The attending physician
A nurse is reviewing a patients lab results prior to discharge and discovers an elevated glucose level. Which of the following health care providers should be altered before the nurse can proceed with discharge planning?
The patients condition and the providers information
On the CMS-1500 Claims for, blocks 14 through 33 contain information about which of the following?
Problem focused examination
A provider performs an examination of a patient’s throat during an office visit. Which of the following describes the level of the examination?
Reinstated or recycled code
The symbol “O” in the Current Procedural Terminology reference is used to indicate which of the following?
Coinsurance
Which of the following is the portion of the account balance the patient must pay after services are rendered and the annual deductible is met?
Place of service
The billing and coding specialist should divide the evaluation and management code by which of the following?
Cardiovascular system
The standard medical abbreviation “ECG” refers to a test used to access which of the following body systems?
add on codes
In the anesthesia section of the CPT manual, which of the following are considered qualifying circumstances?
12
As of April 1st 2014, what is the maximum number of diagnosis that can be reported on the CMS-1500 claim form before a further claim is required?
Nephrolithiasis
When submitting a clean claim with a diagnosis of kidney stones, which of the following procedure names is correct?
Verifying that the medical records and the billing record match
Which of the following is one of the purposes of an internal auditing program in a physician’s office?
The DOB is entered incorrectly
Patient: Jane Austin; Social Security # 555-22-1111; Medicare ID: 555-33-2222A; DOB: 05/22/1945. Claim information entered: Austin, Jane; Social Security #.: 555-22-1111; Medicare ID No.: 555-33-2222A; DOB: 052245. Which of the following is a reason this claim was rejected?
Operative report
Which of the following options is considered proper supportive documentation for reporting CPT and ICD codes for surgical procedures?
Verify the age of the account
Which of the following actions should be taken first when reviewing delinquent claims?
Claim control number
Which of the following components of an explanation of benefits expedites the process of a phone appeal?
Bloc 24D contains the diagnosis code
A claim can be denied or rejected for which of the following reasons?
Privacy officer
To be compliant with HIPAA, which of the following positions should be assigned in each office?
encrypted
All e-mail correspondence to a third party payer containing patients’ protected health information (PHI) should be
patient ledger account
A billing and coding specialist should understand that the financial record source that is generated by a provider’s office is called a
Coding compliance plan
Which of the following includes procedures and best practices for correct coding?
Health care clearinghouses
HIPAA transaction standards apply to which of the following entities?
Appeal the decision with a provider’s report
Which of the following actions should be taken if an insurance company denies a service as not medically necessary?
Accommodate the request and send the records
A patient with a past due balance requests that his records be sent to another provider. Which of the following actions should be taken?
$48
A participating BlueCross/ BlueShield (BC/BS) provider receives an explanation of benefits for a patient account. The charged amount was $100. BC/BS allowed $40 to the patients annual deductible. BC/BS paid the balance at 80%. How much should the patient expect to pay?
Deductible
The physician bills $500 to a patient. After submitting the claim to the insurance company, the claim is sent back with no payment. The patient still owes $500 for this year.
International Classification of Disease (ICD)
Which of the following is used to code diseases, injuries, impairments, and other health related problems?
Ureters
Urine moves from the kidneys to the bladder through which of the following parts of the body?
Angioplasty
Threading a catheter with a balloon into a coronary artery and expanding it to repair arteries describes which of the following procedures?
To ensure the patient understands his portion of the bill
A patient’s portion of the bill should be discussed with the patient before a procedure is performed for which of the following reasons?
Performing periodic audits
Which of the following actions by the billing and coding specialists prevents fraud?
Name and address of guarantor
Which of the following information is required on a patient account record?
Invalid
A claim is submitted with a transposed insurance member ID number and returned to the provider. Which of the following describes the status that should be assigned to the claim by the carrier?
CMS-1500 claim form
Which of the following should the billing and coding specialist complete to be reimbursed for the provider’s services?
The electronic transmission and code set standards require every provider to use the healthcare transactions, code sets, and identifiers.
Which of the following is HIPAA compliance guideline affecting electronic health records?
Verification of coverage.
Which of the following is the purpose of precertification
The entity to whom the information is to be released
Which of the following should the billing and coding specialist include in an authorization to release information?
Report the incident to a supervisor
Which of the following actions should the billing and coding specialist take if he observes a colleague in an unethical situation?
Patient’s responsibility
When posting payment accurately, which of the following items should the billing and coding specialist include?
The parent whose birthdate comes first in the calendar year
A dependent child whose parents both have insurance coverage comes to the clinic. The billing and coding specialist uses the birthday rule to determine which insurance policy is primary. Which of the following describes the birthday rule?
Patient access to psychotherapy notes may be restricted
Which of the following statements is true regarding the release of patient records?
Denied
A patient’s employer has not submitted a premium payment. Which of the following claim statuses should the provider receive from the third-party payer?
Clearinghouse
Which of the following do physicians use to electronically submit claims?
principal diagnosis
When coding on the UB-04 form, the billing and coding specialist must sequence the diagnosis codes according to the ICD guidelines. Which of the following is the first listed diagnosis code?
Block 9
A patient has AARP as secondary insurance. In which of the following blocks on the CMS-1500 claim form should this information be entered?
NPI
According to HIPAA standards, which of the following identifies the rendering provider on the CMS-1500 claim form in Block 24j?
Oxygenating blood cells
Which of the following is the function of the respiratory system?
Coordination of benefits
Which of the following provisions ensures that an insured’s benefits from all insurance companies do not exceed 100% of allowable medical expenses?
Consent agreement
Which of the following is the verbal or written agreement that gives approval to some action, situation, or statement, and allows the release of patient information?
Fraud
A deductible of $100 is applied to a patient’s remittance advice. The provider requests the account personnel write it off. Which of the following terms describes this scenario?
Gross examination
A coroner’s autopsy is comprised of which of the following examinations?
Claims are expedited
Which of the following is the advantage of electronic claim submission?
Title 2
A patient presents to the provider with chest pain and SOB. After an unexpected ECG result, the provider calls a cardiologist and summarizes the patient’s symptoms. What portion of HIPAA allows the provider to speak to the cardiologist prior to obtaining the patient’s consent?
Advanced beneficiary notice
A physician ordered a comprehensive metabolic panel for a 70 year old patient who has Medicare as her primary insurance. Which of the following forms is required so the patient knows she may be responsible for payment?
Assignment of benefits
Which of the following does a patient sign to allow payment of claims directly to the provider?
Military identification
All dependents 10 year of age or older are required to have which of the following for TRICARE?
Private 3rd party payers
Medigap coverage is offered to Medicare beneficiaries by which of the following?
Follow up of insurance claims by date
An insurance claims register (aged insurance report) facilitates which of the following?
Urethratresia
Which of the following describes an obstruction of the urethra?
Admitting clerk
A patient comes to the hospital for an inpatient procedure. Which of the following hospital staff members is responsible for the initial patient interview, obtaining demographic and insurance information, and documenting the chief complaint?
The patient demographics
On the CMS-1500 claim form, Blocks 1 through 13 include which of the following
Pumping blood in the circulatory system
Which of the following is the primary function of the heart?
Submit an appeal to the carrier with the supporting documentation
Which of the following actions should be taken when a claim is billed for a level four office visit and paid at a level three?
Delinquent
Which of the following types of claims is 120 days old?
Aging report
Which of the following shows outstanding balances?
Part D
Which part of Medicare covers prescriptions?
Dermatology
In which of the following departments should a patient be seen for psoriasis?
Patient information was disclosed to the patient’s parent without consent.
Which of the following is an example of a violation of an adult patient’s confidentiality?
Improper code combinations
Which of the following describes the reason for a claim rejection because of Medicare NCCI edits?
History and physical
Which of the following sections of the medical record is used to determine the correct Evaluation and Management code used for billing and coding?
Blue shield/ Blue cross
Which of the following is a private insurance carrier?
National provider identification number
Which of the following information should the billing and coding specialist input into Block 33a on the CMS-1500 claim form?
UB-04
Which of the following forms should the billing and coding specialist transmit to the insurance carrier for reimbursement of inpatient hospital services?
Pulmonary oncologist
A patient who has a primary malignant neoplasm of the lung should be referred to which of the following specialists?
They streamline patient billing by summarizing the services rendered for a given date of service
Why does correct claim processing rely on accurately completed encounter forms?
Sagittal
Which of the following planes divides the body into left and right?
Inform the patient of the reason of the denial
A patient is upset about a bill she received. Her insurance company denied the claim. Which of the following actions is an appropriate way to handle the situation?
The claim is overdue for payment
Which of the following describes a delinquent claim?
Use Arial size 10 font
When completing a CMS-1500 paper claim form, which of the following is an acceptable action for the billing and coding specialist to take?
Pericardium
Which of the following medical terms refers to the sac that encloses the heart?
Adjudication
Which of the following is considered the final determination of the issues involving settlement of an insurance claim?
Encounter form
A form that contains charges, DOS, CPT codes, ICD codes, fees, and copayment information is called which of the following?
Using data encryption software on office workstations
Which of the following privacy measures ensures protected health information (PHI)?
It indicates which claims are outstanding
Which of the following is the purpose of running an aging report each month?
Billing for services not provided
Which of the following actions by a billing and coding specialist would be considered fraud?
Paper claim
Which of the following claims is submitted and then optically scanned by the insurance carrier and converted to an electronic form?
Block 12
Which of the following blocks requires the patient’s authorization to release medical information to process a claim?
Block 24D
Which of the following blocks should the billing and coding specialist complete on the CMS-1500 claim form for procedures, services, or supplies?
Guidelines prior to each section
The unlisted codes can be found in which of the following locations in the CPT manual?
$40
A physician is contracted with an insurance company to accept the allowed amount. The insurance company allows $80 of a $120 billed amount, and $50 of the deductible has been met. How much should the physician write off the patient’s account?
Provider
On a remittance advice form, which of the following is responsible for writing off the difference between the amount billed and the amount allowed by the agreement?
Procedure descriptors
The “><” symbol is used to indicate new and revised text other than which of the following?
The claim requires an attachment
Which of the following indicates a claim should be submitted on paper instead of electronically?
Coinsurance
Which of the following terms describes when a plan pays 70% of the allowed amount and the patient pays 30%?
The number is needed to identify the provider
Claims that are submitted without an NPI number will delay payment to the provider because
UB-04 claim form
Ambulatory surgery centers, home health care, and hospice organizations use the
Red
Which of the following color formats is acceptable on the CMS-1500 claim form?
The deductible is the patient’s responsibility
Which of the following statements is correct regarding a deductible?
Adjustment column of the credits
A provider charged $500 to a claim that had an allowable amount of $400. In which of the following columns should the billing and coding specialist apply the non-allowed charge?
The billing and coding specialist sends the patient’s records to the patient’s partner.
A patient who is an active member of the military recently returned from overseas and is in need of specialty care. The patient does not have anyone designated with power of attorney. Which of the following is considered a HIPAA violation?
Medicaid
A patient’s health plan is referred to as the “payer of last resort.” The patient is covered by which of the following health plans?
Claim adjudication
After a 3rd party payer validates a claim, which of the following takes place next?
Health care clearinghouse
HIPAA transaction standards apply to which of the following entities?
First report of injury
Which of the following is the initial step in processing a workers’ compensation claim?
Coordination of benefits
The provision of health insurance policies that specifies which coverage is considered primary or secondary is called which of the following?
A provider’s office with fewer than 10 full-time employees
Medicare enforces mandatory submission of electronic claims for most providers. Which of the following providers is allowed to submit paper claims to medicare?
The 3rd party payer reimburses the patient, and the patient is responsible for reimbursing the provider.
When submitting claims, which of the following is the outcome if block 13 is left blank?
accounts receivable
Patient charges that have not been paid will appear in which of the following?
Remittance advice
A billing and coding specialist needs to know how much Medicare paid on a claim before billing secondary insurance. To which of the following should the specialist refer?
A bilateral procedure
A billing and coding specialist should add modifier -50 to codes when reporting which of the following?
CMS
In 1995 and 1997, which of the following introduced documentation guidelines to Medicare carriers to ensure that services paid for have been provided and were medically necessary?
Billing using 2 digit CPT modifiers to indicate a procedure as performed differs from its usual 5 digit code
Which of the following is allowed when billing procedural codes?
Cold treatment
The destruction of lesions using cryosurgery would use which of the following treatments?
Code both acute and chronic sequencing the acute first
When a patient has a condition that is both acute and chronic how should it be reported?
An overview of the practice’s outstanding claims
Which of the following describes the content of a medical practice aging report?
Fraud
After reading a provider’s notes about a new patient, a coding specialist decides to code for a longer length of time than the actual office visit. Which of the following describes the specialist’s action?
The claim will not be re submitted and the patient will be sent a bill
A claim is denied because the service was not covered by the insurance company. Upon confirmation of no errors on the claim, which of the following describes the process that will follow the denial?
A billing worksheet from the patient account
A prospective billing account audit prevents fraud by reviewing and comparing a completed claim form with which of the following documents?
Encryption
Which of the following security features is required during transmission of protected health information and medical claims to third party payers?
HIPAA
Which of the following acts applies to the Administrative Simplification guidelines?
Immunizations
Z codes are used to identify which of the following?
-53
Which of the following modifiers should be used to indicate a professional service has been discontinued prior to completion?
Complete the information and re transmit according to the 3rd party standards
When an electronic claim is rejected due to incomplete information, which of the following should the medical billing specialist take?
Claims submitted via a secure network
Which of the following is an example of electronic claim submission?
EEG
Test results indicated that no abnormalities were found in the brain and the brain’s electrical activity patterns are normal. Which of the following tests was used to conduct this exam?
9a
When billing a secondary insurance company, which block should the billing and coding specialist fill out on the CMS-1500 claim form?
Collect copayment from the patient at the time of service
Which of the following actions should the billing and coding specialist take to effectively manage accounts receivable?
12
What is the maximum number of ICD codes that can be entered on a CMS-1500 claim form as of February 2012?
Internal monitoring and audting
Which of the following actions should the billing and coding specialist take to prevent fraud and abuse in the medical office?
30 days
For which of the following time periods should the billing and coding specialist track unpaid claims before taking follow up action
0%
A beneficiary of a Medicare/Medicaid crossover claim submitted by a participating provider is responsible for which of the following percentages?
Direct data entry
A biller will electronically submit a claim to the carrier via which of the following?
Review of systems
When a physician documents a patient’s response to symptoms and various body systems, the results are documented as which of the following?
150 00
Which of the following is a correct entry of a charge of $140 in Block 24F of the CMS-1500 claim form?
Services rendered by a physician whose opinion or advice is requested by another physician or agency
Which of the following situations constitutes a consultation?
Bones and bone marrow
If a patient has osteomyelitis he has a problem with which of the following areas?
An authorization
Which of the following forms must the patient or representative sign to allow the release of protected health information?
Referring physician’s national provider identifier (NPI) number
Block 17b on the CMS-1500 claim form should list which of the following information?
NCCI
Which of the following was developed to reduce Medicare program expenditures by detecting inappropriate codes and eliminating improper coding practices?
Denied
Which of the following describes the status of a claim that does not include required preauthorization for a service?
Lymphatic system
Which of the following parts of the body system regulates immunity?
Clearinghouse
Which of the following is used by providers to remove errors from claims before they are submitted to 3rd party payers?
Explanation of benefits
A provider receives reimbursement from a 3rd party payer accompanied by which of the following documents?
Claims adjudication
Which of the following is the 3rd stage of the life cycle of a claim?
Block 10a
Which of the following blocks on the CMS-1500 claim form is required to indicate a workers’ compensation claim?
Duplication of services
2 providers from the same practice visit a patient in the emergency department using the same CPT code. The claim may be denied due to which of the following reasons?
The patient was out of town during the emergency
A patient has an emergency appendectomy while on vacation. The claim is rejected due to the patient obtaining services out of network. Which of the following information should be included in the claim appeal?
Incomplete claim
Which of the following is a type of claim that will be denied by the 3rd party payer?
Internal monitoring and auditing
Which of the following steps would be part of a physician’s practice compliance program?
$120
A patient has met a Medicare deductible of $150. The patient’s coinsurance is 20% and the allowed amount is $600. Which of the following is the patient’s out of pocket expense?
The age of the account
Which of the following is the primary information used to determine the priority of collection letters to patients?
A claim that is delinquent for 60 days
Which of the following claims would appear on an aging report?
Preauthorization form
Which of the following is a requirement of some 3rd party payers before a procedure is performed?
HCPCS Level 2 manual
Which of the following coding manuals is used primarily to identify products, supplies, and services?
Block 23
A billing and coding specialist should enter the prior authorization number on the CMS-1500 claim form in which of the following blocks?
A signed release from the patient
Which of the following documents is required to disclose an adult patient’s information?
Documenting the patient’s chief complaint, history, exam, assessment, and plan for care
Which of the following billing patterns is a best practice action?
Communicating with the front desk staff during a team meeting about missing information in patient files
Behavior plays an important part of being a team player in a medical practice. which of the following is an appropriate action for the billing and coding specialist to take?
$40
A physician is contracted with an insurance company to accept the allowed amount. The insurance company allows $80 of a $120 billed amount, and $50 of the deductible has not been met. How much should the physician write off the patient’s account?
The physician agrees to accept payment under the terms of the payer’s program
Accepting assignment on the CMS-1500 claim form indicates which of the following?
Any coinsurance, copayments, or deductibles can be collected from the patient
Which of the following statements is true when determining patient financial responsibility by reviewing the remittance advice?
Patient account record
In an outpatient setting, which of the following forms is used as a financial report of all services provided to patients?
Edema
Which of the following is the appropriate diagnosis for a patient who has an abnormal accumulation of fluid in her lower leg that has resulted in swelling?
TRICARE Prime
Which of the following types of health insurance plans best describes a government sponsored benefit program?
Recovery Audit Contractor (RAC)
Which of the following organizations identifies improper payments made on CMS claims?
The reason Medicare may not pay
Which of the following information is required to include on an Advance Beneficiary Notice (ABN) form?
Block 21
Which of the following blocks on CMS-1500 claim form is used to bill ICD codes?
Claim adjustment codes
Which of the following terms is used to communicate why a claim line item was denied or payed differently than it was billed?
The name, address, and ZIP code of the facility where services were rendered goes in this block.
Block 32con the CMS form contains what?
A provider’s office requests a subpoena requesting medical documentation from a patient’s medical record. After confirming the correct authorization, which of the following actions should the billing & coding specialist take?
12 months from the date of service
Which of the following is the deadline for a Medicare for claims submission?
CMS-1500
Which of the following forms does a 3rd party payer require for physician services?
Charging excessive fees
Which of the following is an example of Medicare abuse?
Adjustment
Which of the following terms refers to the difference between the billed and allowed amounts?
Durable medical equipment
Which of the following HMO managed care services requires a referral?
Advanced beneficiary notice (ABN)
Which of the following explains why Medicare will deny a particular service or procedure?
Delinquent
What type of claim is 120 days old?
Photo copy both sides of the card
When reviewing an established patient’s insurance card, the billing and specialist notices a minor change from the existing card on file. Which of the following actions should the billing & coding specialist take?
The wife’s insurance
A husband and wife each have group insurance through their employers. The wife has an appt. with her provider. Which insurance should be used as the primary for this appt?
An experimental chemotherapy medication for a patient who has stage 3 renal cancer.
Which of the following would most likely result in a denial on a Medicare claim?
Phone number
Which of the following pieces of guarantor information is required when establishing a patient’s financial record?
Pleurocentesis
A provider surgically punctures through space between the patient’s ribs using an aspirating needle to withdraw fluid from the chest cavity. Which of the following is the name of this procedure?
Block 9
A patient has AARP as secondary insurance. Which block on the CMS 1500 claim form should this information be entered?
$230
A medicare non-participating provider’s approved payment for $200 for a lobectomy and the deductible was met. Which amounts is the limiting charge for this?
add-on codes
In the anesthesia section of the CPT manual, which are considered qualifying circumstances?
These codes must correspond to the diagnosis blocker in Block 24E
Which of the following statements is accurate regarding the diagnostic codes in Block 21?
Part C
Which of the following parts of Medicare insurance program is managed by private 3rd party insurance providers that have been approved by medicare?
Precertification
A billing & coding specialist can ensure appropriate insurance coverage for an outpatient procedure by 1st using which of the following processes?
The billing and coding specialist unbundles a code to receive higher reimbursement
Which of the following is considered fraud?
Triangle
Which of the following symbols indicates a revised code?
Office inspector general (OIG)
Which of the following entities defines the essential elements of a comprehensive compliance program?
Prevent multiple insurers from paying benefits covered by other policies
Which of the following is the purpose of coordination of benefits?
Clean claim
A billing & coding specialist submitted a claim to Medicare electronically. No errors were found by the billing software or clearinghouse. Which of the following describes the claim?
An italicized code used as the first listed diagnosis
Which of the following would result in a claim being denied?
HIPAA standard transactions
Which of the following standardized formats are used in the electronic filing of claims?
professional component
Which of the following describes a 2 digit CPT code used to indicate that the provider supervised & interpreted a radiology procedure?
837
Which of the following formats are used to submit electronic claims to a 3rd party payer?
Patient eligibility is determined monthly
Which of the following is true regarding Medicaid?
4
Which of the following is the maximum # of modifiers that the billing & coding specialists can use on a CMS-1500 claim form in Block 24D?
Ensure proper payment has been made
When the remittance advice is sent from the 3rd party payer to the provider, which of the following actions should the billing and coding specialists perform first?
Incorrectly linked codes
Which of the following would be a reason a claim would be denied?
The guidelines define items that are necessary to accurately code
The billing and coding specialists should follow the guidelines in the CPT manual for which of the following reasons?
operative report
Which of the following options is considered proper supportive documentation for reporting CPT & ICD codes for surgical procedures?
Block 27
Which of the following blocks on the CMS-1500 claim form is used to accept assignment of benefits?
Contractual allowance
Which of the following is an example of a remark code from an explanation of benefits document?
When an insurance company transfers data to allow coordination of benefits of a claim
Which of the following describes the term “crossover” as it relates to Medicare?
block 24j
Rendering Provider ID Number goes on what block on the CMS-1500 claim form?
The date of the last disclosure
Which of the following is included in the release of patient information?
History
Which of the following describes a key component of an evaluation & management service?
Aging report
Which of the following reports is used to arrange the accounts receivable from the date of service?
Medical standard of conduct
Which of the following best describes medical ethics?
Arthroscopy
An examination of a patient’s knee joint via small incisions & an optical device. Which of the following terms describes this procedure?
A product pending FDA approval is indicated as a lightning bolt symbol
Which of the following accurately describes code symbols found in the CPT manual?
3rd party payer
Which of the following describes an insurance carrier that pays the provider who rendered services to a patient?
Stark law
Which of the following prohibits a provider from referring Medicare patients to a clinical laboratory service in which the provider has a financial interest?
Electronic remittance advice
Which of the following electronic forms is used to post payments?
Remittance advice
For non-crossover claims, the billing & coding specialists should prepare an additional claim for the secondary payer & send it with a copy of which of the following?
18%
When coding a front torso burn, which of the following percentages should be coded?
block 21
Which of the following blocks of the CMS-1500 claim form indicates an ICD diagnosis code?
Billing provider
Which of the following national provider identifiers (NPIs) is required from block 33A of a CMS-1500 claim form?
services require additional information
Which of the following causes a claim to be suspended?
Left upper quadrant
Which of the following terms is used to describe the location of the stomach, the spleen, part of the pancreas, part of the liver, & part of the small & large intestines?
Attach the remittance advice from the primary insurance along with the Medicaid claim.
Which of the following actions should the billing and coding specialist take when submitting a claim to Medicaid for a patient who has primary & secondary coverage?
17b
National provider #
Signed release of information form
When a 3rd party payer requests copies of patient information related to a claim, the billing and coding specialists must make sure which of the following is included in the patient’s file?
Primary care provider
A patient who has an HMO insurance place needs to see a specialists for a specific problem. From which of the following should the patient obtain the referral?
Office inspector general
Which of the following organizations fights waste, fraud, and abuse in medicare and Medicaid?
The 3rd party payer reimburses the patient, and the patient is responsible for reimbursing the provider?
When submitting claims, which of the following is the outcome if block 13 is left blank?
The provider recieves payment directly from the payer
A billing & coding specialists is reviewing a CMS-1500 claim form. “The assignment of benefits box” has been checked “yes”. The checked box indicates which of the following?
0%
A bene
UROLOGIST
A _________________ would be the provider who would perform an orchiopexy
EVALUATION AND MANAGEMENT CODES
The first section of the CPT manual is the _________________________________.
ALLOWED AMOUNT
________________ means the amount of reimbursement an insurance payer and patient agrees to pay a provider.
PLACE OF SERVICE
A billing and coding specialist should determine first, the _________ to determine an appropriate e/m code.
LOWER RIGHT QUADRANT
The appendix is located in the _________________________ of the abdomen.
POLICY NUMBER
For a patient whose insurance coverage is from her partner, the ________________________ is required to bill her claim.
V CODE
An exposure to tuberculosis requires a __________________________.
