regulation established claim standards for electronic filing requirements when a provider uses a computer with software to submit an electronic claim?
HIPAA

Which is NOT used for data entry?
intl audit sys

__ is when the provider has limited access to payer and patient data elements on their patients only.
extranet

When a batch of claims is submitted electronically to a clearinghouse a report is sent to the provider. Which feedback does this report from the clearinghouse identify?
claims sent to payer/rejected

A hospital chargemaster does NOT contain which of the following?
ICD10CM codes

Which of the following documentation is NOT needed for an audit?
EOB

Payments due from patients, payers, or other guarantors that are owed to the practice for services rendered are considered
Accounts Receivable

sent by payers to identify the status of a claim and indicate if that claim has been accepted, adjudicated, and/or received by the payer.
status reports

A __ is a listing of every single procedure that a hospital can provide to its patients that are billed to payers.
chargemaster

Converts nonstandard data received from payers to standard transaction data to meet HIPAA requirements
clearinghouse

The __ determines the amount the hospital will be reimbursed for inpatient services if the patient is covered by Medicare.
MSDRGS

MS-DRGs
Medicare Severity Diagnosis Related Groups

When an adjudication process has been finalized, the payer will send the remittance advice (RA) to?
provider

A _ indicates the location or type of service provided for an inpatient and is reported with __.
revenue code
4 digit code

A fee schedule can be based on
RVUs

Which method is the most common to calculate a fee schedule for physicians?
cost based fee schedule

An audit that occurs before a claim is submitted is a _.
pre payment audit

Which Act prohibits third-party debt collectors from calling debtors at odd hours?
Fair Debt Collection Practices Act

When accepting debit cards in a medical practice, which act requires the office to disclose specific information before completing a transaction?
Electronic Funds Transfer Act

A discount given to self-pay patients when they pay at the time of service.
prompt payment discount

When should patient invoices (statements) be sent to the patient?
RA posting

protects information collected by the consumer reporting agencies such as the credit bureaus, medical information companies, and tenant screening services
Fair Credit Reporting Act

Most medical debt is discharged, the provider will write-off amounts owed.
bankruptcy

Which Chapter of the U.S. Bankruptcy Code combines the debt of the debtor and reduces the monthly payments allowing a potential for a provider to receive a portion of what is owed?
13

Most medical debt is discharged, the provider will write-off amounts owed.
chapter 7 bankruptcy codes

What does a high number of days in A/R indicate for a medical practice?
problem in revenue cycle

TRICARE is the healthcare program for which department of the US government?
dept of defense

Which of the three TRICARE options are not available to active duty service members?
reserve select, select

Medicaid agencies are required to report EPSDT performance information
annually

The conversion factor is updated by CMS
annually

TRICARE Prime as his health plan. Who will be responsible for coordinating his health care, maintaining his medical records and referrals to specialists when needed
primary care manager

Medicare’s payment amount for services are determined by which of the following formulas?
RVU x conversion factor

Barbara’s late husband, Joe, was a lieutenant in the Navy. He served for 30 years, retiring 10 years prior to his death that was related to service connected disability. Barbara will still have healthcare coverage as Joe’s widow under which of the following healthcare programs?
CHAMPVA

To determine the Medicare coverage and payment policy for a service or procedure, which of the following resources will indicate if a service is payable, noncovered, or bundled into another service?
status codes

The term for a supplemental policy for Medicare is:
Medigap

The Clinical Prior Authorization (PA) Program assists in the monitoring of:
drugs not on Medicaid formulary

Which TRICARE option allows enrollees the most choices utilizing the fee-for-service model?
select

Beth has purchased a Medigap policy to supplement her Medicare coverage. She has authorized Medicare to send payments directly to the physician, and Medicare has transferred their claims information to the Medigap insurance company. This transfer of information is known as:
cross over

Early and Periodic Screening, Diagnostic and Treatment (EPSDT) is a program associated with
Medicaid

Which of the following are mandatory benefits that must be provided by Medicaid programs in order to receive matching federal funding.
outpt, home, inpt, fed qual health services

agree to accept the fee schedules determined by the insurance company.
participating providers

Blue Cross/Blue Shield identifies the individual who is eligible for covered services as the:
member

Jared is employed with the United States Internal Revenue Service and has enrolled in the Blue Cross/Blue Shield healthcare insurance offered through this employer. What is the name of the Blue Cross/Blue Shield insurance program offered by the federal government?
FEP (Federal Employee Program)

The process of reviewing and validating professional qualifications of healthcare providers applying to participate with an organization is known as:
credentialing

Carl has enrolled in a healthcare insurance plan that allows him to choose to have services provided within the Blue Cross/Blue Shield network or outside of the network. What type of plan best describes Carl’s insurance coverage?
pt of service

Not allowed under a participating provider’s contract.
balance billing

A savings account that allows individuals to save pre-tax dollars to reimburse for healthcare expenses is known as a(n):
FSA, HSA

Obtaining approval from the insurance payer before a procedure is performed is known as:
prior auth

timely filing restrictions are determined by:
payer

Blue Cross/Blue Shield identifies the individual or employer who pays for healthcare insurance coverage as the:
subscriber

If a claim is denied, investigated, and found to be denied in error, what should a biller do?
appeal

An initial denial is received in the office from Aetna. The denial is investigated and the office considers that the payment was not according to their contract. According to Aetna’s policy, what must the biller do?
submit a reconsideration

Under what Federal Act must insurance companies implement effective to appeals processes?
pt protection and affordable care act

Which of the following can be appealed regarding a claim?
coordination of benefits

According to Cigna’s appeals process, how many level of internal appeals are offered?
11

According to Aetna’s published guidelines, what is the timeframe for filing an appeal?
60 days

A patient is involved in an accident at work and their commercial insurance is billed. What type of denial will be received?
liability issue

When the Cigna appeals process has been exhausted, what happens if the provider still disagrees with the decision?
arbitration

OSHA is an agency of ___?
dept of labor

Which form is used to submit claims to workers’ compensation insurance?
CMS 1500

Who is NOT entitled to Workers’ Compensation Benefits?
ind contractor

Which program provides lump-sum compensation and health benefits for eligible Department of Energy nuclear weapons workers injured on the job?
Energy Employees Occupational Illness Compensation Program

According to OSHA, which industries have the most more work related injuries and illnesses than any other sector?
healthcare and social assistance

What type of plan covers private and public employers and acts as an agent in state workers’ compensation cases involving state employees?
state ins fund

Which program provides workers’ compensation benefits to most waterfront workers and contractors working overseas for the U.S. government?
Longshore and Harbor Workers’ Compensation Program

Which entity governs workers’ compensation law?
state

Which entities require employers to maintain workers’ compensation coverage?
fed, state

__ sets standards and directives to protect workers against transmission of infectious agents.
OSHA

Healthcare workers must be provided specific training including the use of Standard Precautions if they might come into contact with __.
infectious material

Which of the following allows employers in some states to choose coverage options (state, commercial, or self) to comply with workers’ compensation coverage requirements?
combo programs

What is essential to ensure the non-work related issues are not sent to workers’ compensation?
sep charts

only allows you to get health care services from doctors, hospitals, and other care providers who are within a certain network. Your insurance will not cover any costs you get from going to someone outside of that network
EPO

payments contract by a health insurance company and a medical provider. They are fixed, pre-arranged monthly payments received by a physician, clinic or hospital per patient enrolled in a health plan
capitation

Which type of managed care insurance allows patients to self-refer to out-of-network providers and pay a higher co-insurance/copay amount?
POS, PPO

When a nonparticipating provider files a claim for a patient to BC/BS, how is the payment processed?
send to pt

Groups of doctors, hospitals, and other health care providers who coordinate high quality care to Medicare patients.
ACO

Which of the following indicates the frequency of care on a UB-04 claim form?
type of bill

Which Act protects information collected by consumer reporting agencies?
Fair Credit Reporting Act

A plan where a provider accepts a fixed, pre-established monthly payment for enrollees in a health insurance plan
capitated

Deadline for filing Medicare claim
1 year

billing a patient for the difference between what the insurance paid and the total amount the doctor’s office billed for
balance bill

PA billling for E/M uses _ guidelines
1995 or 1997

“with contrast” does not include _ contrast (for CT Scan)
oral, rectal

Billing for a higher E/M service than the documentation indicates is considered _
fraud

person bringing civil action for FCA violation for themselves
qui tam relator

An example of a non-mid level provider
resident

accounts receivable that cannot be collected by the provider or a collection agency.
bad debt

Prompt payment act requires clean claims be paid/denied within _ of receipt
30 days

non participants in Medicare who see a Medicare patient can bill _% of Medicare fee schedule
115

accounts that have not been paid within a certain time frame and should be turned over to a collection agency
deliquent

Not included in hospital chargemaster
diagnosis codes

CMS reuires to file this with claims
routing slip, superbill, encounter form, charge slip

CRNA service, without medical direction by a physician
QZ

CMS develops LCD’s when there is no NCD
False

Tricare that is most similar to an HMO
Prime

CMS preceding to insurer ID on line 9a
Medigap, MG

CPT and HCPSCS Level II code(s) on UB-04 are translated into _ code for Medicare reimbursement
APC

E/M service not recognized by Medicare
consultation codes

daily deposits mean balancing _ receipts
mail, personal payment

When a physician does not accept Medicare and pt elects to go anyway. Medicare will send pt the limiting charge for the services provided in order for them to pay most of their bill
unassigned

Joe and Mary are a married couple and both carry insurance from their employers. Joe was born on February 23, 1977 and Mary was born on April 4, 1974. Using the birthday rule, who carries the primary insurance for their children for billing?

A. Joe, because he is the male head of the household.
B. Mary, because her date of birth is the 4th and Joe’s date of birth is the 23rd.
C. Mary, because her birth year is before Joe’s birth year.
D. Joe, because his birth month and day are before Mary’s birth month and day.
D. Joe, because his birth month and day are before Mary’s birth month and day.

Which type of managed care insurance allows patients to self-refer to out-of-network providers and pay a higher co-insurance/copay amount?

I. HMO
II. PPO
III. EPO
IV. POS
V. Capitation

A. II
B. IV
C. II and IV
D. II, III, and V
C. II and IV

A patient covered by a PPO is scheduled for knee replacement surgery. The biller contacts the insurance carrier to verify benefits and preauthorize the procedure. The carrier verifies the patient has a $500 deductible which must be met. After the deductible, the PPO will pay 80% of the claim. The contracted rate for the procedure is $2,500. What is the patient’s responsibility?

A. $400
B. $500
C. $900
D. $1,600
C. $900

When a nonparticipating provider files a claim for a patient to BC/BS, how is the payment processed?

A. The payment is sent to the patient and the patient must pay the provider.
B. The payment is sent to the provider if the provider agrees to accept assignment.
C. The payment is sent to the provider regardless if he accepts assignment.
D. The claim is not paid because the provider is not participating in the plan.
A. The payment is sent to the patient and the patient must pay the provider.

Which of the following TRICARE options is/are available to active duty service members?

A. TRICARE Select
B. TRICARE Prime
C. TRICARE For Life
D. TRICARE Young Adult
B. TRICARE Prime

A Medicare card will list which of the following:

I. Effective date of coverage
II. Home address
III. Telephone Number
IV. Entitled to Part A and/or Part B
V. When coverage ends
VI. Name of Primary Care Physician

A. I – VI
B. I, IV
C. I-III, VI
D. I, II, IV, V
B. I, IV

In which of the following scenarios is Medicare the secondary payer?

I. A 65 year-old patient who is collecting her deceased spouse’s Medicare benefits and has a supplemental insurance
II. A 72 year-old patient who participates in the group health insurance of his employer
III. A 66 year-old patient is injured at work and the employer does not offer health insurance as a benefit of employment
IV. A 55 year-old patient who is on disability through Social Security and qualifies for Medicaid and Medicare

A. I-IV
B. II and III
C. I and IV
D. None
B. II and III

When a patient has Medicare primary and AARP as Medigap, what is entered on the CMS-1500 claim form in item 9d for the Insurance Plan Name or Program Name for Medicare to cross over the claim?

A. Plan name followed by “MEDIGAP”
B. Plan Payer ID followed by “MEDIGAP”
C. COBA Medigap claim-based identifier (ID)
D. Leave blank
C. COBA Medigap claim-based identifier (ID)

Which guidelines must all billing personnel be knowledgeable about in order to ensure compliance with Medicaid programs?

