NHA Flash Cards

NHA MEDICAL BILLING & CODING — 200 FLASHCARDS

Medical terminology — What is anatomy? → The study of body structures.

Medical terminology — What is physiology? → The study of how the body functions.

Medical terminology — What is pathology? → The study of disease and abnormal conditions.

Medical terminology — What does the suffix -itis mean? → Inflammation.

Medical terminology — What does the suffix -ectomy mean? → Surgical removal.

Medical terminology — What does the suffix -otomy mean? → Incision or cutting into.

Medical terminology — What does the suffix -ostomy mean? → Surgical creation of an opening.

Medical terminology — What does the suffix -algia mean? → Pain.

Medical terminology — What does the suffix -emia mean? → A blood condition.

Medical terminology — What does the suffix -megaly mean? → Enlargement.

Medical terminology — What does the suffix -scopy mean? → Visual examination.

Medical terminology — What does the suffix -plasty mean? → Surgical repair.

Medical terminology — What does the suffix -rrhage mean? → Excessive bleeding.

Medical terminology — What does the suffix -rrhea mean? → Flow or discharge.

Medical terminology — What does the suffix -pathy mean? → Disease.

Medical terminology — What does the suffix -logy mean? → Study of.

Medical terminology — What does brady- mean? → Slow.

Medical terminology — What does tachy- mean? → Fast or rapid.

Medical terminology — What does hyper- mean? → Excessive or high.

Medical terminology — What does hypo- mean? → Below, low, or deficient.

Medical terminology — What does peri- mean? → Around.

Medical terminology — What does endo- mean? → Within.

Medical terminology — What does epi- mean? → Upon or above.

Medical terminology — What does intra- mean? → Within.

Medical terminology — What does sub- mean? → Under.

Medical terminology — What does poly- mean? → Many.

Medical terminology — What does oligo- mean? → Few or scanty.

Anatomy — What does anterior mean? → Toward the front of the body.

Anatomy — What does posterior mean? → Toward the back of the body.

Anatomy — What does superior mean? → Above or toward the head.

Anatomy — What does inferior mean? → Below or toward the feet.

Anatomy — What does medial mean? → Toward the body’s midline.

Anatomy — What does lateral mean? → Away from the body’s midline.

Anatomy — What does proximal mean? → Closer to the point of attachment.

Anatomy — What does distal mean? → Farther from the point of attachment.

Anatomy — What does superficial mean? → Near the body’s surface.

Anatomy — What does deep mean? → Farther from the body’s surface.

Anatomy — What does the sagittal plane divide? → The body into right and left portions.

Anatomy — What does the midsagittal plane divide? → The body into equal right and left halves.

Anatomy — What does the frontal/coronal plane divide? → The body into anterior and posterior portions.

Anatomy — What does the transverse plane divide? → The body into superior and inferior portions.

Body systems — What does the cardiovascular system include? → The heart and blood vessels.

Body systems — What is the primary function of the respiratory system? → Gas exchange and breathing.

Body systems — What organs are part of the urinary system? → Kidneys, ureters, bladder, and urethra.

Body systems — What does the digestive system do? → Breaks down food and absorbs nutrients.

Body systems — What does the endocrine system produce? → Hormones.

Body systems — What does the nervous system include? → Brain, spinal cord, and nerves.

Body systems — What does the musculoskeletal system include? → Bones, muscles, joints, and connective tissue.

Body systems — What does the integumentary system include? → Skin, hair, and nails.

Body systems — What is the primary function of the immune/lymphatic system? → Protect the body against disease and infection.

Body systems — What organ pumps blood throughout the body? → The heart.

Body systems — Which organs filter blood and produce urine? → The kidneys.

Documentation — What is a SOAP note? → A method of documenting patient information using Subjective, Objective, Assessment, and Plan.

Documentation — What does S in SOAP stand for? → Subjective.

Documentation — What does O in SOAP stand for? → Objective.

Documentation — What does A in SOAP stand for? → Assessment.

Documentation — What does P in SOAP stand for? → Plan.

Documentation — What is subjective information? → Information reported by the patient.

Documentation — What is objective information? → Observable or measurable information such as vital signs and test results.

Documentation — What is the assessment? → The provider’s clinical assessment or diagnosis.

Documentation — What is the plan? → The treatment plan and next steps.

