AAPC CPB - Chapter 9 Review

A ______ indicates the location or type of service provided for an inpatient and is reported with _______.

a. Revenue code; four-digit code

b. Revenue code; three-digit code

c. CPT code; five-digit code

d. MSDRG code; three-digit code

a. Revenue code; four-digit code

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

a. Encounter form

b. Medical record

c. Explanation of Benefits

d. CMS-1500 claim form

c. Explanation of Benefits

A clearinghouse is an entity that provides which of the following services?

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

b. Pursues payments of debts owed by individuals or businesses.

c. Assists providers in the collection of appropriate reimbursement for services rendered.

d. Explains insurance benefits, policy requirements, and filing rules to patients.

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

Which is a TRUE statement about daily deposits?

a. Keeping the checks and cash in the office for more than a day opens the practice up to liability for the cash and checks.

b. Daily deposits should be made for the mail receipts and personal payment receipts.

c. Daily deposits of the mail receipts and personal payment receipts should be balanced each day.

d. All the statements are true.

d. All the statements are true.

Mrs. Fryer takes her son to the ED for an injured arm. Her son is covered by both parents. Mr. Fryer's birthday is 10/14/1984 and Mrs. Fryer's birthday is 6/10/1986. Under the birthday rule whose insurance plan will be primary?

a. Mrs. Fryer

b. Mr. Fryer

c. Either one can be primary

d. The parent's birthday closest to the child's birthday

a. Mrs. Fryer

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

a. Shows improper Medicare payments paid to the provider.

b. Patient claims that will be sent to collections.

c. All claims sent to the payer and all rejected claims.

d. Patient claims that have not been paid within a certain time frame.

c. All claims sent to the payer and all rejected claims.

What is a clean claim?

a. A blank claim form

b. A claim that meets medical necessity

c. A claim that has all of the information required to be processed

d. A claim that is paid on time

c. A claim that has all of the information required to be processed

Which of the following can be done to reduce payment delay?

a. Verify patient's insurance information on each patient visit.

b. Submit a paper and electronic claim for a patient's visit.

c. Wait for the clearinghouse to send you a status report.

d. Always submit medical record documentation with every claim.

a. Verify patient's insurance information on each patient visit.

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

a. Health Insurance Portability and Accountability Act (HIPAA)

b. Affordable Care Act (ACA)

c. OIG Work Plan

d. Social Security Act

a. Health Insurance Portability and Accountability Act (HIPAA)

Mrs. Jones went in for a surgical procedure and the claim was denied because the office did not obtain prior authorization. The carrier does not allow authorizations to be obtained after the procedure has been performed. What is done to recover any payment?

a. Bill Mrs. Jones and she is responsible for payment.

b. The provider is required to write off the balance.

c. Bill Mrs. Jones for 20% of the service and write off the balance.

d. None of the above.

b. The provider is required to write off the balance.

Sally who works for Dr. X gets a written request from ABC Insurance for additional documentation to process a claim for Mrs. Wader on date of service 11/22/XXXX. What following actions should Sally do?

a. Copy the whole medical record that includes all dates of service of Mrs. Wader's office visits with Dr. X and send it to the insurance carrier.

b. Add a modifier to a CPT® code and resend the claim.

c. Send the copy of the medical records just for that date of service to the insurance carrier along with the claim and remittance advice.

d. Copy the ICD-10-CM and CPT® codes from the codebooks that were reported for Mrs. Wader's visit on 11/22/XXXX along with the claim to the insurance carrier.

c. Send the copy of the medical records just for that date of service to the insurance carrier along with the claim and remittance advice.

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

a. Medicare Severity-Diagnosis Related Groups (MS-DRGs)

b. Ambulatory Payment Classification (APC)

c. Resource-Based Relative Value Scale (RBRVS)

d. Healthcare Common Procedure Coding System (HCPCS)

b. Ambulatory Payment Classification (APC)

An audit that occurs before a claim is submitted is a _____________.

a. Internal audit

b. Payer's audit

c. Post-payment audit

d. Pre-payment audit

d. Pre-payment audit

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

a. Patient

b. Provider

c. Collection agency

d. Clearing house

b. Provider

Which of the following transmission media is NOT used for submitting electronic claims?

a. DSL

b. Magnetic tape

c. Fax

d. Internet

c. Fax

When an insurance carrier has denied payment for a procedure that did not get prior authorization, the service

a. Can be billed to the patient for the full fee.

b. Will be paid at 50% by the insurance carrier.

c. Is written off by the provider.

d. Is paid 20% by the patient.

c. Is written off by the provider.

A hospital chargemaster does NOT contain which of the following?

a. Revenue Code

b. Service Description

c. CPT Code

d. ICD-10-CM diagnosis code

d. ICD-10-CM diagnosis code

Which of the following are verified by a claim scrubber?

I. ICD-10-CM codes

II. CPT®/HCPCS Level II codes

III. Looks at procedure codes and diagnosis codes justifying medical necessity

IV. Place of service

V. NCCI Edits

VI. Looks for trends in both claim scrubber edits and denials

a. I, III, VI

b. III-V

c. I-V

d. IV-VI

c. I-V

Mr. Cooper was in outpatient surgery for a hernia repair. During the surgery a complication occurs that requires Mr. Cooper to be admitted into the hospital. Which payment system will be used?

a. Outpatient Prospective Payment System (OPPS)

b. Inpatient Prospective Payment System (IPPS)

c. Ambulatory Payment Classification (APC)

d. Both OPPS and IPPS

b. Inpatient Prospective Payment System (IPPS)

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

a. OIG Work Plan

b. Creating a cost-based fee schedule

c. Fee schedule based on NCCI Edits

d. Private and Government payers calculate the fee schedule

b. Creating a cost-based fee schedule

Which is a FALSE statement regarding claim scrubbers?

a. A claim scrubber reviews claims for key components after the claims are sent to an insurance company and denied.

b. The claim scrubber verifies CPT®/HCPCS Level II codes and ICD-10-CM codes.

c. The claim scrubber can verify that an ICD-10-CM code(s) supports medical necessity for LCD/NCD and identify bundled services.

d. Common edits that are identified by claims scrubbers are data entry errors.

a. A claim scrubber reviews claims for key components after the claims are sent to an insurance company and denied.

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

a. Charge Ticket

b. Chargemaster

c. UB-04 claim form

d. CMS-1500 claim form

b. Chargemaster

When creating a fee schedule for a practice, which of the following can be used to set the fees?

a. National Correct Coding Initiatives (NCCI)

b. Local Coverage Determination (LCD)

c. Current Procedural Terminology (CPT®)

d. Relative Value Units (RVU)

d. Relative Value Units (RVU)

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

a. Collections

b. Bad Debt

c. Accounts Receivable

d. None of the above

c. Accounts Receivable

Which information is NOT required for prior authorization?

a. Site where the service will be performed

b. ICD-10-CM and CPT® code(s)

c. Ordering physician

d. Patient's finances

d. Patient's finances