A. Federal guidelines
B. State guidelines
C. Both A and B
D. None
C. Both A and B

Which of the following services is covered by Early and Periodic Screening, Diagnostic, and Treatment (EPSDT)?

A. Family planning
B. Obstetric care
C. Pediatric checkups
D. Emergency department visits
C. Pediatric checkups

A female patient who was involved in an auto accident presents to the emergency department (ED) for evaluation. She does not have any complaints. The provider evaluates her and determines there are no injuries. The provider informs the patient to come back to the ED or see her primary care physician if she develops any symptoms. How is the claim processed for this encounter?

A. The medical insurance is billed primary and the auto insurance is billed secondary.
B. The auto insurance is billed primary and the medical insurance is billed secondary.
C. Bill the medical insurance first to receive a denial and then submit with the remittance advice to the auto insurance.
D. Bill only the medical insurance because the auto insurance only covers damage to the vehicle, not medical expenses.
B. The auto insurance is billed primary and the medical insurance is billed secondary.

What forms need to be submitted when billing for a work-related injury?

A. Progress reports, and WC-1500 claim form
B. UB-04
C. First Report of Injury form and an itemized statement
D. First Report of Injury form, progress reports, and CMS-1500 claim form
D. First Report of Injury form, progress reports, and CMS-1500 claim form

A document provided to Medicare patients explaining their financial responsibility if Medicare denies a service is a(n):

A. Notice of Financial Liability
B. Advance Beneficiary Notice
C. Insurance waiver
D. Explanation of Benefits
B. Advance Beneficiary Notice

What is an Accountable Care Organization (ACO)?

A. Groups of doctors, hospitals, and other health care providers who coordinate high quality care to Medicare patients.
B. An insurance carrier that provides a set fee based on the diagnosis of the patient.
C. A group of providers who contract with a third party administrator to pay fee for service for services.
D. Hospitals who see a subset of patients for cost efficiency.
A. Groups of doctors, hospitals, and other health care providers who coordinate high quality care to Medicare patients.

A new patient presents for her annual exam and has no complaints. She is scheduled to see the physician assistant (PA). How should services be billed ?

A. Bill under the PA.
B. A new patient can be billed incident to the physician.
C. The PA cannot see new patients.
D. Reschedule the patient with the physician
A. Bill under the PA.

CPT® codes 12032 and 12001 were reported together for a 2.6 cm intermediate repair of a laceration to the right arm and a 2.5 cm simple repair of a laceration to the left arm. 12001 was denied as a bundled service. What action should be taken by the biller (following the CPT® guidelines)?

A. Write-off the charge for 12001 as it is a bundled procedure.
B. Resubmit a corrected claim as 12032, 12001-59.
C. Transfer the charge to patient responsibility.
D. Resubmit a corrected claim as 12032, 12001-51.
B. Resubmit a corrected claim as 12032, 12001-59.

According to CMS, which of the following services are included in the global package for surgical procedures?

I. Surgical procedure performed
II. E/M visits unrelated to the diagnosis for which the surgical procedure is performed
III. Local infiltration, digital block, or topical anesthesia
IV. Treatment for postoperative complication which requires a return trip to the operating room (OR)V. Writing Orders
VI. Postoperative infection treated in the office

A. I, III, V, VI
B. I, IV, V
C. I, II, III, V
D. I-VI
A. I, III, V, VI

Which CPT® code below can be reported with modifier 51?

A. 17004
B. 17312
C. 19101
D. 19126
C. 19101

A HCPCS/CPT® code is assigned “1” in the MUE file. What does this indicate?

A. Code pairs cannot be reported together.
B. Codes can be reported together if documented. Append modifier 59.
C. The code can only be reported for one unit of service on a single date of service.
D. Medically unlikely the code pair is performed together.
C. The code can only be reported for one unit of service on a single date of service.

Electronic Healthcare Transactions and code sets are required to be used by health plans, healthcare clearinghouses and healthcare providers that participate in electronic data interchanges. Which of the following are requirements for the code sets?

I. Dental services are reported with CDT codes
II. Inpatient procedures are reported with HCPCS Level II codes
III. Diagnosis codes are reported with ICD-10-CM and ICD-10-PCS codes
IV. Outpatient services are reported with CPT® and HCPCS Level II codes
V. Physician services are reported with ICD-10-PCS codes

A. I and IV
B. II, III, and V
C. II, III, and IV
D. II and IV
A. I and IV

Which of the following indicates the frequency of care on a UB-04 claim form?

A. Revenue code
B. Type of Bill
C. MSDRG
D. Condition code
B. Type of Bill

Pam works for a medical practice. She discovered a claim was overpaid by Medicare. What Act requires the money to be refunded?

A. Health Insurance Portability and Accountability Act
B. The Stark Act
C. False Claims Act
D. Consumer Credit Protection Act
C. False Claims Act

Security involves the safekeeping of patient information by:

I. Setting office policies to protect PHI from alteration, destruction, tampering, or loss
II. Allowing full access to all employees to the electronic medical records
III. Giving employees a policy on confidentiality to read
IV. Requiring employees to sign a confidentiality statement that details the consequences of not maintaining patient confidentiality, including termination

A. I and IV
B. I, II, and IV
C. II, III, and IV
D. II and III
A. I and IV

Dr. Taylor’s office has a new medical assistant (MA) who is responsible for blood collection for lab specimens. Because the MA is new, she often misses when obtaining blood on the first stick. To be sure the office is billing for all services, the office now has a rule that all patients will be billed a minimum of two blood draws to demonstrate the work that is being done for lab collection. Which statement is true regarding this rule?

A. The rule covers the office and allows them to get paid for all services performed.
B. The rule is fraudulent because the office is billing for services not performed and services that are a result of provider error.
C. The rule would be legal if changed to only bill for two blood draws on the patients the MA misses on the first stick.
D. The rule is only legal if the clinic is in a hospital-based office.
B. The rule is fraudulent because the office is billing for services not performed and services that are a result of provider error.

An example of an overpayment that must be refunded is _?

A. Payment based on a reasonable charge.
B. An unprocessed voided claim.
C. Incorrect posting of an EOB.
D. Duplicate processing of a claim
D. Duplicate processing of a claim

Which of the following is true regarding provider credentialing?

A. A provider can complete an application with CAQH which handles credentialing for many payers.
B. A provider is required to complete the credentialing process with private payers before an NPI application can be submitted.
C. A provider can complete an application with NCQA to credential with private payers and obtain an NPI.
D. Approval of the NPI number is all the provider needs to be credentialed with all payers.
A. A provider can complete an application with CAQH which handles credentialing for many payers.

Which Act protects information collected by consumer reporting agencies?

A. Equal Credit Opportunity Act
B. Fair Credit Reporting Act
C. Fair Debt Collection Practices Act
D. Truth in Lending Act
B. Fair Credit Reporting Act

There is a written office policy to write off patients co-insurance and copayment amounts as a professional courtesy. Is this appropriate?

A. Yes, if it is a policy in writing it must be followed.
B. Yes, if it is a written policy and everyone in the office adheres to it.
C. No, it is considered fraud to write off the patients’ responsibility for all patients.
D. No, it is a violation of Stark law to write off patients’ responsibility.
C. No, it is considered fraud to write off the patients’ responsibility for all patients.

Which statement is TRUE regarding the Fair Debt Collection Practices Act (FDCPA)?

A. Collectors are allowed to threaten legal action even if it will not be pursued.
B. The FDPCA does not apply to medical practices.
C. Collectors are allowed to contact debtors repeatedly.
D. Collectors are not allowed to contact debtors at odd hours.
D. Collectors are not allowed to contact debtors at odd hours.

Which of the following is an allowed collection policy after a patient files for bankruptcy?

A. Unpaid insurance claims for dates of service occurring after the date of the bankruptcy can be collected.
B. Any co-payments or deductibles that are past due and owed by the patient can be collected.
C. Unpaid claims for dates of service occurring before the date of the bankruptcy and any co-pays or deductibles adjudicated on that same claim.
D. Discuss a payment arrangement with the patient to settle the past due account.
A. Unpaid insurance claims for dates of service occurring after the date of the bankruptcy can be collected.

A patient with an acute myocardial infarction is brought by ambulance to the emergency department. The patient is taken into the cardiac catheterization lab. Angioplasty and a stent was placed in the LAD. The patient’s insurance requires preauthorization for all surgical procedures. Which of the following statements is true for most payers?

A. If the biller did not obtain authorization prior to the procedure being performed, the surgical services will not be paid.
B. Because this was an emergency, it is acceptable to obtain authorization following the surgery.
C. Because this was an emergency, a preauthorization is not required.
D. If the biller did not obtain authorization prior to the procedure being performed, the entire claim will not be paid.
B. Because this was an emergency, it is acceptable to obtain authorization following the surgery.

Which of the following steps should be completed when filling an appeal?

I. Submit in the format required by the payer.
II. Review the reason for the denial and determine if the payer made an error.
III. Provide supporting documentation from an official source to support your reason for appeal.
IV. Keep a copy of the information submitted to the payer for the appeal.
V. Appeal the claim as soon as a denial is received.
VI. Appeal the claim as soon as you are certain the payer denied in error and the claim cannot be reprocessed.

A. I, II, and V
B. I, IV, V and VI
C. I, II, III, IV, and VI
D. I-VI
C. I, II, III, IV, and VI

What should a biller do when a claim is denied for not being submitted within the timely filing period?

A. Track the transmission date of the claim. If within the timely filing period, provide the information to the payer to reprocess the claim.
B. Write off the claim. The patient is not responsible for claims denied for not being submitted within the timely filing period.
C. Resubmit the claim with a different date of service that is within the timely filing period.
D. Transfer the balance to patient responsibility and try to collect from the patient.
A. Track the transmission date of the claim. If within the timely filing period, provide the information to the payer to reprocess the claim.

Incorrect entry of the patient demographics can have an effect on many areas of the practice. What documents are necessary to verify demographics?

I. Photo Identification
II. Insurance card
III. Credit card information
IV. Social Security card
V. Patient completed demographic form

A. I and V
B. II and IV
C. II, IV and V
D. I, II, and V
D. I, II, and V

CMS has a standard enrollment form in which the provider agrees to:

I. Submit claims to Medicare
II. Have authorization from the Medicare beneficiary to file claims
III. Retain all source documentation and medical records
IV. Submit claims within 60 days of the date of service
V. Submit all claims with a group NPI number
VI. Research and correct claim discrepancies.

A. I, II, and IV
B. II, IV, and V
C. I, III, IV, and VI
D. I, II, III, and VI
D. I, II, III, and VI

Ms. Turner had surgery one month ago for hernia repair. She is still in the post-operative period and comes in today to the see the same physician that performed the hernia repair surgery about a lump that she noticed on her tailbone. The physician performs an examination and the diagnosis is that she has a pilonidal cyst which is unrelated to the surgery. Can the physician bill an E/M service for today’s visit during the post-operative period?

A. Yes, the E/M service can be reported with modifier 24 to indicate it is unrelated to the surgery.
B. No, because the examination falls in the post-operative period of the original procedure.
C. No, report code 99024 instead of the E/M service for all services provided in the post-operative period.
D. Yes, the E/M can be reported with modifier 25 to indicate a separate procedure or service was performed.
A. Yes, the E/M service can be reported with modifier 24 to indicate it is unrelated to the surgery.

When you respond to a patient with “How may I help you, Mrs. Jones?”, the use of the patient’s name:

A. Is too familiar
B. Violates HIPAA
C. Indicates to the caller you are interested and listening
D. Is too formal for an existing patient
C. Indicates to the caller you are interested and listening

A dermatologist performed an excision of a squamous cell carcinoma from the patients forehead with a 1.2 cm excised diameter. The excision site required an intermediate wound closure measuring 1.8 cm. What is/are the correct code(s)?

A. 11642
B. 11442
C. 11642, 12051-51
D. 11442, 12051-51
C. 11642, 12051-51

55-year-old female presents to the office with ongoing history of type I diabetes which has been controlled with insulin. During the exam the physician notes that gangrene has set in due to the diabetic peripheral angiopathy on her left great toe. Patient is recommended to see a general surgeon for treatment of the gangrene on her left great toe.