GUARANTOR INFORMATION
A billing and coding specialist should use ___________________________________ when transmitting a claim for a minor without health insurance.
OFFICE OF THE INSPECTOR GENERAL
The ________________________ investigates cases of fraud and prepares a referral for prosecution.
CLEAN CLAIM
An insurance claim is considered a __________________ when further reviewed by the insurance company, is not necessary before submitting the claim.
PERFORM INTERNAL AUDITS TO MONITOR THE BILLING PROCESS
A billing and coding specialist should ____________________________________________to identify areas of risk associated with billing compliance.
THE BODY MAINTAINS NORMAL BALANCE AND FUNCTION
When _______________________________, then it is said to be in a state of homeostasis.
ANSI ASC X12 837
The _______________________ is an example of an electronic claim format.
PATIENT’S DEDUCTIBLE
The ___________________________________information is included in an electronic remittance advice.
EXCISION
The provider performed an _________ if a lesion needed to be removed with no pathology report and the billing and coding specialist is coding from the integumentary system.
SHOULD EMAIL AN ELECTRONIC FILE FORMAT OF THE SUPPORTING DOCUMENT
If a supporting document is to be submitted to the payer for a particular electronic claim the coding and billing specialist _____________.
OFFICE OF THE INSPECTOR GENERAL (OIG)
The ________________________________is tasked to conduct investigations and audits regarding patient privacy violations.
SERVICE FACILITY LOCATION
On the CMS 1500 form the provider’s name and address should be placed in the block for _______________________________________by the billing and coding specialist filling out the form for a satellite office.
CPT CODING MANUAL
The code 99214 place in the CMS 1500 form is found in the _______________________ .
WORLD HEALTH ORGANIZATION
The ICD codes were initiated by the ___________________________.
E000
The supplemental classification of causes of injury and poisoning begins with the alphanumeric codes ____________.
ABN FORM
The __________ is required for a Medicare non-covered procedure.
THE PAYMENT AMOUNT EQUALS THE BILLED AMOUNT
In an explanation of benefits (EOB), _______________________________.
CALLING PATIENT BY INSURANCE NAME
The billing and coding specialist is allowed to make an incidental disclosure within HIPAA guidelines by ______________________________.
ABN FORM
The patient signs an ____________ when a -GA modifier is used on a patient claim
NOTIFY THE PROVIDER
If an abuse occurs the billing and coding specialist should ____________________________.
MEDICAL NECESSITY
The code linkage in the charge capture process should be verified to ensure that there is __________________________.
TO ASSIST PROVIDERS WITH PREVENTING HEALTH CARE FRAUD AND ABUSE
The primary purpose of HIPAA is ___________________________________________.
NAME OF REFERRING PHYSICIAN OR OTHER SOURCE
The ___________________ in the CMS 1500 form can be left blank and still result in a clean claim.
INSURANCE CARD
During an initial visit, the ________________ of the patient should be collected.
CENTERS FOR MEDICARE AND MEDICAID SERVICES
The ________________________________________sets the standards applicable to private insurance through its proposed and final rules
EXPIRATION DATE
The release of Information form always includes the ______________________________.
CREDIT COLUMN
When posting the payment to an account, an insurance payment should be recorded on the __________________________.
STONE IN THE GALLBLADDER
Cholelithiasis is associated with _________________ causing abdominal pain.
DATE OF SERVICE
A billing and coding specialist working on an aging report within the payer area should sort next by _____________________________.
UNITS OF SERVICE
No data on the _________________________ could delay claim processing.
SUPERIOR
The terminology when coding a directional area is ___________________.
RHINOPLASTY
A patient with nasal deformity undergoes ___________________.
THE ADJUSTMENT AMOUNT IS $75
Office Visit allowed amount is $175. Co-payment is $15. The insurance paid $85. ______________________________________.
KIDNEY STONES
Nephrolithiasis is associated with ________________________.
NPI OF THE PROVIDER WHO PROVIDED THE SERVICE
The _______________________________ is the billing provider NPI.
DEDUCTIBLE
______________ is the amount that the patient is responsible for before insurance provides coverage.
EXAMPLE OF EDI
An _________________________ is the exchange of personal health information via a standardized format through computer systems.
EXAMPLE OF FRAUD
An _________________________ is when a service not undertaken or done in an appointment is billed to the insurance company.
EMERGENCY ROOM CHARGES
Medicare Part B covers _____________________________________.
CLAIMS SHOULD BE MAILED
_____________________________________ if the practice management software is not able to transmit claims electronically.
GASTROENTEROLOGIST
An endoscopy is performed by a ___________________.
THE PAYMENTS SHOULD BE APPLIED
After the billing and coding specialist receives an EOB, _____________________________________.
AN INFECTION FOLLOWING A SNAKEBITE
______________________________ is coded using an E code.
AN EMANCIPATED MINOR
_____________________________________ is a patient under 18 years who is qualified to sign a consent form.
AN EXAMPLE OF ABUSE
_____________________________________ is billing a Medicare patient using a higher fee schedule than a non-Medicare patient.
DHHS
The _____________ is the government agency that has launched a website where consumers can find sources of public and private insurance coverage.
A RUNNING BALANCE
If several patients have outstanding balances of greater than 90 days, _______________________ will determine the outstanding balances.
A CREDIT
A payment by the third party payer which is more than the estimated amount is entered as __________________.
ADD THE REQUIRED INFORMATION AND RETRANSMIT THE CLAIM
If a service or procedure charge is denied by the insurance company, the billing and coding specialist should ____________________________.
AT THE TIME THE APPOINTMENT IS MADE
The physician-patient impled contract begins _____________________________________.
MM DD YYYY
The DOB format on the CMS-1500 form is _____________________.
INSURANCE COMPANY FILE
When appealing for a claim, the contact information can be found in the ________________________________.
RELEASE OF INFORMATION FORM
The _________________________________________________should be signed before the release of documentation to a third-party payer
HE/SHE DOES NOT HAVE A PCP
If a new patient has a PPO, he/ she should pay out-of-pocket if ______________________________.
COLLECTING INSURANCE INFORMATION
The first step in the life cycle of a claim is _____________________________________.
OFFICE OUTPATIENT CLAIMS
The CMS-1500 claim form is used for _____________________________________.
PROCEDURES ARE NOT MEDICALLY NECESSARY
Other than a processing error, claims can be denied because the ________________________.
THE NATIONAL CORRECT CODING INITIATIVE
______________________________________ publishes the coding rules for Medicare and Medicaid.
123456789A
THe Medicare ID number 123456789A should be entered in Block 1a in the CMS-1500 form as: ______________________________________.
A PREAUTHORIZATION
______________________________________ is needed for a sinus procedure with an HMO.
SHOULD SUBMIT A NEW CLAIM TO THE CORRECT INSURANCE CARRIER
When a patient is found ineligible and a denied claim is returned to the provider, the billing and coding specialist ____________________________.
MANAGED CARE CONTRACT
If a third-party payer is awarded a ___________________________________ by the CMS, a provider can submit a claim to this third-party payer.
ENTERING ALL INFORMATION IN UPPERCASE LETTERS
______________________________________ is the appropriate way to key in information in a form for ICR scanning.
AN OBSTETRICIAN
______________________________________ provides patient care for a full-term delivery of a healthy infant.
TO FIND THE MAIN TERM IN THE DIAGNOSTIC STATEMENT LOCATED IN VOLUME 2
The most direct way of looking up an ICD code is _________________________________________________.
POLICY NUMBER
The field “Insureds ID Number” in the CMS-1500 form is ______________________________________.
INSURANCE CLAIMS REGISTER
The billing and coding specialist should use an ______________________________________ to keep track of the status of each claim that is billed.
FEWER ERRORS AND DENIALS
______________________________________ is one advantage of electronic claims.
THE PATIENT’S PRIVATE INSURANCE
A patient who was injured while working as a subcontractor should file a claim with _________________________________________.
MEMBER CONTRACT
After the CMS-1500 form, the next most important source of financial information about a patient is the _______________________________.
ASSIGNMENT OF BENEFITS
A patient should sign the __________________ so the provider can be paid.
IF SERVICES WERE NOT PREAUTHORIZED
______________________________________, a Medicare form may be denied.
12 MONTHS FROM THE DATE OF SERVICE
Medicare claims should be submitted within ______________________________________.
THE OFFICE OF WORKER’S COMPENSATION
______________________________________ is a state-mandated third-party payer.
CONTACT THE INSURANCE PAYER
______________________________________ to verify a patient’s co-payment amount.
TRENDS OF NONPAYMENT BY THE INSURANCE PAYER
The aging report also informs the billing and coding specialist _____________________________ aside from immediate claims pending.
TYPE OF PAYER
Aging reports should be sorted out by ______________________________________.
STANDARD, EXTRA, AND PRIME
The three types of plans covered under TRICARE programs are_________________________________.
AMBULATORY CARE CENTER
______________________________________ is where a patient undergoes a surgical procedure and returns home the same day
AN INFORMED CONSENT
______________________________________ is required before an appendectomy is performed.
AN AGING REPORT
______________________________________ is used to review and track balances from an insurance company by date of service.
A REVIEW BY THE OFFICE OF THE INSPECTOR GENERAL
A provider committing abuse could result in _____________________________________________.
VERIFY THE COORDINATION OF BENEFITS
If a balance remains on a patient’s account who has insurance from her employer and from her spouse, the billing and coding specialist should ___________________________________________.
THE RECOVERY AUDIT CONTRACTORS
____________________________________________________work with the CMS to prevent overpayment.
AN OMISSION OF THE DIAGNOSIS CODE
________________________________________ in the claim form can prevent a clean claim.
SHOULD DISCUSS POTENTIAL CODING PROBLEMS WITH THE PROVIDER AT LEAST ONCE A YEAR.
To prevent fraud and abuse, a billing and coding specialist_________________________________________.
THE REMITTANCE ADVICE (RA)
______________________________________ contains the information regarding payments received for the dates of service provided.
THE DEDUCTIBLE
On the first office visit of the year, __________________________ should be collected first from the patient.
HMO
A provider accepts pre-established payments from an ________.
LOW BLOOD OXYGEN LEVEL
A bluish discoloration of the skin is usually associated with ______________________________.
CPT AND ICD CODES
To process a medical claim, the______________________ are always required.
A RETROSPECTIVE AUDIT
______________________________________ is performed after a payment is sent to a third-party payer.
INDIVIDUAL HEALTH INSURANCES
Medicaid Medicare and Tricare are examples of ______________________________________.
COMPLETE THE CMS-1500 WITH A COMPUTER
When submitting a hard copy of the CMS-1500 form ______________________________________.
BLOCK 24J OF THE CMS-1500 FORM SHOULD BE LEFT BLANK
If a provider does not have an NPI, ______________________________________.
FAMILY OF ACTIVE DUTY SERVICE PERSONNEL
______________________________________ is eligible for TRICARE Prime.
SHOULD BE ENTERED AS A WRITE OFF
If the patient’s payment is uncollectible, the amount ______________________________________ on the patient’s ledger.
THE E CODE ON ACCIDENT DUE TO NATURAL AND ENVIRONMENTAL FACTORS
______________________________________ should be used to code a patient’s fall in his yard at home and consequently breaks his arm.
USE OF AN INSURANCE CLAIMS REGISTER
______________________________________ ensures that all claims are being submitted and received.
TABULAR LIST OF DISEASES
The final ICD code is chosen from the ______________________________________.
TO MONITOR CODING ACCURACY
Clearinghouse audits of medical records by insurance carriers are used ______________________________________.
ENDOCRINOLOGIST
A patient with thyroid issues should be referred to an ______________________________________ .
DURING THE GLOBAL PERIOD
______________________________________ all services related to a surgical procedure or not additionally reimbursed under CPT guidelines.
CURRENT PROCEDURAL TERMINOLOGY
The healthcare common procedure coding system (HCPCS) manual includes the ______________________________________.
PATIENT IS RESPONSIBLE FOR $40
Provider billed Medicare for $360. The allowable amount is $200. ______________________________________.
EXCLUSIONS
Some third party payers withhold from coverage ___________________________.
THE PROVIDER RECEIVES THE PAYMENT
______________________________________ when the patient signs the assignment of benefits block on the CMS-1500 form
THE BILLING AND CODING SPECIALIST SHOULD CODE THE RIGHT TIBIA FRACTURE SECOND
A patient has a right tibia fracture and receives a cast upon x-ray the patient is also diagnosed tumor on his right patella patient is admitted to the facility for further treatment. ___________________________________________________.
THE INSURANCE CARRIER WILL DENY THE CLAIM
If a provider continues with a patient’s appointment despite an expired pre-authorization, ______________________________________.
PREDETERMINATION
______________________________________ is the process a payer to determine if a claim should be paid.
AN ADD ON CODE
______________________________________ is indicated buy a + sign per CPT-4 coding conventions.
VALID FOR A MAXIMUM OF 90 DAYS
A patient’s authorization for release of information is ______________________________________.
SUPPLEMENTAL DIAGNOSIS CODE
The V code is a ______________________________________.
THE NEXT STEP IS TO FILE AN APPEAL
When a claim is denied, ______________________________________.
FLASH SYMBOL
THE _______________IS USED FOR PROCEEDURES WHICH ARE PENDING FDA APPROVAL
FIRST LISTED DIAGNOSIS
IN THE OUTPATIENT SETTING ____________IS USED
Medical Ethics
Standards of conduct based on moral principals. Acting within ethical behavior boundries means carrying out one’s responsibilities with integrity, decency, respect, honesty, competence, fairness and trust.
Compliance Regulations
Most billing related cases are based on HIPAA and the False Claims Act.
HIPAA is an acronym for
Health Insurance Portability and Accountability Act of 1996.
Category 1 CPT codes
Medical Procedures.
Category 2 CPT codes
Supplemental Codes for Performance Measures.
Category 3 CPT codes
Emerging Technologies.
Add on Codes
Used for procedures that are always performed during the same operative session, as another surgery in addition to the primary service/procedure and is never performed separately.
Anesthesia is found
00100-01999, 99100-99140.
Evaluation and Management (E&M) codes
Are listed first in the CPT manual because they are used by all the different specialties.
Brackets
Used to enclose synonyms, alternative wording or and explanatory phrase.
Bullets
Represents a new procedure or service code added since the previous edition of the manual.
Chief Complaint (CC)
The reason the patient came to see the physician.
Circle with a line through it (🚫)
Exemption from modifier 51.
CPT
Used to report services and procedures by physicians.
E&M codes
99201-99499
Guidelines are found
At the beginning of each section and used to provide specific coding rules for that section.
History (HX)
The set of information the physician gathers from the patient concerning his/her past.
History of Present Illness (HPI)
A chronological account of the development of the complaint from the first sign or symptom that the patient experienced to the present.
Indented Codes
Listed under associate and stand alone codes.
E Codes
For durable medical equipment for use in home.
Level 1 codes
Codes found in the CPT manual.
Level 2 codes
National codes for the physician and non-physician service not found in the CPT Level 1.
Level 3 codes
Used locally or regionally and have been eliminated by the CMS since the implementation of HIPAA.
The List of Modifiers is found where in the CPT
Appendix A and in the front of the book.
Modifier 50
Bilateral procedure.
Modifier 24
Attach to E/M service code when service is provided during postoperative period to indicate that the service is not part of postoperative care and not included in the Surgical Package.
Modifier 26
Provider only provided the professional component.
Modifier 51
Used more than one procedure during the same surgical episode.
Modifier 57
Modifier 57 is used on E/M services the day before or day of major surgery when the initial decision to perform the surgery is identified.
Modifier 78
Physician must return to Operating Room to address complication stemming from initial procedure.
Modifier 79
Procedure or service provided during postoperative period not associated with initial procedure.
Modifiers
Reporting indicators that indicate that the procedure or service has been altered by specific circumstance but has not changed in it’s definition of code.
Parentheses
Used to enclose supplementary words, non-essential modifiers.
Past, Family and Social History (PFSH)
Consists of patients personal experiences with illnesses, surgeries, and injuries; Information of illnesses predominant in family’ Patients educational background, occupation, marital status and other factors.
Pathology and Laboratory
80048-89356.
Plus sign indicates (➕)
Add on codes.
Radiology
77010-79999.
Review of Symptoms (ROS)
Inventory of the constitutional symptoms regarding the various body systems.
Stand Alone Codes
Contain full description to the procedure for a code.
Sideways triangle means ( ▶️ )
Change in wording between triangles.
Bullet means
New procedure codes.
Circle with a line through it means
Modifier 51 exempt code.
Six sections of CPT
E&M, Anatomical Site, Condition or Disease, Synonym or Eponym, Abbreviation.
Three Components for E&M Codes
1.History, 2.Physical Exam, and 3.Medical Decision-Making.
Three Categories for E&M Codes
Category I: Procedures that are consistent with contemporary medical practice and are widely performed. Category II: Supplementary tracking used for performance measures. Category III: Temporary codes for emerging technology, services and procedures.
4 contributing factors for E&M Codes
New or existing patient, History, Physical Exam, Medical Decision making, Time spent can be a 5th factor.
Medicare Part A
Part A is hospital insurance provided by Medicare. Most people do not pay a premium for this coverage.
Medicare Part B
Part B is medical insurance to pay for medically necessary services and supplies provided by Medicare. (Doctors, Outpatient care, Physical and Occupational Therapist, etc.)
Medicare Part C
Part C is the combination of Part A and B. The main difference in Part C is that it is provided through private insurance companies approved by Medicare.
Medicare Part D
Part D is stand-alone prescription drug coverage insurance.
Medicaid
Free or low-cost health insurance coverage through the state.
Medicaid categorically needy
A distinction for individuals who fall into a specific category (or criteria) of mandatory Medicaid eligibility established by the federal government. These categories apply to every state Medicaid program.
Medicaid Medically Needy
Provide Medicaid to certain groups not otherwise eligible for Medicaid, must cover: ▪️Pregnant women ▪️Children under 18: States have option to cover: ▪️Children up to 21 ▪️ Parents and other caretaker relatives ▪️ Elderly ▪️ Individuals with disabilities.
Who is the Payer of Last Resort
Medicaid is always the payer of last resort.
Tricare
Health care program for Uniformed Service members, retirees and their families.
Tricare Standard
Option that provides the most flexibility to TRICARE-eligible beneficiaries. It is the fee-for-service option that gives beneficiaries the opportunities to see any TRICARE-authorized provider.
Tricare Extra (PPO)
A preferred provider option, rather than an annual fee, a yearly deductible is charged. Health care is delivered through a network of civilian health care providers who accept payments from CHAMPUS and provide services at negotiated, discounted rates.
Tricare Prime (HMO)
An HMO type plan in which enrollees receive health care through a Military Treatment Facilities PCM or a supporting network of civilian providers.
CHAMPVA
Comprehensive health care program in which the VA shares the cost of covered health care services and supplies with eligible beneficiaries.
Private payer vs Commercial payer
Private individuals are responsible for securing their own health insurance coverage. Commercial Government, Employer, Group health insurance coverage.
Group Health Plans
An insurance plan that provides healthcare coverage to a select group of people. Group health insurance plans are one of the benefits offered by many employers. These are generally uniform in nature, offering the same benefits to all members of group.
Indemnity Insurance
Health indemnity insurance is a fee for service insurance that is sometimes used when a person is in between health plans, and will cover some (but not all) expenses.
HMO
Health Maintenance Organization. A form of health insurance combining a range of coverages in a group basis. A group of doctors and other medical professionals offer care through the HMO for a flat monthly rate with no deductibles.
PPO
PPO is similar to an HMO, but care is paid for as received instead of in advance in form of a schedule. PPOs may offer more flexibility by allowing for visits to out-of-network professionals. Visits within network require only the payment of a small fee.
Point of Service
Feature of an insurance plan that allows a patient to choose between in-network care and out-of-network care every time he or she sees a doctor. The patient is allowed the freedom to go to whichever doctor is most convenient, although the cost will vary.
Disability Insurance
Policyholder becomes incapable of working.
Workman’s Comp
Workman’s compensation is a job benefit that provides money and services to employees that are injured or become sick on the job. Woker’s comp helps injured and sick workers to survive financially as they recover from health problems.
Usual Customary and Reasonable
Refer to the base amount that is treated as the standard or most common charge for a particular medical service when rendered in a particular geographic area.
Relative Value Payment Method
The payment amount for each service paid under the physician fee schedule is the product of three factors; a nationally uniform relative value for service; a geographic adjustment factor (GAF); a nationally uniform conversion factor for the service.
Medicare Resource Based Relative Value Unit (RVU) Payments/Components
The schedule assigns certain values to procedures/costs based upon Total RVUs. The total consists of three components; work, practice expense, and malpractice. Medicare adjusts payment by geographic price cost index (GPCI) and pays depending on locale.
Clean Claim
A completed insurance claim form submitted with the program time limit that contains all the necessary information without deficiencies so it can be processed and paid promptly.
Dirty Claim
A claim submitted with errors or one that requires manual processing to resolve problems or is rejected for payment.
Invalid Claim
Any Medicare claim that contains complete, necessary information but is illogical or incorrect (e.g., listing an incorrect provider member for a referring physician). Invalid claims re identified to the provider and may be resubmitted.
Rejected Claim
A rejected claim is an electronically submitted claim that is unprocessable due to missing or invalid information required by the payer.
ABN/Advance Beneficiary Notice
A notice that a doctor, supplier, or provider gives a Medicare beneficiary before furnishing an item or service if the doctor, supplier, or provider believes that Medicare may deny payment.
Paper Claims/CMS 1500
An insurance claim submitted on paper, including those optically scanned and converted to an electronic form by the insurance carrier.
Electronic Claim
An insurance claim submitted to the insurance carrier via a central processing unit (CPU), tape, diskette, direct data entry, direct wire, dial-in telephone, digital fax, or personal computer download or upload.
CMS 1500 Universal Claim Form
Developed by the AMA and the Centers for Medicare and Medicaid Services (CMS). Used by physicians and other professionals to bill outpatient services and supplies to Tricare, Medicare, some Medicaid programs and some private insurance/managed care plans.
Basic Billing Reimbursement Steps
Patient Info, Verify Ins. Prepare encounter form, Code DX & CPT, Review Linkage Protocol, Calculate physicians charges, Prepare claim, Transmit claim, Follow up on Reimbursement.
Review Linkage Protocol
Appropriateness of Codes, Payers rules about linkage, Documentation to support codes, Compliance with regulation and guidelines.
Life Cycle of a Claim
Submission, Processing, Adjudication, Non-covered, Unauthorized, Medical Necessity Checks, Payment/RA/ERA.
What does Mac stand for
Medicare Administrative Contractor
Complication
” A condition that develops after, the outpatient care has been provided or during an inpatient admission.”
Comorbidity
” A concurrent condition that coexists with the first-listed diagnosis or principle diagnosis, has potential to affect treatment of the aforementioned diagnosis and is an active condition for which the patient is treated and/or monitored.”
Preauthorization
The process by which the provider contacts the insurance carrier to see if the proposed procedure is covered by a specific patients insurance policy.
Accounts Receivable (A/R)
Monies or Funds that are owed to the practice for services provided.
Accounts Payable (A/P)
Monies being paid from the medical practice, for instance to pay for supplies, rent, utilities, payroll, etc.
Hypertension, Neoplasm, and Table of Drugs and Chemicals
What are the names of the three tables that appear in the Index to Diseases?
Remittance Advice
The explanation of payments received from the insurance company is often referred to or called the __.
Balance Billing
Billing a patient for the difference between a higher usual fee and a lower allowed charge is called __.
Medicare
_ is the national health insurance program for Americans aged 65 and older.
Medicaid “payer of last resort”
A health-benefit program designed for low-income, blind, or disabled patients; needy families; foster children; and children born with birth defects.
What is the single largest healthcare program in the United States?
Medicare
Affordable Care Act (ACA)
Signed into law in 2010, an act that resulted in improved access to affordable healthcare coverage and protection from abusive practices by healthcare insurance companies is what?
Guarantor
Person who is responsible for a patients debt is called?
Medigap
Medicare beneficiaries can also obtain supplemental insurance called what?
What does Medigap do?
Helps cover costs not reimbursed by the original Medicare plan.
Subpoena
A writ requiring the appearance of a person at a trial or other proceeding is a _.
When does the tertiary insurance pay?
After the primary and secondary insurers.
Health Common Procedure Coding System (HCPCS)
A numeric and alphabetic coding system used for billing/pricing of procedures, medical supplies, medications, and durable medical equipment (DME).
Preferred Provider Organization (PPO)
A managed care organization that establishes a network of providers who care for their patients is called a/an _.
Clearinghouse
A group that takes nonstandard medical billing software formats and translates them into the standard Electronic Data Interchange (EDI) formats is called a/an?
Deductible
The out-of-pocket payment amount that a policyholder must meet before insurance covers the service(s) is called?
National Provider Identifier (NPI) number
A unique 10-digit number assigned to providers in the U.S. to identify themselves in all HIPAA transactions.
What is a capitation?
A payment structure in which a health maintenance organization prepares an annual set fee per patient to a physician.
Copayment
A fixed fee collected at the time of the patient’s visit.
Coinsurance
A fixed percentage of covered charges applied to the patients bill after the deductible has been met.
Premium
The charge for keeping the insurance policy in effect.
