Medical Billing & Coding Fundamentals – Review Flashcards

These flashcards review key concepts from Modules 1–4, including revenue cycle basics, HIPAA, patient registration rules, ICD-10-CM, CPT, HCPCS, and deductible/coinsurance calculations.

What is the process of verifying a physician’s education, license, and background to participate in a health plan called?

Credentialing

In medical billing, what term describes money owed to a medical office?

Accounts receivable (patient accounts)

When does the revenue cycle officially end?

When payment has been made

Name three elements of good customer service in a medical office.

Telephone courtesy, professionalism, and respect

Which fixed fee is paid by the insured at the time of service?

Copayment (copay)

List two common duties of a patient‐registration or insurance specialist during check-in.

Collect insurance information, verification of eligibility and collection of copayments

What type of patient has no insurance coverage?

Self-pay patient

Give one example of a managed-care plan.

Preferred Provider Organization (PPO)

In what healthcare settings might an insurance specialist work?

Clinics, hospitals, or nursing homes

What specifically might a potential employer think about one who prepares and achieves certification in their field?

It demonstrates dedication and validated knowledge/skills

Which component is always part of managed-care coverage?

A network of providers

Which is true of a capitation plan?

Prepayment for services

It refers to how a patient's established diagnosis or condition must justify the medical treatment.

Medical necessity

Which is/are a type of insurance coverage?

Worker’s compensation, group and individual

The revenue cycle is often completed in ___ phases.

Three phases

If required, when do most facilities collect the copayment?

During check in

Which describes demographics?

Patient information

When a patient describes the development of an illness from its onset and symptoms when seen by a physician, which is being documented?

History of present illness (HPI)

Which documentation includes a patient’s age, marital status, employment and habits?

Social history

Which organization is designed to better coordinate patient care across different providers?

Accountable Care Organization (ACO)

Under HIPAA, name three covered entities.

Health plans, healthcare providers, and clearinghouses

What makes clinical documentation valid?

A physician’s signature

If a patient’s information is shared with their spouse, what would allow that disclosure? 

Patient consent

Which HIPAA title addresses portability and renewability of health coverage?

Title I

Which HIPAA title targets fraud and abuse prevention?

Title II

Which federal law greatly expanded health-insurance coverage in 2010?

Affordable Care Act (ACA)

Which law incorporated the HITECH provisions?

American Recovery and Reinvestment Act (ARRA)

Define Protected Health Information (PHI).

Any individually identifiable health data such as name, address, DOB, or genetic info

Which federal office audits medical records to combat fraud and abuse?

Office of Inspector General (OIG)

Distinguish expressed from implied consent.

Expressed is spoken or written; implied is assumed by patient’s actions or circumstances

What consent is mandatory before surgery?

Informed (expressed) consent

A patient was seen in the office today with services totaling $325.00. After verification, it is determined that the patient is covered by one health insurance plan and coverage includes an annual deductible of $1500.00 with an 80/20 coinsurance. Other healthcare charges have been paid by the patient throughout the year and $1350.00 of the total deductible has already been met. Based on the details of this scenario, do the math to answer the questions.

What is the patient’s remaining deductible that has not yet been met? 

$150

A patient was seen in the office today with services totaling $325.00. After verification, it is determined that the patient is covered by one health insurance plan and coverage includes an annual deductible of $1500.00 with an 80/20 coinsurance. Other healthcare charges have been paid by the patient throughout the year and $1350.00 of the total deductible has already been met. Based on the details of this scenario, do the math to answer the questions. 

What is the remaining balance after today’s charges and after the remaining deductible is paid by the patient? 

$175 ($325 – $150)

A patient was seen in the office today with services totaling $325.00. After verification, it is determined that the patient is covered by one health insurance plan and coverage includes an annual deductible of $1500.00 with an 80/20 coinsurance. Other healthcare charges have been paid by the patient throughout the year and $1350.00 of the total deductible has already been met. Based on the details of this scenario, do the math to answer the questions. 

What is the patient’s estimated balance for services provided today? 

$185 ($150 deductible + $35 coinsurance)

A patient was seen in the office today with services totaling $325.00. After verification, it is determined that the patient is covered by one health insurance plan and coverage includes an annual deductible of $1500.00 with an 80/20 coinsurance. Other healthcare charges have been paid by the patient throughout the year and $1350.00 of the total deductible has already been met. Based on the details of this scenario, do the math to answer the questions. 

What is the estimate of insurance reimbursement after the patient’s estimated balance for today’s services?

$140 (80% of $175)

Which of the following contains patient data and diagnoses and tracks the patient during an office visit?

Encounter form (also called superbill or charge slip)

Which rule do many insurers use to decide primary coverage for a child with married parents?

Birthday rule (earliest birth month/day is primary)

How long after the last visit is a patient considered 'established' rather than 'new'?

If seen within the past three years, the patient is established

What document notifies Medicare patients when a service may not be covered?

Advance Beneficiary Notice (ABN)

Which of the following statements is true?

• Benefits are the services that are covered

• The key to insurance coverage is the copayment

• Insurance coverage depends on fee-for-service

• Every patient is a policyholder

Benefits are the services that are covered

If paper-based medical records are utilized as a billing resource, which of the following names is filed first to ensure records are easily accessed when needed?

• L. Timothy Mathison 

• L. Mathison

• Lawrence Mathison 

• Lawrence T. Mathison

L. Mathison

For privacy, what is the recommendation if there is a window in the reception area?

Keep it closed

If a patient wants to talk about abnormal lab results, which is the most appropriate personnel?

Physician

Implementing various aspects of HIPAA is the responsibility of which entity?

CMS (Centers for Medicare & Medicaid Services)

___ is any data used to identify a person.

PHI