A. I96, E10.9, Z79.4
B. E11.52, I96, Z79.4
C. E10.52
D. I96, E11.52
C. E10.52

What is the correct HCPCS Level II code for Depo-Provera (medroxyprogesterone acetate) injection of 100 mg?

A. J1050
B. J1050 x 100
C. J1020 x 5
D. J1030 x 3
B. J1050 x 100

The provider performs an office visit with an expanded problem focused history, expanded problem focused exam and low MDM to manage the patient’s hypertension. The provider also destroys two plantar warts. How is this reported?

A. 99213-25, 17110
B. 99213-25, 17110-59
C. 99213, 17110-25
D. 99213, 17110-59
A. 99213-25, 17110

HMO plans require the enrollee to:
To have referrals to see a specialist that is generated by the patient’s PCP

What are PPOs (preferred provider organizations)?
Organizations in which medical professionals and facilities provide services to subscribed clients at reduced rates.

What is a covered entity?
Health plans, clearinghouses, and any entity transmitting health information is considered to be as is stated by the Privacy Rule.

What are the three steps to be taken when there is a breach of contract between a covered entity and a business associate?

Take steps to correct or end the violation
Terminate the contract
Report the breach to HHS

A request for medical records is received for a specific date of service from patient’s insurance company with regards to a submitted claim. No authorization or release of information is provided. What action should be taken?
Release the requested records to the insurance company.

Can you release PHI without authorization from a patient if it is for a workers’ compensation claim?
Yes, Workers compensation information is not protected under HIPAA

HIPAA mandated what entity to adopt national standards for electronic transactions and code sets?
HHS

What is the standard time frame established for record retention?
There is no single standard record retention time frame. It varies by state and federal regulation.

CMS defines __ as billing for a lower level of care than is supported in documentation, making false statements to obtain undeserved benefits or payment from a federal healthcare program, or billing for services that were not performed.
Fraud

A claim is submitted for a patient on medicare with a higher fee schedule that a patient on Insurance ABC. What is this considered under CMS?
Abuse

A person that files a claim for a Medicare beneficiary knowing that the service is not correctly reported is in violation of what statue?
FCA (False claims act)

What act is “upcoding or unbundling services” considered under?
The false claims act

A patient is seen in your clinic. Her husband calls later in the day to ask for information about the visit. The practice pulls the patients privacy authorization to see if they can speak to the husband. What act does this action fall under?
HIPAA

Medicare was passed into law under what Act?
SSA

Are healthcare regulations the same in each state?
No, they will vary from state to state.

A physician’s office (covered entity) discovers that the billing company (Business associate) is in breach of their contract. What is the first steps to be taken.
Take steps to correct the problem and end the violation.

OIG, CMS, and the DOJ are the government agencies enforcing what laws?
Federal fraud and abuse laws

Do fraud and abuse penalties include the ability to refile claims in question?
No

A biller at a medical practice notices that all claims contain CPT code 81002. She questions the nurse who tells her that because they are an OB/Gyn office, they bull every patient for a urinalysis. What does this violate?
FCA

Medical records are requested for a patient for a specific date of service. When records are copied, multiple dates of service are copied and sent in reply to the request. What standard does this violate?
Minimum necessary

Individuals have the right to review and obtain copies of the PHI. What is excluded from rights of access?

Psychotherapy notes
Certain lab results
Information involved in research studies
Information related to legal proceedings

Patient questions and concerns regarding the Privacy Practices in the clinic should be addressed by what party?
The Privacy official

How many standard EDI transactions were adopted under HIPAA?
8

What are the standard EDI transactions adopted under HIPAA?

Claims and encounter info
Payment and remittance advice
Claim status
Eligibility for a health plan
Enroll / Dis-enrollment in a health plan
Referrals and authorizations
COB
Premium payments

In addition to the standardization of the codes what other identifier is used on all claims?
A unique identifier for employers and providers

The federal false claims act allows for claims to be reviewed for how many years after an incident?
Seven years

Entities that have been identified as having improper billing practices are defined by CMS as a violation of what standard?
Abuse

What penalties can be imposed for Fraud and / or abuse related to the US code?
Monetary penalties ranging from $10k to $50k (before inflation) for each item or service, imprisonment, and exclusion from federal healthcare programs.

How long after being identified should a practice return medicare over payments? (days)
60 days

A private practice hires a consultant to come in and audit some medical records. Under the Privacy Rule, what is this consultant considered?
A covered entity

According to the privacy rule, what health information may not be de-identified?
The physician provider number

A hospital records transporter is moving medical records from the hospital to an off-site building. During the transport, a chart falls from the box on the street. It is discovered when the transporter arrives at the off-site building and the number of charts is not correct. What type of violation is this?
A breach

When a practice sends an electronic claim to a commercial health plan for payment, what is this considered?
A transaction

While working in a large practice, medicare over-payments are found in several patient accounts. The manager states that the practice will keep the money until medicare asks for it back. What does this action constitute?
Fraud

What were the eight standard EDI transactions adopted under?
HIPAA

A practice agrees to pay $250k to settle a lawsuit alleging that the practice used x-rays of one patient to justify services on multiple other patient’s claims. That manager of the office brought the civil suit. What type of case is this?
Qui Tam

A health plan sends a request for medical records in order to adjudicate a claim. Does the office have to notify the patient or have them sign a release to send the information?
No, since the information is used for payment activities it is not necessary to notify or obtain authorization (reference: TPO)

Fraud or Abuse: A clinic fails to maintain adequate medical records
Abuse

Fraud or Abuse: A clinic bills every new patient at the highest level E/M visit no matter what
Fraud

Fraud or Abuse: A clinic is found to be falsifying documentation to support a service that was billed to receive payment
Fraud

Fraud or Abuse: Reporting a diagnosis code that the patient does not have, but is payable by medicare.
Fraud

According to the privacy rule, what must a business associate and covered entity have in order to do business?
A contract

If a provider is excluded from federal health plans, what does that mean?
They many not participate in Medicare, Medicaid, VA programs, or Tricare and They cannot bill for services or provide services, order services, or prescribe medication to any beneficiary of a federal plan.

What is the purpose of the privacy rule?
To protect patient privacy

A records request is received from a health plan for three dates of service in a chart months apart. What should the biller do?
Copy each date of service individually and send to the health plan.

Is a healthcare consulting firm considered a covered entity?
No

A new radiology company opens in town. The manager calls your practice and offers to pay $20 for every medicare patient you send them for radiology services. What does this offer violate?
The Anti-kickback law

How many national priority purposes are under the Privacy rule to disclose PHI without an individuals authorization?
12

What are the 12 national priority purposes under the privacy rule?

Required by law
Public health activities
Victims of abuse / neglect/ domestic violence
Health oversight activities
Judicial and administrative proceedings
Law enforcement purposes
decedents
cadaver organ / eye / tissue donation
Research
Serious threat to health or safety
Essential government functions
Workers comp.

What types of entities doe conditions of participation apply to for health plans?
Hospitals, clinics, transplant centers, psychiatric hospitals, etc

What is the key term that distinguishes fraud from abuse?
“knowingly”

Federal agencies are required to pay clean claims within how many days?
30

What is the prompt payment act?
An act that was enacted to ensure the federal government makes timely payments.

When accepting debit cars in a medical practice, which act requires the office to disclose information before completing a transaction?
The electronic funds transfer act

A claim has been denied as not medically necessary by medicare. The biller has checked the patient’s medical record and the patient’s insurance policy. No ABN was signed. What is the next action the biller should take?
Write off the charge or check with the provider to appeal the claim.

A provider removes a skin lesion in an ASC and receives the denial from the insurance carrier that states “Lower level of care could have been provided.” What steps should the biller take?
Check with the provider and write an appeal to the insurance carrier explaining why the service was provided in an ASC.

A claim was resubmitted to AAPC Insurance Company through a clearinghouse 60 days after the date of service and the claim was denied. AAPC Insurance Plan has a 60 day timely filing limit. The biller checked the claim status system and determined AAPC Insurance Plan did not receive the claim. What action should the biller take?
Check the clearinghouse’ report and appeal the denial with proof of claim submission

What is the definition of bad debt?
A debt that is likely to remain unpaid and end up sent to collections and written off by the provider.

What does a high number of days in A/R indicate for a medical practice?
The practice potentially has a problem in the revenue cycle.

What should be included in a financial policy?

Explanation that patient balances are due at the time services are provided
List of insurance carriers the providers are contracted with
List of the practice’s policy when seeing patients who are out of network.

How often should insurance coverage verification happen?
at each visit

What are some potential patient errors that can happen at patient registration?
Invalid address, invalid insurance info, invalid phone number

What is the best way to ask a patient about their demographic information?
By asking open ended questions

When a provider want to give a discount on services to a patient, what must they do prior to billing the insurance carrier?
The provider must discount the charge prior to billing insurance

What is a prompt payment discount?
A discount given to self pay patient when they pay at the time of service

Which Act protects information collected by the consumer reporting agencies?
The fair credit reporting act

If a medical office receives notice that a patient has filed for bankruptcy, what steps should be taken?
-obtain the case number
-verify the case filing
-verify the provider is listed as a creditor
-stop all collection efforts for balances filed under the bankruptcy

What is the number one thing you should obtain from an insurance call?
The call reference number

When given a denial, what should be done?
Review the denial to determine if additional information is needed, if errors need to be corrected, or if the denial should be appealed

When should patient invoices be sent to the patient?
As soon as the RA is posted and the balance has been transferred to the patient account.

May small balances for which processing costs exceed potential collections be automatically written off?
Yes, as long as it is allowed according to the financial policy of the practice.

What documents are needed for a successful appeal?
-Copy of the RA
-Copy of the medical record
-Copy of the original claim

A letter detailing why the claim should be paid

A biller received a request for medical records for Patient A for DOS 05/15/20XX. Patient A’s entire medical record (multiple dates of service) was copied and sent to the insurance carrier. What is this a violation of?
HIPAA

Once a credit balance for an insurance carrier has been identified, what action should the biller take?
Research to determine if it is a true overpayment, the submit a refund to the insurance carrier for the overpayment.

What a patient files for Chapter 7 under the U.S. bankruptcy code, what happens to the debt?
Most medical debt is discharged, the provider will write-off amounts owed.

Which chapter of U.S. Bankruptcy combines the debt of the debtor and reduces the monthly payments allowing the provider to potentially receive a portion of what is owed?
Chapter 13

According to the Prompt Pay Act, who must pay bills within 30 days?
Federal Agencies

What is a prior authorization?
A requirement that your physician receives approval form your heath insurance plan to approve payment for a specific service for you

What is a pre-determination?
A request from a healthcare facility to get an idea whether or not a service may be covered. This is not a guarantee of payment and is not required.