Abuse
Coding and billing that is inconsistent with typical coding and billing practices.
How does HIPAA define fraud?
An intentional deception of misrepresentation.
Intent
“The difference between fraud and abuse is __.”
Current Procedural Terminology (CPT) codes
Numeric codes developed by the American Medical Association (AMA) to standardize medical services and procedures.
Is abuse intentional?
No
Roster Billing
What simplified process was developed to enable Medicare beneficiaries to participate in mass pneumococcal pneumonia virus (PPV) and influenza virus vaccination programs offered by public health clinics.
Claimant
A person filing an appeal is called?
Liability Insurance
Covers injuries caused by insured that occurred on the insured’s property.
Remittance Advice (RA)
A detailed accounting of the claims for which payment is being made by an insurance company. The __ accompanies the payment from the insurance company.
Assignment of Benefits
Authorization by a policyholder that allows a payer to pay benefits directly to a provider is called?
Inpatient
A/An _ is a person admitted to a hospital or long-term care facility (LTCF) for treatment with the expectation that the patient will remain in the hospital for a period of 24 hours or more.
What is confidentiality?
Involves restricting patient information access to those with proper authorization and maintaining the security of patient information.
Principal diagnosis
The first listed diagnosis can also be referred to as __.
Participating Providers
Physicians who enroll in managed care plans are called __. They have contracts with Managed Care Organizations (MCO)s that stipulate their fees.
Compliance Plan
A formal, written document that describes how the hospital or physician’s practice ensures rules, regulations, and standards that are being followed is known as a/an _.
The Medicare Catastrophic Coverage Act of 1988
What act mandated the reporting of ICD-9-CM diagnosis codes?
Electronic Data interchange (EDI)
Transmitting electronic medical insurance claims from providers to payers using the necessary information systems is called _.
Malignant
“A severe form of hypertension with vascular damage and a diastolic pressure reading of 130 mm hg or greater.”
Benign
“Mild and/or controlled hypertension, with no damage to the patient’s vascular system or organs.”
Unspecified
“No notation of benign or malignant status is found in the diagnosis or in the patient’s chart.”
Comorbidities and Complications
For Inpatient coding, the initials CC mean?
Insurance
What does policy mean?
Payer
A person who receives a check in payment is the _.
Policyholder
Insurer/Insured, Subscriber, Member, Recipient are all terms that apply to the?
True or False, Preferred Provider Organizations (PPO)s never allow members to receive care from physicians outside the network.
False, Policyholders may choose to go out of network, but the may have to pay greater expenses.
Confidential
Everything a medical claims specialist learns about a patient’s condition must remain.
Which of the following electronic forms is used to post payments?
Electronic remittance advice (ERA)
If a clean claim is received March 1 of this year, which of the following is the allowable last day of payment in order to meet Medicare compliance requirements?
March 30
Threading a catheter with balloon into a coronary artery and expanding it to repair arteries describes which of the following procedures?
Angioplasty
The authorization number for a service that was approved before the service was rendered is indicated in which of the following blocks on the CMS-1500 claim form?
Block 23
Which of the following blocks of the CMS-1500 claim form indicates an ICD diagnosis code?
Block 21
A patient who has an HMO insurance plan needs to see a specialist for a specific problem. From which of the following should the patient obtain an referral?
Primary Care Provider
A provider surgically punctures through the space between the patient’s ribs using an aspirating needle to withdraw fluid from the chest cavity. Which of the following is the name of this procedure?
Pleurocentesis
Which of the following standardized formats are used in the electronic filing of claims?
HIPAA standard transactions
Which of the following blocks on the CMS-1500 claim form is used to accept assignment of benefit?
Block 27
On the CMS-1500 claim form, blocks 14 through 33 contain information about which of the following?
The patient’s condition and the provider’s information
The explanation of benefits states the amount billed was $80. The allowed amount is $60, and the patient is required to pay a $20 copayment. Which of the following describes the insurance check amount to be posted?
$40
Which of the following should a billing coding specialist use to submit a claim with supporting documents?
Claims Attachment
When reviewing an established patient’s insurance card, the billing and coding specialist notices a minor change from the existing card on file. Which of the following actions should the billing and coding specialist take?
Photo copy both sides of the card
Which of the following accurately describes code symbols found in the CPT manual?
A product pending FDA approval is indicated as a lightning-bolt symbol
Which of the following Medicare policies determines if a particular item or service is covered by Medicare?
National Coverage Determination (NCD)
Which of the following options is considered proper supportive documentation for reporting CPT and ICD codes for surgical procedures? *
Operative report
Which of the following is an example of a remark code from an explanation of benefits document?
Contractual allowance
Which of the following forms should the billing and coding specialist transmit to the insurance carrier for reimbursement of inpatient hospital services?
UB-04
A claim is denied due to termination of coverage. Which of the following actions should the billing and coding specialist take next?
Follow up with the patient to determine current name, address, and insurance carrier for resubmission
Which of the following national provider identifiers (NPIs) is required in Block 33a of a CMS-1500 claim form?
Billing provider
Which of the following is a reason a claim would be denied?
Incorrectly linked codes
The unlisted codes can be found in which locations in the CPT manual?
The guidelines prior to each section
When the remittance advice is sent from the third-party payer to the provider, which of the following actions should the billing and coding specialist perform first?
Ensure proper payment has been made
Which of the following symbols indicates a revised code?
Triangle
Which of the following terms is used to describe the location of the stomach, the spleen, part of the pancreas, part of the liver, and part of the small and large intestines?
Left Upper Quadrant
When coding a front torso burn, which of the following percentages should be coded?
18%
Which of the following is true regarding Medicaid eligibility?
Patient eligibility is determined monthly
Which of the following describes a key component of an evaluation and management service?
History
Which of the following is considered fraud?
The billing and coding specialist unbundles a code to receive higher reimbursement
Which of the following is an example of Medicare abuse?
Charging Excessive fees
Which of the following privacy measures ensures protected health information (PHI)?
Using data encryption software on office workstations
Which of the following organizations fights waste, fraud, and abuse in Medicare and Medicaid?
Office of Inspector General (OIG)
A billing and coding specialist should routinely analyze which of the following to determine the number of outstanding claims?
Aging Report
Which of the following parts of the Medicare insurance program is managed by private, third-party insurance providers that have been approved by Medicare?
Part C
A patient’s st employer has not submitted a premium payment. Which of the following claim statuses should the provider receive from the third-party payer?
Denied
Which of the following blocks should the billing and coding specialist complete on the CMS-1500 claim form for procedures, services or supplies?
Block 24 D
Which of the following forms does a third-party payer require for physician services?
CMS-1500
Which of the following reports is used to arrange the accounts receivable from the date of service?
Aging Report
Which of the following provisions ensures that an insured’s benefits from all insurance companies do not exceed 100% of allowable medical expenses? *
Coordination of Benefits
A physician’s office fee is $100 and the Medicare Part B allowed amount is $85. Assuming the beneficiary has not met his annual deductible, the office should bill the patient for which of the following amounts?
$85
Which of the following statements is accurate regarding the diagnostic codes in Block 21?
These codes must correspond to the diagnosis pointer in block 24E
Which of the following describes an insurance carrier that pays the provider who rendered services to a patient?
Third-party payer
Which of the following formats are used to submit electronic claims to a third-party payer?
837
Which of the following entities defines the essential elements of a comprehensive compliance program?
Office of Inspector General (OIG)
Which of the following causes a claim to be suspended?
Services require additional information
A Medicare non-partcipating (non-PAR) provider’s approved payment amount is $200 for a lobectomy and the deductible has been met. Which of the following amounts is the limiting charge for this procedure?
$230
For non-crossover claims, the billing and coding specialist should prepare an additional claim for the secondary payer and send it with a copy of which of the following?
Remittance Advice
As of April 1, 2014, what is the maximum number of diagnoses that can be reported on the CMS-1500 claim form before a further claim is required?
12
On a CMS-1500 claim form, which of the following information should the billing and coding specialist enter into Block 32?
Service facility location information
Which of the following best describes medical ethics?
Medical standard of conduct
A patient has AARP as secondary insurance. In which of the following blocks on the CMS-1500 claim form should this information be entered?
Block 9
A billing and coding specialist can ensure appropriate insurance coverage for an outpatient procedure by first using which of the following processes?
Precertification
When a third-party payer requests copies of patient information related to a claim, the billing and coding specialist must make sure which of the following is included in the patient’s file?
Signed release of information form
In the anesthesia section of the CPT manual, which of the following are considered qualifying circumstances?
Add-on codes
Which of the following describes the term “crossover” as it relates to Medicare?
When an insurance company transfers data to allow coordination of benefits of a claim
A provider performs an examination of a patient’s knee joint via small incisions and an optical device. Which of the following terms describes this procedure?
Arthroscopy
Which of the following qualifies as an exception to the HIPAA Privacy rule?
Psychotherapy notes
A patient has laboratory work done in the emergency department after an inhalation of toxic fumes from a faulty exhause fan at her palce of employment. Which of the following is responsible for the charges?
Workers’ compensation
If both parents have full coverage for a dependent child, which of the following is considered to be the primary insurance?
The parent whose birthdate comes first in the calendar year is the primary insurance holder
Which of the following describes the organization of an aging report?
By Date
Which of the following actions by the billing and coding specialist prevents fraud?
Performing periodic audits
A billing and coding specialist has four past-due charges: $400 that is 10 weeks past due; $800 that is 6 weeks past due; $1,000 that is 4 weeks past due; and $2,000 that is 8 weeks past due. Which of the following charges should be sent to collections first?
$2000
Which of the following is a federal government health insurance program?
TRICARE
A patient who is an active member of the military recently returned from overseas and is in need of specialty care. The patient does not have anyone designated with power of attorney. Which of the following is considered a HIPAA violation?
The billing and coding specialist sends the patient’s records to the patient’s partner
Which of the following documentation is a valid authorization to release medical information to the judicial system?
Supoena duces tecum
The EOB states the amount billed was $170. However, the allowed amount is $150. The patient has an unmet deductible of $50 and a copayment of $20. Which of the following amounts is the patient’s responsibility?
$70
Which of the following is the primary function of the heart?
Pumping blood in the circulatory system
Which of the following is used to code diseases, injuries, impairments, and other health related problems?
ICD
A husband and wife each have group insurance through their employers. The wife has an appointment with her provider. Which insurance should be used as primary for the appointment?
The wife’s insurance
Which of the following is the deadline for Medicare claim submission?
12 months from the date of service
Which of the following prohibits a provider from referring Medicare patients to a clinical laboratory service in which the provider has a financial interest?
Stark Law
Which of the following terms refers to the difference between the billed and allowed amounts?
Adjustment
A patient is preauthorized to receive vitamin B12 injections from January 1 to May 31. On June 2, the provider orders an additional 6 month of injections. In order for the patient to continue with coverage of care, which of the following should occur?
The provider should contact the patient’s insurance carrier to obtain a new authorization
The “><” symbol is used to indicate new and revised text other than which of the following?
Procedure descriptors
Which of the following pieces of guarantor information is required when establishing a patient’s financial record?
Phone number
Which of the following is a HIPAA compliance guideline affecting electronic health records?
The electronic transmission and code set standards require every provider to use the healthcare transactions, code sets, and identifiers
Which of the following would result in a claim being denied?
An italicized code used as the first listed diagnosis
Urine moves from the kidneys to the bladder through which of the following parts of the body?
Ureters
Which of the following sections of the SOAP note indicates a patient’s level of pain to a provider?
Subjective
Which of the following actions by a billing and coding specialist would be considered fraud?
Billing for services not provided
Which of the following HMO managed care services requires a referral?
Durable medical equipment
The billing and coding specialist should follow the guidelines in the CPT manual for which of the following reasons?
The guidelines define items that are necessary to accurately code
Which of the following explains why Medicare will deny a particular service or procedure?
Advance Beneficiary Notice (ABN)
A provider’s office receives a subpoena requesting medical documentation from a patient’s medical record. After confirming the correct authorization, which of the following actions should the billing and coding specialist take?
Send the medical information pertaining to the dates of service requested
Which of the following is included in the release of patient information?
The date of last disclosure
Which of the following actions should the billing and coding specialist take when submitting a claim to Medicaid for a patient who has primary and secondary insurance coverage?
Attach the remittance advice from the primary insurance along with the Medicaid claim
Which of the following terms is used to communicate why a claim line item was denied or paid differently than it was billed?
Claim adjustment codes
A patient who has a primary malignant neoplasm of the lung should be referred to which of the following specialists?
Pulmonary Oncologist
Which of the following describes a two-digit CPT code used to indicate that the provider supervised and interpreted a radiology procedure?
Professional component
In 1996, CMS implemented which of the following to detect inappropriate and improper codes?
National Correct Code Initiative (NCCI)
Which of the following planes divide the body into left and right?
Sagittal
A billing and coding specialist is preparing a claim form for a provider from a group practice. The billing and coding specialist should enter the rendering provider’s NPI into which of the following block on the CMS-1500 claim form?
Block 24J
Which of the following would most likely result in a denial on a Medicare claim?
An experimental chemotherapy medication for a patient who has stage III renal cancer
On a remittance advice form, which of the following is responsible for writing off the difference between the amount billed and the amount allowed by the agreement?
Provider
A billing and coding specialist submitted a claim to Medicare electronically. No errors were found by the billing software or clearing house. Which of the following describes the claim?
Clean Claim
Which of the following is the purpose of coordination of benefits?
Prevent multiple insurers from paying benefits covered by other policies
Which of the following does a patient sign to allow payment of claims directly to the provider?
Assignment of Benefits
Which of the following is the maximum number of modifiers that the billing and coding specialist can report on a CMS-1500 claim form in block 24D?
4
In which of the following blocks on the CMS-1500 claim form should the billing and coding specialist enter the referring provider’s NPI?
block 17b
Which of the following types of claims is 120 days old?
Delinquent
Medical Billing & Coding as a Career
Claims assistant professional or claims manager, Coding Specialist, Collection Manager, Electronic Claims Processor, Insurance Billing Specialist, Insurance Coordinator, Insurance Counselor, Medical Biller, Medical & Financial Records Manager, Billing & Coding Specialist
What are Medical Ethics?
Standards of conduct based on moral principle. They are generally accepted as a guide for behavior towards pt’s, dr’s, co-workers, the gov, and ins co’s.
What does acting within ethical behavior boundaries mean?
carrying out one’s responsibilities w/ integrity, dignity, respect, honesty, competence, fairness, & trust.
Legal Aspects of of Medical Billing & Coding:
…
Compliance regulations:
Most billing-related cases are based on HIPPA and False Claims Act
Health Insurance Portability & Accountability Act (HIPPA)
Enacted in 1996, created by the Health Care Fraud & Abuse Control Program-enacted to check for fraud and abuse in the Medicare/Medicaid Programs and private payers
What are the 2 provisions of HIPPA?
Title I: Insurance Reform
Title II: Administrative Simplification
What is Title I of HIPPA?
Insurance Reform-primary purpose is to provide continuous ins coverage for worker & their dependents when they change or lose jobs. Also Limits the use of preexisting conditions exclusions Prohibits discrimination from past or present poor health Guarantees certain employees/indv the right to purchase new health ins coverage after losing job Allows renewal of health ins cov regardless of an indv’s health cond. that is covered under the particular policy.
What is Title II of HIPPA?
Administrative Simplification-goal is to focus on the health care practice setting to reduce administrative cost & burdens. Has 2 parts- 1) development and implementation of standardized health-related financial & administrative activities electronically 2) Implementation of privacy & security procedures to prevent the misuse of health info by ensuring confidentiality
What is the False Claims Act (FCA)?
Federal law that prohibits submitting a fraudulent claim or making a false statement or representation in connection w/ a claim. Also protects & rewards whistle-blowers.
What is the National Correct Coding Initiative (NCCI)?
Developed by CMS to promote the national correct coding methodologies & to control improper coding that lead to inappropriate payment of Part B health ins claims.
How many edits does NCCI include?
2: 1)Column 1/Column 2 (prev called Comprehensive/Component) Edits
2) Mutually Exclusive Edits
Column 1/Column 2 edits (NCCI)
Identifies code pairs that should not be billed together b/c 1 code (Column 1) includes all the services described by another code (Column 2)
Mutually Exclusive Edits (NCCI)
ID’s code pairs that, for clinical reasons, are unlikely to be performed on the same pt on the same day
What are the possible consequences of inaccurate coding and incorrect billing?
delayed processing & payment of claims reduced payments, denied claims fine and/or imprisonment exclusion from payer’s programs, loss of dr’s license to practice med
Who has the task of investigate and prosecuting health care fraud & abuse?
The Office of Inspector General (OIG)
Fraud
knowingly & intentionally deceiving or misrepresenting info that may result in unauthorized benefits. It is a felony and can result in fines and/or prison.
Who audits claims?
State & federal agencies as well as private ins co’s
What are common forms of fraud?
billing for services not furnished, unbundling, & misrepresenting diagnosis to justify payment
Abuse
incidences or practices, not usually considered fraudulent, that are inconsistent w/ the accepted medical business or fiscal practices in the industry.
What are examples of Abuse?
submitting a claim for services/procedures performed that is not medically necessary, and excessive charges for services, equipment or supplies.
What is a method use to minimize danger, hazards, & liabilities associated w/ abuse?
Risk Management
Patient Confidentiality
All pt’s have right to privacy & all info should remain privileged. Only discuss pt info when necessary to do job. Obtain a signed consent form to release medical info to ins co or other individual.
When may providers use PHI (Protected Health Information) w/o specific authorization under the HIPPA Privacy Rule?
When using for TPO, Treatment (primarily for the purpose of discussion of pt’s case w/ other dr’s) Payment (providers submit claims on behalf of pt’s) & Operations (for purposes such as training staff & quality improvement)
What is Employer Liability?
Means physicians are legally responsible for their own conduct and any actions of their employees (designee) performed w/in the context of their employment. Referred to as “vicarious liability. A.K.A “respondent superior”-“let the master answer”. Means employee can be sued & brought to trial
What is Employee Liability?
“Errors & Omissions Insurance”-protection against loss of monies caused by failure through error or unintentional omission on the part of the indv or service submitting the claim. ***Some dr’s contract w/ a billing service (clearinghouse) to handle claims submission, & some agreements contain a clause stating that the dr will hold the co harmless from “liability resulting from claims submitted by the service for any account”, means dr is responsible for mistakes made by billing service, errors & omissions is not needed in the instance. *****However, if dr ever asks the ins biller to do the least bit questionable, such as write of pt’s balances for certain pt’s automatically, make sure you have a legal document or signed waiver of liability relieving you of responsibility for such actions.
What is a Medical Record & what is it comprised of?
documentation of the pt’s social & medical history, family history, physical exam findings, progress notes, radiology & lab results, consultation reports and correspondence to pt- Is the foremost tool of clinical care and communication.
What is a medical report?
part of the medical record & is a permanent legal document that formally states the consequences of the pt’s exam or treatment in letter or report form. IT IS THIS RECORD THAT PROVIDES INFO NEEDED TO COMPLETE THE INS CLAIM FORM.
Reasons for Documentation
Important that every pt seen by dr has comprehensive legible documentation about pt’s illness, treatment, & plans for following reasons:
*Avoidance of denied or delayed payment by ins co investigating the medical necessity of services
*Enforcement of medical record-keeping rules by ins co requiring accurate documentation that supports procedure & diagnosis codes.
*Subpoena of medical records by state investigators or the court for review
*Defense of professional liability claim
Retention Of Medical Records
Is governed by state & local laws & may vary from state-to-state. Most dr are required to retain records indefinitely, deceased pt records should be kept for @ least 5 years
Med Term
…
Diagnosis suffixes:
…
-algia
pain
-emia
blood condition
-itis
inflammation
-megaly
enlargement
-meter
measure
-oma
tumor, mass
-osis
abnormal condition
-pathy
disease condition
-rrhagia
bursting forth of blood
-rrhea
discharge, flow
-sclerosis
hardening
-scopy
to view
Procedural Suffixes:
…
-centesis
surgical puncture
-ectomy
removal, resection, excision
-gram
record
-graphy
process of recording
-lysis
separation, breakdown, destruction
-pexy
surgical fixation
-plasty
surgical repair
-rrhapy
suture
-scopy
visual examination
-stomy
opening
-therapy
treatment
-tomy
incision, to cut into
Common Prefixes:
…
a, an
without
ante
before
anti
against
brady
slow
dys
painful, difficult
endo
inside, within
epi
upon, above
ex
out, out of
hemi
half, partial
hypo
below, deficient
infra
below
inter
between
neo
new
oligo
scanty, little
pan
all
para
beside
per
through
poly
many
pre
before, in front of
pseudo
false
sub
under
supra
above, beyond
tetra
four
Common Root Words
…
arth
cartilage
cephal
head
cardi
heart
cholecyst
gall bladder
chondro
cartilage
colp
vagina
derm
skim
enter
intestine
episi
vulva
gastro
stomach
gloss
tongue
hepato
liver
hyster
uterus
lapar
abdomen
lact
milk
lith
stone
mast
breast
myo
muscle
nat
birth
oophor
ovary
oste
bone
pneum
lung
rhin
nose
salping
fallopian tubes
stomat
mouth
Directional Terms:
…
Anterior, Ventral
front surface of the body
Posterior, Dorsal
back side of the body
Superior
above another structure
Inferior
below another structure
Proximal
near the point of attachment to the trunk
Distal
far from the point of attachment to the trunk
Medial
pertaining to the middle of the body
Lateral
pertaining to the side
Frontal, Coronal
Vertical plane dividing the body into anterior & posterior portions
Sagittal
vertical plane dividing the body into right & left sides
Transverse, Cross-sectional
Horizontal plane dividing the body into upper & lower portions
Anatomy & Physiology
A professional medical coder must have knowledge of anatomy & physiology so that coding assignment is quick & accurate.
What is the 1st body system for which medical procedures are described in the CPT manual?
The Integumentary System (the skin and it’s accessory organs) Integument means covering. It is a complex system of specialized tissues containing glands, nerves and blood vessels.
How much area does the skin cover?
an area of 22 sq ft (an average adult). It is the largest organ of the body
What is the main function of the skin?
To protect the deeper tissues from excessive loss of minerals, heat & water. It also provides protection form diseases by providing a barrier. It accomplishes its diverse functions w/ assistance from the hair, nails and glands.
SEBACEOUS (OIL) GLANDS & SUDDORIFERIOUS (SWEAT GLANDS)
produce secretions that allow the body to be moisturized or cooled.
How many layers to the skin?
3;
1) Epidermis (thin, cellular membrane layer that contains keratin)
2) Dermis (dense, fibrous, connective tissue that contains collagen)
3) Subcutaneous layer (thicker & fatter tissue)
Hair, Nail & Glands
…
Hair
composed of tightly fused meshwork of cells filled w/ hard protein called karatin. Has its roots in the dermis & together w/ their coverings, is called HAIR FOLLICES. Main function is to assist in regulating body temp. Holds heat when body is cold by standing on end & holding a layer of air as insulation.
Nails
cover & protect the dorsal surface of the distal bones of the fingers & toes. Part that is visible is nail body, nail root is under skin @ the base of the nail and nail bed is the vascular tissue under the nail that appears pink when the blood is oxygenated or blue/purple when it is oxygen deficient.
What is the moon like white area of the nail called?
lunula
What is the eponychium?
the cuticle at the lower part of the nail sometime referred to as such
SEBACEOUS GLANDS
located in the dermal layer of the skin over the entire body, expect for palm of hands and soles of feet. Secrete oily substance called SEBUM. SEBUM CONTAINS LIPIDS THAT HELP LUBRICATE THE SKIN & MINIMIZE WATER LOSS. It is the overproduction of sebum during puberty that contributes to acne in some people
SUDDORIFEROUS GLANDS
sweat glands that are tiny, coiled gland found on almost all body surfaces. They are most numerous in the palms and soles of feet. Coiled sweat glands originate in the dermis and straighten out to extend up through the epidermis. Tiny opening at surface is called a PORE.
How many types of sweat glands?
2;
1) eccrine sweat glands (most common)
2) apocrine sweat glands (secrete orderless sweat)
What organ secretes hormones?
the adrenal glands, they secrete epinephrine & steriods
Integumentery Vocabulary
…
Albino
deficient in pigment (melanin)
Collagen
structural protein found in the skin & connective tissue
Melanin
major skin pigment
Lipocyte
a fat cell
Macule
discolored, flat lesion (freckles,, tattoo marks)
Polyp
benign growth extending from the surface of the mucous membrane
Fissure-
groove or crack like sore
Nodule
solid, round or oval elevated lesion more than 1 cm in diameter
Ulcer
open sore on the skin or mucous membrane
Vesicle
small collection of clear fluid; blister
Wheal
Smooth, slightly elevated, edematous (swollen) area that is redder or paler than the surrounding skin
Alopecia
absence of hair form areas where it normally grows
Gangrene
death of tissue associated w/ the loss of blood supply
Impetigo
bacterial inflammatory skin disease characterized by lesion, pustules, and vesicles
Multigravida
a pregnant woman who has had at least one previous pregnancy
The Musculoskeletal System
includes bones, muscles & joints. Acts as a framework for the organs, protects many of those organs, and also provides the body w/ the ability to move
What are bones connected to one another by?
by fibrous bands of tissues called LIGAMENTS
What are muscles attached to the bone by?
tendons
What is the fibrous covering of muscles called?
the fascia and the aricular cartilage, covers the end of many bones and serves as a protective function.
