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NHA exam review

CBCS "Certified Billing & Coding Specialist

The Three Key Components of E&M (Evaluation & Management) CODES History, examination, and medical decision making complexity
The levels of E/M services are based on documentation located in patient's medical record and are based on KEY COMPONENTS (history/Hx, examination, & medical decision-making complexity) and CONTRIBUTORY FACTORS (counseling, coordination of care, nature of presenting problem & time)
History is the subjective information the patient tells the physician
Four elements of a history are chief complaint (CC) history of present illness (HPI) review of systems (ROS) and past, family, and social history (PFSH)
Invalid claim is one that is submitted with a transposed member ID number
According to CLIA (Clinical Laboratory Improvement Amendments)when billing medicare for a waived laboratory test what modifier should be used QW
What take precedence over ICD-9-CM chapter specific quidelines Coding conventions and instructions
what action should be taken when a claim is billed for a level 4 office visit and paid at a level 3 submit an appeal with supporting documentation
On a patient's remittance advice, a deductible of $100 has been applied. The provider has requested the patient account personnel to write it off. What describes this scenero FRAUD
Patient presents for an incision & drainage of Pilonidal Cyst. what part of the body is it referring to Coccyx (tail bone)
Which is a valid ICD-9-CM principal? Code signs and symptoms in the absence of an established diagnosis
Patient calls your office and is upset about bill received. Her Insurance company denied claim, what should you do You should inform the patient the reason for denial
A billing and coding specialist should understand that the financial record source that is generated by a providers office is called a Patient Ledger Account
A claim can be denied or rejected for Block 24D containing a diagnosis code? True block 24D is for CPT codes (diagnosis codes go in Block 21)
This scenerio is most appropriate to submit an electronic claim Claim submitted contains an outpatient procedure
What component of an EOB (explanation of benefits)expedites the process of a phone appeal Claim Control Number
An example of a diagnostic category code is 541 (3 digits/no decimal point)
In managed care organizations PPO (preferred provider option)help control a patient's insurance cost by offering low-cost deductibles
Which describes an "implied contract" A patient schedules an appointment with a new provider's office
An insurance claims register (aged insurance report)facilitates which follow-up insurance claims by date
How does a third party payer determine timely filing for claims Contract with the provider
A woman in her 3rd trimester of pregnancy present to her Dr.s office with a diagnosis of a sprained wrist w/ swelling due to falling on a wet floor.Dr.documented no relationship between the sprain & pregnancy. What is appropriate coding sequencing Sprained wrist, pregnancy, fall on floor
A UB-04 claim form is the appropriate claim form for reimbursement of services from ambulatory surgery centers, home healthcare and hospice organizations, inpatient
a non-allowed charge goes in? the adjustment column of the credits
Claim to be correctly processed via optical character recognition(OCR) billing & coding specialist should use 12 pitch (PICA) characters
What transports oxygenated blood from the Heart Aorta
What is the valve that controls opening between the right atrium and right ventricle Tricuspid valve
What valve is located between the left atrium and left ventricle Bicuspid valve AKA mitral valve
Nocturia is excessive urination at night
the duodenum is the first section of the small intestine
the ileum is the last section of the small intestine
V-codes are used as the 1st listed diagnosis to indicate family history
How many behavior classifications are included in Table of neoplasms 6
What is the form that contains DOS (date of service), CPT codes, ICD-9-CM, fees and copayment info an Encounter form
What is the medical term that describes the body's inability to compensate for position change orthostatic hypotension
what font is the standard font for the CMS 1500 paper claim 10 pitch (PICA)
An integral part of an autopsy is what type of examination gross examination
A paper claim should be submitted if a claim contains unlisted procedure codes
What organization accepts electronic claims MAC - Medicare Administrative Contractors
Because of medicare NCCI (National Correct Coding Initiative) edits improper code combinations are in what type of claim claim rejection
What type of insurance coverage is offered to Medicare beneficiaries by private third-party payers Medigap coverage
What is the accrediting agency for laboratories CLIA (Clinical Laboratory Improvement amendments
What is it called when an insurance claim is overdue for payment delinquent claim
What is a fixed dollar amount for office, pharmacy and emergency department services co-payment
What is a percentage of the costs for covered services that is approved by the insurance company co-insurance
what is the condition in which the urethral opening is on the lateral aspect of the penis paraspadias
What is the standard form for professional outpatient services and procedures CMS-1500
What can never be reported as a stand alone code an add-on code
What is a pre-existing condition An illness or condition present before insurance coverage begins
What insurance policy is NEVER primary when the insured has more than one policy medicaid (payer of last resort)