The provider, hospital, or entity that agrees to provide healthcare services to an insurance plans enrolees is a:
Participating provider

What is the process of determining which of two or more insurance policies will have the primary responsibility of processing a claim?
Coordination of benefits

Balance billing by participating providers is:
Not allowed under participating providers contract

Claim rejections are due to what?
Claims that do not contain necessary information for adjudication

What information can be found on the BCBS insurance identification card?
-Type of plan
-ID number
-Group number
-phone number for member services/benefits questions
-mailing address of the BCBS office

According to aetna’s published guidelines what is the time frame for filing a reconsideration?
Within 180 calendar days of the initial claim decision

A BCBS insurance plan that allows members to choose any provider but offers higher levels of coverage when members obtain services from network providers would be an example of:
PPO

If a claim is denied, investigated, or found to be denied in error what should a biller do?
Appeal that claim

Carl has enrolled in a healthcare insurance plan that allows him to choose to have services provided within the BCBS network or outside of the network what type of plan best describes Carl’s coverage
POS

What is the limit called what payrs allow to submit a claim or appeal?
Timely filing

Jerod is employed with the US IRS and has enrolled in the BCBS healthcare insurance offered through his employer, what is the name of the BCBS insurance program offered by the federal government?
FEP(Federal Employee Program)

What may be appealed?
A denied claim

A savings account that allows individuals to save pre tax dollars to reimburse for healthcare expenses is known as an:
FSA and HSA

What modifiers will appropriately bypass the NCCI bundling edits?
25, 58

Tony’s BCBS insurance policy states that he must seek healthcare services only from providers that are part of a specific network what type of BCBS does Tony have?
HMO

BCBS identifies the individual who pays for healthcare insurance coverage as the:
subscriber

What can be done in the practice to ensure liability denials will not be received?
Perform thorough intake on patients that present with injuries

BCBS identifies the individual who is eligible for covered services as the:
Member

Under what federal act must insurance companies implement effective appeals processes?
The patient protection and affordable care act

BCBS received a claim on 4/15/14 for services performed on 3/15/13 the claim would be denied because:
The claim was filed after the timely filing limit

Submitting a secondary claim without a primary insurance EOB is what kind of issue?
COB

The process of reviewing and validating professional qualifications of healthcare providers applying to participate with an organization is known as:
Credentialing

An initial denial is received in the office from Aetna, the denial is investigated and the office considers that the payment was not according to their contract. According to Aenta’s policy what must the biller do?
Resubmit a reconsideration

Participating providers agree to:
Accept the fee schedules determined by the insurance company

What is “Medically necessary”
Services appropriate to the evaluation and treatment of a disease condition illness or injury and consistent with the applicable standard of care

What information can be found on an EOB

What rejections/Denials are mostly preventable with good front office policy?
Incorrect patient information, eligibility expiration, and liability denials

Timely filing requirements are determined by:
The payer

The best practice to prevent a non-covered service denial would be to:
Determine if the procedure is covered prior to providing the service

A denial is received in the office indicating that a service that was billed is denied due to bundling issues. The medical record is obtained and, upon review, it is documented that the second procedure is a staged procedure that was planned at the time of the initial procedure. When the claim is reviewed, no modifier was attached to the codes on the claim. What should be done to resolve the claim?
Add modifier 58 to the procedure and follow the payer’s guidelines for appeals

What type of denial is more likely to happen when the patient is insured through an HMO?
No referral

Best practice to prevent receiving a denial due to coverage termination would be to:
Verify coverage prior to the patient’s scheduled appointment.

What is the first step in the majority of denial cases, that you should take?
Call the insurance company and find out why the claim is being denied.

The liaison between BCBS and the contracted provider community is known as what?
The insurance representative. Also known as the provider representative or the provider network consultant.

In what box on the CMS-1500 form does a PA number get placed?
Box 23

A health insurance plan that reimburses for healthcare services provided to members based on providers bills submitted after the services are rendered is known as:
Traditional insurance. Also known as Fee-for-service, or an indemnity plan.

What is the difference between non-covered services and not medically necessary services?
Non-covered services are pre-determined to not be re-reimbursable by the insurance while not-medically necessary services have been found to not be necessary for the evaluation and treatment of an individuals disease, condition, illness, or injury.

When a patient presents for their appointment, insurance coverage should be verified and:
A copy should be made of both the front and back of the member’s insurance card.

For which denial is it acceptable to balance bill the patient?
Non-covered service

BCBS offers which type of Medicare plan?
A medicare advantage plan (part C)

A participating provider of BCBS sees a patient in the ER. The charges equal $500. The patient has a $1000 deductible of which none has been met, and a $75 ER copay, How much should be collected from the patient for this service?
$75

What is a copay?
A fixed amount of money that you will pay for an office visit same day.

What is a deductable?
The amount of money you need to pay for services before insurance will pay anything.

What is Co-insurance?
The amount of money you will pay for services after the deductible is met but before you have reached your maximum out of pocket amount.

What is Out-of-pocket?
The amount of money you need to pay out of pocket before insurance will pay at 100%.

What are the 4 parts of Medicare?
A,B,C,D

What does Medicare A cover?
Hospital services

What does Medicare B cover?
Out-patient services

What is Medicare C?
This is a Medicare replacement plan for A+B offered by private companies that are contracted with Medicare. AKA a medicare advantage plan.

What is Medicare D?
Coverage for prescription medicine

A patient receiving inpatient care in a critical access hospital would be covered under which part of Medicare?
Part A

For services such as screening for depression, bone mass measurements, and glaucoma screenings, what does Medicate consider these services to be?
Preventative

To determine the Medicare coverage and payment policy for a service or procedure, which resources will indicate if a service or procedure is payable, non-covered, or bundled into another service?
Status codes

Medigap policies must conform to minimum standards identified as federal and state laws and clearly be identified as:
Medicare supplemental insurance

Allen who is a non-par provide who doesn’t accept assignment performs an appendectomy on a 67 year old Medicare patient. The physician’s UCR for the surgery is $1500. Medicare’s approved fee for this procedure is $1100. What is the charge that this non-par provider can charge to this Medicare patient?
$1201.75

A Medicare patient is seen by a participating provider. A claim is sent for $123 and an EOMB is received that states the approved amount is $100. If the patient has met their deductible, what should the reimbursement on this claim be from Medicare?
$80

If a physician opts-out of Medicare and has a private contract with the medicare patient, at what percent of the Medicare fee schedule may they charge the patient for services rendered?
They do not participate with Medicare therefore do not abide by their fee schedules. They may charge the whole amount of the service as long as they have the contract with the patient prior to services being rendered.

Should an ABN be signed before or after services are performed on Medicare patients?
Before

EPSDT is a program associated with:
Medicaid

Medicaid’s minimum eligibility is based on what criteria?
The federal poverty level.

A 21 year old patient presents for fillings for two of his teeth. Are these services covered under EPSDT?
No, because the patient is not under the age of 21

The clinical prior authorization program assists in the monitoring of:
Drugs not on medicaid’s formulary

What is Medicaids standard timely filing limit?
There is no standard limit, it is based on the individuals states timely filing required requirements.

What is AK medicaid’s timely filing limit?
One year

How often should medicaid eligibility be verified?
At every visit

Medicaid agencies are required to report EPSDT performance information how often?
Annually

Medicare supplemental insurance policies or medigap is sold by:
Private insurance companies

When Medigap is purchased to supplement a person’s Medicare benefits, what entity will the client pay their monthly premium to?
The Medigap insurer

When Medicare transfers claim information to a Medigap insurer, what is this called?
Cross-over

When processing Medigap claims, Item 9a of the CMS-1500 must have the policy and / or group number of the Medigap insured proceeded by:
MEDIGAP, MG, or MGAP

What does “accepting assignment” mean?
A provider accepts medicare’s allowed amount as payment in full for a service

What type of codes should be used (when available) when billing preventative services for Medicare beneficiarys?
HCPCS codes

Is Medicaid Federal or State ran?
State ran

What modifiers are used when an ABN has been signed?
GA,GX,GY, GZ

What are mid-level provider credentials?
PA, ANP, CNM

When a provider opts out of Medicare, what must they have with a patient who is a medicare beneficiary prior to providing serviceS?
A private contract.

Deductible
Amount you must pay before you begin receiving any benefits from your insurance company

copay
a fixed fee you pay for specific medical services

oop
total amount you pay before ins. pays at 100%

What information can be found on the BCBS insurance ID card
-type of plan
-ID number
-group number
-phone number for member svs/benefits questions
-mailing address of BCBS office

What rejections/denials are mostly preventable with good front office policy
-Incorrect patient information
-Eligibility expirations
-Liability denials

What are two ways that non-covered service denials can be decreased in a practice
-verify coverage before a major service
-understand policies of largest payer contracts

Metabolism
the body ability to produce energy and burn fat through proper diet, exercise and hydration

Inferior
lower part of the body

Efferent
carrying away; carries nerves impulse away from the CNS

Cicatrix
A scar remaining after healing of a wound

Neoplasm
abnormal growth mass

Malunion
a fracture that healed in an abnormal position

Parasympathetic
part of the nervous system that control homeostasis and responsible for the body rest and digest function

Meatus
opening of the urethra where urine exit the body

Hormone
it regulated the body temperature, sleep cycle and mood of the body

Nevus
pigmented spot on the skin e.g. mole

Bruit
abnormal narrowing of the artery

Interstitial
relating to a space between or within a tissue or organ

Perforation
cut into the skin or a hole or break in the walls or membrane of organ or structure of the body

Proliferative
increasing in numbers of similar forms

Transplanation
transfer of living organs or tissue from one part of the body to another or from one individual to another

Medicare statutorily excluded services are
-non-covered items and services
-not reimbursed by Medicare

Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) is a program associated with
medicaid

The clinical Prior Authorization (PA) Program assists in the monitoring of
drugs not on Medicaid’s formulary

Albert has purchased a Medigap policy to supplement his Medicare benefits, To which entity will Albert pay his monthly premium
Medigap insurance company

The total RVU is composed of which of the following components
physician work, practice expense and malpractice insurance

To determine the Medicare coverage and payment policy for a service or procedure, which of the following resources will indicate if a service or procedure is payable, noncovered, or bundled into another service
status codes

Medicare A
Medicare B
Medicare C
Medicare D
Inpatient hospital stays
Outpatient hospital care
Medicare Advantage
Prescription drugs

Medicare has four categories of items and services that are not covered under the program, they are:
1) Services and supplies that are not medically
reasonable and necessary;
2) Non-covered items and services;
3) Services and supplies denied as bundled or included
in the basic allowance of another service; and
4) Items and services reimbursable by other
organizations or furnished without charge.

Explain incident to services and who they are preformed by
Once the initial physician relationship has been established, incident-to services can be billed even when there is not a physician in the room. He or she must only be on the premises and immediately available to assist the non-physician providers (nurse practitioners, physician assistants, certified nurse midwives and clinical nurse specialists) provider rendering the services

An NPI doesn’t ensure
a provider is licensed or credentialed
guarantee payment by a health plan
enroll a provider in a health plan
turn the provider into a covered provider
require a provider to conduct HIPPA transactions

Medicare was passed into law under the title XVIII of what Act
social security act

The federal False Claim Act allows for claims to be reviewed for how many years after an incident
seven years

A practice agrees to pay $250,000.00 to settle a lawsuit alleging that the practice used x-rays of one patient to justify services on multiple other patients’ claims. The office manager brought the civil suit. What type of case is this?
Qui Tam

In which of the following circumstances may PHI not be disclosed without the patient’s authorization or permission?
An office receives a call from the patient’s husband asking for information about his wife’s recent office visit.

According to the Privacy Rule, what must a Business Associate and a Covered Entity have in order to do business?
A contract

HMO plans require the enrollee to:
To have referrals to see a specialist that is generated by the patient’s primary care provider.

Which of the following is NOT a component of the PPO payer model?
Require the enrollee to maintain a Primary Care Provider.

Under the Privacy Rule a health plan, clearinghouses, and any entity transmitting health information is considered?
Covered entity

A request for medical records is received for a specific date of service from a patient’s insurance company with regards to a submitted claim. No authorization for release of information is provided. What action should be taken?
Release the requested records to the insurance company.

Which of the following situations allows the release of PHI without authorization from the patient?
Workers’ Compensation

HIPAA mandated what entity to adopt national standards for electronic transactions and code sets?
HHS

What is the standard time frame established for record retention?
There is no single standard for record retention; it varies by state and federal regulations.