Bones
complete organs made up of connective tissue called OSSEOUS. Inner core of bones is comprised of HEMATOPOIETIC tissue. This is where the red bone marrow manufactures blood cells. Other parts of the bones are storage areas for minerals necessary for growth, ie; calcium and phosphorous
How are bones categorized?
as belonging to either the AXIAL SKELETON or the APPENDICULAR SKELETON.
Axial Skeleton
consist of the skull, rib cage & spine
Appendicular Skeleton
made up of the shoulder, collar, pelvic, arm & legs
Long Bones
typically very strong, are broad at the ends and have large surfaces for muscle attachment. IE: HUMERUS & FEMUR.
Short Bones
are small w/ irregular shapes, they are found in wrist and ankle
Flat Bones
are found covering the soft body parts, IE; SHOULDER BLADES, RIBS AND PELVIC BONES
Sesamoid Bones
small, rounded bones that resemble a sesame seed. they are found near joints and increase the efficiency of muscles near a joint. IE, KNEE CAP
The Axial Skeleton-Skull, Rib Cage, Spine
…
Skull
made up of 2 parts, the cranium and the facial bone
Cranium
includes following bones
*Frontal Bone- forms the anterior part of the skull & forehead
*Parietal Bone- Forms the sides of the cranium
*Occipital Bone- forms the back of the skull, there is a large hole at the ventral surface in this bone, called the foramen magnum, which allows the brain communication w/ the spinal cord
*Temporal Bone- forms the 2 lower sides of the cranium
*Ethmoid Bone- forms the roof of the nasal cavity
*Sphenoid Bones- anterior to the temporal bones
Facial Bones
…
Zygoma
cheekbone
Lacrimal Bones
paired bones at the corner of each eye that cradle the tear ducts
Maxilla
upper jaw bone
Mandible
lower jaw bone
Vomer
bone that forms posterior/inferior part of the nasal septal wall between the nostrils
Palatine bones
Make up part of the roof of the mouth
Spinal/Vertebral Column
is divided into 5 regions from the neck to the tailbone. There are 26 bones in the spine & are referred to as the VERTABRAE
Cervical
Neck Bones
Thoracle
Upper Back
Lumbar
Lower Back
Sacral
Sacrum
Coccygeal
Coccyx (tailbone)
Rib Cage
There are 12 pairs of ribs. The 1st 7 pairs join the sternum anteriorly through the cartilaginous attachments called COSTAL CARTILAGE. The TRUE RIBS #’s 1-7 attach directly to the sternum in the front of the body. The FALSE RIBS, #’s 8-10 are attached to the sternum by cartilage. Ribs 11 & 12 are FLOATING RIBS, b/c they are not attached at all
The Appendicular Skeleton
…
Upper Appendicular Skeleton
includes the shoulder girdle which is made up of the SCAPULA, CLAVICLE, & UPPER EXTREMITIES
Scapula
or shoulder blades are flat bones that help support the arms
Clavicle
or collarbone, is curved horizontal bones that attach to the upper sternum at one end, these bones help stabilize the shoulder
Upper Extremities
consist of the following:
Humerus
upper arm bone
Ulna
lower medial arm bone
Radius
lateral lower arm bone (in line w/ the thumb)
Carpals
Wrist bones, there are 2 rows of 4 bones in the wrist
Metacarpals
the 5 radiating bones in the fingers. These are the bones in the palm of the hand.
Phalanges
finger bones, each finger has 3 phalanges, except for the thumb. The 3 phalanges are the proximal, middle and a distal phalanx. The thumb has a proximal and distal
Lower Appendicular
can be divided into the pelvis and the lower extremities
Pelvis
superior & widest bone
Ischium
lower portion of the pelvic bone
Pubic Bone
lower anterior part of the bone
Lower Extremeties
…
Femur
thighbone
Patella
kneecap
Tibia
shin
Fibula
smaller, lateral leg bone
Malleolus
ankle
Tarsal
hind foot bone
Metatarsal
midfoot bone
Phalanx
toe bones, 14 in all (2 in great toe, 3 in each of the other toes)
Joints
parts of the body where 2 or more bones of the skeleton join. Different joints have different ROM (range of motion), ranging from no movement at all to full range of movement
No ROM
most synarthroses are immovable joints held together by fibrous tissue
Limited ROM
amphiathroses are joints joined together by cartilage that is slightly moveable, such as the vertebrae of the spine or the pubic bone
Full ROM
diathroses are joints that have free movement, Ball-and-socket joints (hip) and hinge joints (knees) are common diathroses joints (synovial joints)
Synovial Joints
free moving joints, are surrounded by joint capsules. Many of the synovial joints have BURSAE-SACS OF FLUID THAT ARE LOCATED BETWEEN THE BONES OF THE JOINT AND THE TENDONS THAT HOLD THE MUSCLES IN PLACE.
Muscles
Muscle is tissue comprised of cells. Have the ability to contract & relax.
What are the 3 different functions of the human muscles?
1) allow the skeleton to move
2) responsible for movement of organs
3) to pump blood to the circulatory cystem
How are muscles attached to bones?
by strong, fibrous bands of connective tissues called tendons.
Muscle Actions
…
Extension
to increase the angle of the joint
Flexion
to decrease the angle of the joint
Abduction
movement away from the midline
Adduction
movement towards the midline
Supination
turning the palm or foot upward
Pronation
turning the palm or foot downward
Dorsiflexion
raising the foot, pulling the toes toward the shin
Plantar Flexion
lowering the foot, pointing the toes away form the shin
Eversion
turning outward
Inversion
turning inward
Protraction
moving a part of the body forward
Retraction
Moving a part of the backward
Rotation
revolving a bone around its axis
Fractures
broken bone, most occur as a result of trama, however some disease such as cancer or osteoporosis can also cause spontaneous fractures. Can be classified as simple or compound. Simple fractures don’t rupture the skin as compound fractures split open the skin allowing for an infection to occur.
Communicated Fracture
the bone is crushed and/or shattered
Compression Fracture
the fractured area of the bone collapses on itself
Colles Fracture
the break of the distal end of the radius at the epiphysis often occurs when the pt has attempted to break his/her fall
Complicated Fracture
the bone is broken and the ends are driven into each other
Hairline Fracture
a minor fracture appears as a thin line on x-ray; and may not extend completely through the bone
Greenstick Fracture
the bone is partially bent & partially broken, this is a common fracture in children b/c their bones are still soft
Pathologic Fracture
any fracture occurring spontaneously as a result of disease
Salter-Harris Fracture
a fracture of the epiphyseal plate in children
Sprains, strains and dislocation/subluxation
SPRAIN is a traumatic injury to the joint involving the soft tissue, soft tissue includes the muscles, ligaments and tendons.
Strain
lesser injury, usually this is a result of overuse or overstretching
Dislocation
is when the bone is completely out of place
Subluxation
bone is partially out of joint
Evaluations & Management Review
The E&M section include codes that pertain to the nature of the physicians work. Codes depend on type of service, pt status, and place where service was rendured. The E&M section is divided into broad categories such as office visit, hospital visits, and consultations
Basic Format of the levels of E&M services
1) a unique code # is listed
2) the place & type of service is specified
3) the content of the service is defined
4) the nature of the presenting problem(s) usually associated w/ a given level is (are) described
5) time is typically specified in the descriptor of the code
New Patient
defined as one who has not received medical services w/in the last 3 years
Established Patient
defined as someone who has recieved medical services w/in the last 3 years from the physician or another physician of the same specialty who belongs to the same group practice
Chief Complaint
brief statement describing the symptom, problem, diagnosis, or condition that is the reason the pt seeks medical care
How many Volumes to ICD manual?
3;
*Volume 1- Disease: Tabular List
*Volume 2- Disease: Alphabetic Index
*Volume 3- Procedures: Tabular list and Alphabetic Index
Volume 1-Index to Diseases, Tabular List
contains the disease and condition codes and the descriptions, also contains the V codes and E codes
Volume 2-Index to Diseases, Alphabetic Index
the is the alphabetic index of Volume 1; use this first then volume 1 to confirm codes
Volume 3-Procedures
contains codes for surgical, therapeutic, and diagnosis procedures, used primarily in hospitals
Which volume(s) are used in the inpatient and outpatient settings (physician office)?
Volume’s 1 & 2
How to ensure you have chosen the correct code?
First locate the code in the alphabetic index (Volume 2) then cross-reference this code in the Tabular List (Volume 1)
Supplementary Classification Codes
…
What are V codes?
Supplementary Classification of Factors Influencing Health Status and Contact of Health Services-supplementary classification code used to identify health care encounters that occur for reasons other that illness or injury or to indentify pt’s whose illness is influenced by special circumstances or problems. Can be found in both Volume 1 & Volume 2
What are circumstances when V codes are used?
*When a person who is not currently sick encounters health services for some specific reason such as to act as an organ donor or receive a vaccination. (IE; V59.3 is the code for donor of bone marrow)
*When a person w/ a resolving disease or chronic condition presents for specific treatment of that disease or condition. (IE; V56.0 is used for extracorporeal dialysis)
*When a circumstance may influence the pt’s health status but is not a current illness (IE; V16.3 is used for family history of coronary artery disease)
*To indicate the birth status of a newborn (IE; V30.0 is uused for a newborn male born in the hospital by c-section)
What are E codes?
Supplementary Classification of External Causes of Injury and Poisoning-supplementary classification codes used to describe the reason of EXTERNAL CAUSE of injury, poisoning and other adverse effects. Can be found in both Volumes ! & 2.
What codes are used to classify environmental events, circumstances, and conditions as the cause of injury, poisoning & other adverse effects and capture how the injury or poisoning happened, the intent and the place where the event happened?
E codes
/When is the ICD manual updated
Annually, Usually in October
How many chapters does the Tabular List(Volume 1) contain?
17; based on either body system or cause or type of disease
What do the codes range from? (ICD-Volume 1)
001-999
Chapters
are the main division on the ICS-9-CM, they are divided into secctions
Sections
composed of a group of 3 digit categories representing a group of conditions or related conditions, they are divided into categories
Categories
are composed of 3 digit codes representing a single disease or condition. the 3 digit code is used only if it is not further subdivided. There are about 100 category codes and most requires a 4th digit (subcategory code) Ex; 242
Subcategories
provide a 4th digit code (one digit after the decimal point) which is more specific that category code (3 digit) in terms of causes, site, manifestation of the condition. This must be used in available. Ex; 242.0
Subclassification
provides a 5th digit code which gives the highest specificity of description to a condition. Use of it is mandatory when available. A code not reported to the full # of digits required is invalid ex; 242.01
Level of detail in coding
a category code is used only if it is not further subdivided. Where subcategory and subclassifaction codes are provided, their assignment is mandatory. A code is invalid if it has not been coded to the level of specificity required for that code.
Sequencing the diagnosis
the diagnosis, condition, or other reason for the encounter or visit shown in the medical record to be chiefly responsible for the services provided is listed first. Coexisting conditions that were treated or medically managed or influenced by the pt during the encounter are listed as additional codes. (Conditions that were previously treated and no longer exist are not coded.) If personal history or family history has an impact on current care or influence treatment, history code may be assigned as a secondary code
Alphabetic Index (Volume 2)
Everything in the Index is listed by condition-that is, diagnosis, signs, symptoms, and conditions such as pregnancy or admission
Nonessential Modifers
the main term may be followed by these in paranthesis, their presence or absences does not have an effect on the the selection of the code listed for the main term
Essential Modifiers
Terms indented two spaces to the right below the main term called subterms. Are essential modifiers b/c they have bearing on the right selection of the code.
Hypertension table
found in the Index under the main term “Hypertension” and it contains a list of conditions that are due to or associated with hypertension. The Table classifies the conditions as:
-Malignant; an accelerated sever form of hypertension w/ vascular damage and a diastolic pressure of 130mmHg>
-Benign; Mild or controlled hypertension & no damage to the vascular system or organs
-Unspecified; This is not specified as benign or malignant in the diagnosis or medical record
Neoplasm Table
this is located in the Index under the main term “Neoplasm” and is organized by anatomic site. Each site has 6 columns w/ 6 possible codes determined by whether the neoplasm is malignant, benign, of uncertain behavior or of unspecified nature
Describe the 6 columns of the neoplasm table
…
Malignant
further classified as to primary, secondary or carcinoma in situ
Primary Malignancy
the original cancer site. Malignant tumors are considered primary unless documented as secondary or mastastic
Secondary Malignancy
cancer that has metastasized (spread) to a secondary site either adjacent or remote region of the body
Carcinoma (Ca) in Situ
cancer that is localized and has not spread to adjacent tissues or distant parts of the body
Benign
noninvasive, non-spreading, nonmalignant
Uncertain Behavior
uncertain whether benign or malignant, borderline malignancy
Unspecified Nature
a neoplasm is identified; however, no nature of the tumor is documented in the diagnosis of the medical record
Choose the code that represents the current status of the neoplasm
a neoplasm code is assigned if the tumor has been removed and pt is still receiving chemotherapy tx or radiation. A V code is assigned if the tumor is no longer present or if the patient is not receiving treatment, but is returning for follow-up care
3 sections to Alphabetic Index
Section 1) Index to diseases
Section 2) Table of drugs and chemical
Section 3) Index to External Cause of Injury (E Codes)
Section 1: Index to diseases
each term is followed by the code or codes that apply to that term
Section 2: Table of Drugs and Chemicals
contains a list of drugs & chemicals w/ the corresponding poisoning code and E codes. The E codes are used to explain the circumstances surrounding the poisoning which may be:
-Accident: Poisoning was due to accidental overdose, wrong substance taken, accidents in use of drugs and biologicals, external causes of poisoning classifiable to 980-989
-Therapeutic Use: instances when a correct substance properly taken is the cause of an adverse effect
-Suicide Attempt: the poisoning was self-inflicted
-Assault: poisoning was inflicted by another person w/ intent to kill or injury
-Understand: poisoning cannot be determined whether intentional or accidental
Section 3: Index to External Cause of Injury (E codes)
this is the index for the E codes. It classifies in alphabetical order, environment events and other conditions as the cause of injury and other adverse effects.
Health Care Financing Administration Common Procedure Coding System
HCPCS Reference Manual
Who assigns NPI#’s & what are they?
The CMS assigns a standard unique identifier known as National Provider Identifier (NPI).
Who developed HCPCS & What is it?
The CMS developed Healthcare Common Procedure Coding System (HCPCS) which is a collection of codes for procedures, supplies, products, and services that may be provided to Medicare/Medicaid beneficiaries and also to those enrolled in a private health ins program. Codes are divided into 2 levels:
Level I Codes
Consist of codes found in the CPT manual. They have five position numeric codes used to report physicians services rendered to patients.
Level II Codes (National Codes)
codes formulated thru the joint efforts of the CMS, the health insurance association of america, and the bcbs association.they are five position alpha-numeric codes for physician and non-physician services not found in the cpt(level 1), start w/ a letter followed by 4 #’s and make up more than 2,400 5 digit alphanumeric codes divided into 22 sections, each covering a related group of items. Most of these items are supplies, materials or injections that are covered by medicare. Some codes are for physicians & non-physician services not found in the CPT (Level I) Ex; E section is for the Durable Medical Equipment category which covers reusable medical equipment ordered by the physician for use in the home, such as wheelchairs or portable oxygen tanks.
Level III Codes
codes that were used locally or regionally have been eliminated by the CMS since the implementation of the HIPPA. Some of the codes are now in the Level II
CPT
Current Procedural Terminology- codes from CPT code book used to report services and procedures by dr’s. The CPT coding system uses a 5 digit numeric system for coding services rendered by dr’s. Some codes use a 2 digit modifier to five a more accurate description of the services rendered
Who publishes CPT and updates it?
The American Medical Association (AMA) and they update it annually withe a new one coming out each November & becoming effective on January 1st of the following calender year
Category I Codes
represents services and procedures widely used by many health care prof in clinical practice in multiple locations and have been approved by the FDA
Category II Codes
supplemental codes used for performance measures. Although these codes are intended to facilitate data collection about the quality of care, their use is optional. Cat II codes are published twice a yr, Jan 1st and July 1st
Category III Codes
temp codes for emerging technology, services and procedures. If a Cat III code is available, it is reported instead of Cat I unlisted code
How many sections to the CPT Manual?
8; each section begins w/ guidelines that provide specific coding rules for that section. Guidelines at the beginning of the section are applicable to all codes in the section, while notes that pertain to specific codes appear before or after such codes. Guidelines usually contain definitions of terms, applicable modifiers, subsection info, unlisted services, special reports of info, or clinical samples. The 8 sections are
1)Evaluation & Management (E&M) 2)Anesthesia 3)Surgery 4)Radiology 5)Pathology and Laboratory 6) Medicine 7) Category I codes 8)Category III codes
What format does CPT coding system use and why?
Indented format, to save space
2 types of CPT Codes
*Stand Alone Codes; contain the full description of the procedure for the code
*Indented Codes- these are codes listed under associated stand-alone codes. To complete the the description for indented codes, one must refer to the portion of the stand alone code description before the semi-colon
Other CPT Codes
*Add-on codes- used for procedures that is always performed during the same operative session as another surgery in addition to the primary service/procedure and is never performed separately
*Modifiers-provide the means by which the reporting physician can indicate that a service or procedure that has been performed has been altered by some specific circumstance but not changed by the definition of the code
How do you know if an update has been made to the CPT manual?
**A triangle- represents a change in the code description since the last edition. The change may be minor or significant and it could be an addition, deletion, or revision
**2 triangle symbols-represent changes in the text or definition between the triangles
**A bullet-represents a new procedure or service code added since the previous addition of the manual
**A plus sign-indicates add-on codes
**A circle w/ a line through it- represents exemption from use of modifier
How many parts to CPT Manual?
t3; the main text, the appendices and the alphabetic index and is divided into 6 sections; these sections are subdivided into
Evaluation & Management
99201-99499 (going to dr feeling 99% leave getting high 5)
Anesthesia
00100-01999, 99100-99140 (knocked out=0)
Surgery
10021-69990 (Surgery always want to feel 100%)
Radiology (including nuclear medicine and diagnostic ultrasound)
77010-79999 (RPM-789)
Pathology and Laboratory
80048-89356 (RPM-789; P=8)
Medicine (except anesthesiology)
90281-99199, 99500-99602 (RPM-789, M=9)
Add-on codes
some procedures are carried out in addition to the primary procedure performed. Designated as “add-on” codes w/ a “+” sign and they apply only to procedures performed by same dr to describe additional intra-service work provided. Are never used alone, rather they are always reported in addition to the primary procedure code. All add-on codes are modifier -51 (multiple procedures) exempt
Location Methods
The CPT Index is arranged in alphabetic order by main terms which are further divided by subterms. There are 5 location methods;
1)Service or Procedure
2)Anatomic Site
3)Condition or Disease
4)Synonym/Eponym
5)Abbreviation
CPT Modifiers
these are 2 digit add-ons attached to regular codes to tell 3rd party payers of circumstances in which the services or procedures were altered. All modifiers are listed in CPT appendix A. Modifiers relevant to each of the CPT sections are also found in the section guidelines. One must use the modifier that depicts the circumstances most accurately.
-24 Unrelated E/M Service by the same physician during a postoperative period
this is attached to the code of the E/M service provided to a pt during the postop period to indicate that the service is not part of the postoperative care which is usually part of the package of services of the surgery performed. Major surgical procedures will usually have a postop period of 90 days, minor, 10 days. Used only w/ E/M codes
-26 Professional Component
Most procedures have both professional (physician) and technical components. This modifier is attached to the procedure to indicate that the dr provided only the professional componenet
-32 Mandated Services
used to indicate that the service provided was required by 3rd party payer, gov, legislative or regulatory body. this does not include second opinion requested by a pt, family member, or another physician
-50 Bilateral Procedure
used when the same procedure is performed on a mirror-image part of the body
-51 Mulitple Procedure
used when
-more than 1 procedure is performed in the same surgical episode
-one code does not describe all of the procedures performed
-the secondary procedure is not minor or incidental to the major procedure
Ex; same operation, different site, multiple operations, same operative session, *procedure performed multiple times
-58 Staged or Related Procedure or Service by the same Physician during the Postoperative Period
used to explain that the procedure or service done during a postop period was planned at the time of the original procedure. also used if a therapeutic procedure is performed b/c of the findings from a diagnostic procedure
-78 Return to Operating Room for a Related Procedure During the Postoperative Period
to report a circumstance in which the dr returns to the operating room to address a complication stemming from the initial procedure (third party payers usually pay the surgery portion of the complications surgical package b/c the pt remains in the postop period of the initial procedure. documentation must clearly indicate the reason for the return to the operating room)
79 Unrelated Procedure or Service by the same physician during the postoperative period
used to indicate that the procedure or service provided during the postop period was not associated w/ the period. payment for the full fee of the subsequent procedure is requested and a new global period starts
-90 reference (outside) laboratory
used to indicate that the procedure was done by outside lab and not by reporting facililty
-99 Multiple Modifiers
used to report a procedure or service that has more than one modifier but the payer does not allow the addition of multiple modifiers to the code. is attached to the procedure code and the multiple modifier are listed in block 19 of claim form
Evaluation and Management (E/M Codes)
these are listed 1st in the CPT manual b/c they are used by all different specialties. they cover physician services that are performed to determine the best course for pt care.
What are the key components of E/M?
a; history
-chief complaint
-History of present illness (HPI)
-review of systems (ROS)
-Past, family and social history (PFSH)
b;physical examination
c;medical decision making complexity
Unlisted Procedures
Procedures considered experimental, newly approved, or seldom used may not be listed in the CPT manual. Can be coded as unlisted procedures. they are located at the end of the subsections or subheadings. when unlisted procedure code is reported must be described in the accompanying documentation
Surgical Package
also called “global surgery” includes a variety of services rendered by a surgeon which includes the following:
-surgical procedure performed
-local infiltratration, metacarpal/metatarsal/digital block or topical anesthesia
-Preoperative E/M services; on day immediately prior to the day of the procedure
-immediate postoperative care
-Normal, uncomplicated postop care
What is Health Insurance?
A contract between a policyholder (one who purchases the contract) and an insurance carrier to reimburse the policyholder of all or most medical expenses
What 3 ways can an individual obtain health insurance?
1)Group Ins-when a group of employees & their dependents are insured under 1 group policy issued to the employer. Generally the employer pays the premium or portion of premium and the employee pays the difference.
2)Personal Insurance- an insurance plan issued to an individual. premium rates are usually higher than group rates and service availability is lessened w/ this type of coverage
3)Pre-paid health plan- pre-determined set of benefits covered under one set annual fee
Indemnity Insurance
also known as a fee-for-service. under this plan, the services that are paid for are listed in the policy and payments are based on the physicians charge for the service. there are no restrictions as to the physicians or hospital the beneficiaries may use and pre-approval of medical visits are not required. Each yr the beneficiary must meet a deductible, after which the benefit may cover for all or part of the charge. Usually a co-insurance for each service applies
HMO
Health Maintenance Organization- managed care plan that provides wide range of services to individuals that are enrolled. Generally least costly but most restrictive. Uses a gatekeeper (primary care physician) whom the pt is required to visit initially for any case. If the pt goes to another physician w/o prior approval pcp pt will be responsible for all costs. Physician-Hospital Organization is when physicians, hospitals, and other health care providers contract w/ one or more HMO’s or directly w/ employers to provide care.
PPO
Preferred Provider Organization- basically same as HMO however PPO’s charge a higher premium than HMO’s in exchange for more flexibility & more options for beneficiaries, No gatekeeper and pt choose dr they want to see as long as they are in network, if pt chooses to see dr not in network they will shoulder all costs.
POS
Point-of-service- managed care plan that gives beneficiaries the option whom to see for service. If the beneficiary see provider w/in network they will receive benefits similar to HMO but if they choose to see a provider not in the network, the POS will still pay for the services but at a rate significantly lower than the in-network dr and difference will be billed to pt
Preferred Provider Plan
the type of plan a patient may have where they can see providers outside their plan, the pt is responsible for higher portion of the fee
How is a fee schedule determined?
UCR method, the usual, customary, and reasonable- the carrier compare the dr’s most frequent charge for a given service (the usual) the average charge of all providers of similar training/experience in a given geographical area (the customary) the actual charge submitted on a claim (must be reasonable to the provider) the lowest amount is used as the basis for payment (the allowed charge)
Relative Value Payment Schedule Method
involves the use of relative value scales which assign a relative weight to individual services according to the basis for the scale. Services that are more difficult, time consuming, or resource intensive to perform typically have higher relative values than other services
Medicare’s Resource Based Relative Vale Scale (RBRVS) Payment Schedule
under this schedule a procedure’s relative value is the sum total of 3 elements
1) Work; represents the amount of time, intensity of effort, and medical skill required of the dr
2) Overhead; practice costs related to the performing of the service
3) Malpractice: cost of medical malpractice insurance
-medical malpractice insurance that covers the insured only for those claims made while the policy is in force is called claims-made coverage
How are payments determined under Medicare’s RBRVS?
by multiplying a code’s relative value by constant dollar amount called the conversion factor (multiplier). The conversion factors are determined annually by the CMS in cooperation with congress. The conversion factor varies according to the type of service provided such as medical, surgical, non-surgical
A geographic practice cost index is applied to account for the economic variation across the different area of the country
true
What % does Medicare pay?