A triangle in front of a code in the updated CPT manual means the description of the code has been changed
a CPT coding system is service and procedure based
A respirator used by a Medicare patient is an example of Durable medical equipment (DME)
Medical ethics are Standards of conduct
the way to correct an error on a patient's medical record is to cross out the incorrect data with a single line, write in correct information, followed by initials and date
A patient was diagnosed with cardiomegaly, what does this mean enlargement of heart
What is the ICD-9-CM subclassification code 5 digits (282.60)
What is the ICD-9-CM subcategory code 4 digits (255.0)
Ann Smith had a biopsy take from a lump found in her left breast. 3 days after procedure she was informed that the biopsy is positive for carcinoma. 5 days later she undergoes radical mastectomy. what modifier can be attached to primary code modifier -58 (staged or related procedure or service by the same physician during the same post-operative period
A document that contains dates of service (DOS), list of detail charges, co-payments & deductibles paid, date insurance was filed, adjustments and account balance is called an Itemized statement
What people DO NOT qualify for Medicaid High income earners
ICD-9-CM is the International Classification of Diseases, 9th Revision, Clinical Modification
An established patient is defined as one who has received professional services from the physician or another physician of the same specialty in the same group within the past how many years 3 years
A patient is diagnosed with metastatic bone neoplasm. The neoplasm will be coded as Secondary malignant
Under the RBRVS (Resource-based relative value scale) method of reimbursement, "conversion factor" is a dollar amount
An organization that initiated the development of ICD codes is WHO (World Health Organization)
The patient's birth date on the CMS-1500 form is entered in which of these formats MM/DD/CCYY (month/date/century & year)(8 digits)
A patient has contracture of the right hand due to a third degree burn suffered a year ago. Code for the third-degree burn from a year ago will be referenced from the alphabetic index under which main term and subterm late, effects of burn
The term used to describe of the five long bones of the midfoot is Metatarsal bones
A service that is rarely provided, unusual, variable, or new may require a ______ (blank) in determining medical appropriateness of the service Special report
A new patient is one who has not visited a physicians office in more than 3 years
Category I CPT codes health care providers report for reimbursement for the procedures & services rendered
Category II codes HCPCS (Healthcare Common Procedure Coding System) for performance measure
Category III codes HCPCS (Heathcare Common Procedure Coding System) temporary codes/emerging technologies
Triangle means change in wording
Sideways Triangles means change of wording between the triangles/contains new or revised text
Bullet (solid circle)/RED means new procedure code
Plus sign (+) means add-on code
Circle with line through it represents modifier 51 exempt code
circle means recycled or reinstated code
Circle with a dot in center (bulls-eye) means moderate sedation
Brackets [] means enclose synonyms, alternative wording or explanatory phrases/found in the tabular list (volume 1)
Slanted brackets means used in the alphabetic index, volume 2,used to enclose the manifestation of the underlying condition. Sequence code inside slanted brackets after underlying condition code
parentheses () means used in both the index and tabular to enclose supplementary words. (nonessential modifiers) that may be present or absent in the statement of a disease or procedure without effecting the code number to which it is assigned
colon : means located in tabular list after an incomplete term that needs one or more of the modifiers that follow in order to make the condition assignable to a given category
Six sections of the CPT manual are Evaluation & Management (E&M), Anesthesia, Surgery, Radiology, Pathology, Medicine
Evaluation & Management (E&M) are numbered 99201-99499
Anesthesia is numbered 00100-01999
Surgery is numbered 10021-19499
Radiology is numbered 70010-79999
Pathology is numbered 80048-89398
Medicine is numbered 90281-99607
Where are Modifiers found in the CPT book Front cover and Appendix A
What modifier is used for "unrelated evaluation & management (E&M) services by the same physician or other qualified healthcare professional during a post operative period" Modifier 24
What modifier is used for "significant, separately identifiable evaluation & management (E&M) service by the same physician or other qualified healthcare professional on the same day of the procedure or other service" Modifier 25
What modifier is for the "professional component" Modifier 26
What modifier is for "bilateral procedure" Modifier 50
What modifier is for "multiple procedures" Modifier 51
What modifier is use for "decision made for surgery" Modifier 57
What modifier is for "unplanned return to the operating/procedure room by the same physician following the initial procedure for a relative procedure during the post operative period" Modifier 78
What modifier is for "unrelated procedure or service by the same physician during the post operative period" Modifier 79
Types of Government health insurance include Medicare (A,B,C,D), Medicaid (categorically needy, medically needy), Tricare (Standard, Extra, Prime), CHAMPVA
Types of private health insurance include Private payers/commercial carries,Group Health Plans, Indemnity Insurance, HMO (Health Maintenance Organization), PPO (Preferred Provider Option), Point of Service, Disability, Workers Compensation.