CMS defines _ as billing for a lower level of care than is supported in documentation, making false statements to obtain undeserved benefits or payment from a federal healthcare program, or billing for a service that was not performed.
Fraud

A claim is submitted for a patient on Medicare with a higher fee than a patient on Insurance ABC. What is this considered by CMS?
Abuse

A person that files a claim for a Medicare Beneficiary knowing that the service is not correctly reported is in violation of what statute?
False Claims Act

Which of the following actions is considered under the False Claims Act?
Up-coding or unbundling services

Medicare was passed into law under the title XVIII of what Act?
Social Security Act

Which of the following statements are true regarding healthcare regulations?
Healthcare regulations may vary by state and by payer

A physician office (covered entity) discovers that the billing company (business associate) is in breach of their contract. What is the first step to be taken?
Take steps to correct the problem and end the violation

OIG, CMS, and the Department of Justice are the government agencies enforcing __?
Federal fraud and abuse laws

Fraud and Abuse penalties do NOT include:
Ability to re-file claims in question

A biller at a medical practice notices that all claims contain CPT code 81002. She questions the nurse who tells her that because they are an OB/GYN office they bill every patient for a urinalysis. What does this violate?
False Claims Act

Individuals have the right to review and obtain copies of the PHI. What is excluded from the right of access?
Psychotherapy notes

Medical Records are requested for a patient for a specific date of service. When records are copied, multiple dates of service are copied and sent in reply to the request. What standard does this violate?
Minimum Necessary

Patient has questions and concerns regarding the Privacy Practices in the clinic should be addressed by what party?
Privacy Official

What standard transactions are NOT included in EDI and adopted under HIPAA?
Waiver of liability

The Federal False Claim Act allows for claims to be reviewed for how many years after an incident?
Seven years

What penalties can be imposed for Fraud and/or Abuse related to the United States Code?
a. Monetary penalties ranging from $10,000 to $50,000 for each item or service
b. Imprisonment
c. Exclusion from Federal Healthcare Programs
(d.) All of the above

Medicare overpayments should be returned within __ days after the overpayment has been identified?
60 days

What entities are exempt from HIPAA and not considered to be covered entities?
Workers Compensation

A private practice hires a consultant to come in and audit some medical records. Under the Privacy Rule, what is this consultant considered?
A business associate

A hospital records transported is moving medical records from the hospital to an off-site building. During the transport, a chart falls from the box onto the street. It is discovered when the transporter arrives at the off-site building and the number of charts is not correct. What type of violation is this?
A breach

When a practice sends an electronic claim to a commercial health plan for payment, what is this considered?
A transaction

Which statement is true regarding the Prompt Pay Act?
Federal agencies are required to pay all clean claims within 30 days of the receipt.

Review the policy: Collections policy: Invoices not paid within 60 days begin our collection process. Invoices not paid within 120 days are subject to patient dismissal and submission to our collections agency and notification to your insurance plan. According to this policy, at what age is a balance owed by the patient considered bad debt and sent to the collection agency?
120 days

When accepting debit cards in a medical practice, which act requires the office to disclose specific information before completing a transaction?
Electronic Funds Transfer Act

A claim has been denied as not medically necessary. The biller has checked the medical record and the medical policy and verified it is not covered according to the carrier’s medical policy. What is the next action the biller should take?
Check with the provider to appeal the claim and if necessary write off the balance.

A provider removes a skin lesion in an ASC and receives a denial from the insurance company that states “lower level of care”. What steps should the biller take?
Check with the provider and write an appeal explaining why the service required the ASC.

A claim was resubmitted to Medicare through a clearinghouse 60 days after the date of service and the claim was denied. The biller checked the clearinghouse claim status system and determined Medicare did not receive the claim. What action should the biller take?
Check the clearinghouse reports and appeal the denial with proof of the claims submission.

What does a high number of days in A/R indicate for a medical practice?
The practice potentially has a problem in the revenue cycle.

What should be included in a financial policy?
A. Convey that the patient balances are due at the time of service
B. List insurances the providers are contracted with
C. List insurances the providers are not contracted with
D. List the practice’s policy for out-of-network insurance policies
E. List the patients on the Medicaid roster
A, B, D

Which statement is true about a patients insurance?
Verification should happen at each visit.

Which option below is the better way to ask the patient about their current demographic information?
What is your current address?

Review the following office policy: Financial policy:
You are responsible for paying all co-pays at the time of service. Co-pays, co-insurance, deductibles and non-covered services can not be waived by our office, as it is a requirement placed on you by your insurance carrier…
Co-pay collection fee: If we must bill you for your co-pay, you may be required to pay a $20 co-pay collection fee.
When must a co-pay be collected from the office by the patient to avoid a penalty?
At the time of service.

When a provider wants to give a discount on services to a patient, which option is acceptable?
The provider must discount the change prior to billing the insurance carrier.

What is a prompt pay discount?
A discount given to self-pay patients when they pay for the service at the time of the visit.

Which act protects information collected by the consumer reporting agencies?
Fair Credit Reporting Act

What steps should be taken when a medical office receives notice that a patient has filed bankruptcy?
Obtain the case number, verify the case filing, and verify the provider is listed as the creditor, stop all collection efforts for balances filed under the bankruptcy.

Which statement is true regarding denials?
Denials should be reviewed to determine whether additional information is needed, if errors need to be corrected, or if the denial should be appealed.

When should patient invoices (statements) be sent to the patient?
As soon as the RA is posted and a balance is transferred to the patient.

Which statement is true regarding patient balances?
Small balance for which processing cost exceeds potential collections may be automatically written off according to the financial policy of the practice.

What documents are needed for a successful appeal?
Copies of the RA, medical record, and original claim, along with a letter detailing why the claim should be paid.

A biller receives a request for medical records for patient A for DOS 05/15/20XX. Patient A’s entire medical record (multiple dates of service) was copied and sent to the insurance carrier. Which statement below is true?
This is a violation of HIPAA.

Once a credit balance for an insurance carrier has been identified, what action should the biller take?
Research to determine if it is a true overpayment, and then submit a refund to the insurance carrier for the overpayment.

When a patient files Chapter 7 bankruptcy, which statement is true?
Most medical debt is discharged, the provider will write off amounts owed.

Which bankruptcy chapter combines the debt of the debtor and reduces the monthly payments allowing a potential for a provider to receive a portion of what is owed?
Chapter 13

Review the following accounts receivable management policy: …
Insurance balances will be referred to internal follow-up staff for follow up at 45 days post initial claim and personal balances will be referred at the time the patient becomes responsible for all balances as soon as the charge is entered. Personal balances will be eligible for referral to an outside collection agency after 3 statements have been sent.
Based on this policy, when does follow-up of insurance balances begin?
When are patient balances eligible for an outside collection agency?
45 days post initial claim
After 3 statements have been sent

A patient receiving inpatient care in a critical access hospitable would be covered under which part of Medicare?
Part A

Which of the following services does Medicare consider preventative?
Screening for depression
Bone mass measurements
Glaucoma screening
All of the above

Medicare statutorily excluded services are?
Non-covered items and services
Not reimbursed by Medicare
Both A and B

A Medicare patient has prescription drug coverage, but does not have Medicare Advantage. What Medicare coverage does the patient have for his medications?
Part D

Medigap policies must conform to minimum standards identified as federal and state laws clearly be identified as
Medicare Supplemental Insurance

Dr. Allen who is a non-PAR provider who doesn’t accept assignment preforms an appendectomy on a 67 year old Medicare patient. The physician’s UCR for the surgery is $1500.00. Medicare’s approved fee for this procedure is $1100.00. What is the limiting charge that this non-PAR provider can charge to this Medicare patient?
$1201.75

A Medicare patient is seen by a participating provider. A claim is sent for $123.00 and an EOMB is received that states the approved amount is $100.00. If the patient has met their deductible, what should the reimbursement on this claim be from Medicare?
$80.00

A Medicare patient is seen by her physician. The physician has opted out of the Medicare program. The patient and physician have a private contract. The charges for the service rendered are $300.00. Medicare’s approved amount would be $200.00. What can the office charge this patient?
$300.00

A Medicare patient presents for her pelvic, pap, and breast examination (PPB). The patient is not sure when she had her last PPB. As she is checking out, the front desk rep has her sign an ABN. The service is billed and denied for frequency. Can the patient be balance billed and why or why not?
No. The ABN must be signed before the service is preformed.

Medicare Advantage plans fall under which part of Medicare?
Part C

EPSDT is a program associated with:
Medicaid

Medicaid’s minimum eligibility is based on which of the following criteria:
Federal Poverty Level

A 21 year-old patient presents for fillings for two of his teeth. Are these services covered under EPSDT?
No, because the patient is not under the age of 21.

Which of the following are mandatory benefits that must be provided by Medicaid programs in order to receive matching federal funding?
a. Outpatient hospital services
c. Home health services
d. Federally qualified health center services
e. Inpatient hospital services
iii. a,c,d,e

The Clinical Prior Authorization Program assists in the monitoring
Drugs not on Medicaid’s formulary

Medicaid claims must be filed
Based on the individual state’s timely filing requirement

Medicaid agencies are required to report EPSDT performance information
Annually

The term for a supplemental policy for Medicare is
Medigap

Medicare Supplemental Insurance policies or Medigap is sold by
Private Insurance Companies

Albert has purchased a Medigap policy to supplement his Medicare benefits. To which entity will Albert pay his monthly premium?
Medigap Insurer

Beth has purchased a Medigap policy to supplement Medicare coverage. She has authorized Medicare to send payments directly to the physician, and Medicare has transferred their claims information to the Medigap insurer. This transfer of information is known as:
cross-over

When processing Medigap claims, Item 9a of the CMS-1500 must have the policy and/or group number of the Medigap insured proceeded by:
MEDIGAP
MG
MGAP
All of the above

Tricare is the healthcare program for which department of the US government?
Department of Defense

What does accept assignment mean?
Agreement to accept payment in full from Medicare and the check will go to the provider.

Barbara’s late husband, Joe, was a lieutenant in the Navy. He served for 30 years retiring 10 years prior to his death. Barbara will still have healthcare coverage as Joe’s widow under which of the following healthcare programs?
CHAMPVA

Andrew has selected TRICARE prime as his health plan. Who will be responsible for coordinating his health care, maintain his health records and referrals to specialists when needed?
PCM

Which TRICARE options allow enrollees the most choices utilizing the fee for service model?
TRICARE Standard

Which of the three TRICARE options are not available to active duty service members?
TRICARE Extra
TRICARE Standard
Both B & C

TRICARE and CHAMPVA timely filing is
1 year from date of service

What types of codes are used when billing preventative services for Medicare Beneficiaries?
HCPCS

ESRD or EPSDT is a reason to receive Medicare coverage?
ESRD

MCR or MCD- which of these programs are state ran?
MCD

What disease is a qualifier for Medicare coverage and spurred on the national Ice Bucket Challenge Craze?
ALS

Which of the following are modifiers used with ABN’s
GA
GX
GY
GZ
all of the above

Which are mid-level provider credentials?
PA
ANP
CNM
all of the above

The office receives an RA from a commercial payer. One of the denials has a reason code of CO97; Benefit included in payment/allowance for another service. What type of denial is this?
Bundled services

What should a biller do if a medical necessity denial is received from an insurer?
The medical record should be pulled, reviewed, and assessed

What is the difference between a rejected claim and a denied claim?
A rejection cannot be appealed

A denial is received in the office from a patient’s insurance company. It stated that the services billed are not covered due to exclusions under the patient’s plan. What should be done at this point?
The patient should be balance billed

An RA is received that contains a denial for a coordination of benefits issue. What could this mean?
b. Another insurer is primary
c. The claim was submitted without the primary insurance RA
both b and c

According to the Patient Protection and Affordable Care Act, and insurance plan must offer?
Internal and external review processes

What type of denial indicates there may be an issue with the front desk registration/intake policies?
Eligibility expired

A denial is received for services bundled into the global period. The record is reviewed and it is found that the denial is for a staged service that fell within the global days of the initial service. There were no modifiers appended to the codes on the claim form. What should be done?
A modifier should be attached to the claim to show staged procedure and the claim should be appealed.

What is a timely filing requirement?
The time frame a provider has to submit a claim.

A _ is a correspondence sent from the insurance payer to the patient after they receive healthcare services to explain the status of their claim.
Explanation of Benefits

Which one of the following is NOT a data entry denial?
Coverage Terminated

What does being a “participating provider” agrees to when signing a contract with an insurance payer?
The provider wishes to participate with and agree to accept the fee schedules set by that specific insurance.

Which of the following type of insurance that allows members to choose medical services as needed and can go in or out of network.
POS

Which of the following is an account that is usually funded by the employee only and reimburses employee for specified expenses as they are incurred?
FSA

What role does an Insurance Provider Representative play?
Is the liaison between the insurance payer and the provider.

The provider, hospital, or other entity that agrees to provide healthcare services to an insurance plan’s enrollees is a:
Participating provider

Balance billing by participating providers is:
Not allowed under a participating provider’s contract

What information can be found on a Blue Cross Blue Shield

What information can be found on a Blue Cross Blue Shield insurance identification card?
A type of plan
C ID number
D group number
F phone number for member service/benefits questions
G mailing address of BC/BS office
4 a,c,d,f,g

A BC/BS insurance plan that allows members to choose any provider, but offers higher level of coverage when members obtain services from network provider would be an example of:
PPO

Carl has enrolled in a healthcare insurance plan that allows him to choose to have services within the BC/BS network or outside of the network. What type of plan best describes Carl’s insurance coverage?
Point of Service

Jared is employed with the United States Internal Revenue Service and has enrolled in the BC/BS healthcare insurance offered through his employer. What is the name of the BC/BS insurance program offered by the federal government?
Federal Employee Program

Tony’s BC/BS healthcare insurance policy states that he must seek healthcare services only from providers that are part of a specific network. What type of BC/BS plan does Tony have?
HMO

BC/BS identifies the individual who pays for healthcare insurance coverage as the:
Subscriber

BC/BS identifies the individual who is eligible for covered services as the:
Member

Participating providers agree to:
Accept the fee schedules determined by the insurance company.