80%
What portion of services do the beneficiary pay?
20%, deductible, premiums, and for non-covered services
The St. Anthony Relative Value for Physicians (RVP)
unlike the RBRVS the RVP has no geographical adjustment factor or individual RVU component to calculate. However, for each category of procedures, a separate conversion factor must be developed
Contracted Rates w/ MCO’s
physicians agree to provide services at a discount of their usual fee in return for a pool of existing pt’s
Capitated Rates
the dr provides a full range of contracted services to covered pt’s for a fixed amount on a periodic basis. While guaranteed a fixed amount the dr assumes the risk that the cost of providing the care the pt’s may exceed the payment amount. the only additional charge may be a co-payment and a deductible co-insurance
Medicare
is the federall gov’s health ins program created by Social Security Act of 1965 titled “Health Insurance for the Aged & Disabled” It is administered by the CMS, formally known as Health Care Financing Administration (HFCA)
Who is Medicare available to?
-persons aged 65 or older, retired on Social Security Benefits
-spouses of a person paying into the Social Security System
-those who received social security disability payments for 24 months
-those diagnosed w/ end stage renal disease (ERSD)
-kidney donors to ERSD pt’s (all expenses related to kidney transplant are covered)
-retired federal employees of the Civil Service Retirement System (CSRS)
What are Medicare Health Insurance Claim Numbers (HCIN’a)?
issued by CMS and are usually SS #’s with letter (alpha) or letter/number (alphanumeric) suffixes.
Common Suffixes used by Medicare:
A-Wage earner (upon retirement)
B-Spouse of wage earner
C-Disabled Child
D-Widow
HaD- Disabled Adult
M- Part B benefits only
T- Uninsured and entitled only to health ins benefits
Medicare Part A
aslo called the Hospital Insurance for the Aged and Disabled. It covers institutional providers for inpatient, hospice, and home health services, such as the following
-a bed pt in a hospital
-pt’s in a pysch hospital
-bed pt’s in a nursing facility
-pt’s receiving home health care services
-terminally ill pt who has <6 to live and needs hospice care
-terminally ill pt who needs respite care
How do individuals that are not eligible for Social Security Obtain Medicare Part A?
By paying a premium and they must enroll in Part B this is however limited to applicants 65+ and US resident. A deductible is req for each episode of illness and a co-insurance applies for hospitalizations of more than 60 days
Medicare Part B
referred to as Supplementary Medical Insurance (SMI). coverage is a supplement of Part A, which covers medical expenses, clinical lab services, home health care, outpatient hospital treatment, blood, and ambulatory surgical services.
What out of pocket costs for beneficiaries are associated w/ Medicare part B?
Contains an annual deductible that must be met b4 benefits begin, beneficiaries pay 20% of the Medicare-approved amount for services after the deductible has been met. Premiums are usually deducted from the monthly SS check.
How are services paid to physicians associated w/ Medicare Part B?
services are paid according to a fee schedule which is based on the relative value multiplied by the geographical adjustment and conversion factors. All dr’s in a given area are paid the same for same service regardless of specialization. However, non par’s are paid 5% less for assigned claims. Non PAR’s, not accepting assignment, can charge no more than 115% of the participating allowance w/o facing possible Medicare fines and penalties.
Medicare Part C
Medicare Managed Care Plans (formally Medicare Plus (+) Choice Plan) was created to offer a # of healthcare services in addition to those available under Part A & Part B. The CMS contracts w/ managed care plans or PPO’s to provide Medicare benefits. A premium similar to Part B may be required for coverage to take affect
Medicare Part D
Prescription Drugs- enacted by the Medicare Prescription Drug, Improvement and Modernization Act in Dec 2003 and began implementation in Jan 2006 where Medicare beneficiaries can enroll in the Medicare Prescription drug plan. the beneficiaries have the choice of among several plans that offer drug coverage for which they pay a monthly premium
Claim Status
Various terms are used to describe the state of submitted forms.
Clean Claim
has all required fields accurately filled out, contains no deficiencies and passes all edits, the carrier does not require investigation outside of the carrier’s operation before paying the claim
Dirty Claim
contains errors and omissions, usually these claims do not pass front end edits they are either processed manually for resolving problems or rejected for payment
Invalid Claim
contains complete necessary information but is incorrect or illogical in some way
Rejected Claim
requires investigation and needs further clarification
What is an Advance Beneficiary Notice?
a document provided to a Medicare beneficiary by a provider prior to a service being rendered letting the beneficiary know of his/her responsibility to pay if Medicare denies the claim
What is Medigap?
Medicare Supplemental Insurance-to pay for medical services and items not covered by Medicare and Medicare’s coinsurance and deductible. Medigap is a private insurance designed to help pay for those amounts that are typically the pt’s responsibility under Medicare. there are several standard Medigap policies established by the federal gov w/ the ins industry
Medicaid
a federal program administrated by state gov to provide medical assistance to the needy, each state sets its own guidelines for eligibility and services, therefore benefits and coverage may very widely from state to state
How is eligibility for Medicaid classified?
divided into 2 classifications
A) Categorically Needy: 1) families, pregnant women & children 2) Aged and disabled persons 3) Persons receiving institutional or other long-term care in nursing facilities (NF’s) and intermediate care facilities (ICF’s)
B) Medically Needy: 1) medically indigent low-income and families 2)low-income persons losing employer health ins coverage (Medicaid purchase of COBRA purchase)
Medicaid is the payer of last resort
True
Medicaid and Medicare (dual coverage)
if pt has Medicare and Medicaid, medicaid usually pays for the Medicare Part B deductible, coinsurance, and monthly premium amounts.
Some of the Services covered by Medicaid
-inpatient hospital services
-outpatient hospital services
-Physician services
-emergency service
-prenatal care
-vaccines for children
-cosmetics procedures necessitated by an injury (elective cosmetic procedures are not included)
-family planning and supplies
Workers Compensation
is a state required ins plan, the coverage of which provides benefits to employees and their dependents for work related injury, illness or death. Each state has established minimum # of employees required before this laws comes into effect. Further, not all states offer WC plans
Who covers cost of Workers Compensations?
employers pay for premiums, the amount of which will depend on the specific job, occupational category, and level of risks
What are the 5 types of benefits offered?
1) Medical treatment 2) Temporary disability 3) Permanent disability 4) Vocational rehabilitation 5) Death benefits for survivors
Disability Insurance
defined as reimbursement for income and lost as a result of of a temporary or permanent illness or injury. When pt’s are treated for disability diagnosis and other medical problems, separate pt records must be maintained. Disability ins does not pay for healthcare services, but provides the disabled person w/ financial insurance
Liability Insurance
a policy that covers losses to a 3rd party caused by the insured, by an object owned by the insured, or on premises owned by insured. Liability ins claims are made to cover the cost of medical care for traumatic injuries, lost wages, and in many cases, remuneration for the “pain and suffering” of the insured party. Most health ins contracts state that health ins benefits are secondary to liability ins.
TRICARE
regionally managed health care program for active duty and retired members of the armed forces, their families and survivors. It is a service benefit and contains no premium. TRICARE is the new title for CHAMPUS program (Civilian Health and Medical Program of the Uniformed Services)
What are the 3 types of plans covered under TRICARE?
1) Standard- fee-for service, cost-sharing plan
2) Extra- preferred provider organization
3) Prime- health maintenance organization plan w/ a point of service option
***All have annual deductibles, w/ the exception of PRIME
How are co-payments determined with TRICARE?
according to 2 programs
a) active duty family members
b) retirees, their families members and survivors of deceased personnel
CHAMPVA
(Civilian Health and Medical Program of the Veteran Affairs)- was created to provide medical benefits to spouses and children of veterans w/ total, permanent service related disabilities or for surviving spouses and children of a veteran who died as a result of service related disability. It is a service benefit therefore no premiums. Members who receive TRICARE do not qualify for CHAMPVA
Commercial Carriers
-are for profit organizations that operate in the private sector selling different health ins benefits plans to groups or individuals. Most have predefined pt yearly deductibles and coinsurance generally based on the 80/20 split. EX; Aetna, Cigna, Travelers, and Prudential
-most have coordination of benefits (COB) clauses to identify the primary and secondary payer responsibility status for dependent children
Gender rule
male of household is primary payer
Birthday rule
the plan of the parent whose birthday falls earlier in the year (month and date, not year) is primary to that whose b-day falls later in the calender year. If both parents have same birthday, then the plan of the parent who has had the longest coverage is primary. **In case of divorce, the plan of the parent w/ custody of the children is the primary payer unless the divorce settlement states otherwise
Blue Cross/Blue Shield Plans
group of independently licensed local companies, usually nonprofit that contracts w/ dr’s and other health entities to provide services to their insured companies and individuals. Most BC/BS plans offer HMO’s, PPO’s and POS plans
Blue Cross
covers hospital services, outpatient care, some institutional services and home care
Blue Shield
covers physician services, and in some cases, dental, outpatient services and vision care
What are BC/BS plans reimbursement methodologies?
physician reimbursement had been based on the UCR method but more plans have adapted the RBRVS method while some are using capitated rates.
Paper Claim
traditional method used by providers for submission of charges to ins co’s. The most commonly used form is the CMS-1500. Few plans will still accept the physicians encounter forms or superbill and Medicare will only accept claims onthe CMS-1500
Electronic Claim
alternative to paper claim, submitted to payer directly by physician or clearinghouse. Are usually paid faster. Most electronic claims software have self-editing features that detect and report entries that may cause to be rejected, such as invalid codes or incomplete claims
What is a clearinghouse?
an entity that receives transmission of claims for dr’s offices, separate the claims by carriers and performs software edits on each claim to check for errors. One this process is complete, the claim is then sent to proper ins carrier. The dr pays the clearinghouse a fee for their services. A result of the review is sent back to the claims preparer using and audit/edit report
What are the 2 major sections of a claims form?
-Blocks 1-13, refers to pt info
-Blocks 14-33, refers to physician info
What should be done in absences of payer provided instructions for completing claim form?
Instructions on the claim form
Basic Billing & Reimbursement Steps:
-collect pt info
-verify insurances
-prepare encounter form (should reflect the diagnosis and services provided to pt, this is used as the basis for billing)
-code diagnosis and procedures
-review linkage and compliance, review should include the following appropriateness of the codes link between the diagnosis and the procedure payers rules about the diag and proc documentation of the procedure *compliance w/ regulations
-calculate physician charges
-prepare claims
-transmit claims
-payer adjudication, claims received by the payers go through a series of steps to determine whether it should be paid
-follow up reimbursement/record retention
Life cycle of Insurance Claims
I. Claims submission-transmission of claims data either electronically or manually to payers or clearinghouses for processing
II. Claims Processing-payers and clearinghouses verify the info found in the submitted claims about the pt and provider
III. Claims Adjudication-process by which the claim is compared to payer edits and the pt’s health plan benefits to verify that:
-required info is available to process claim
-claim is not a duplicate
-payer rules and procedures have been followed
-procedures performed or services provided are covered benefits
Non-covered benefit
any procedure or service reported on the ins claims that is not listed in the payer’s master benefit list. This will result in the denial of the claim. Providers may be able to recover the charges from the pt
Unauthorized Benefit
procedure or service provided w/o proper authorization or was not covered by a current authorization. The claim is denied and the provider cannot bill the pt for the charges
What does Medical Necessity edit check for?
-procedure codes match the diagnosis code
-procedure are not elective
-procedures are not experimental
-procedures are essential for treatment
-procedures are furnished at an appropriate level
VI. Payment
once the claim is approved for payment, a remittance advice (RA) is sent to the provider and an explanation of benefits (EOB) is mailed to the policyholder
Assignment of Benefits
reimbursement is sent directly from payer to provider
Accept Assignment
mean the provider agrees to accept what the ins co approves as payment in full for the claim
New Patient
Individual who has not received any professional services from the physician or another physician of the same specialty who belongs to the same group practice within the past 3 years.
Established Patient
Individual who has received any professional services from the physician or another physician of the same specialty who belongs to the same group practice within the past 3 years.
Inpatient
term used when a patient is admitted to the hospital w/ the expectation that the pt will stay for a period of 24 hrs or more
Outpatient
pt who receives treatment in any of the following settings:
-physicians office
-hospital clinic, emergency department, hospital same day surgery unit, ambulatory surgical center (pt is released w/in 23 hrs)
-hospital admission for observation
Consultation
service performed by a physician whose opinion or advice is requested by another physician in the evaluation or treatment of a pt’s illness or suspected problem. The consultation does not assume any responsibility for the pt’s care and must send a written report back to the requesting physician
Fee-for-service
fee that is charged for each procedure or service performed by the physician. This fee is obtained from a FEE SCHEDULE, which is a list of charges or allowances that have accepted for specific medical services. The system in which fee schedules are determined is referred to a USUAL, CUSTOMARY, AND REASONABLE, (UCR)
Fiscal Intermediary
an ins co that bids for a contract w/ CMS to handle the medicare program in a specific area
Explanation of Benefits (EOB)
describes the services billed and includes a breakdown of how the payment is determined (sent to pt)
Premium
the cost of ins coverage paid annually, semi-annually or monthly to keep a policy in effect
Deductible
a cumulative out-of-pocket amount that must be paid annually by the policyholder before benefits will be paid by the ins co
co-payment
cost-sharing requirement for the insured to pay at the time of service. This amount is usually a specific dollar amount
Coinsurance
percentage of the cost of covered services that a policyholder or a secondary ins pays. A common payment % for coinsurance is 80/20 which indicates that 20% is the coinsurance for the beneficiary or secondary ins is responsible
Coding
process of converting diagnosis, procedures, and services into numeric and alphanumeric characters
Medical Neccessity
defined by Medicare as “the determination that a service or procedure rendered is reasonable and necessary for the diagnosis or treatment of an illness or injury”
Exclusion and Limitations
conditions, situations, and services not covered by the ins carrier
Pre-certification
to determine coverage for a specific treatment such as surgery, hospitalization or tests, under the insured’s policy
Pre-determination
to determine the pt’s benefits and the maximum dollar amount that the ins company will pay. Often the 1st step of the ins verification process, it is completed prior to the first visit
Pre-authorization
requirement for some health ins plans to obtain permission for a service or procedure before it is done. It indicates that a specific procedure or service is deemed “medical necessary”
Qualified diagnosis
working diagnosis which is not yet established
Eligibility
the qualify factor or factors that must be met before a pt receives benefits
Coordination of benefits (COB)
when 2 ins co work together to coordinate payment of the benefits
encounter form
also called the superbill; it is a listing of the diagnosis, procedures, and charges for a pt’s visit
Itemized statement
statement of the pt’s account history, showing dates of service, detailed charges, payment (deductibles, co-pays), the date the ins claim was submitted, applicable adjustments and account balance
Peer Review Organization (PRO)
a state based group of physicians working under gov guidelines to review the cases and determine their appropriateness and quality of professional care
Health Insurance Portability And Accountability Act (HIPPA)
deals w/ the prevention of healthcare fraud and abuse of patients on Medicare/Medicaid
Civil Monetary Penalties Law (CMPL)
law passed by the fed gov to prosecute cases of medicaid fraud
The Good Samaritan Act
was developed to protect healthcare professionals from liability of any civil damages as a result of rendering emergency care
Remittance Advice
an electronic or paper-based report of payment sent by the payer to the provider
The Patient Care Partnership (Patients Bill of Rights)
was developed to promote the interests and well being of the pt’s and residents of the healthcare facility. This bill has still not become law
Physician
a doctor of medicine or osteopathy, dental medicine, dental surgery, podiatric medicine, optometry, or chiropactic medicine legally authorized to practice by the state in which he/she performs
Health Practitioner
includes, but is not limited to, physician assistant, certified nurse-midwife, qualified psychologist, nurse practitioner, clinical social worker, physical therapist, occupational therapist,, respiratory therapist, certified registered nurse anesthetist, or any other practitioner as may be specified
Group Practice
group of 2 or more physicians and non-physician practitioners legally organized by a partnership, professional corporation, foundation, not-for-profit corporation, faculty practice plan, or similar association
Physician’s Identification Numbers
-State license #, dr must obtain this # in order to practice w/in a state
-Employer Identification # (EIN), also known as federal tax identification #, used by IRS
-SS#, typically not used on claim form unless provider does not have (EIN)
-Provider Identification # (PIN), # assigned by ins co to a physician who renders services to pt’s
-Unique Provider Identification # (UPIN), # assigned to the physician by medicare
-performing Provider Identification provider # (PPIN), dr has a separate PPIN for each group office/clinic in which he/she practices. In the medicare program, in addition to a group #, each member of a group is issued a 8-character PPIN
-Group Provider Number, # is used instead of the individual dr’s # for the performing provider who is a member of a group practice that sub,its claims to ins co under the group name
A patient’s health plan is referred to as the payer of last resort. The patient is covered by which of the following health plans?
Medicaid
CHAMPA
Medicare
TRICARE
Medicaid
A provider charged $500 to a claim that had an allowable amount of $400. In which of the following columns should the CBCS apply the non allowed charge?
-Reference column (For notations)
-Description column
-Payment column
-Adjustment column of the credits
Adjustment column of the credits
Which of the following statements is correct regarding a deductible?
-Coinsurance is a type of deductible
-The physician should write off the deductible
-The insurance company pays for the deductible
-The deductible is the patient’s responsibility
The deductible is the patient’s responsibility
Which of the following color formats allows optical scanning of the CMS-1500 claim form?
-Red
-Blue
-Green
-black
red
Ambulatory surgery centers, home health and hospice organizations use the __.
-CMS-1500 claim form
-UB-04 claim form
-Advance Beneficiary notice
-First report of injury form
UB-04
Claims that are submitted without an NPI number will delay payment to the provider because __.
-The number is the patient’ id number
-The number is needed to identify the provider
-Is is used as a claim number
-It is used as a pre authorization number
The number is needed to identify the provider
Which of the following terms describes when a plan pays 70% of the allowed amount and the patient pays 30%?
-Coinsurance
-Deductible
-Premium
-copayment
coinsurance
Which of the following indicates a claim should be submitted on paper instead of electronically?
-The software claims review process indicates the claim is not complete
-The claim needs authorization
-The claim requires an attachment
-The practice management software is non functional.
the claim requires an attachment
On a remittance advice form, which of the following is responsible for writing off the difference between the amount billed and the amount allowed by the agreement?
-Provider
-Insurance company
-Patient
-Third party payer
provider
A physician is contracted with an insurance company to accept the amount. The insurance company allows $80 of a $120 billed amount, and $50 of the deductible has not been met. How much should the physician write off the patient’s account?
-$40
-$15
-$0
-$50
$40
The unlisted codes can be found in which of the following locations in the CPT manual?
-Appendix L
-Guidelines prior to each section
-End of each body system
-Table of contents
Guidelines prior to each section
Which of the following blocks should the billing and coding specialist complete the CMS 1500 claims form for procedure, services or supplies?
-Block 12
-Block 2
-Block 24D
-Block 24J
Block 24D
-Block 12 (patient’s authorization block
-Block 2 ( patient’s name)
-Block 24J ( for the rendering provider)
Which of the following blocks requires the patient’s authorization to release medical information to process a claim?
Block 12
Block 13
Block 27
Block 31
Block 12
- Block 13 patient authorization for benefits required for third party payer
- Block 27 accepting assignment of benefits
- Block 31 (treating physician)
Which of the following steps would be part of a physician’s practice compliance program?
-HIPAA compliance audit
-Physician recruitment
-Internal monitoring and auditing
-Notice of privacy practice
Internal monitoring and auditing
Behavior plays an important part of being a team player in a medical practice. Which of the following is an appropriate action for the CBCS to take?
-Reprimanding another staff member during a team meeting for displaying a bad attitude toward a patient
-Looking in the medical record of a friend who receives services at the office
-Communicating with the front desk staff during a team meeting about missing information in patient files
-Questioning the nurse about the provider documentation in the medical record
Communicating with the front desk staff during a team meeting about missing information in patient files
Which of the following acts applies to the administrative simplification guideline?
-HIPAA
-Deficit reduction act of 2005
-The patient protection and affordable care act 2009
-National correct coding initiative of 1995
HIPAA
Which of the following is an example of a violation of an adult patient’s confidentiality?
-While reviewing a claim, the CBCS reads the diagnosis before realizing that the patient is a neighbor
-A CBCS queries the physician about a diagnosis in a patient’s medical record
-The physician uses his home phone to discuss patient care with the nursing staff
-Patient information was disclosed to the patient’s parents without consent
Patient information was disclosed to the patient’s parents without consent
Which of the following is the purpose of running an aging report each month?
-If indicates the balances the patients owe the provider
-It indicates which patients have upcoming or missed appointment
-It indicates which claims are outstanding
-It indicates what the insurance company has paid for the provider’s services to a patient.
It indicates which claims are outstanding
Which of the following describes the status of a claim that does not include the required preauthorization for a service?
-Delinquent (overdue)
-Denied
-Suspended
-Adjudicated (claim still being processed)
Denied
-Delinquent (overdue)
-Adjudicated (claim still being processed)
Which of the following actions should the CBCS take to prevent fraud and abuse in the medical office?
-Serviced procedure preauthorization
-Internal monitoring and auditing
-Utilization review
-Correct coding initiative
Internal monitoring and auditing
In an outpatient setting, which of the following forms is used as a financial report of all services provided to patients?
-Encounter form
-Patient account record
-CMS-1500 claim form
-Accounts receivable journal
Patient account record (patient ledger, all transactions between patient and the practice)
-Accounts receivable journal (Day sheet = chronological summary of all transaction on a specific day)
Patient charges that have not been paid will appear in which of the following?
-Accounts receivable
-Accounts payable
-Tracer
-Rejected claim
Accounts receivable
Which of the following is considered the final determination of the issues involving settlement of an insurance claim?
-Processing
-Translation
-Adjudication
-Transmission
Adjudication (process of putting a claim through a series of edits for final determination)
-Processing ( handling a claim from the first encounter to claim submission)
-Translation (claim is send from the host system to the clearing house)
-Transmission (how the claim was sent)
Which of the following information should the CBCS input into block 33a on the CMS-1500 claim form
-Provider social security number (no Social security number on CMS1500)
-Federal tax id number (entered in block 25)
-Patient id number (on block 1a)
-National provider identification number
National provider identification number
A prospective billing account audit prevents fraud by reviewing and comparing a completed claim form with which of the following documents?
-A billing worksheet from the patient account
-A superbill
-A day sheet
-Am accounts receivable report of the patient account
A billing worksheet from the patient account
When a patient has a condition that is both acute and chronic, how should it be reported?
-Code only the acute code
-Code both acute and chronic, sequencing the acute first
-Code only the chronic code
-Code both acute and chronic, sequencing the chronic first
Code both acute and chronic, sequencing the acute first
Which of the following types of health insurance plan best describes a government sponsored benefit program?
-Unemployment compensation disability
-TRICARE prime
-Foundation for Medicare
-Worker’s compensation
TRICARE prime
-Unemployment compensation disability (state insurance covering non work related illness and injury)
Accepting assignment on the CMS-1500 claim form indicates which of the following?
-The patient agrees to accept payment and forward the payment to the physician
-The physician agrees to accept payment under the terms of the payer’s program.
-The physician agrees to bill according the third payer’s fee schedule
-The patient agrees to pay the difference between the billed amount and the allowed amount
The physician agrees to accept payment under the terms of the payer’s program.
Which of the following parts of the body system regulates immunity?
-Endocrine system (regulates growth, metabolic)
-Respiratory system (removes carbon dioxide)
-Urinary system (filters blood to remove waste of cellular metabolism)
-Lymphatic system
Lymphatic system
-Endocrine system (regulates growth, metabolic)
-Respiratory system (removes carbon dioxide)
-Urinary system (filters blood to remove waste of cellular metabolism)
Which of the following sections of the medical record is used to determine the correct evaluation and management code to use for billing and coding?
-Codes used during prior patient visits
-Patient’s insurance plan
-Plan of care
-History and physical
History and physical
A patient has met a Medicare deductible of $150. The patient’s coinsurance is 20%, and the allowed amount is $600. Which of the following is the patient’s out of pocket expense?
-$450
-$300
-$120
-$150
$120
Which of the following is allowed when billing procedure codes?
-Unbundling codes to ensure that all medical services were received and billed for
-Billing using two digit CPT modifiers to indicate a procedure as performed differs from its usual five digit code
-Billing for a surgical package with itemized codes
-Referring to the ICD book for the accurate description of the procedural code.
Billing using two digit CPT modifiers to indicate a procedure as performed differs from its usual five digit code
Which of the following describes the content of a medical practice aging report?
-An overview of the practice’s net worth
-An overview of the practice deposits.