Documentation — What fundamental coding principle applies to undocumented services? → If it isn’t documented, it wasn’t done.

Documentation — Should a coder assume an undocumented diagnosis? → No.

HIPAA — What does HIPAA stand for? → Health Insurance Portability and Accountability Act.

HIPAA — What does PHI stand for? → Protected Health Information.

HIPAA — What is PHI? → Individually identifiable health information related to a person’s health, healthcare, or payment for healthcare.

HIPAA — What does the HIPAA Privacy Rule regulate? → The use and disclosure of protected health information.

HIPAA — What does the HIPAA Security Rule protect? → Electronic protected health information.

HIPAA — What is the minimum necessary principle? → Limiting PHI use or disclosure to what is reasonably necessary for the intended purpose.

HIPAA — Is accessing a patient’s record without a legitimate need acceptable? → No.

HIPAA — Should passwords be shared with coworkers? → No.

HIPAA — Should PHI be discussed where unauthorized people can hear it? → No.

Ethics — What is beneficence? → Acting for the patient’s benefit.

Ethics — What is nonmaleficence? → The principle of doing no harm.

Ethics — What is autonomy? → Respecting the patient’s right to make decisions.

Ethics — What is justice? → Treating patients fairly.

Ethics — What is veracity? → Truthfulness.

Ethics — What is fidelity? → Keeping commitments and responsibilities.

Coding — What is medical coding? → Converting medical documentation into standardized codes.

Coding — What is the primary purpose of ICD-10-CM? → Reporting diagnoses and health conditions.

Coding — What is the primary purpose of CPT? → Reporting procedures and professional services.

Coding — What is HCPCS Level II used for? → Supplies, equipment, medications, ambulance services, and other applicable services.

Coding — What is the basic coding rule? → Code what is documented.

Coding — Should a coder choose a code because it provides higher reimbursement? → No.

Coding — Should a coder guess when documentation is insufficient? → No.

ICD-10-CM — What does ICD-10-CM stand for? → International Classification of Diseases, 10th Revision, Clinical Modification.

ICD-10-CM — What is the Alphabetic Index used for? → Locating possible diagnosis codes.

ICD-10-CM — What should be done after finding a code in the Alphabetic Index? → Verify the code in the Tabular List.

ICD-10-CM — What is the Tabular List? → The section containing complete code descriptions and coding instructions.

ICD-10-CM — Where are Excludes notes found? → In the Tabular List.

ICD-10-CM — What is an Excludes1 note? → It generally means the two conditions should not be coded together.

ICD-10-CM — What is an Excludes2 note? → It means the excluded condition is not part of the coded condition, but both may be coded when appropriate.

ICD-10-CM — What does laterality identify? → The side of the body affected.

ICD-10-CM — What are common laterality choices? → Right, left, or bilateral.

ICD-10-CM — What is a placeholder X? → A character used when necessary to hold a position so a required 7th character can be placed correctly.

ICD-10-CM — What is a 7th character used for? → Additional information required by certain code categories, such as encounter or healing information.

ICD-10-CM — What does “Code First” mean? → The underlying condition should be sequenced first.

ICD-10-CM — What does “Use Additional Code” mean? → An additional code may be required to fully describe the condition.

ICD-10-CM — What does “with” sometimes indicate? → An assumed or classified relationship between certain conditions.

ICD-10-CM — Should the unspecified code be used when laterality is documented? → No.

CPT — What does CPT stand for? → Current Procedural Terminology.

CPT — What are CPT codes primarily used to report? → Medical procedures and professional services.

CPT — How many main CPT categories are commonly recognized? → Three: Category I, Category II, and Category III.

CPT — What are Category I CPT codes? → Established procedures and services.

CPT — What are Category II CPT codes? → Optional performance measurement/tracking codes.

CPT — What are Category III CPT codes? → Temporary codes for emerging technologies, procedures, and services.

CPT — What are the major Category I CPT sections? → Evaluation and Management, Anesthesia, Surgery, Radiology, Pathology and Laboratory, and Medicine.

Modifiers — What is the purpose of a CPT modifier? → To provide additional information about a service without changing the basic procedure code.

Modifiers — What does modifier -25 indicate? → A significant, separately identifiable E/M service on the same day as another procedure/service.

Modifiers — What does modifier -26 indicate? → The professional component.

Modifiers — What does modifier -TC indicate? → The technical component.