The best practice to prevent a non-covered service denial would be to:
Determine if the procedure is covered prior to providing the service

Obtaining approval from the insurance payer before a procedure is preformed is known as:
Prior authorization

Best practice to prevent receiving a denial due to coverage termination would be to:
Verify coverage prior to the patient’s scheduled appointment

A patient seeks care from a neurologist without a referral from the patient’s primary care physician which is required by the insurance company. What is the likely outcome for the neurologist’s claim?
What type of plan did the patient have?
Claim will be denied
HMO

Developing a strong relationship with the Insurance Provider Representative will result in:
Increases ability to resolve billing, contracting issues that may arise

What is the difference between co-payment and co-insurance?
Co-payment is a set amount, co-insurance is a percentage

When a patient presents for their appointment, insurance coverage should be verified and:
A copy of their drivers license or other form of ID and a copy of both the front and back of the members insurance card
both b and c

A participating provider sees a patient in the ER. the charges equal to $500.00. The patient has a $1000.00 deductible of which none has been met, and a $75.00 ER copay. How much should be collected from the patient for this service?
$75.00

Claim rejections are due to what?
Claims that do not contain necessary information for adjudication

A patient is involved in an accident at work and their commercial insurance is billed. What type of denial will be received?
Liability issue

What is the process of determining which of two or more insurance policies will have the primary responsibility of processing the claim?
Coordination of benefits.

According to Cigna’s submission guidelines in the study guide, what must be submitted with an incomplete submission denial?
EOB or EOP, and requested information

If a claim is denied, investigated, and found to be denied in error, what should a billet do?
Appeal the claim

According to Cigna’s appeal guidelines, what must accompany a timely filing reconsideration request?
Proof of timely filing

What can be done in the practice to ensure that liability denials will not be received?
Perform thorough intakes on patients that present with injuries.

Under what federal act must insurance companies implement effective appeals processes?
The Patient Protection and Affordable Care Act

Which of the following is a coordination of benefits issue?
Submitting a secondary claim without a primary insurance EOB

What are services appropriate to the elevation and treatment of a disease, condition, illness or injury and consistent with the applicable standard of care?
Medically necessary

A denial is received in the office for timely filing. The payer has a 60 day timely filing policy for appeals. The internal process is investigated and it is found that the appeal was filed at 90 days. What can be done?
Write off the claim amount

Which type of denial is more likely to happen when the patient is insured through an HMO?
No referral

Which of the following defines point of service coverage?
Coverage that allows members to choose medical services as needed within the BCBS network or seek medical care outside of the network

Which of the following is NOT correct regarding timely filing?
If the physician fails to send a claim during the timely filing limit, the balance can be sent to the patient.

A 6 year-old is seen in the pediatrician office for the first time. He has insurance coverage through both his mother (DOB: 02/08/86 and his father (DOB: 05/15/85). Whose insurance is primary?

A. Mother’s insurance plan
B. Father’s insurance plan
C. The policy that has the best benefits
D. Either mother’s or father’s insurance plan depending who brings the child in for medical care.
A. Mother’s insurance plan

Which managed care plan has the patient receiving care from participating providers (network provider) and the providers are only paid for services provided?

A. Health Maintenance Organization (HMO)
B. Point-of-Service Plan (POS)
C. Exclusive Provider Organization (EPO)
D. Integrated Delivery System (IDS)
C. Exclusive Provider Organization (EPO)

Which TRICARE plan is similar to an HMO plan?

A. TRICARE For Life
B. TRICARE Select
C. TRICARE Prime
D. TRICARE Young Adult
C. TRICARE Prime

Which of the services are covered by Medicare Part A?

I. Skilled Nursing Facility Care
II. Ambulatory Surgery
III. Durable Medical Equipment
IV. Hospice Care
V. Home Health Services
VI. Long Term Care
VII. Outpatient prescription drugs

A. I-VII
B. II, III, VI
C. I, II, IV, VII
D. I, IV, V
D. I, IV, V

Which is a TRUE statement regarding Workers’ Compensation?

A. There is no copayment for the injured worker in workers’ compensation cases.
B. The filing deadline for a first report of injury form is one week from the date of the accident.
C. Providers can balance bill a patient when compensation payment is not paid in full.
D. There is a deductible for the injured worker in workers’ compensation claims.
A. There is no copayment for the injured worker in workers’ compensation cases.

A. Healthcare Anywhere
B. Managed Care Plan
C. Fee-for-service (traditional coverage)
D. Health Maintenance Organization (HMO)
C. Fee-for-service (traditional coverage)

Which of the following benefits are NOT covered by all Medigap policies?

I. Part A co-insurance and hospital costs
II. Skilled nursing facility care co-insurance
III. Parts A & B deductible
IV. Part B excess charges
V. Foreign travel exchange

A. I, II, III
B. I, III
C. I, IV, V
D. II, III, IV, V
D. II, III, IV, V

Medicaid eligibility is primarily determined by?

A. Income
B. Prior insurance coverage
C. Marital status
D. Number of living relatives
A. Income

__ is incorporated by CMS into the NCCI program to limit the number of times a service or procedure can be reported by a physician on the same date of service to a patient.

A. Outpatient Code Editor (OCE)
B. Medically Unlikely Edits (MUE)
C. Physician Fee Schedule
D. National Coverage Determination (NCD)
B. Medically Unlikely Edits (MUE)

In the CPT® codebook, which of the following codes may be used for reporting synchronous telemedicine services when appended by modifier 95?

A. 93000
B. 99441
C. 99225
D. 99253
D. 99253

Which service is NOT included in the global package for surgical procedures?

A. Treatment for postoperative complications that require a return trip to the OR.
B. Writing orders
C. Evaluating the patient in the Post-Anesthesia Care Unit
D. Local infiltration, digital block, topical anesthesia
A. Treatment for postoperative complications that require a return trip to the OR.

A. 675974608
B. AETNA675974608
C. MG675974608
D. Item 9a is left blank
C. MG675974608

When item 18 on a CMS-1500 claim form has dates of service for inpatient care, what is entered in item 32?

A. Physician’s name and office address who saw the patient in the hospital.
B. Patient’s name and address.
C. Name and address of the facility that provided the service
D. You can leave block Item 32 blank because block Item 33 has the required information.
C. Name and address of the facility that provided the service

According to CPT® subsection guidelines for Excision-Malignant Lesions, when there is a removal of a 3 cm malignant lesion on the arm and the defect area is repaired with an intermediate layer closure, how is it reported?

A. 11603, 12032-51
B. 11603
C. 12032
D. 11603, 12002-51
A. 11603, 12032-51

On the UB-04 claim form the type of bill (TOB) is reported with four digits. Which digit classifies the type of care provided?

A. Digit 1
B. Digit 2
C. Digit 3
D. Digit 4
C. Digit 3

The CPT® or HCPCS Level II code reported on a UB-04 is translated to what type of code by Medicare to reimburse for outpatient facility services?

A. Ambulatory Payment Classification (APC)
B. National Drug Code (NDC)
C. International Classification of Diseases, 10th Revision, Procedural Coding System (ICD-10-PCS)
D. Both B and C
A. Ambulatory Payment Classification (APC)

Which of the following are common identifiers for protected health information (PHI) which can be used to identify an individual?

I. Birth Date
II. Past mental health condition
III. Driving records
IV. Mailing Address
V. Medical record number

A. I-V
B. I, II, IV, V
C. III, V
D. I, IV
B. I, II, IV, V

Which of the following service type providers is required to accept assignment on Medicare claims?

I. Clinical diagnostic laboratory services
II. Specialized radiology services
III. Services provided to Medicare/Medicaid patients
IV. Simplified billing roster for influenza virus vaccine and pneumococcal vaccine
V. Physical therapy services

A. I, III, and IV
B. I, II, and V
C. III, IV, and V
D. I, III, and V
A. I, III, and IV

A Medicare patient comes in for a consultation from the orthopedist. The patient was referred by her primary care provider due to right hip pain. The orthopedist documents a detailed history and an expanded problem focused exam. An X-Ray of the hip is ordered. The medical decision making was moderately complex. The orthopedist provides a report back to the primary care provider with recommendations for physical therapy and potential hip replacement. What codes are reported by the orthopedist?

A. 99203, M79.651
B. 99242, M25.551
C. 99243, M79.651
D. 99202, M25.551
D. 99202, M25.551

Which of the following scenarios is the best example of fraud?

A. Asking a patient presenting for their initial visit with the practice to pay their copayment prior to the visit.
B. Submitting a claim for services prior to the physician performing the scheduled service.
C. Providing a chest x-ray without prior authorization from Medicare.
D. Requiring a patient to sign an ABN prior to providing a service that may be denied by Medicare.
B. Submitting a claim for services prior to the physician performing the scheduled service.

A. Truth in Lending Act
B. False Claims Act
C. Anti-Kickback Statute
D. Criminal Health Care Fraud Statute
A. Truth in Lending Act

A large group practice has implemented an electronic medical record system. They are setting up security groups and want to be sure access is correctly established to comply with HIPAA’s minimum necessary requirements. Which of the following positions would generally not need to have access to the clinical notes of a patient’s medical record?

A. Biller
B. Receptionist
C. Office Manager
D. All of these positions need to have full access to patient’s’ medical records.
B. Receptionist

Payments may be denied by the payer because:

I. The service is not medically necessary.
II. The claim was coded incorrectly.
III. The conditions of the payment policy were not met.
IV. The patient’s insurance was terminated following the service.
V. The provider is credentialed with multiple insurance plans.
VI. The incorrect place of service was submitted.
VII. The NPI for the provider is incorrect.
VIII. More than one modifier was appended to a procedure code.

A. I, II, IV, VI, VII, VII
B. I, II, III, VI, VII
C. I, II, III, IV, V, VII, VIII
D. I-VIII
B. I, II, III, VI, VII

Hospitals billing for inpatient services are based on which of the following reimbursement?

A. Ambulatory Payment Classifications (APC)
B. Medicare Severity-Diagnosis Related Groups (MS-DRG)
C. Fee for Service
D. Outpatient Prospective Payment System (OPPS)
B. Medicare Severity-Diagnosis Related Groups (MS-DRG)

External cause codes report the circumstances surrounding an injury or illness. Which statement is TRUE regarding external cause codes?

A. External cause codes will always be rejected by commercial carriers.
B. All external cause codes contain seven characters.
C. External cause codes are only reported on the initial encounter.
D. Payer policy may dictate how external cause codes are reported.
D. Payer policy may dictate how external cause codes are reported.

A “reasonable” charge in UCR is:

A. What Medicare deems reasonable
B. A computer calculation for a particular service based on all the claims data submitted by individual doctors and group practices.
C. A fee which meets the criteria of usual and customary charges or (after appropriate peer review) is justified because of the special circumstances of a case.
D. The fee generally charged by an individual doctor or group for a particular service (the claim form charge).
C. A fee which meets the criteria of usual and customary charges or (after appropriate peer review) is justified because of the special circumstances of a case.

A 35-year-old female member of an HMO decides to go to an out-of-network specialty clinic for evaluation and surgery because she heard that this clinic provides superior services. The clinic submits claims totaling $15,000 for all services provided to this member. The insurance would typically have paid $10,000 for an in-network provider for the same services. This insurance would most likely pay as follows:

A. Pay the $10,000 it would have paid leaving the patient responsible for the balance
B. Pay the $15,000 since it was reasonable for the patient to go to a superior facility
C. Pay nothing as this provider was out-of-network
D. Negotiate with the provider to accept the $10,000 as payment in full
C. Pay nothing as this provider was out-of-network

At the end of each day, daily deposits should be balanced. Which of the following items should the daily deposits be balanced against?