-An overview of the practice’s debts
-An overview of the practice’s outstanding claims
An overview of the practice’s outstanding claims
Which of the following is the correct term for an amount that has been determined to be uncollectible?
-Discounted fee
-Bad debt
-Financial hardship
-Professional courtesy
bad debt
Which of the following is the function of the respiratory system?
-Deoxygenating blood cells
-Oxygenating blood cells
-Generating red blood cells
-Generating white blood cells
Oxygenating blood cells
A CBCS needs to know how much Medicare paid on a claim before billing the secondary insurance. To which of the following should the specialist refer?
-Assignment of benefits
-Medicare summary notice (how much the provider was billed and how much the patient has to pay)
-Remittance advice
-Coordination of benefits
remittance advice
The standard medical abbreviation “ECG” refers to a test used to assess which of the following body systems?
-Endocrine system
-Cardiovascular system
-Male reproductive system
-Respiratory system
Cardiovascular system
Which of the following blocks on the CMS-1500 claim form is used to bill ICD codes?
-24D
-22
-17a
-21
21
-24D (CPT or HCPCS codes)
-22 (resubmitting to Medicare)
-17a not required
Which of the following is the initial step in perceiving a worker’s compensation claim?
-First report of injury
-Notice of contest (carrier’s denial of the employers’ liability for an incomplete claim)
-Disability claim
-Progress notes
First report of injury
A participating blue cross/blue shield provider receives an explanation of benefits for a patient account. The charged amount was $100. Blue shield allowed $80 and applied $40 to the patient’s annual deduction. Blue shield paid the balance at 80%. How much should the patient expect to pay?
-$80
-$56
-$40
-$48
$48
A biller will electronically submit a claim to the carrier via which of the following?
-Electronic remittance advice (response from insurance)
-Direct data entry
-Electronic fund transfer
-Charge data entry
Direct data entry
What is the maximum number of ICD codes that can be entered on a CMS-1500 claim form as of February 2012?
4
6
10
12
12
Medicare enforces mandatory submission of electronic claims for most providers. Which of the following providers’ is allowed to submit paper claims to Medicare?
-A provider’s office with fewer than 10 full time employees
-A provider’s office with fewer than 25 full time employees
-A Medicare advantage contractor (MAC)
-A provider who submits a secondary insurance claim
A provider’s office with fewer than 10 full time employees
Test results indicated that abnormalities were found in the brain’s brain electrical activity patterns are normal. Which of the following tests was used to conduct the exam?
-EEG
-ECT
-EMG
-EGD
EEG
-ECT (electroconvulsive therapy – to treat major depression that does not respond to standard treatment)
-EMG (electromyography = test and recording the electrical activity produced skeletal muscles)
-EGD (esophagogastroduodenoscopy = test that examines the lining of the esophagus, stomach and upper part of the small intestine)
The destruction of lesions using cryosurgery would use which of the following treatments?
-Laser treatment
-Chemical peel treatment
-Cold treatment
-Electric current treatment
Cold treatment
On the CMS-1500 claim form, block 1 through 13 include which of the following?
-The patient’s demographics
-The provider’s information
-The patient’s diagnosis
-The procedures performed
The patient’s demographics
-The provider’s information (on blocks 25-33)
-The patient’s diagnosis (block 21)
-The procedures performed (block 24)
Which of the following is a type of claim that will be denied by the third party payer?
- Rejected claim
-Pending claim - Secondary claim
- Incomplete claim
incomplete claim
Which of the following is the appropriate diagnosis for a patient who has an abnormal accumulation of fluids in her lower leg that has resulted in swelling?
-Ptosis (drooping)
-Emesis (vomiting)
-Edema
-Dilation (widening)
edema
-Ptosis (drooping)
-Emesis (vomiting)
-Dilation (widening)
Which of the following is an example of electronic claim submission?
-Claim submitted via a secure network
-Claims submitted via fax
-Claims that are computer generated paper claims
-Claims that are completed using the CMS-1500 claim form
claim submitted via a secure network
Which of the following security features is required during transmission of protected health information and medical claims to third party payers?
-Unique used IDs and passwords
-Role based access controls
-Electronic data interchange
-Encryption
encryption
Which of the following actions should the CBCS take to effectively manage accounts receivable?
-Collect payment from the patient at the time of service
-Have the patient pat the balance up front and wait for reimbursement
-Delay submission until the patient pays the deductible
-Ask the patient to pay half now and bill the insurance for the balance
Collect payment from the patient at the time of service
Which of the following insurance carriers is considered the payer of last resort?
-Medicaid
-Medicare
-TRICARE
-Blue cross/shield
Medicaid
Which of the following blocks on the CMS-1500 claim form is required to indicate a worker’s compensation claim?
11a
21
10a
22
10a
-11a primary injured date of birth and gender
-21 diagnosis code
-22 Medicaid resubmission number
The provision of health insurance policies that specifies which coverage is considered primary or secondary is called?
-Eligibility verification
-Explanation of benefits
-Assignment of benefits
-Coordination of benefits
coordination of benefits
A provider receives a reimbursement from a third party payer accompanied by with document?
-Monthly statement
-Explanation of benefits
-Age analysis
-Benefit summary sheet (guideline for billing)
Explanation of benefits
When submitting claims, which of the following is the outcome if block 13 is left blank?
-The provider accepts assignment and payment as payment in full
-The provider cannot collect deductible, copayment, and coinsurance amounts
-This has no effect on the claim processing and reimbursement
-The third party payer reimburses the patient, and the patient is responsible for reimbursing the provider
The third party payer reimburses the patient, and the patient is responsible for reimbursing the provider
Which of the following situations constitutes a consultation?
- Services rendered by a physician whose opinion or advice is required by another physician or agency.
- The physician needs to meet the family and the patient to discuss the medical condition
- The transfer of the total or specific care of a patient from one physician to another for known problem
- The physician has had the initial treatment and needs to follow-up with the patient regarding the care plan
Services rendered by a physician whose opinion or advice is required by another physician or agency.
Which of the following billing patterns is the best practice action?
- Billing for diagnostic tests without a separate report in patient’s health record
- Billing the patient for the difference between the charges and the allowed amounts
- Documenting the patient’s chief complaint, history, exam, assessment, and plan for care
- Separating service or procedure codes to increase reimbursement
Documenting the patient’s chief complaint, history, exam, assessment, and plan for care
When billing a secondary insurance, which block should the CBCS fill out on the CMS-1500 form?
9a
28
24J
24F
9a
- 28 (total billed amount)
- 24J (NPI)
- 24F (charge per service)
Which of the following describes an obstruction of the urethra?
-Urethralgia (pain)
-Urethratresia
-Urethrism (stricture)
-Uretritis
Urethratresia
-Urethralgia (pain)
-Urethrism (stricture)
Which of the following is the correct entry of a charge of $150 in block 24F ?
150 00
150
150.00
15000
150 00
Which of the following organizations identifies improper payments made on CMS claims?
- Office of inspector general (OIG)
- Quality improvement organization (QIOs)
- Recovery audit contractor (RAC)
- Medicare administrative Contractors (MACs)
Recovery audit contractor (RAC) - Office of inspector general (OIG) (protect the integrity of the department of Health and Human services programs)
- Quality improvement organization (QIOs) (perform utilization and quality control review of healthcare furnished to Medicare beneficiaries
- Medicare administrative Contractors (MACs)
If the patient has osteomyelitis, he has problems with which of the following?
- Bones and muscles
- Bones and bone marrow
- Bones and skin
- Bones and tendons
bone and bone marrow
When coding on the UB-04 form, the CBCS must sequence the diagnosis codes according to ICD guidelines. Which of the following is the first listed diagnosis code?
- Primary diagnosis
- Chief complaint
- Etiology (underlying cause of the disease)
- Principal diagnosis
Principal diagnosis
A provider performs an examination of a patient’s sore throat. Which of the following describes the level of the examination?
- Expanded problem focused examination
- Detailed examination
- Problem focused examination
- Comprehensive examination
Problem focused examination - Expanded problem focused examination ( specific examination of an affected organ system and related organ systems)
- Detailed examination (extended examination of an affected organ system, and other related organ systems
- Comprehensive examination (general multi system examination)
Which of the following coding manuals is used to identify products, supplies and services?
- ICD-10 manual (diagnosis codes)
- HCPCS level II manual
- ICD-10-PCS manual (inpatient facilities to assign procedures)
- CPT manual (outpatient professional service and procedure codes in an
HCPCS level II manual - ICD-10 manual (diagnosis codes)
- ICD-10-PCS manual (inpatient facilities to assign procedures)
- CPT manual (outpatient professional service and procedure codes in an
A patient has an emergency appendectomy while on vacation. The claim is rejected due to the patient obtaining services out of network. Which of the following information should be included in the claim appeal?
- The provider’s network status
- The names of the travelers who where with the patient during the emergency
- The patient was out of town during the emergency
- The reason why the patient was out of town
The patient was out of town during the emergency
After reading a provider’s notes about a new patient, a CBCS decides to code for a longer length of time than the actual office visit. Which of the following describes that action?
- Unbundling
- Abuse
- Fraud
- Error
fraud
Two providers from the same practice visit a patient in the ER using the same CPT code. The claim may be denied due to which of the following reasons?
- Continuity of care
- Incident to service (non physician practitioner bills in place of the physician)
- Critical care
- Duplication of services
duplication of service
Which of the following statements is true when determining patient financial responsibility by reviewing the remittance advice?
- Any service not paid by a third party payer
- Any coinsurance, copayment, deductions
- The difference between the billed amount and the allowed amount
- claims not billed to a third party payer within the correct time period
Any coinsurance, copayment, deductions
Which of the following is a requirement of some third party payers before a procedure is performed?
- Predetermination form
- Pre Authorization form
- Advanced beneficiary notice
- Precertification form
Pre Authorization form
Which of the following modifiers should be used to include a professional service has been discontinued prior to completion?
-73 (used by facilities to indicate a discontinued outpatient procedure prior to procedure)
-52 ( physician to indicate that a service code was reduced from its original description)
-74 ( facilities to indicate a discontinued outpatient procedure after the procedure)
-53 (physician uses this for a procedure begun but discontinued prior to its completion)
53 (physician uses this for a procedure begun but discontinued prior to its completion)
- 73 (used by facilities to indicate a discontinued outpatient procedure prior to procedure)
-52 ( physician to indicate that a service code was reduced from its original description)
-74 ( facilities to indicate a discontinued outpatient procedure after the procedure)
Which of the following is used by providers to remove errors from claims before they are submitted to third party payers?
- National committee for quality assurance
- HIPAA transaction and code sets (TCS)
- Correct coding initiative (CCI)
- clearinghouse
clearinghouse - National committee for quality assurance (report standards that compare performance between health care plans)
- HIPAA transaction and code sets (TCS) (standardizes electronic claim transactions)
- Correct coding initiative (CCI) ( prevents unbundling)
Block 17b should list which of the following information?
- Referring physician’s national provider identification number
- Referring physicians name
- Rendering physician’s national provider identification number
- Rendering physician’s name
Referring physician’s national provider identification number - Referring physicians name (block 31)
- Rendering physician’s national provider identification number (24i)
- Rendering physician’s name (17)
Which of the following is the third stage of the life cycle of a claim?
- Claim processing
- Claims payment
- Claims adjudication
- Claims submission
Claims adjudication - Claim processing (second)
- Claims payment ( fourth)
- Claims submission (first)
A patient presents to the provider with chest pain and shortness of breath. After an unexpected ECG result, the provider calls a cardiologist and summarizes the patient’s symptoms. What portion of HIPAA allows the provider to speak to the cardiologist prior to obtaining the patient’s consent?
- Title I
- The privacy rule
- Title II
- FERPA
Title II - Title I (regulates insurance reform)
- The privacy rule
- FERPA ( family education right and privacy act = protects the privacy of student records, not part of HIPAA)
When a physician documents a patient’s response to symptoms and various body systems. The results are documented as which of the following?
- Past medical history
- Family history
- Review of systems
- Comprehensive examination
Review of systems
Which of the following statements is true regarding the release of patient records?
- Verbal requests for records from life insurance companies are appropriate
- Identification is not required when requesting access to patient records
- Providers cannot share a patient’ medical information with other health care professionals if the patient’s mentally unstable
- Patient access to psychotherapy notes may be restricted
Patient access to psychotherapy notes may be restricted
A claim is denied because the service was not covered by the insurance. Upon confirmation of no errors on the claim, which of the following describes the process that will follow the denial?
- The claim will be submitted with a new CPT code
- The claim will not be resubmitted and the patient will be sent a bill
- The claim will be resubmitted with a modifier on the CPT code
- The claim will not be resubmitted, but the claim will be appealed.
The claim will not be resubmitted and the patient will be sent a bill
When an electronic claim is rejected due to incomplete information, which of the following action should the CBCS take?
- Process the claim as an adjustment
- Complete the information and retransmit according to the third party standards
- Reprocess the rejected claim within 30 days
- Send the claim back with the next batch of claims
Complete the information and retransmit according to the third party standards
Which of the following documents is required to disclose an adult patient’s information
- A signed released for the patient’s family member
- The patient’s driver’s license
- A signed release from the patient
- The patient’s social security card
A signed release from the patient
In 1995 and 1997 , which of the following introduced documentation guidelines to Medicare carriers to ensure that service paid for have been provided and were medically necessary?
- HIPAA
- OIG
- CMS
- AMA
CMS - OIG – fraud and abuse
- AMA – physician patient relationship
For which of the following time periods should the CBCS track unpaid claims before taking follow up action?
10 days
30 days
60 days
90 days
30 days
A beneficiary of a Medicare/Medicaid crossover claim submitted by a participating provider is responsible for which of the following percentage?
40%
20%
10%
0%
0%
A CBCS should add modifier -50 to codes when reporting which of the following?
- A bilateral procedure
- A unilateral procedure
- Multiple procedure
- Reduces services
A bilateral procedure
Z codes are used to identify which of the following?
-Behavior disorders
- Digestive diseases
- Infectious diseases
- Immunizations
Immunizations
Behavior disorders (F)
Digestive diseases (K)
Infectious diseases (A and B)
Which of the following was developed to reduce Medicare program expenditure by detecting in appropriate cades and eliminating improper coding practice?
- NCCi
- HIPAA
- MAC
- NPI
NCCi (national correct coding initiative – detect inappropriate codes and eliminate improper coding practices) - HIPAA
- MAC (Medicare administrative contractor)
- NPI
Which of the following is a verbal or written agreement that gives approval to release PHI?
- Notice of privacy practices
- Right to privacy
- Consent
- Assignment of benefits
consent
After a third party validates a claim, which of the following takes place next?
- Claim payment
- Claim adjudication (process of analyzing the claim)
- Claim resolution (small claims court)
- Claim attachment
Claim adjudication (process of analyzing the claim) - Claim payment
- Claim resolution (small claims court)
- Claim attachment
A CBCS is reviewing a CMS-1500 claim form. The assignment of the benefits box has been checked “yes”. The check box indicates which of the following?
- The provider receives payment directly from payer
- The payer sends reimbursement for service to the patient
- The payer pays the provider a set amount for each enrolled person assignment of benefit box
- The provider can collect full payment from the patient
The provider receives payment directly from payer
Which of the following forms must the patient or representative sign to allow the release of PHI?
- An authorization
- An affidavit
- A copy of the HIPAA security rule
- A copy of the HIPAA privacy rule
an authorization
Which of the following is the primary information used to determine the priority of collection letters to patients?
- The age of the account
- The type of the account
- The type of the insurance
- The last payment received
the age of the account
Which of the following claims would appear on an aging report?
- A claim paid in full within the past 90 days
- A claim that is delinquent for 60 days
- A claim processed and paid within past 60 days
- A claim that billed and reimbursed the patient within the past 30 days
A claim that is delinquent for 60 days
A CBCS should enter the prior authorization number on the CMS-1500 claim form in which of the following blocks?
- 21A (diagnosis code)
- 24 D (procedures and services)
- 23 (prior authorization)
- 24E (federal tax id)
23 (prior authorization) - 21A (diagnosis code)
- 24 D (procedures and services)
- 24E (federal tax id)
Which of the following blocks require the patient’s authorization to release medical information to process a claim?
- 12
- 13 (patient authorization for assignment of benefits required for third party payer
- 27 (accepting assignment of benefits)
- 31 (treating physician’s name)
12 - 13 (patient authorization for assignment of benefits required for third party payer
- 27 (accepting assignment of benefits)
- 31 (treating physician’s name)
Which of the following claims is submitted and then optically scanned by the insurance and converted to an electronic form?
- Paper claim
- Pending claim
- Clean claim
- Rejected claim
paper claim
Which of the following actions by a CBCS would be considered fraud?
- Submitting a claim for services that are not medically necessary
- Violating participating provider agreements with third party payer
- Billing for services not provided
- Billing non-covered services as covered services
billing for services not provided
Which of the following privacy measures ensures PHI?
- Confirming test results with the patient over the phone at the reception
- Asking patients the reason for their visit at check in
- Using data encryption software on office workstation
- Calling a patient into the clinical area using first and last name.
Using data encryption software on office workstation
A form that contains charges, DOS, CPT codes, ICD codes, fees and copayment information is called which of the following?
- Encounter form
- Itemized bill
- Chargemaster
- Remittance advice
encounter form
Which of the following medical terms refers to the sac that encloses the heart?
-Endocardium
-Epicardium
-Myocardium
-pericardium
pericardium
When completing CMS-1500 paper claim form, which of the following is an acceptable action for the CBCS to take?
- Use appropriate title for all patients
- Fold the form in half for mailing
- Use Arial size 10 font
- Attach documents with staples in the left hand corner
use Arial size 10 font
Which of the following describes a delinquent claim?
- The claim was submitted beyond the timely filing limit
- The claim had more than one procedure submitted
- The claim is an incoming claim
- The claim is overdue for payment
the claim is overdue for payment
A patient is upset about a bill she received. Her insurance denied the claim. Which of the following actions is an appropriate way to handle the situation?
- Tell the patient to resubmit the claim to the insurance
- Inform the patient of reason of the denial
- Tell the patient to speak with the provider
- Inform the patient the insurance will follow up
inform the patient of reason of the denial
Why does correct claim processing rely on accurately completed encounter forms?
- The billing codes contained on the form can be trusted due to automatic updates, as required for compliant claims
- They increase the efficiency of the medical practice by replacing extensive documentation in the medical record
- They same time as the form does not require authorization by the provider
- They streamline patient billing by summarizing the service rendered for a given date of service
They streamline patient billing by summarizing the service rendered for a given date of service
A patient who has a primary malignant neoplasm of the lung should be referred to which of the following specialists?
- Cardiologist
- Pulmonary oncologist
- Thoracic surgeon
- hematologist
pulmonary oncologist
Which of the following forms should the CBCS transmit to the insurance carrier for reimbursement of inpatient hospital services?
- UB-02 (obsolete version of UB-04)
- UB-04
- HCFA-1500 ( obsolete version of CMS 1500)
- CMS-1500
UB-04
Which of the following information should the CBCS input into block 33a ?
-Provider social security number
-Federal tax ID number (25)
-Patient’s ID number (1a)
-NPI
NPI
- Provider social security number
-Federal tax ID number (25)
-Patient’s ID number (1a)Which of the following is a private insurance carrier?
Which of the following is a private insurance carrier?
Medicare
Medicaid
TRICARE
Blue cross/shield
blue cross/shield
Which of the following sections of the medical record is used to determine the correct evaluation and management code for billing and coding?
-Codes used during prior patient visit
-Patient’s insurance plan
-Plan of care
-History and physical
History ad physicals
Which of the following describes the reason for a claim rejection because of Medicare NCCI edits?
- Reporting codes without proper modifiers
- Coding without proper documentation
- Medicare NCCI edit will trigger a claim rejection for improper code combination
- Use of outside codes
Medicare NCCI edit will trigger a claim rejection for improper code combination
Which of the following departments should a patient be seen for psoriasis?
- Cardiologist
- Dermatologist
- Otolaryngology
- gastroenterology
dermatologist
A nurse is reviewing a patient’s lab results prior to discharge and discovers an elevated glucose level. Which of the following health care providers should be alerted before the nurse can proceed with discharge planning?
- The attending physician
- The admitting physician
- The nursing supervisor
- The physician assistant
attending physician
On the CMS-1500 claim form, blocks 14 to 33 contain information about which of the following?
- Patient demographics
- The patient’s condition and the provider’s information
- The insurance name and address
- The patient’s medical history
- The patient’s condition and the provider’s information
The star symbol in the CPT code book is used to indicate which of the following?
- New code
- Exempt from the used of modifier 51
- Revised code
- telemedicine
telemedicine - New code (bullet or dot symbol)
- Exempt from the used of modifier 51 (circle with line through it)
- Revised code (blue triangle)
Which of the following is the portion of the account balance the patient must pay after services are rendered and the annual deductible is met?
Coinsurance
Allowed amount
Premium
capitation
&
The CBCS should first divide the evaluation and management code by which of the following?
- Place of service
- Severity
- Combination code (diagnosis)
- Point of service (type of insurance)
place of service
In the anesthesia section of the CPT manual, which of the following are considered qualifying circumstances?
-Physical status modifiers
-Primary procedure code
-Mutually exclusive codes
- Add-on codes
Add-on codes (listed after the primary procedure code, cannot ever be listed as a primary or coded as the only procedure code) - Physical status modifiers (level of complexity of the anesthesia service provided)
- Primary procedure code (not a qualifying circumstance)
- Mutually exclusive codes (codes that could not reasonable be performed during the same operative event)
As of April 1, 2014, what is the maximum number of diagnoses that can be reported on the CMS-1500 claim form before further claim is required?
4
10
12
6
12
When submitting a clean claim with a diagnosis of kidney stones, which of the following procedure names is correct?
- Nephrolysis
- Nephrectomy
- Nephrolithiasis
- Enterorrhexis
- Nephrolithiasis
- Nephrolysis (washing free of adhesions)
- Nephrectomy
- Enterorrhexis (rupture)
Which of the following is one of the purposes of an internal auditing program in a physician’s office?
- Verifying that the medical records and the billing record match
- Increasing revenue for the physician
- Improving communication between the coding supervisor and coding professional
- Protecting patients from sanctions or fines
Verifying that the medical records and the billing record match
patient : Jane Austin; Social Security No: 555-22-1111, Medicare ID no:555-33-2222A, DOB 05/22/1945. Claim information entered. Austin, Jane: social security no :555-22-1111, Medicare no: 555-33-2222A , DOB: 052245. Which of the following is a reason the claim was rejected?
- The Medicare Id is entered incorrectly
- The DOB is entered incorrectly
- The patient’s name is entered incorrectly
- The social security is entered incorrectly
The DOB is entered incorrectly
Which of the following options is considered proper supportive documentation for reporting CPT and ICD codes for surgical procedure?
- Approval on previous claim form
- Operative report
- Encounter form
- Progress note
Operative report
Which of the following actions should be taken first when reviewing a delinquent claim?
- Verify the age of the account
- Query the insurance company
- Obtain claim status
- Resubmitting the claim
Verify the age of the account
Which of the following components of an explanation of benefits expedites the process of a phone appeal?
- NPI number
- Claim control number
- Insured’s ID number
- Check number
Claim control number
A claim can be denied or rejected for which of the following reasons?
- All data is uppercase
- Block 25 contains the EIN of the rendering provider
- The patient’s DOB is in eight digit format
- Block 24 D contains the diagnosis code
Block 24 D contains the diagnosis code (should be in 21)
To be compliant with HIPAA, which of the following positions should be assigned in each office?
- Gatekeeper
- Privacy officer
- Compliance official
- Health insurance administrator
Privacy officer - Compliance official ( ensures that all staff comply with industry standards)
- Health insurance administrator (facilitates the payer’s side)
All email correspondence to a third party payer containing a patient’s PHI should be _ .
Encrypted
Removed
Forwarded to the patient
Accompanied with an authorization
Encrypted
A CBCS should understand that the financial record source that is generated by the provider’s office is called a _ .
- Chargemaster
- Fee schedule
- Encounter form
- Patient ledger account
Patient ledger account (history of patient’s financial record)
Which of the following includes procedures and best practices for correct coding?
- Coding compliance plan
- Retrospective audit
- Prospective review
- Diagnosis related group
Coding compliance plan (contains rules, procedures and best practices to ensure accurate coding) - Retrospective audit (ensure correctness of billing documents)
- Prospective review ( ensure the appropriateness and necessity of the care provided)
- Diagnosis related group (Prospective payment for acute care is based on the Diagnosis related groups)
HIPAA transaction standards apply to which of the following entities?
- Employers who provide worker’s compensation plans
- Automobile insurance agencies
- Health care clearinghouses
- Educational facilities
healthcare clearinghouse
Which of the following actions should be taken if an insurance denies a service as not medically necessary?
- Send the patient a copy of the remittance advice
- Appeal the decision with a provider’s report
- Submit a claim to the patient’s secondary insurance
- Call the patient to confirm eligibility
Appeal the decision with a provider’s report
A patient with a past due balance requests that his records be sent to another provider. Which of the following actions should be taken?
