Billing and Coding Final

The ICD-10-PCS coding system and coding guidelines are:

maintained by CMS and updated each October

The significant reason for patient admission to the hospital is coded as the:

principal diagnosis

The ICD-10-PCS coding system is used to report:

inpatient procedure codes

Utilization managmenet is a process performed in order to:

control health care cost and ensure patient care is medically necessary

Preadmission testing performed a day or two before admission for surgery often includes all of the following EXCEPT:

pulmonary function testing

The revenue cycle is divided into three periods:

preadmission, patient care, and post hospitalization

Providers furnishing services to Medicare Part B patients are reimbursed via:

Medicare Physician Fee Schedule

The accrediting body for ambulatory surgical centers is:

AAAHC

The first telephone call to the patient to try to collect on an account should be made:

after there is no response from the third statement

In a bankruptcy case, most medical bills are considered:

unsecured debt

When writing a collection letter:

use a friendly tone and ask why payment has not been made

The reason for a fee reduction must be documented in the patient's:

health record

Medical offices can take the following steps to prevent missed appointments EXCEPT:

all of the above are acceptable strategies to prevent missed appointments

What should be done to inform a new patient of office fees and payment policies?

send a patient information brochure

send a confirmation letter

Discuss fees and policies at the time of the intial contact

Cash flow is:

the ongoing availability of cash in a medical practice

The first level of appeal in the Medicare program is:

redetermination

A submitted claim that does not follow specific third-party payer instructions or contains a technical error is referred to as:

rejected

When billing secondary insurances, which of the following is NOT true?

the secondary insurance is billed at the same time the primary insurance is

Delinquent claims are claims that have not been paid:

within 30-45 days of the service date

The maximum dollar value that the insurance company assigns to each medical service is:

allowed amount

The document together with the payment voucher that is sent to a physician who has accepted assignment of benefits is referred to as an:

EOB

Guidelines for claims submission, such as which services are covered, and reimbursement:

the insurance company

Disadvantage of electronic claim submission is more time spent processing claims.

False

Transmission report which identifies the most common reasons for claim denial is the:

rejection analysis report

Clearinghouse is a/an:

entity that receives transmission of insurance claims

Separates the claims

And sends each one electronically to the correct insurance payer

Which of the following is a lifetime 10 digit number issued to physicians that replace all others:

NPI

Office visits may be grouped on the insurance claim form if each visit:

Consecutive

Uses the same procedure code

And results in the same fee

The CMS-1500 is known as the:

basic paper claim

When a new CPT code is used, it may take as long as 6 months before an insurance company has a mandatory value assignment.

True

The Health care Common Procedure Coding System (HCPCS) consists of two levels of codes.

True

What does bundling mean?

grouping codes that are related to a procedure

Resource-based relative value scale (RBRVS) was developed for:

the Centers for Medicare and Medicaid Services (CMS)

What is the name of the book used in physician's office to code procedures?

CPT

Which of the following is the correct order of steps to take in ICD-10-CM coding?

locate the main term in Alphabetic Index

Verify the code in Tabular List

Read any instructions in Tabular List

Check for exclusions notes

Assign the code

Terms enclosed in parentheses following the main term are referred to as:

non-essential modifiers

ICD-10-CM, a placeholder for future code expansion is shown as:

X character

First three characters of an ICD-10-CM code are composed as:

Character 1 (Alphabetic) Character 2 (Numeric) Character 3 (Numeric)

Locating a diagnosis, look up the main term, which is the:

disease and injury

Why is the correct sequence of codes on an insurance claim important?

to make the chronology of patient care events understood and to make the severity of disease understood

Diagnoses that relate to a patient's previous medical problem and that have no bearing on the patients' present condition should be __________ when coding.

excluded

Diagnostic codes on an insurance claim explain:

the patient's condition that was treated during the visit

The official American Hospital Association policy states, 'Abbreviations should be totally eliminated from the more vital sections of the record, such as the"

all are correct

In dealing with managed care plans, a referral is:

the transfer of the total or specific care of a patient from one physician to another and the term used when requesting an authorization for the patient to receive services elsewhere

When a patient fails to return for needed treatment, documentation should be made:

all are correct

An advantage of electronic medical records is:

greater standardization in clinical medical terminology

Disabled workers younger than 65 years of age are eligible for SSDI.