I. Charges
II. Personal payment receipts
III. Mail receipts
IV. Co-pays due
V. Deductibles due

A. IV and V
B. II and III
C. I, IV, and V
D. I, II, and III
B. II and III

A 48-year-old female awakens in the middle of the night with severe abdominal pain and excessive vomiting. She calls for an ambulance, which takes her to the closest hospital. She had a ruptured appendix and underwent an emergency appendectomy. Neither the hospital nor physician was in the payer network for her HMO. In this situation, the payer will most likely pay the following:

A. The hospital claim because it was reasonable to go to the closest hospital, but not the physician claim
B. Both the hospital and physician claims for the emergency services
C. The physician claim for the emergency services provided, but not the hospital claim
D. Neither claim, as the member should have gone to an in-network facility since this was not a life threatening emergency.
B. Both the hospital and physician claims for the emergency services

Ms. Sally’s provider does not accept the Medicare approved amount as full payment. Instead Ms. Sally has to pay her provider the limiting charge. The provider files a claim to Medicare. Medicare sends payment to the patient. This is what type of claim?

A. Open
B. Delinquent
C. Unassigned
D. Assigned
C. Unassigned

For claims assigned a “pending status” by the payer, the provider should:

A. Write off the claim.
B. Appeal the payer’s decision and resubmit the claim for reconsideration attaching documentation to justify the service.
C. Contact the insurance carrier to determine what additional information is needed and provide it to the insurance carrier.
D. Bill the patient and then reimburse the patient when the payer pays the claim.
C. Contact the insurance carrier to determine what additional information is needed and provide it to the insurance carrier.

Ms. Robinson is seen by Dr. Judy on 4/13/17. The claim is sent to Medicare for payment on 4/12/18. Which of the following statements is correct?

A. Medicare will deny the claim based on the timely filing statute.
B. Medicare will reimburse the claim at 80% of the charges billed.
C. Medicare will pass on the claim to the secondary insurance.
D. Medicare will pay the claim for the services provided based on the timely filing statute
D. Medicare will pay the claim for the services provided based on the timely filing statute

A. File the homeowner’s liability as the primary payer and the commercial carrier as the secondary carrier if the primary denies the claim.
B. File the homeowner’s liability only
C. File the commercial insurance only.
D. File the commercial insurance carrier as the primary payer and the homeowner’s carrier as the secondary carrier if the primary denies the claim
A. File the homeowner’s liability as the primary payer and the commercial carrier as the secondary carrier if the primary denies the claim.

What resources could a biller use to determine whether a procedure is bundled with another procedure according to Medicare?

I Star icon
II. CPT® section guidelines
III. Parenthetical instructions in the CPT® codebook
IV. NCCI edits
V. RVU file

A. I, IV, and V
B. II, III, and IV
C. IV only
D. II only
B. II, III, and IV

Which statement is TRUE regarding appeals?

A. An appeal should be written if a claim is denied by the payer in error.
B. An appeal should be completed for all denials.
C. Timely filing claims cannot be appealed.
D. All insurance carriers have the same standard for appeals.
A. An appeal should be written if a claim is denied by the payer in error.

A patient has a major surgery on her hip on January 3. Two weeks later, the same patient is seen by the provider for migraines. How would the office visit be reported?

A. Modifier 59 is appended to the office visit to identify it is a distinct visit from the surgical procedure.
B. The office visit is reported without a modifier as this is outside of the global period for a major surgical procedure.
C. Modifier 24 is appended to the office visit to indicate it is unrelated to the surgical procedure.
D. The office visit is not reported as it is considered inclusive to the major surgical procedure.
C. Modifier 24 is appended to the office visit to indicate it is unrelated to the surgical procedure.

A Medicare patient has bilateral open treatment of iliac wing fracture patterns that do not disrupt the pelvic ring. How is this service reported?

A. 27215
B. G0412
C. 27215-50
D. G0412-50
B. G0412

A 12-month-old established patient is coming in to see the pediatrician for an annual physical exam. The physician decides to administer the Hib-HepB vaccine intramuscularly. Counseling was provided by the physician to the mother about each vaccine. What codes are reported for this encounter?

A. 99392-25, 90460, 90461, 90748
B. 99391-25, 90460 x 2, 90748
C. 99382-25, 90460 x 2, 90743, 90648
D. 99391-25, 90460, 90461, 90748
A. 99392-25, 90460, 90461, 90748

Patient had an open cholecystectomy three weeks ago. During the postoperative period the patient comes in to see his doctor (who performed the cholecystectomy) for a sore throat and productive cough. The physician performs a problem focused history, expanded problem focused exam, and medical decision of low complexity. The patient has an upper respiratory infection. How is this reported?

A. 99213-55
B. 99213-78
C. 99213-24
D. 99213-26
C. 99213-24

A. I12.0, N18.5
B. I12.0, N18.6
C. N18.5, I12.0
D. I12.0
A. I12.0, N18.5

A. 99291, 99292-51 x 3
B. 99291, 99292 x 3, 31500-51
C. 99291, 99292 x 3, 31500
D. 99291, 99292 x 3
C. 99291, 99292 x 3, 31500

A patient undergoes a craniotomy to evacuate a hematoma. The anesthesiologist prepared the patient in the OR starting the anesthesia at 0300. Surgery started at 0320 and ended at 0505. The anesthesiologist stopped the anesthesia at 0515 and the patient was placed under postoperative supervision.

The total anesthesia time the anesthesiologist should report on the claim form is:

A. 2 hours and 15 minutes (135 minutes)
B. 1 hour and 45 minutes (105 minutes)
C. 2 hours and 5 minutes (125 minutes)
D. 1 hour and 55 minutes (115 minutes)
A. 2 hours and 15 minutes (135 minutes)

Due to an extreme infection, the patient required an injection of amphotericin B of 50 mg. How should this be reported to the insurance company?

A. J0285
B. J0289 x 5
C. J0287 x 5
D. J0285 x 5
A. J0285

A. LD
B. LT
C. LC
D. LM
A. LD

What is the term for the total amount of covered medical expenses a policyholder must pay each year out-of-pocket before the health insurance company begins to pay any benefits?

A. Copayment
B. Deductible
C. Secondary Payment
D. Coinsurance
B. Deductible

Which type of insurance covers physicians and other healthcare professionals for liability as to claims arising from patient treatment?

A. Business liability
B. Bonding
C. Medical malpractice
D. Workers’ compensation
C. Medical malpractice

Which of the following does NOT fall under group policy insurance?

I. The premium is paid for by the employee.
II. The premium is paid for (or partially paid for) by an employer.
III. The employer selects the plan(s) to offer to employees.
IV. Physical exams and medical history questionnaires are a mandatory part of the application process.
V. Employee can make changes to the policy.
VI. The employee’s spouse and children are not eligible for coverage.

A. III, IV, and V
B. II, III, and VI
C. II, IV, and V
D. I, IV, V, and VI
D. I, IV, V, and VI

Dr. Wallace is in a capitation contract with Belleview Managed Care Health Plan. He received $25,000 from the health plan to provide services for the 175 enrollees on the health plan. The services provided by Dr. Wallace to the enrollees cost $23,000. Based on the information, what must be done?

A. Dr. Wallace can keep the $2,000 profit under the terms of the capitated plan.
B. Dr. Wallace experienced a loss under the capitated plan and will need to pay $2,000 to the health plan.
C. Dr. Wallace will need to payout the $2,000 to the 175 enrollees.
D. Dr. Wallace is required to put the $2,000 in a mutual fund.
A. Dr. Wallace can keep the $2,000 profit under the terms of the capitated plan.

What is the deadline for filing a Medicare claim?

A. One year from the date of service
B. 30 days from the date of service
C. 90 days from the date of service
D. Two years from the date of service
A. One year from the date of service

A provider sees a patient who has TRICARE Select. The provider is not contracted with TRICARE but is certified by the regional TRICARE Managed Care Support Contractor (MCSC). The provider charges $200 for the office visit. TRICARE allows $160 and pays $140. How much can the provider bill the patient for?

A. $0.00
B. $20.00
C. $60.00
D. $160.00
C. $60.00

What organization is responsible in evaluating the medical necessity, appropriateness, and efficiency of the use of healthcare services and procedures?

A. Utilization Review Organization
B. External Quality Review Organization
C. Quality Assurance Organization
D. Managed Care Organization
A. Utilization Review Organization

Medicaid providers are forbidden by law to:

A. Refer patients to specialists
B. Bill patients for non-covered services
C. Balance bill patients
D. Accept co-payments
C. Balance bill patients

Which statement is FALSE about Local Coverage Determinations (LCDs)?

A. LCDs list covered codes, but do not include coding guidelines.
B. If a Medicare Administrative Contractor (MAC) develops an LCD, it applies only within the area serviced by that contractor.
C. National Coverage Determination (NCD) takes precedence when an NCD and LCD exist for the same procedure.
D. CMS develops LCDs when there is no National Coverage Determination
D. CMS develops LCDs when there is no National Coverage Determination

When a minor procedure is performed on a Medicare patient, what is the global period and what time frame is covered?

A. 90-day global period – the day of the procedure and 90 days following the procedure.
B. 10-day global period – the day before the procedure and 10 days following the procedure.
C. 90-day global period – the day before the procedure and 90 days following the procedure.
D. 10-day global period – the day of the procedure and 10 days following the procedure.
D. 10-day global period – the day of the procedure and 10 days following the procedure.

If add-on procedure code 11103 is performed twice during an office visit, how is it indicated on the CMS-1500 claim form?

A. Code 11103 is reported with a modifier 50
B. Code 11103 is reported twice
C. Code 11103 is reported once with the number 2 in box 24G
D. Code 11103 is reported twice with the number 2 in box 24G
C. Code 11103 is reported once with the number 2 in box 24G

Which set of documentation guidelines can be used for E/M services submitted to Medicare for a physician assistant (PA)?

A. Physician assistants cannot report E/M services
B. Only the 1995 CMS documentation guidelines
C. Only the 1997 CMS documentation guidelines
D. Either 1995 or 1997 CMS documentation guidelines
D. Either 1995 or 1997 CMS documentation guidelines

Select the scenario that meets the incident-to requirements.

A. The physician is in the office suite actively treating a patient and the physician assistant in the next room is treating a new patient complaint.
B. Care is delivered to an established patient by the physician assistant as part of the physician’s treatment plan while the physician is seeing another patient in the same office suite in a different room.
C. The physician assistant traveled for the physician to provide the service in the patient’s New York City home and the physician is available by phone.
D. The physician assistant provided a necessary part of the patient’s medical treatment and the physician signed the chart when he returned to the office.
B. Care is delivered to an established patient by the physician assistant as part of the physician’s treatment plan while the physician is seeing another patient in the same office suite in a different room.

Medicare beneficiary is having a screening colonoscopy performed. How is the service reported to Medicare?

A. G0121
B. 45378
C. 45378, G0121
D. G0121, 45378
A. G0121

Which providers submit the CMS-1500 claim form?

I. Independent diagnostic testing facilities (IDTFs)
II. Emergency department physicians
III. Hospice organizations
IV. Ambulance companies submitting under their own Medicare number
V. Physicians in a group practice
VI. Ambulatory surgery centers

A. III-VI
B. IV and VI
C. I, III, IV, and VI
D. I, II, IV, V and VI
D. I, II, IV, V and VI

According to CPT® Radiology Guidelines, if a patient is given oral contrast for a CT scan of the abdomen which code is reported?

A. 74150 Computed tomography, abdomen; without contrast material
B. 74160 Computed tomography, abdomen; with contrast material(s)
C. 74170 Computed tomography, abdomen; without contrast material, followed by contrast material(s) and further sections
D. 74176 Computed tomography, abdomen and pelvis; with contrast material(s)
A. 74150 Computed tomography, abdomen; without contrast material

Which of the following is NOT in the HIPAA Privacy Rule?

A. Physician must obtain a patient’s written consent and authorization before using or disclosing PHI to carry out treatment.
B. Implementing hardware, software, and/or procedural mechanisms to record and examine access and other activity in information systems that contains or use electronic PHI (e-PHI).
C. Doctor’s office leaving a message on the patient’s answering machine to confirm an appointment time.
D. Patient is given greater access to his own medical record(s) and control over how his PHI is used.
B. Implementing hardware, software, and/or procedural mechanisms to record and examine access and other activity in information systems that contains or use electronic PHI (e-PHI).