- Withhold the records until the account is paid (HIPAA requires to honor the request)
- Send the patient a statement
- Accommodate the request and send the record
- Begin collection action on the balance due
accommodate the request and send the record
The physician bills $500 to a patient. After submitting the claim to the insurance, the claim is sent back with no payment. The patient still owes $500 for the year. This amount is called?
- Deductible
- Coinsurance
- Copayment
- Premium
deductible
Which of the following is used to code diseases, injury and other health related problems?
- ICD
- CPT
- HCPCS
- CDT
ICD - CDT ( Current Dental terminology)
A patient’s portion of the bill should be discussed with the patient before a procedure is performed for which of the following reasons?
- To determine the procedure
- To verify insurance coverage
- To give the patient the option to negotiate their portion of the bill
- To ensure the patient understands his portion of the bill
To ensure the patient understands his portion of the bill
Which of the following information is required on a patient account record?
- Name and address of guarantor
- Procedures performed
- Family history of the guarantor
- Diagnosis
Name and address of guarantor
A claim is submitted with a transposed insurance member ID number and returned to the provider. Which of the following describes the status that should be assigned to the claim by the carrier?
- Suspended
- Pending
- Denied
- invalid
invalid
Which of the following should the CBCS complete to be reimbursed for the provider’s service?
- CMS-1500 claim form
- CMSC-1450
- Superbill
- Leger
CMS-1500 claim form - CMSC-1450 (used by institutions)
- Superbill (encounter form)
- Leger (financial document)
Which of the following is a HIPAA compliance guideline affecting electronic health records?
- The privacy requirements cover facilities health information, whether paper of electronic
- Electronic health records should be sent to the insurance at 835P format (remittance advice is in the 835 P format)
- The electronic transmission and code set standards require every p provider to use the health care transaction, code set and identifiers
- The Health information technology of economic and clinical health (HITECH) act encrypts provider PHI.
The electronic transmission and code set standards require every p provider to use the health care transaction, code set and identifiers - (remittance advice is in the 835 P format)
Which of the following is the purpose of precertification?
- Verification of coverage
- Assignment of benefits
- Determining the annual deductible amount
- Determining the coinsurance amount
verification of coverage
Which of the following should the CBCS include in an authorization to release information?
- The number of pages to be released
- The health record number
- The entity to whom the information is to be released
- The name of the physician
the entity to whom the information is to be released
Which of the following actions should the CBCS take if he observes a colleague in an unethical situation?
- File a complaint with the company compliance officer
- Confront the employee
- Report the incident to a supervisor
- Ignore the incident
report the incident to a supervisor
When posting payment accurately, which of the following items should the CBCS include?
- CPT code
- ICD codes
- Insurance number
- Patient’ responsibility
patient responsibility
A dependent child whose parents both have insurance coverage, comes to the clinic. The CBCS uses the birthday rule to determine which insurance policy is primary. What is the birthday rule?
- The parent who has the birthdate closer to the child
- The parent whose birthday comes first in the calendar year
- The parent who is older
- In the case of identical birthdates, the payment whose name is first alphabetically
the parent whose birthday comes first in the calendar year
Which of the following statements is true regarding the release of patient records?
- Verbal requests for records from life insurance are appropriate.
- Identification is not required when requesting access to patient records
- Providers can not share a patient’s medical information with other health care professionals if the patient is mentally unstable
- Patient access to psychotherapy notes be restricted
Patient access to psychotherapy notes be restricted
A patient’s employer has not submitted a premium payment. Which of the following claim statuses should the provider receive from the third party payer?
- Invalid
- Adjusted
- Denied
- incomplete
denied
Which of the following do physicians use to electronically submit claims?
- Claim scrubber
- Clearinghouse
- CMS-1050
- 835P
clearinghouse
When coding on the UB-04 form, the CBCS must sequence the diagnosis codes according to ICD guidelines. Which of the following is the first listed diagnosis code?
- Primary diagnosis
- Chief complaint
- Etiology
- Principal diagnosis
principal diagnosis (inpatient) - primary diagnosis = outpatient
Which of the following does a patient sign to allow payment of claim directly to the provider?
- Advance beneficiary notice
- Assignment of benefits
- Adjudication of claim
- Release of information
assignment of benefits
According to HIPAA standards, which of the following identifies the -rendering provider in Block 24J?
- UPIN (unique provider number – no longer used)
- EIN (employee id number – 25 )
- SSN (25 and 33)
- NPI
NPI - UPIN (unique provider number – no longer used)
- EIN (employee id number – 25 )
- SSN (25 and 33)
Which of the following provisions ensures that an insured’s benefits from all insurances do not exceed 100% of allowable medical expenses?
- Source document (financial draft that is the initial point of entry to an accounting system)
- Assignment of benefits
- Coinsurance
- Coordination of benefits
Coordination of benefits - Source document (financial draft that is the initial point of entry to an accounting system)
Which of the following is the verbal or written agreement that gives approval to some action, situation, or statement and allows the release of patient information?
- Compliance agreement (prevents fraudulent activities)
- Security rule agreement
- Consent agreement
- HIPAA
consent agreement
The deductible of $100 is applied to a patient’s remittance advice. The provider requests the account personnel write it off. Which of the following terms describes this scenario?
- Fraud
- Abuse
- Adjudication
- spend-down
Fraud
A coroner’s autoplay is comprised of which of the following examinations?
- Suppression testing
- Gross examination
- Diagnostic endoscopy
- Mohs micrographic examination
Gross examination
Which of the following is the advantage of electronic claim submission?
- Claims are expedited
- Claims are scrubbed
- Claims are clean
- Claims are paid
Claims are expedited
A physician ordered a comprehensive metabolic panel for a 70 year old patient who has Medicare as her primary insurance. Which of the following forms is required so the patient knows she may be responsible for payment?
- HIPAA
- Advance beneficiary notice
- Assignment of benefits
- CMS-1500
advance beneficiary notice
All dependents 10 years or older are required to have which of the following for TRICARE?
- Signature on file
- Military identification
- Assignment of benefits
- Provider signature
Military identification
Medigap coverage is offered to Medicare beneficiaries by which of the following?
- Medicaid (Medicaid supplemental coverage is called Medi-Medi and it picks up Medicare’s premium to qualified applicants)
- Federal health plans (not private, therefore do not offer supplemental coverage)
- Managed care plans (primary or secondary, not supplemental)
- Private third party payer
private third party payer
An insurance claim register (aged insurance report) facilitates which of the following?
- Batching of claims for submission to the insurance
- Determination of the patient’s insurance coverage
- Compensation of the CMS-1500 claim form
- Follow up of insurance claim by date
Follow up of insurance claim by date
A patient comes to the hospital for an inpatient procedure. Which of the following staff members is responsible for the initial patient interview, obtaining demographic and insurance information, and documenting the chief complaint?
- Nurse
- Insurance billing clerk
- Admitting clerk
- Ward clerk
admitting clerk
Which of the following is the primary function of the heart?
- Pumping blood in the circulatory system
- Creating new blood form the bone marrow
- Deoxygenating blood in the lungs
- Ridding the blood of free radicals
Pumping blood in the circulatory system
Which of the following actions should be taken when a claim is billed for a level 4 office visit and paid at a level 3?
- Charge the patient for the difference
- Submit the claim to the patient’s secondary carrier
- Write off the difference between the two services
- Submit an appeal to the carrier with the supporting documentation
Submit an appeal to the carrier with the supporting documentation
Which of the following types of claims is 120 days old?
- Clean
- Delinquent
- Open
- closed
delinquent
Which of the following shows outstanding balances?
- Bad debt report
- Fee schedule
- Aging report
- Remittance advice
aging report
Which part of Medicare covers prescription?
A
B
C
D
D
Which of the following best describes medical ethics?
- Medical etiquette
- Medical standard of conduct
- Medical laws
- Medical principles and practices
medical standard of conduct
A provider’s office receives a subpoena requesting medical documentation from a patient’s medical record. After confirming the correct authorization, which of the following actions should the billing and coding specialist take?
- Send the patient’s demographic information from the dates of services
- Send the medical information pertaining to the dates of service requested
- Send the patient’s financial record ledger from the dates of service requested
- Send the claim pertaining to the dates of service requested
Send the medical information pertaining to the dates of service requested
Which of the following prohibits a provider from referring Medicare patients to a clinical laboratory service in which the provider has a financial interest?
- Federal anti-kickback statute
- Health insurance portability and accountability act (HIPAA)
- Consolidated omnibus budget reconciliation act (COBRA)
- Stark Law
Stark Law - Federal anti-kickback statute (prohibits exchange or offer for exchange, anything of value, in an effort to reward the business
- Health insurance portability and accountability act (HIPAA)
- Consolidated omnibus budget reconciliation act (COBRA)
Which of the following explains why Medicare will deny a particular service or procedure?
- Local coverage determination (LCD)
- Advance beneficiary notice
- CMS-1500
- UB-04
advance beneficiary notice
Which of the following documentation is valid authorization to release medical information to the judicial system?
- Consent for treatment form
- Deposition
- Signed release of information form
- Subpoena duces tecum
Subpoena duces tecum
A physician’s office fee is $100 and the Medicare Part B allowed amount is $85. Assuming the beneficiary has not met his annual deductible, the office should bill the patient for which of the following amounts?
$85
$15
$100
$0
$85
A CBCS has four past-due charges: $400 that is 10 weeks past due; $800 that is 6 weeks past due; $1000 that is 4 weeks past due; and $2000 that is 8 weeks past due. Which of one should be sent to collection first?
-$400
-$800
-$1000
- $2000
$2000 (the largest amount first)
Threatening a catheter with a balloon into a coronary artery and expanding it to repair arteries describes which of the following procedures?
- Valvuloplasty
- Atherectomy
- Angioplasty
- Ablation
Angioplasty - Valvuloplasty (open a stenotic heart valve)
- Atherectomy (Non surgical procedure to open blocked coronary arteries or vein grafts by using a device on the end of a catheter to cut or shave away atherosclerotic plaque. It does not us a balloon.
- Ablation (radio frequency waves of the heart is used to cure a variety of cardiac arrhythmia.)
Which of the following should a CBCS use to submit a claim with supporting documents?
- Aging report
- claim s attachment
- Electronic explanation of benefits
- Electronic remittance advice details services billed and payment
claims attachment
If a clean claim is received on March 1 of this year, which of the following is the allowable last day of payment in order to meet Medicare compliance requirements
March 15
April 2
March 30
April 10
March 30 (paid in 30 days)
Which of the following is a reason for a claim to be denied?
- Unpaid copayment
- incorrectly linked codes
- Missing attachment (suspended)
- Omission of patient gender (suspended)
A CBCS should routinely analyze which of the following to determine the number of outstanding claims?
- Accounts payable report
- Aging report
- Remittance advice
- Explanation of benefits
aging report
When reviewing an established patient’s insurance card, the CBCS notices a minor change from the existing card on file. Which of the following actions should the CBCS take?
- Photocopy both sides of the new card
- Describe the change on the patient registration form
- Instruct the patient to contact the insurance company to verify coverage
- Confirm with the patient that the insurance coverage is the same
Photocopy both sides of the new card
Which of the following is an example of a remark code from an explanation of benefits document?
- Contractual allowance (standard response to the amount charged)
- Amount charged
- Statement summary
- Out of pocket
Contractual allowance (standard response to the amount charged)
Which of the following national provider identification is required in Block 33a of a CMS-1500 claim form?
- Referring provider
- Insurance provider
- Service facility provider
- Billing provider
Billing provider - Referring provider (17b)
- Insurance provider (not required)
- Service facility provider (32a)
Which of the following is true regarding Medicaid eligibility?
- Eligibility of dependents is automatic
- Providers who accept Medicare must also accept Medicaid
- Patient eligibility is determined monthly
- Patient eligibility begins at 65
Patient eligibility is determined monthly
Which of the following is the purpose of coordination of benefits?
- Collect and verify information about the patient and provider by sorting claims upon submission
- Compare payer edits and patient’s health plan
- Prevent multiple insurers from paying benefits covered by other policies
- Reduce the number of paper claim submitted
Prevent multiple insurers from paying benefits covered by other policies
When the remittance advice is sent from the third-party payer to the provider, which of the following actions should the CBCS perform first?
- Generate a patient statement of responsibility
- Post necessary contractual adjustment
- Ensure proper payment has been made
- Evaluate the claim for collection activity
ensure proper payment has been made
Which of the following pieces of guarantor information is required when establishing a patient’s financial record?
- Procedural codes used
- Providers name
- Phone number
- diagnosis
phone number
The “<>” symbol is used to indicate new and revised text other than which of the following?
- Diagnostic nonessential modifier
- Procedure descriptors
- HCPCS description
- Diagnostic specificity
procedure descriptors
A provider surgically punctures through the space between ribs using an aspirating needle to withdraw fluids from the chest cavity?
- Thoracotomy (incision)
- Pleurocentesis
- Thoracoscope (visual exam)
- Pleurodesis (pleural space is obliterated)
Pleurocentesis - Thoracotomy (incision)
- Thoracoscope (visual exam)
- Pleurodesis (pleural space is obliterated)
Which of the following formats are used to submit electronic claims to a third-party payer?
-835 (claims payment and remittance advice)
- 270 (transaction for an eligibility inquiry to centers for Medicare and -Medicaid or Medicare administrative contractor)
- 837
- 271 (response from Medicare and Medicaid to 270)
837 - 835 (claims payment and remittance advice)
- 270 (transaction for an eligibility inquiry to centers for Medicare and -Medicaid or Medicare administrative contractor)
- 271 (response from Medicare and Medicaid to 270)
Which of the following actions by the CBCS prevents fraud?
- Writing of a deductible
- Performing periodic audits
- Unbundling codes
- Upcoding claims
performing periodic audits
Which of the following describes an insurance carrier that pays the provider who rendered services to a patient?
- Fee-for-service (patient pays provider at each visit)
- First party payer (patient)
- Third-party payer
- Retrospective payment
third party payer
Which of the following causes a claim to be suspended?
- The patient’s medical coverage is canceled (denied)
- The patient other primary insurance (denied)
- Services require additional information
- Services were not authorized (denied)
Services require additional information
For non-crossover claims, the CBCS should prepare an additional claim for the secondary payer and send it with a copy of which of the following?
- Primary insurance card
- Coordination of benefits
- Remittance advice
- Assignment of benefits
remittance advice
Which of the following terms is used to communicate why a claim line item was denied or paid differently that it was billed?
Claim adjustment codes
Clearinghouse report
Provider taxonomy codes (identification of type of provider)
Claim control number
claim adjustment codes
Which of the following describes a two-digit CPT code used to indicate that the provider supervised and interpreted a radiology procedure?
- Technical component
- Professional component
- Descriptive qualifier
- Physical status modifier
- Professional component
- Technical component (use of equipment)
- Descriptive qualifier (terms not codes)
- Physical status modifier (patient condition at time of anesthesia administration)
Which of the following parts of the Medicare insurance program is managed by private, third-party insurance providers that have been approved by Medicare?
Medicare part A
Medicare part B
Medicare part C
Medicare part D
Medicare Part C
When a third-party payer requests copies of patient information related to a claim, the CBCS must make sure which of the following is included in the patient’s file?
- Consent to treat
- Signed release of information form
- Pre Authorization form for the patient to see a specialist
- Signed subpoena information form
Signed release of information form
A husband and wife each have group insurance through their employers. The wife has an appointment with her provider. Which insurance should be used as primary for the appointment?
- Husbands insurance
- Whoever is older
- Whoever has their birthday first in the calendar year
- Wife’s insurance
wife’s insurance
Which of the following is a federal government health insurance
- Blue shield and Blue cross
- Worker’s compensation
- Cigna
- TRICARE
TRICARE
Which of the following terms refers to the difference between the billed and allowed amounts?
- Adjustment
- Copayment
- Deductible
- coinsurance
adjustment
Which of the following actions would be considered fraud?
- Which of the following actions would be considered fraud?
- Submitting a claim for services that are not medically necessary
- Violating participating provider agreements with third-party payers
- Billing for services not provided
- Billing non-covered services as covered services
Billing for services not provided - Submitting a claim for services that are not medically necessary (abuse)
- Violating participating provider agreements with third-party payers (abuse)
- Billing non-covered services as covered services (abuse)
The CBCS should follow the guidelines in the CPT manual for which of the following reasons?
- The guidelines define items that are necessary to accurate code
- The guidelines assist with coding proper diagnoses (ICD)
- The guidelines indicates medical necessity
- The guidelines negate the need for documentation
The guidelines define items that are necessary to accurate code
Which of the following entities defines the essential elements of a comprehensive compliance program?
- Centers for Medicare and Medicaid Services
- Health information Portability and accountability act
- American health information management association
- Office of inspector general
Office of inspector general (OIG) - Centers for Medicare and Medicaid Services (CMS)
- Health information Portability and accountability act (HIPAA)
-American health information management association (AHIMA) (promotion of knowledge and integrity of the profession)
A claim is denied due to termination of coverage. Which of the following actions should the CBCS take next?
- Follow up with the provider to determine current procedure code, diagnostic code and provider number for resubmission
- Follow up with the patient to determine current primary care provider for resubmission
- Follow up with the provider to determine current patient’s status and include a billing history for resubmission
- Follow up with the patient to determine current name, address, and insurance carrier for resubmission
Follow up with the patient to determine current name, address, and insurance carrier for resubmission
Which of the following sections of the SOAP note includes a patient’s level of pain to a provider?
- Subjective
- Objective
- Assessment
- plan
subjective
Which of the following reports is used to arrange the accounts receivable from the date of service?
- Explanation of benefits report
- Remittance advice report
- Itemized report
- Aging report
aging report
Which of the following is used to code illness, injury, impairments, and other health related problems?
- ICD
- CPT
- HCPCS
- CDT
ICD
CPT (procedures)
HCPCS (hospital)
CDT (dental)
Which of the following is fraud?
- submitting a bill for claims not medically necessary
- Submitting a bill for services that are not covered
- Submitting a bill for duplicate charges on a claim
- Unbundling a code for higher reimbursement
Unbundling a code for higher reimbursement
Which of the following Medicare policies determines if a particular item or service is covered by Medicare?
- National coverage determination (NCD)
- Prospective payment system ( PPS)
- Advance beneficiary notice
- Resource based relative value scale
National coverage determination (NCD) - Prospective payment system ( PPS)
Which of the following terms is used to describe the location of the stomach, the spleen, part of the pancreas, part of the liver, and part of the small and large intestine?
- Left upper quadrant
- Right upper quadrant (right lobe of liver, gallbladder, part of pancreas, small and large intestine)
- Right lower quadrant (small and large intestines, appendix, and right ureter
- Left lower quadrant (parts of small and large intestine, left ureter
Left upper quadrant - Right upper quadrant (right lobe of liver, gallbladder, part of pancreas, small and large intestine)
- Right lower quadrant (small and large intestines, appendix, and right ureter
- Left lower quadrant (parts of small and large intestine, left ureter)
Which of the following would result in a claim being denied?
- An italicized code used as the first listed diagnosis
- A CPT code used as the procedure code in an outpatient setting
- An ICD-10-PCS code used as the primary diagnosis code in an inpatient setting
- A HCPCS code used as the procedure code in an outpatient setting
An italicized code used as the first listed diagnosis
The authorization number for a service that was approved before the service was rendered is indicated in which of the following blocks on the CMS-1500 claim form?
22 (Medicaid resubmission code)
23 (prior authorization number)
25 (federal tax ID number)
26 ( patient’s account number)
23 (prior authorization number)
- 22 (Medicaid resubmission code)
- 25 (federal tax ID number)
- 26 ( patient’s account number)
Which of the following HMO managed care services requires a referral?
- Durable medical equipment
- Annual physical examination
- Emergency room visit
- Annual gynecological services
durable medical equipment
In which of the following blocks on the S=CMS-1500 form should the CBCS enter the referring provider’s NPI?
- 17b (referring providers NPI)
- 24J (rendering provider’s NPI)
- 24D (CPT code)
-25 (federal tax ID)
17b (referring providers NPI) - 24J (rendering provider’s NPI)
- 24D (CPT code)
-25 (federal tax ID)
In the anesthesia section of the CPT code manual, which of the following are considered qualifying circumstances?
- Physical status modifiers
- Primary procedure code
- Mutually exclusive codes
- Add-on codes
Primary procedure code - Physical status modifiers (levels of complexity of the anesthesia service provided)
- Mutually exclusive codes (codes that could not be reasonably be performed during the same operative event)
- Add-on codes
Which of the following blocks on the CMS-1500 form indicates an ICD diagnosis code?
- 24 d (procedure and service code)
- 18 (additional claim information)
- 20 (outside reference)
- 21
21 - 24 d (procedure and service code)
- 18 (additional claim information)
- 20 (outside reference)
Which of the following is the deadline for Medicare claim submission?
- 6 month from the date of service
- 1 month form the date of service
- 3 month form the date of service
- 12 month from the date of service
12 month from the date of service
A patient is pre authorized to receive vitamin B12 injections from January 1 to May 31. On June 2, the provider orders an additional 6 month of injections. In order for the patient to continue with coverage of care, which of the following should occur?
- The patient should stop receiving the injection because the authorization has lapsed
- The patient should stop receiving the injection and find a new provider
- The provider should go ahead with the injections due to medical necessity
- The provider should contact the insurance carrier to obtain a new authorization
The provider should contact the insurance carrier to obtain a new authorization - The patient should stop receiving the injection because the authorization has lapsed
- The patient should stop receiving the injection and find a new provider
- The provider should go ahead with the injections due to medical necessity
A patient who has an HMO insurance plan needs to see a specialist for a specific problem. From which of the following should the patient obtain referral?
- Insurance provider
- Specialist
- HMO physician network
- Primary care provider
primary care provider
When coding front torso burn, which of the following percentages should be coded?
18%
1%
36%
10%
18%
If both parents have full coverage for a dependent child, which of the following is considered to be the primary insurance?
- Both parents are primary insurance holders
- The parent who’s birthday comes first in the calendar year is primary
- The parent with the higher coverage level is the primary insurance holder
- The parent who is older is the primary insurance holder
The parent who’s birthday comes first in the calendar year is primary
On a CMS-1500 form, which of the following information should the CBCS enter into block 32?
- Patient’s account number
- Federal tax id number
- Billing providers information and phone number
- Service facility location number
Service facility location number (32) - Patient’s account number (26)
- Federal tax id number (25)
- Billing providers information and phone number (33)
Which of the following actions should the CBCS take when submitting a claim to Medicaid for a patient who has primary and secondary coverage?
- Attach the remittance advice from the primary insurance along with the Medicaid claim
- Submit the claim and Medicaid remittance advice to the secondary insurance
- Attach the remittance advice from the patient’s most recent visit to confirm Medicaid eligibility
- Submit both claim simultaneously and then review the remittance advice from both to determine which one provided more coverage
Attach the remittance advice from the primary insurance along with the Medicaid claim (Medicaid is always secondary) - Submit the claim and Medicaid remittance advice to the secondary insurance
- Attach the remittance advice from the patient’s most recent visit to confirm Medicaid eligibility
- Submit both claim simultaneously and then review the remittance advice from both to determine which one provided more coverage
A patient has AARP as secondary insurance, in which of the following blocks on the CMS-1500 form should this information be entered?
- 1a ( primary insurance carrier)
- 9 (secondary insurance)
- 21 (diagnoses)
- 16 (dated patient is unable to work)
9 (secondary insurance) - 1a ( primary insurance carrier)
- 21 (diagnoses)
- 16 (dated patient is unable to work)
In 1996, CMS implemented which of the following to detect inappropriate and improper codes?
- National committee of quality assurance (NCQA)
- Electronic data interchange (EDI)
- National correct code initiative (NCCI)
- Procedural coding system (PCS)
National correct code initiative (NCCI)
A CBCS submitted a claim to Medicare electronically. No errors were found by the billing software or clearinghouse. Which of the following describes this claim?
- Pending claim
- Clean claim
- Tertiary claim (processed by both primary and secondary insurance)
- Physically clean claim (no staples, no highlighters)
clean
The explanation of benefits states the amount billed was $80. The allowed amount is $60, and the patient is required to pay a $20 copayment. Which of the following describes the insurance check amount to be posted?
$40
$80
$60
$20
$80
Urine moves from the kidney to the bladder through which of the following parts of the body?
- Ureters
- Renal pelvis (hollow chamber that passes waste material)
- Urethra (discharges urine from the bladder
- Adrenal gland (above the kidney, part of endocrine system
Ureter - Renal pelvis (hollow chamber that passes waste material)
- Urethra (discharges urine from the bladder
- Adrenal gland (above the kidney, part of endocrine system
Which of the following blocks should the CBCS complete on the CMS-1500 form for procedure, services, and supplies?
12 (patient authorization)
2 (patient name)
24D
24J (rendering provider)
24D
- 12 (patient authorization)
- 2 (patient name)
- 24J (rendering provider)
Which of the following describes the organization of an aging report?
- By date
- By amount
- By patient name
- By insurance carrier
by date
Which of the following planes divides the body into left and right?
- Sagittal
- Coronal (anterior and posterior0
- Transverse (superior and inferior)
- Distal (farthest away from body)
sagittal
A CBCS is preparing a claim from a provider from a group practice.. The CBCS should enter the rendering provider’s NPI into which of the following blocks on the CMS-1500?