Modifiers — What does modifier -59 indicate? → A distinct procedural service.

Modifiers — What does modifier -24 indicate? → An unrelated E/M service during a postoperative period.

Modifiers — What does modifier -51 indicate? → Multiple procedures.

Modifiers — What does modifier -52 indicate? → Reduced services.

Modifiers — What does modifier -53 indicate? → A discontinued procedure in applicable circumstances.

Modifiers — What does modifier -57 indicate? → Decision for surgery.

Modifiers — What does modifier -79 indicate? → An unrelated procedure/service during the postoperative period.

Modifiers — What does modifier -91 indicate? → A repeat clinical diagnostic laboratory test.

HCPCS — What does HCPCS stand for? → Healthcare Common Procedure Coding System.

HCPCS — What is HCPCS Level II? → A code set used for supplies, equipment, medications, ambulance services, and other services not represented by CPT.

HCPCS — What is the general format of HCPCS Level II codes? → One letter followed by four numbers.

Medical necessity — What does medical necessity mean? → A service is reasonable and necessary for diagnosis or treatment.

Medical necessity — What code type generally explains why a service was performed? → ICD-10-CM diagnosis codes.

Medical necessity — What code type generally explains what service was performed? → CPT or HCPCS codes.

POS — What does POS stand for? → Place of Service.

POS — What do POS codes identify? → Where healthcare services were provided.

POS — What is POS 11? → Office.

POS — What is POS 12? → Home.

POS — What is POS 21? → Inpatient hospital.

POS — What is POS 22? → Hospital outpatient.

POS — What is POS 23? → Emergency department.

POS — What is POS 24? → Ambulatory surgical center.

POS — What is POS 31? → Skilled nursing facility.

POS — What is POS 32? → Nursing facility.

POS — What is POS 81? → Independent laboratory.

CMS-1500 — What is the CMS-1500? → A claim form primarily used for professional healthcare services.

UB-04 — What is the UB-04/CMS-1450? → A claim form primarily used for institutional healthcare services.

Claims — What is an NPI? → National Provider Identifier.

Claims — How many digits are in an NPI? → 10 digits.

Claims — What is a revenue code? → A code used on institutional claims to identify specific services or departments.

Claims — What is a Type of Bill? → Information identifying the type of institutional claim being submitted.

Claims — What is a clean claim? → A claim containing required information that can be processed without correction or additional information.

Claims — What is a claim scrubber? → A system that checks claims for potential errors before submission.

Claims — What is a clearinghouse? → An intermediary that checks, formats, and routes electronic claims between providers and payers.

Claims — What does EDI stand for? → Electronic Data Interchange.

Claims — What is the typical electronic claim pathway? → Provider → Clearinghouse → Payer.

Claims — What should be done when a claim is rejected because of incorrect information? → Correct the error and resubmit the claim.

Claims — What is a claim denial? → A payer decision not to pay a claim or portion of a claim after processing.

Claims — What is a claim rejection? → A claim that cannot be processed because of an error or missing/invalid information.

Claims — What is the basic response to a rejection? → Correct the problem and resubmit.

Claims — What is the basic response to a denial? → Determine the reason and take appropriate corrective or appeal action.

Claims — What is an appeal? → A formal request asking a payer to reconsider a denied claim.

Claims — What can support an appeal? → Medical records, provider documentation, coding information, medical necessity information, and other required supporting documentation.

Claims — What is timely filing? → The payer’s deadline for submitting a claim.

Claims — What can happen if a claim misses the timely filing deadline? → The claim may be denied.

EDI — What is an 837 transaction? → Healthcare claim submission.

EDI — What is an 835 transaction? → Electronic remittance advice.

EDI — What is a 270 transaction? → Eligibility inquiry.

EDI — What is a 271 transaction? → Eligibility response.

EDI — What is a 276 transaction? → Claim status inquiry.

EDI — What is a 277 transaction? → Claim status response.

Insurance — What is eligibility verification? → Confirming that the patient’s insurance coverage is active and applicable.

Insurance — What is a deductible? → An amount the patient generally pays before applicable insurance benefits begin paying.

Insurance — What is a copayment? → A fixed dollar amount the patient pays for a covered service.

Insurance — What is coinsurance? → A percentage of the applicable allowed amount the patient is responsible for.

Insurance — What is a premium? → The amount paid to maintain insurance coverage.