When a physician intentionally bills procedures to Medicaid that he did not perform he is in violation of which Act?

A. Truth in Lending Act
B. Federal Claims Collection Act
C. False Claims Act
D. Health Insurance Portability and Accountability Act
C. False Claims Act

Cardiologist Dr. W has been consistently reporting a higher E/M level than what is documented to cover the revenue being lost in his practice. Is this considered fraud or abuse and why?

A. Abuse; the provider’s practice is common and therefore would not be considered fraudulent.
B. Fraud; the provider intentionally over-coded to gain financially
C. Abuse; charging one level higher on each visit does not show intent.
D. Fraud; failing to maintain adequate medical or financial records.
B. Fraud; the provider intentionally over-coded to gain financially

What is a Qui tam relator?

A. A person who brings civil action for violation under the False Claims Act (FCA) for themselves and the US government
B. Defendant in a Stark Law case.
C. A person assigned to investigate accusations of fraudulent billing.
D. A physician who is the defendant in a Qui Tam case.
A. A person who brings civil action for violation under the False Claims Act (FCA) for themselves and the US government

Dr. Wilson assigns all established Medicare patients E/M level 99215 regardless of the work performed during the visit. He considers all Medicare patients to be complicated patients and therefore, he should be paid at the highest rate possible. Is Dr. Wilson’s actions considered fraud or abuse?

A. Abuse; some of the visits would be correctly reported at 99215 so all of the claims are not overpayments.
B. Abuse, he is knowingly billing patients incorrectly to obtain higher payment.
C. Fraud; some of the visits would be correctly reported at 99215 so all of the claims are not overpayments.
D. Fraud; he is knowingly billing patients incorrectly to obtain higher payment.
D. Fraud; he is knowingly billing patients incorrectly to obtain higher payment.

JR had surgery on January 15, 20XX by Dr. Waters (a Medicare participating provider). The Medicare fee schedule for the surgery is $500. Four months later, JR and Dr. Waters each received a check from Medicare in the amount of $400. JR signed over his $400 to Dr. Waters. JR had previously paid the doctor $100 for the co-insurance. In total Dr. Waters has received $900 for the surgery provided on January 15, an overpayment of $400. What should Dr. Waters do?

A. Keep half of the overpayment and refund the other half to the Medicare Administrative Contractor (MAC).
B. Refund $450 back to the patient.
C. Contact the MAC of the overpayment and provide a refund.
D. Use the $450 toward future co-insurance for the patient.
C. Contact the MAC of the overpayment and provide a refund.

Which one is NOT a Nonphysician Practitioner (aka mid-level provider)?

A. Certified nurse midwife
B. Resident
C. Physician Assistant
D. Clinical social workers
B. Resident

Which Federal Law requires written acknowledgement of consumer billing disputes and investigation of billing errors by creditors?

A. Fair Credit Billing Act
B. Fair Credit and Charge Card Disclosure Act
C. Equal Credit Opportunity Act
D. Fair Credit Reporting Act
A. Fair Credit Billing Act

Mr. Doyle had seen a non-participating provider for a hernia repair in outpatient surgery. His insurance company Telehealth provided a reimbursement check of $400 for the anesthesia services provided to him for the surgery. Mr. Doyle cashed the check and kept the money. Mr. Doyle receives the bill from the anesthesiologist, but he no longer has the money to pay it. The account becomes delinquent and is outsourced to a collection agency. The collection agency is unable to obtain any monies from Mr. Doyle. What is this is considered?

A. Past-due account
B. Open claim
C. Pending account
D. Bad debt
D. Bad debt

Mr. Jones is 67, retired, and has insurance coverage through Medicare and TRICARE. Mrs. Jones is 62 and still working for an employer that has 10 employees. Mr. and Mrs. Jones have health coverage through Mrs. Jones’ employer’s group health plan, United Plan. Mr. Jones is seen in a non-military hospital in the ED for a fractured wrist. Who gets billed first?

A. Medicare
B. Group health plan, United Plan
C. TRICARE
D. Medicare, the group health plan, and TRICARE will be billed at the same time.
A. Medicare

Relative Value Units (RVUs) are payment components consisting of:

A. Actual time of the physician work; Place of service; Geographic adjustment
B. Practice Expense; Diagnostic services; Payment Rate
C. Physician work; Practice Expense; Professional liability/malpractice insurance
D. Patient classification system; Geographic adjustment; Practice Expense
C. Physician work; Practice Expense; Professional liability/malpractice insurance

Which of the following falls under the Prompt Payment Act?

A. Physician needs to refund overpayments within 30 days to the Medicare Administrative Contractor (MAC) from the date of receipt.
B. Medicare and MACs have 60 days to pay or deny electronic clean claims.
C. Clean claims must be paid or denied within 30 days from the date of receipt by MACs.
D. Penalty fees will only be issued on clean claims if payments are 60 days overdue starting the day after the receipt date.
C. Clean claims must be paid or denied within 30 days from the date of receipt by MACs.

25 year-old is 32 weeks pregnant. She was admitted to the labor and delivery unit because she was having severe pre-eclampsia and needed to have an emergency cesarean section. Reduced payment was sent to the obstetrician by the payer with a remittance advice stating that preauthorization for the cesarean section was not obtained. What does the biller do?

A. Verify in the payer contract/policies that prior authorization is required for this procedure. If preauthorization was not obtained, bill the patient the rest of what is due to the obstetrician.
B. Appeal the claim, explaining the reason for the emergency cesarean section
C. Write off the claim because it was denied.
D. Verify in the payer contract/policies that prior authorization is required for this procedure. If preauthorization was not obtained, bill the patient for the entire amount.
B. Appeal the claim, explaining the reason for the emergency cesarean section

When a provider chooses not to participate in the Medicare program and does not accept assignment on claims, the maximum amount the provider can charge is _ percent of the approved fee schedule amount for non-participating providers.

A. 115
B. 100
C. 50
D. 25
A. 115

Mr. Allen is scheduled for an appointment with his physician for follow-up of his rheumatoid arthritis and hypertension. The physician is called away for a personal emergency just after Mr. Allen arrives for his appointment and the patient is seen by the physician assistant, who orders labs and refills the patient’s prescriptions. Mr. Allen is scheduled to return in one month. How should this patient’s visit should be billed?

A. Under the PA as the incident-to guidelines have not been met.
B. As incident-to because labs were ordered and prescriptions refilled.
C. As a new patient under the PA because the PA has not seen the patient before.
D. As “no-charge” since the physician was unable to see the patient.
A. Under the PA as the incident-to guidelines have not been met.

Jill presents to Dr. Calvert for collagen injections to her upper lip for cosmetic reasons. She is informed by the office staff that cosmetic surgery may not be a benefit of her insurance plan in which case she would be responsible for the charges. Jill requests the claim to be submitted to her insurance. The claim is submitted to her insurance for payment. Dr. Calvert’s office receives a remittance advice stating that the injections are considered cosmetic and are not a covered service. What is the appropriate next step for resolution?

A. Change the diagnosis code to support medical necessity for the injections.
B. Send an appeal to the payer demanding payment.
C. Move charges to patient responsibility and send the patient a statement.
D. Write off the charges.
C. Move charges to patient responsibility and send the patient a statement.

The financial policy for Midtown Physicians Group states that when all means for collecting payments have been exhausted and payment has not been received within 120 days, the account is turned over to a collection agency. When generating an accounts receivable aging report, you see an outstanding claim for Mrs. Smith that has not received payment for 150 days. Mrs. Smith’s account is considered to be:

A. open
B. delinquent
C. aging
D. pending
B. delinquent

Which of the following is considered by CMS to be a source document when a provider and billing service file claims electronically?

I. Patient’s registration form
II. Routing Slip
III. Superbill
IV. Encounter form
V. Charge slip
VI. Patient’s insurance card

A. I, VI
B. II-V
C. II, III, V
D. II-VI
B. II-V

A hospital chargemaster does not include __.

A. CPT® codes
B. Revenue codes
C. HCPCS Level II codes
D. Diagnosis codes (ICD-10-CM)
D. Diagnosis codes (ICD-10-CM)

Mary is tasked to perform an audit on Dr. Pain’s practice to verify charges are documented as reported. What are the key elements Mary needs for the audit process on 25 records to support what Dr. Pain is charging?

A. Patient financial record, encounter form and CMS-1500 claim form
B. Patient registration form, insurance card, CMS-1500 claim form
C. Medical record, encounter form, CMS-1500 claim form
D. Medical record, day sheet, and ledger
C. Medical record, encounter form, CMS-1500 claim form

Mr. Peabody is an established patient who was told by Dr. Woods to come back for an injection in his right knee if he was still getting pain due to arthritis. Mr. Peabody is in for just the injection. The physician only examines the knee (problem focused exam) before he gives the injection. Dr. Woods explains the risks associated with the procedure and the patient gives consent. The doctor prepped the knee with betadine and injects the right knee with 10 mg of Depo-Medrol. How is this visit reported?

A. 20610, J1020
B. 99212-25, 20610, J1020
C. 99212, 20610-25, J1020
D. J1020
A. 20610, J1020

A CRNA is performing a case personally without medical direction from an anesthesiologist. Which modifier is appropriately reported for the CRNA services?

A. QX
B. QZ
C. QK
D. QS
B. QZ

Patient presents to her physician 10 weeks following a true posterior wall myocardial infarction. The patient is still exhibiting symptoms of chronic ischemic heart disease. The physician reviews the current medications to confirm the patient is compliant and discusses a heart-healthy diet and exercise. What is the correct ICD-10-CM code for this condition?

A. I25.9
B. I21.29
C. I21.21
D. I25.2
A. I25.9

10-year-old girl is scheduled for her yearly physical exam with her pediatrician .At the time of her visit, the patient complains of watery eyes, scratchy throat, and stuffy nose for the past two days. The physician first performs a complete physical. Then he also evaluates and treats the patient for a URI supported with separate documentation of an expanded problem focused exam and low medical decision making. What CPT® code(s) is/are reported for this visit?

A. 99393, 99213-25
B. 99393
C. 99213
D. 99393-25, 99213
A. 99393, 99213-25

The patient is admitted for radiation therapy for metastatic bone cancer, unknown primary. What ICD-10-CM codes should be reported?

A. C79.51, C80.1, Z51.0
B. C80.1, C79.51, Z51.0
C. Z51.0, C79.51, C80.1
D. Z51.0, C80.1, C79.51
C. Z51.0, C79.51, C80.1

60-year-old woman is seeking help to quit smoking. She makes an appointment to see Dr. Lung for an initial visit. The patient has a constant cough due to smoking and some shortness of breath. No night sweats, weight loss, night fever, CP, headache, or dizziness. She has tried patches and nicotine gum, which has not helped. Patient has been smoking for 40 years and smokes 2 packs per day. She has a family history of emphysema. A limited three system exam was performed. Dr. Lung discussed in detail the pros and cons of medications used to quit smoking. Counseling and education was done face to face for 20 minutes on smoking cessation of the 30 minute visit. Prescriptions for Chantix and Tetracycline were given. The patient to follow up in 1 month. A chest X-ray and cardiac work up was ordered. Select the appropriate CPT® code(s) for this visit:

A. 99203, 99354
B. 99214, 99354
C. 99214
D. 99407
D. 99407

A 14-year-old male patient fell while skateboarding. He went to the emergency department at the local hospital. The diagnosis was a fracture of the upper right arm. The ICD-10-CM codes reported were S42.301A, V00.131A, and Y93.51.Is this correct?

A. No; the codes reported should be S43.309B, V00.131B, Y93.51
B. No; the codes reported should be V00.131B, Y93.51, S42.309D
C. No; the codes reported should be V00.131A, Y93.51, S42.301A
D. Yes; the ICD-10-CM codes reported are correct
D. Yes; the ICD-10-CM codes reported are correct

Obstetrician A recommends a new type of cancer treatment for patient who has ovarian cancer. Before the patient’s private insurance company approves the treatment, the insurer mandates Obstetrician B (in a different practice) to conduct a physical examination of the patient. What modifier should obstetrician B append to the E/M consultation code?

A. Modifier 25
B. Modifier 24
C. Modifier 32
D. Modifier 59
C. Modifier 32