- 17b (referring provider NPI)
- 24J
- 31 (providers signature)
- 25 (federal tax id number)
24J - 17b (referring provider NPI)
- 31 (providers signature)
- 25 (federal tax id number)
Which of the following organizations fights waste, fraud, and abuse in Medicare and Medicaid?
- Department of health and Human services
- Centers for Medicare and Medicaid services
- Office of inspector general
- Health resources and services administration
Office of inspector genereal - Department of health and Human services (protecting the health of Americans)
- Centers for Medicare and Medicaid services
- Health resources and services administration (improving access to services for people who are uninsured, isolated or medically vulnerable)
Provider performs an examination of a patient’s knee joint and an optical device. Which of the following terms describes this procedure?
- Arthroscopy
- Arthrography
- Meniscectomy
- Chondroplasty
Arthroscopy - Arthrography (imaging procedure)
- Meniscectomy (open surgical excision of the meniscus)
- Chondroplasty (surgical repair of cartilage)
On the CMS-1500 form, blocks 14 though 33 contain information about which of the following?
- Patient demographics (2,3,5,7)
- patient ‘s condition and providers information
- The insurance name and address (1a,4,11)
- Patient medical history (not on the form)
- patient ‘s condition and providers information
- Patient demographics (2,3,5,7)
- The insurance name and address (1a,4,11)
- Patient medical history (not on the form)
Which of the following symbols indicate a revised code?
- Bullseye (moderate sedation)
- Bullet (new code)
- Plus sign ( add-on code)
- Triangle
Triangle - Bullseye (moderate sedation)
- Bullet (new code)
- Plus sign ( add-on code)
A CBCS can ensure appropriate insurance coverage for an outpatient procedure by first using which of the following processes?
- Predetermination (finals step to determine insurance reimbursement and patient responsibility)
- Precertification (first step to determine if the patient has coverage)
- Preaudit (review of claim before adjudication)
- Preauthorization ( insurance approval for the procedure)
Precertification (first step to determine if the patient has coverage) - Predetermination (finals step to determine insurance reimbursement and patient responsibility
- Preaudit (review of claim before adjudication)
- Preauthorization ( insurance approval for the procedure)
Which of the following qualifies as an exception to the HIPAA rule?
- Operative notes
- Radiology results
- Laboratory results
- Psychotherapy notes
psychotherapy notes
A patient has laboratory work done in the emergency department after an inhalation of toxic fumes from a faulty exhaust fan at her work place. Which of the following is responsible for the charge?
- Disability insurance
- Indemnity insurance
- Worker’s compensation
- Managed care
worker’s compensation
Which of the following forms does a third party payer require for physician services?
- Explanation of benefits
- Advance directive
- CMS-1500
- UB-04
CMS-1500
Which of the following is included in the release of patient information?
- The date of the most recent clinical exam
- The date of the last disclosure
- Provider’s signature
- Emergency contact information
the date of the last disclosure
Which of the following standardized formats are used in the electric filing claims?
- HIPAA standard transaction
- Electronic data interchange (standardized format)
- Encryption
- Technical and physical safeguards
HIPAA standard transaction
The explanation of benefits states the amount billed was $170. However the allowed amount is $150. The patient has an unmet deductible of $50 and a copayment of $20. Which of the following amounts is the patient’s responsibility.
70
50
20
80
70 = unmet deductible + copay)
A Medicare non-participating (non-PAR) provider’s approved payment amount is $200 for a lobectomy and the deductible has been met. Which of the following amounts is the limiting charge for this procedure?
- $160
- $200
- $170
- $230 (can collect a max of 15% over the non-PAR Medicare schedule amount)
$230 = can collect a max of 15% over the non-PAR Medicare schedule mount
Which of the following is an example of Medicare abuse?
- Billing for services not furnished
- Charging excessive fees
- Falsifying medical necessity
- Upcoding charges
charging excessive fees (all others are fraud)
Which of the following describes the term “crossover” as it relates to Medicare?
- When an insurance company transfers data to allow coordination of benefits of a claim
- When more than one insurance pays for the same service
- When the insurance pays twice for the same service
- When an insurance company transfers data to allow adjudication of a claim to occur
When an insurance company transfers data to allow coordination of benefits of a claim
Which of the following is the maximum of modifiers that the CBCS can report on a CMS-1500 claim in block 24D.
Five
Four
Two
three
four
Which of the following would most likely result in a denial on a Medicare claim?
- An experimental chemotherapy medication for a patient who has stage III renal cancer.
- A radiation therapy treatment for a patient who has stage II lymphoma
- A skin cancer screening for a patient who has a history of melanoma
- An annual physical examination on a patient who has no known illness
an experimental chemotherapy medication for a patient who has stage III renal cancer
Which of the following blocks on the CMS-1500 form is used to accept assignment of benefits?
- 13 (patient signature)
- 33 ( billing providers address and phone number)
- 27
- 21 (diagnosis codes)
27 - 13 (patient signature)
- 33 ( billing providers address and phone number)
- 21 (diagnosis codes)
Which of the following describes a key component of an evaluation and management service?
- History
- Diagnosis
- procedure
- Patient status
History (history, examination and medical decision making)
Which of the following provisions ensures that an insured’s benefit from all insurance companies do not exceed 100% of allowable medical expenses?
- Source document (financial draft that is the initial point of entry to an accounting system)
- Assignment of benefits
- Coinsurance
- Coordination of benefits
assignment of benefits
Which of the following statements is accurate regarding the diagnostic codes in block 21?
- The codes must correspond to the procedure and service codes in block 24 D (only if correlation is established in block 24E)
- These codes must contain a decimal point to eliminate any confusion regarding the type of code. (no decimal point)
- A minimum of four diagnostic codes is necessary to obtain a clean, medically necessary claim.
- The codes must correspond to the diagnosis pointer in block 24E
The codes must correspond to the diagnosis pointer in block 24E
A patient who is an active member of the military service returned from overseas and is in need of specialty care. The patient does not have anyone designated with power of attorney. Which of the following is considered a HIPAA violation?
- The military provider requests the patient’s records without a signed authorization to disclose form
- The patient request an amendment to his record
- The CBCS sends the patient’s records to the patient’s partner
- The patient’s insurance requests additional records to process the claim
the CBC sends the patient’s record to the patient’s partner
Which of the following is the portion of the account balance the patient must pay after services are rendered and the annual deductible is met?
- coinsurance
- allowed amount
- premium
- capitation
Coinsurance - capitation = fixed amount that is paid to the provider by the managed care organization
Which of the following describes the reason for a claim rejection because of Medicare NCCI edits?
- Reporting codes without proper modifiers
- Coding without proper documentation
- Improper code combination
- Use of outdated codes
improper code combination
Which of the following information is required to include on an Advance Beneficiary Notice form?
- CPT codes
- ICD codes
- The reason Medicare may not pay
- The reason the patient needs the procedure
the reason Medicare may not pay - Which of the following is considered the final determination of the issues involving the settlement of an insurance claim?
- Adjudication – is the process of putting an insurance claim through a series of edits for final determination.
- Chapter 4
- A form that contains charges, DOS, CPT codes, fees, and copayment information is called which of the following?
- Encounter form is a form that contains charges, DOS, CPT code, ICD codes, fees, and copayment information.
- page 67
- A patient comes to the hospital for an inpatient procedure. Which of the following hospital staff members is responsible for the initial patient interview, obtaining demographic and insurance information, and documenting the chief complaint?
- Admitting these duties clerk has Chapter 3
- Which of the following privacy measures ensures protected health information (PHI)?
- Using data encryption software on office workstations – encryption software ensures that electronically transmitted health information cannot be read by third parties. This privacy measure guarantees PHI.
- Chapter 1
- Which of the following planes divide the body into left and right?
- Sagittal plane divides the body into right and left sections
- Which of the following provisions ensures that an insured’s benefits from all insurance companies do not exceed 100% of allowable medical expenses?
- Coordination of benefits ensures that the insured benefits from all insured companies do not exceed 100% of allowable medical expenses.
- page 16
- Which of the following actions should be taken first when reviewing a delinquent claim?
- Verify the age of the account is the first action.
- page 45
- Which of the following is the advantage of electronic claim submission?
- Claims are expedited – submitting claims electronically is faster than submitting paper claims.
- page 15
- Which of the following components of an explanation of benefits expedites the process of a phone appeal?
- Claim control number expedites the process of a phone appeal.
- Chapter 4
- The standard medical abbreviation “ECG” refers to a test used to assess which of the following body systems?
- Cardiovascular system- which is a test that checks for problems with the electrical activity of the heart.
- Chapter 5
- Which of the following actions by a billing coding specialist (bcs) would be considered fraud?
- Billing for a service not provided is considered fraud and can result in fines for the bcs and the physician page 6
- The “> <” symbol is used to indicate new and revised text other than which of the following?
- Procedures descriptors Chapter 5
- On the CMS-1500 claim form, blocks 14 through 33 contain information about which of the following?
- The patient’s condition and the provider’s information are found on the CMS-1500 at blocks 14 – 33 page 21
- Which of the following includes procedures and best practices for correct coding?
- Coding Compliance Plan contains rules, procedures, and best practices to ensure accurate coding.
- Chapter 5
- When completing a CMS-1500 paper claim form, which of the following is an acceptable action for the bcs to take?
- Use Arial size 10 font or OCR size 10-, or 12-point for paper claims.
- Chapter 2
- A participating BCBS provider received an explanation of benefits for a patient account. The charge amount was $100. BC/BS allowed $80 and applied $40 to the patient’s annual deductible. BC/BS paid the balance at 80%. How much should the patient expect to pay?
- $48 page 38-39
- Which of the following indicates a claim should be submitted on paper instead of electronically?
- The claim requires an attachment – should submit a paper form if the claim requires an attachment.
- Chapter 2
- According to HIPAA standards, which of the following identifies the rendering provider on the CMS-1500 claim form in Block 24J?
- NPI Page 23
- Which of the following blocks should the bcs complete on the CMS-1500 form for procedures, services, or supplies?
- Block 24D.
- Page 23
- Which of the following terms describes when a plan pays 70% of the allowed and the patient pays 30%?
- Coinsurance is a percentage of the cost for covered services that is approved by the insurance company.
- Page 39
- A provider charges $500 to a claim that had an allowable amount of $400. In which of the following columns should the bcs apply the non-allowed charge?
- The adjustment column of the credits is where adjustments are recorded.
- page 47
- Which of the following is a HIPAA compliance guideline affecting electronic health records?
- The Health Information Technology for Economic and Clinical (HITECH) Act encrypts provider – protected health information
- page 1 & 3
- Patient: Justin Austin; Social Security NO.: 555-22-1111; Medicare ID NO.: 555-33-2222A; DOB: 05/22/1945. Claim information entered: Austin, Jane; Social Security No.: 555-22-111; Medicare ID No.: 555-33-2222A; DOB: 052245. Which of the following is a reason the claim was rejected?
- The DOB is entered incorrectly – the format is two digits for the month and four digits for the year.
- page 18
- Why does correct claim processing rely on accurately completed encounter forms?
- They streamline patient billing by summarizing the services rendered for a given date of service – encounter forms allow a provider to summarize services rendered by code, which reduces time spent by bcs when posting charges. Page 18
- A patient’s health plan is referred to as the “payer of last resort.” The patient is covered by which of the following health plans?
- Medicaid is the health plan that is referred to as the “payor of last resort.” All of the patient’s health plans must meet their obligations before Medicaid will pay.
- page 30
- Which of the following color formats allows optical scanning of the CMS-1500 claim form?
- Red ink allows optical scanning of the CMS-1500.
- Chapter 2
- Which of the following is an example of a violation of an adult patient’s confidentiality?
- Patient information was disclosed to the patient’s parents without consent.
- Page 5
- In the anesthesia section of the CPT manual, which of the following are considered qualifying circumstances?
- Add-on codes are listed after the primary procedure code, and cannot ever be listed as a primary, or be coded as the only procedure code.
- Ambulatory surgery centers, home health care, and hospice organizations use the_____?
- UB-04 claim form which is the appropriate claim form for reimbursement of services from ambulatory surgery centers, home health care, and hospice organizations
- Which of the following is a private insurance carrier?
- BC/BS is a private insurance carrier. Page 35
- Which of the following shows outstanding balances?
- Aging report lists the status of outstanding claims from each payer. Page 44
- Which of the following is one of the purposes of an internal auditing program in a physician’s office?
- Verifying that the medical record and the billing record match – the purpose of internal auditing is to verify that the medical records and the billing record march, which protects from sanctions or fines.
- Chapter 1
- The star symbol in the CPT code book is used to indicate which of the following?
- Telemedicine has the star code symbol Chapter 5
- Medigap coverage is offered to Medicare beneficiaries by which of the following?
- Private third-party payers offer supplement coverage to Medicare beneficiaries who pay their Medicare premium.
- Page 32
- A patient’s portion of the bill should be discussed with the patient before a procedure is performed for which of the following reasons?
- To ensure the patient understands his portion of the bill – the bill should be discussed prior to the procedure to ensure the patient understands how much the procedure will cost and how much the patient is responsible.
- Chapter 4
- The physician bills $500 to a patient. After submitting the claim to the insurance company, the claim is sent back with no payment. The patient still owes $500 for the year. This amount is called which of the following?
- Deductible is the amount for which the patient is financially responsible before an insurance policy providers coverage page 29 & 38
- A patient who is an active member of the military recently returned from overseas and is in need of specialty care. The patient does not have anyone designated with power of attorney. Which of the following is considered a HIPAA violation?
- The bcs sends the patient’s records to the patient’s partner
- page 4
- A patient is upset about a bill she received. Her insurance company denied the claim. Which of the following actions is an appropriate way to handle the situation?
- Inform the patient of the reason for the denial
- page 52
- A patient presents to the provider with chest pain and shortness of breath. After an unexpected ECG result, the provider calls a cardiologist and summarizes the patient’s symptoms. What portions of HIPAA allows the provider to speak to the cardiologist prior to obtaining the patient’s consent?
- Title II deals with administrative simplifications, which include communication with parties involved in the patient’s care. The patient signs an agreement and is given a copy of the HIPAA standards upon becoming a patient page 15 on ASCA but nothing about Title II
- A physician ordered a comprehensive metabolic panel for a 70-year-old patient who has Medicare as her primary insurance. Which of the following forms is required so the patient knows she may be responsible for payment?
- Advanced Beneficiary Notice is a form that is required for Medicare recipients page 48
- Which of the following describes the reason for a claim rejection because of Medicare NCCI edits?
- Improper code combinations – Medicare NCCI edits will trigger a claim rejection for improper code combinations
- Chapter 4
- Which of the following is the purpose of running an aging report each month?
- It indicates which claims are outstanding with a status of all
- page 44
- Which of the following do physicians use to electronically submit claims?
- Clearinghouse is an independent organization that receives insurance claims from physicians’ offices, performs software edits, and distributes those claims electronically to third party payers.
- Page 3
- Which of the following should the bcs include in an authorization to release information?
- The entity to whom the information is to be released – the receiving entity must be included in the authorization.
- page 4
- Which of the following information is required on a patient account record?
- Name and address of guarantor which are a required part of the patient account record
- page 14, 18 block 2
- Which of the following forms should the bcs transmit to the insurance carrier for reimbursement of inpatient hospital services?
- UB-04 is the form used to bill hospital inpatient claims
- Chapter 2
- An insurance claims register (aged insurance report) facilitates which of the following?
- Follow up of insurance claims by date – an aged insurance report is run by date. It can be sorted by date of service or date of submission
- Chapter 4
- When posting a payment accurately, which of the following items should the bcs include?
- Patient’s responsibility could include a copayment, deductible, or coinsurance page 49
- Which of the following should the bcs complete to be reimbursed for the provider’s services?
- CMS-1500 claim form is used for all providers services
- page 18
- As of April 1, 2014, what is the maximum number of diagnoses that can be reported on the CMS-1500 claim form before a further claim is required?
- 12 diagnoses can be placed on a CMS 1500 paper form
- Chapter 2
- Which of the following describes an obstruction of the urethra?
- Urethratresia describes a blockage of the urethra dup b-50
- Chapter 5
- Which of the following options is considered proper supportive documentation for reporting CPT and ICD codes for surgical procedures?
- Operative reports are required to support surgical procedures dup c-51 Chapter 5
- Which of the following describes a delinquent claim?
- It is considered delinquent when it is overdue for payment
- Chapter 4
- All dependents 10 years of age or older are required to have which of the following for TRICARE?
- Military identification cards pertain to retirees, active duty sponsors, and their eligible family members as means of identification for TRICARE
- Chapter 3
- Which of the following types of claims is 120 days old?
- Delinquent claim is a claim that is 120 days or older and is not paid
- page 45
- HIPAA transaction standards apply to which of the following entities?
- Health care clearinghouse is a covered entity, same as providers of health care services, and health care third party payers who submit transactions electronically
- page 3
- Which of the following actions should be taken when a claim is billed for a level four office visit and paid at a level three?
- Submit an appeal to the carrier with the supporting documentation, it is appropriate to appeal the down coded claim
- page 52
- When submitting a clean claim with a diagnosis of kidney stones, which of the following procedure names is correct?
- Nephrolithiasis is the destruction of kidney stones
- Chapter 5
- All e-mail correspondence to a third-party payer containing patient’s protected health information (PHI) should be?
- Encrypted
- Chapter 1
- The bcs should first divide the e/m code by which of the following?
- Place of service which narrows down the specific code as one of the three deciding factors
- Chapter 5
- In which of the following departments should a patient be seen for psoriasis?
- Dermatology since it is a condition of the skin and they specialize in conditions related to the integumentary system which includes hair, skin, and nails
- Chapter 5
- A nurse is reviewing a patient’s lab results prior to discharge and discovers an elevated glucose level. Which of the following health care providers should be alerted before the nurse can proceed with discharge planning?
- The attending physician is responsible for the patient’s care, as well as discharge decisions; therefore, the attending physician should be notified of unexpected lab results, including elevated glucose levels
- Chapter 5
- Which of the following actions should be taken if an insurance company denies a service as not medically necessary?
- Appeal the decision with a provider’s report
- page 52
- A bcs should understand that the financial record source that is generated by a provider’s office is called___?
- A patient ledger account which is a history of the patient’s financial record Chapter 4
- Which of the following is used to code diseases, injuries, impairments, and other health-related problems?
- International Classification of Diseases page 57-58
- Threading a catheter with a balloon into a coronary artery and expanding it to repair arteries describes which of the following procedures?
- Angioplasty is performed to widen arteries narrowed by stenosis. A balloon is threaded into the artery and expanded.
- Chapter 5
- A coroner’s autopsy is comprised of which of the following examinations?
- Gross examination is an integral part of an autopsy.
- Chapter 5
- A patient’s employer has not submitted a premium payment. Which of the following claim statuses should the provider receive from the third-party payer?
- Denied claim status from the third-party payer.
- Chapter 4
- Which of the following blocks requires the patient’s authorization to release medical information to process a claim?
- Block 12 – Patient authorization to release medical information is Block 12 and is required for all claims. Block 12 also acts as the assignment of benefits for Medicare patients.
- Page 20
- The unlisted codes can be found in which of the following locations in the CPT manual?
- Guidelines prior to each section – the unlisted codes can be found in the guidelines prior to each section. dup c-20
- Chapter 5
- Which of the following is the portion of the account balance the patient must pay after services are rendered and the annual deductible is met?
- Coinsurance is the portion the patient is responsible to pay after the annual deductible has been met
- page 29 & 39
- When coding on the UB-04 form, the bcs must sequence the diagnosis codes according to ICD guidelines. Which of the following is the first listed diagnosis code?
- Principal diagnosis is used in inpatient hospital settings to code the reason why the patient was hospitalized. Chapter 5
- Which of the following actions by the bcs prevents fraud?
- Performing Periodic audits on a routine basis will prevent fraud
- Chapter 1
- Which of the following does a patient sign to allow payment of claims directly to the provider?
- Assignment of benefits allow payment of claims directly to the provider.
- page 17
- Which of the following actions should the bcs take if he observes a colleague in an unethical situation?
- Report the incident to a supervisor is the appropriate action.
- Chapter 1 if fraud or abuse, but the question is very vague.
- Which of the following is the purpose of precertification?
- Verification of coverage is the purpose of precertification.
- page 37
- A provider performs an examination of a patient’s sore throat during an office visit. Which of the following describes the level of the examination?
- Problem-focused examination is a specific examination of an affected organ.
- Chapter 5
- Which of the following is the verbal or written agreement that gives approval to some action, situation, or statement, and allows the release of patient information?
- Consent agreement – can be verbal or written that gives approval to some action situation or statement.
- page 2
- A claim can be denied or rejected for which of the following reasons?
- Block 24D contains the diagnosis code page 32
- On the CMS-1500 claim form, blocks 1 through 13 include which of the following?
- The patient’s demographics are found in Blocks 2,3,5, and 7 on the CMS-1500. page 18
- To be compliant with HIPAA, which of the following positions should be assigned in each office?
- Privacy officer ensures security, privacy, and safety within the health care industry.
- Chapter 1
- Which of the following information should the bcs input into Block 33a on the CMS-1500 claim form?
- National provider identification number should be input into Block 33a on the CMS-1500. This is a unique 10-digit number assigned to the provider under the Health Insurance Portability and Accountability Act.
- page 24
- Which part of Medicare covers prescriptions?
- Part D covers prescriptions dup b-8, page 32
- Which of the following is the function of the respiratory system?
- Oxygenating blood cells – the lungs which are part of the respiratory system, are responsible for providing oxygen for the blood.
- page 72
- Urine moves from the kidney to the bladder through which of the following parts of the body?
- Ureters transport urine to the bladder from the kidneys.
- page 73
- Claims that are submitted without an NPI number will delay payment to the provider because?
- The number is needed to identify the provider by the Centers for Medicare and Medicaid Services to all providers dup c-46
- page 21
- Which of the following sections of the medical record is used to determine the correct E/M code used for billings and coding?
- History and physical – The E/M code for the patient’s current condition can be found in the history and physical section.
- Chapter 5
- On a remittance advice form, which of the following is responsible for writing off the difference between the amount billed and the amount allowed by the agreement?
- Provider is responsible for writing off the difference between the amount billed and the amount allowed.
- page 47
- A dependent child whose parents both have insurance coverage comes to the clinic. The bcs uses the birthday rule to determine which insurance policy is primary. Which of the following describes the birthday rule?
- The parent whose birthday comes first in the calendar year – is responsible for primary coverage of a dependent child
- Which of the following statements is correct regarding a deductible?
- The deductible is the patient’s responsibility – the patient pays the deductible as part of the insurance contract
- page 29 & 38
- Which of the following claims is submitted and then optically scanned by the insurance carrier and converted to an electronic form?
- Paper claim is submitted on paper and requires optical scanning to convert to electronic form.
- page 15
- A patient who has a primary malignant neoplasm of the lung should be referred to which of the following specialists?
- Pulmonary oncologist – a patient who has lung cancer would be referred to a pulmonary oncologist
- Chapter 5
- Which of the following statements is true regarding the release of patient records?
- Patient access to psychotherapy notes may be restricted – patients cannot access psychotherapy notes or information compiled for lawsuits.
- page 4
- Which of the following is the primary function of the heart?
- Pumping blood in the circulatory system – the heart muscle that is responsible for circulating blood through the body. Chapter 5
- A deductible of $100 is applied to a patient’s remittance advice. The provider requests the account personnel write it off. Which of the following terms describes this scenario?
- Fraud – this scenario is considered fraud because the patient is responsible for paying the deductible
- page 29
- A patient has AARP as secondary insurance. In which of the following blocks on the CMS-1500 claim form should this information be entered?
- Block 9 is for secondary insurance.
- page 19
- A patient with a past due balance requests that his records be sent to another provider. Which of the following actions should be taken?
- Accommodate the request and send the records
- page 4
- A claim is submitted with a transposed insurance member ID number and returned to the provider. Which of the following describes the status that should be assigned to the claim by the carrier?
- Invalid – an invalid claim contains illogical or incorrect information and is returned to the provider unprocessed. page 28
- Which of the following medical terms refers to the sac that encloses the heart?
- Pericardium – peri – means “around” and – cardium means “pertaining to heart”
- A physician is contracted with an insurance company to accept the allowed amount. The insurance company allows $80 of a $120 billed amount, and $50 of the deductible has been met. How much should the physician write off the patient’s account?
- $40 – this is the difference between the amount billed and amount allowed. The physician should write off $40
- page 47 & 49
- Which of the following would result in a claim being denied?
- An italicized code used as the first listed diagnosis – which identifies a manifestation of the primary disease and should not be listed first.
- page 61
- Which of the following terms is used to describe the location of the stomach, the spleen, part of the pancreas, part of the liver, and part of the small and large intestines?
- Left upper quadrant includes the left lobe of the liver, the stomach, the spleen, part of the pancreas, and part of the small and large intestines.
- Chapter 5
- Which of the following Medicare policies determines if a particular item or service is covered by Medicare?
- National Coverage Determination (NCD) is a Medicare policy stating whether and under what circumstances a service is covered by the Medicare program.
- Chapter 3 page 35 but the chapter makes no mention of NCD