Insurance — What is an allowed amount? → The amount recognized under the applicable payer plan for a covered service.

Insurance — What is prior authorization? → Payer approval required before certain services are performed.

Insurance — Does prior authorization guarantee payment? → No.

Insurance — What is a referral? → Authorization or direction from one healthcare provider to another for evaluation or treatment.

Insurance — Why should eligibility be verified before services? → To confirm active coverage and identify applicable benefits and requirements.

Insurance plans — What is an HMO? → A health plan that generally emphasizes a provider network and coordinated care.

Insurance plans — What is a PPO? → A plan that generally provides more provider flexibility and may cover out-of-network services at a higher cost.

Insurance plans — What is a POS plan? → A Point-of-Service plan combining features of HMO and PPO plans.

Insurance plans — What is an EPO? → An Exclusive Provider Organization that generally requires in-network care except for emergencies.

COB — What does COB stand for? → Coordination of Benefits.

COB — What does COB determine? → Which insurance is primary and which is secondary when a patient has multiple plans.

COB — What is the primary payer? → The insurance plan that pays first.

COB — What is the secondary payer? → The insurance plan that may consider remaining eligible charges after the primary payer processes the claim.

Medicare — What is Medicare? → A federal health insurance program.

Medicare — What does Medicare Part A primarily cover? → Hospital insurance, including inpatient hospital care and certain related services.

Medicare — What does Medicare Part B primarily cover? → Physician and outpatient medical services.

Medicare — What is Medicare Part C? → Medicare Advantage.

Medicare — What does Medicare Part D cover? → Prescription drugs.

Medicare — Is Medicare Part C the same thing as Original Medicare? → No. Part C is Medicare Advantage offered through private Medicare-approved plans.

Medicaid — What is Medicaid? → A joint federal and state program providing health coverage to eligible individuals.

Medicaid — Does Medicaid eligibility work exactly the same in every state? → No. Program rules and eligibility can vary by state.

TRICARE — What is TRICARE? → A healthcare program serving eligible members of the military community and qualifying family members and survivors.

Claims processing — What is claim adjudication? → The payer’s process of reviewing a claim and determining payment or denial.

Claims processing — What can a payer determine during adjudication? → Coverage, allowed amount, patient responsibility, payment, adjustments, or denial.

EOB — What does EOB stand for? → Explanation of Benefits.

EOB — What does an EOB explain? → How the payer processed a claim.

EOB — Is an EOB generally a bill? → No.

EOB — What information can appear on an EOB? → Billed amount, allowed amount, payment, adjustments, deductible, coinsurance, copayment, and patient responsibility.

ERA — What does ERA stand for? → Electronic Remittance Advice.

ERA — What does an ERA provide? → Electronic information about how a payer processed and paid or adjusted claims.

Billing — What is accounts receivable? → Money owed to the healthcare organization.

Billing — What is an A/R aging report? → A report organizing unpaid balances by how long they have been outstanding.

Billing — What are common A/R aging categories? → 0–30, 31–60, 61–90, 91–120, and 120+ days.

Billing — Why should older A/R receive attention? → Older accounts may be closer to payer deadlines or collection issues.

Billing — What is payment posting? → Recording insurance payments, patient payments, adjustments, denials, and related transactions.

Billing — What should payment posting be compared against? → The payer’s remittance information.

Billing — What can patient responsibility include? → Copayments, deductibles, coinsurance, and other amounts permitted under the plan and applicable rules.

Compliance — What is healthcare fraud? → Knowingly submitting false information or engaging in deception to obtain improper payment.

Compliance — What is healthcare abuse? → Practices that may result in unnecessary costs or improper payment without necessarily involving intentional deception.

Compliance — What is upcoding? → Reporting a higher-level service than what was actually performed or supported by documentation.

Compliance — What is unbundling? → Improperly reporting services separately when they should be reported as a bundled service.

Compliance — Why is upcoding dangerous? → It can result in improper reimbursement and compliance violations.

Compliance — Why is unbundling dangerous? → It can result in improper reimbursement and compliance violations.

Compliance — What is the purpose of coding compliance? → To ensure accurate, ethical, and legally compliant reporting.

Patient privacy — Should a biller provide PHI to a spouse simply because the spouse asks? → Not without verifying that the spouse is authorized to receive it.

Patient privacy — What should be verified before releasing PHI? → The identity and authorization of the person requesting the information.