True

What is the correct order in the appeals process?

reconsideration, hearing, review by the appeals council, review by federal court

A policy that offers an insured person protection when loss of sight or loss of limb(s) occurs is:

dismemberment benefit

Disability income insurance is available from:

all are correct

Coverage that provides a specific monthly or weekly income when a person is unable to work:

disability income insurance

In a workers' compensation case, the contract and financial responsibility exists between the:

physician and the insurance company

OSHA stands for:

occupational safety and health administration

The simplest type of workers' compensation claim is:

non-disability

When billing workers' compensation for a truck driver who was injured outside of the state:

follow the rules of the state in which the claim was originally filed

The reason for workers' compensation laws is:

all are correct

TRICARE Plus limits coverage to:

primary care

TRICARE for Life provides coverage:

TRICARE eligible beneficiaries with Medicare Part A and B

TRICE Prime Remote can only be used if both the sponsor's home and work addresses are:

50 miles from a military hospital or clinic and one hour's drive from a military hospital

Enrollment in TRICARE Prime is for:

1 year at a time

A physician who chooses not to participate in TRICARE bills:

no more than 115% of the TRICARE allowable charge

TRICARE, formerly known as CHAMPUS, is funded through:

the US Congress

Under Medicaid, all recipients will have the same copayment amount that must be collected.

False

The Medicaid service for prevention, early detection, and treatment for welfare children is:

EPSDT

Time limit to appeal a claim varies from state to state, but it is usually for:

30 to 60 days

Medicaid is available to the needy and low-income people such as:

All are correct

Partnership between the federal and state governments that provides low-cost health coverage to children in families that earn to much money to qualify for Medicaid:

CHIP

The Medicaid program is funded:

jointly by state and federal governments

Patients who elect Medicare Part B coverage pay annually increasing basic premium.

True

A participating physician with the Medicare plan agrees to accept:

80% of the Medicare approved charge

A program that contracts with CMS to review medical necessity and appropriateness of inpatient care:

QIO

Medigap insurance may cover:

the deductible not covered under Medicare

Some Medicare Advantage plans may provide services not covered by Medicare, such as:

eyeglasses and prescription drugs

Plans that may be offered under a Medicare Advantage Plan include:

All are correct

Medicare identification cards are currently being shifted from social security numbers to Medicare Beneficiary Identifier (MBI) numbers. Effective from _____, all claims must be submitted with the patient's MBI.

January 1, 2020

Medicare Part A:

hospice care

A physician-owned business that has the flexibility to deal with all forms of contract medicine:

PPG

A program that offers a combination of HMO-style cost management and PPO-style freedom of:

Point of Service (POS)

An organization that gives members freedom of choice among physicians and hospitals and provides a higher level of benefits if the providers listed on the plan are used is called a/an:

preferred provider organization (PPO)

The Blue Shield plans were established primarily to cover:

physician services

The Blue Cross plans were established primarily to cover:

hospital services

Private insurance companies must meet the requirements and laws of:

state insurance agency in which they conduct business

A coordination of benefits statement in an insurance policy refers to the waiting period.

False

Under HIPAA guidelines, physicians must send all claims electronically:

if they have more than 10 full time employees

Assignment of benefits is:

the transfer of one's legal right to collect an amount payable under an insurance contract

Mr. Ott was laid off from his job. He is protected by Consolidated Omnibus Budget Reconciliation Act (COBRA), which requires his employer to:

extend group health insurance coverage for 18 months

What is the correct term used to determine if a procedure is covered and medically necessary?

preauthorization

According to the birthday law, if both the mother and the father have the same birthday:

plan of the person who has coverage longer is the primary payer

If a child has health insurance coverage from two parents, according to the birthday law:

the health plan of the person whose birthday (month and day) falls earlier in the calendar year will pay first.

Mr. Talili has two medical insurance policies. To prevent duplication of payment for the same medical expense, the policies include a:

coordination of benefits statement

An emancipated minor is a:

person younger than 18 who lives independently

When a patient carries private medical insurance, the contract for treatment exists between the:

physician and the patient

What action could happen if an employee knowingly submits a fraudulent Medicare or Medicaid claim at the direction of the employer and subsequently the medical practice is audited?

the employee and the employer could be brought into litigation by the state or federal government

When an insurance billing specialist bills for a physician and completes a Medicare claim form with information that does not reflect the true situation:

he or she may be subject to fines and imprisonment

To bill Medicare beneficiaries at a higher rate than other patients is considered:

Abuse

Under HIPAA guidelines, an outside billing company that manages claims and accounts for a medical clinic is known as a covered entity.

False

What is the best response when telephoning a patient about an insurance matter and the patient's voice mail is reached?

Use care in the choice of words when leaving the message

What is the correct response when a relative calls asking about a patient?

Have the physician return the telephone call

The Office of Civil Rights enforces:

privacy and security rules

The amount of money an insurance billing specialist earns is dependent on which of the following factors?

All of them

What is "cash flow" in a medical practice?

The actual money available to a medical practice