Medicare part "A" covers Hospital stay
Medicare Part "B" covers physician office
Medicare Part "C" covers combination of both "A & B"
Medigap (MG)/Medifill is a type of policy designed to supplement coverage under a fee for service medicare plan. May cover prescription costs and the deductible & co-payment (20% of the Medicare allowed amount)
Tricare Health Insurance is Military insurance that covers uniformed military men and woman and their families
Tricare standard beneficiaries to see any doctor
Tricare EXTRA (PPO-preferred provider organization) Yearly deductable, provide services at discounted rate, healthcare delivered by a network of civilian healthcare providers who accept payments from CHAMPUS
Tricare PRIME HMO type of plan that receive healthcare through military facilities such as VA clinic and or Hospitals
CHAMPVA healthcare plan for military, where the VA share costs of supplies and services with eligible beneficiaries
Private Payers/Commercial carriers people who are responsible for securing there own health insurance
Group Health Plans are insurance plans that provide insurance for a group offered by employers to all employees
Indemnity Insurance (fee for service) is a fee for service when a person is between health plans. covers somethings but not everything
HMO Health Maintenance Organization
PPO (preferred provider organization) Care is paid for as received instead of in advance
Point of Service Choose to get TRICARE covered non-emergency services outside the prime network of providers without a referral
Disability insurance for people who can not work due to a disability
Workers Compensation insurance for people who are injured on the job, can get medical information without consent
Clean Claim is a claim that all information is correct
Dirty Claim is claim submitted with errors - manual processing, can be resubmitted
An ABN (Advanced Beneficiary Notice) is a notice given by doctor or supplier to the patient when they believe Medicare will deny payment (patient will have to pay if denied)
Basic Billing & Reimbursement Steps are Collect patient information, verify insurance, prepare encounter form, code diagnosis and CPT, review Linkage Protocal, Calculate physician charges, prepare claim, transmit claim, follow-up on reimbursement
Review Linkage Protocal is appropriateness of codes, payers rules about the linkage, documentation to support the codes,& compliance with regulations & guidelines through HIPPA
Life cycle of a claim is 1)submission 2)processing 3)adjudication 4)non-covered 5)unauthorized 6)medical necessity checks 7) payment/RA/ERA (remittance advice/electronic remittance advice)
E-codes are for durable medical equipment(DME) used in home (medicare Part "C")
E-codes are also used for Environmental, external cause of injury, poisoning, & other adverse effects as well as reactions to medications
ROS (Review of Symptoms) is inventory of the constitutional symptoms regarding the varies body systems
What action should be taken if an insurance company denies a service as not medically necessary Appeal decision with a providers report
What is the appropriate code selection for the removal of a malignant lesion on the arms Subsection of Integumentary system (located in the CPT manual in the surgery subsection)
Which Block(s) requires the patient's authorization to release medical information to process a claim Block 12 (also acts as assignment of benefits for Medicare)
Under which circumstances should a paper claim be submitted to the Insurance carrier A claim containing unlisted procedure codes
Health care clearinghouses are covered entities affected by HIPAA security rules. They are the middle men between the provider & the payer
The provision of health insurance policies that specifies which coverage is considered primary or secondary is called Coordination of Benefits
Eligibility verification is the process of checking & confirming that a patient is covered under an insurance plan
The purpose of precertification is the Verification of Benefits
What expedites the process of a phone appeal Claim control number
-tomy a surgical incision
-stomy a new artificial opening
Can employees (billing specialist) of a physician be held liable of malpractice for billing errors (whether intentional or not) and what is it called Yes and it is referred to as "vicarious liability" AKA "Respondent superior"
Created by: Patti Belfi Reed Patti Belfi Reed