Patient privacy — What is confidentiality? → Protecting patient information from unauthorized disclosure.

Coding principles — What does “code to the highest level of specificity” mean? → Select the most specific code supported by the documentation.

Coding principles — Can a coder code an undocumented diagnosis because it seems obvious? → No.

Coding principles — Can a coder change a diagnosis simply to obtain payment? → No.

Coding principles — What should determine code selection? → Provider documentation and applicable coding guidelines.

Coding principles — What should a coder check before finalizing an ICD-10-CM code? → The Alphabetic Index, Tabular List, notes, specificity, laterality, and applicable coding guidelines.

Billing workflow — What is the first major step in the claims process? → Patient registration.

Billing workflow — What information is collected during patient registration? → Demographics, insurance information, subscriber information, and contact information.

Billing workflow — What comes after patient registration? → Insurance verification.

Billing workflow — What should be checked during insurance verification? → Eligibility, coverage, effective dates, benefits, copays, deductibles, coinsurance, authorization, and referral requirements.

Billing workflow — What comes after provider documentation? → Coding.

Billing workflow — What happens after coding? → Claim creation.

Billing workflow — What happens after claim creation? → Claim scrubbing and submission.

Billing workflow — What happens after claim submission? → Payer adjudication.

Billing workflow — What happens after adjudication? → Payment, adjustment, rejection, or denial.

Billing workflow — What happens after insurance processing when a balance remains? → Appropriate patient billing.

Exam review — What does ICD-10-CM answer? → WHY the patient received care.

Exam review — What does CPT answer? → WHAT procedure or service was performed.

Exam review — What does HCPCS Level II commonly identify? → Supplies, equipment, medications, ambulance services, and other applicable services.

Exam review — CMS-1500 equals what type of claim? → Professional claim.

Exam review — UB-04 equals what type of claim? → Institutional claim.

Exam review — What does “25 = E/M Extra” help you remember? → Modifier -25 identifies a significant, separately identifiable E/M service on the same day as another service.

Exam review — What does “26 = Doctor” help you remember? → Modifier -26 identifies the professional component.

Exam review — What does “TC = Technical” help you remember? → Modifier -TC identifies the technical component.

Exam review — What does “59 = Separate” help you remember? → Modifier -59 identifies a distinct procedural service.

Exam review — What does “Rejection = Repair” mean? → Correct the claim problem and resubmit.

Exam review — What does “Denial = Determine” mean? → Determine why the claim was denied and take appropriate action.

Exam review — What are the four Medicare parts? → Part A, Part B, Part C, and Part D.

Exam review — Which Medicare part is hospital insurance? → Part A.

Exam review — Which Medicare part is medical insurance? → Part B.

Exam review — Which Medicare part is Medicare Advantage? → Part C.

Exam review — Which Medicare part is prescription drug coverage? → Part D.

Exam review — What is the difference between a deductible and copay? → A deductible is an amount generally paid before applicable benefits begin; a copay is a fixed amount for a covered service.

Exam review — What is the difference between copay and coinsurance? → Copay is generally a fixed dollar amount; coinsurance is generally a percentage of the applicable allowed amount.

Exam review — What is the difference between EOB and ERA? → EOB is an Explanation of Benefits; ERA is an electronic remittance transaction.

Exam review — What is the difference between rejection and denial? → A rejection prevents processing because of an error; a denial is a payer decision after processing.

Exam review — What is the most important coding rule to remember? → Code what is documented and follow official coding guidelines.

Exam review — What is one of the most important HIPAA rules to remember? → Protect PHI from unauthorized access, use, or disclosure.

Exam review — What should you do if you are unsure about a code? → Review the official coding resources and documentation rather than guessing.

Exam review — What should a biller do with a denial? → Review the denial reason, documentation, claim, payer requirements, and determine whether correction or appeal is appropriate.

Exam review — What should a biller do with a rejected claim? → Correct the identified error and resubmit it.

Exam review — What is medical necessity’s role in billing? → It supports why a service was reasonable and necessary for the patient’s condition.

Exam review — What is the key relationship between diagnosis and procedure codes? → The diagnosis explains why care was provided; the procedure code describes what was done.

Exam review — What is the best general strategy for NHA coding questions? → Read the documentation carefully, identify exactly what is being asked, eliminate incorrect choices, and choose the answer supported by coding rules.