Final Exam Review

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Question

Answer

The term "upcoding" means:

Maximizing

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The fastest growing segment of the United States population.

Elderly

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The hospital insurance portion of Medicare.

Part A

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The supplemental portion of Medicare

Part B

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Medicare Advantage and provides beneficiaries with the option of selecting the type of health coverage they want.

Part C

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Medicare that provides outpatient prescription drug coverage.

Part D

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Who is responsible for the Medicare program?

Department of Health and Human Services (DHHS)

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The operation of the Medicare programs is delegated to:

Medicare Administrative Contractors (MACs)

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Medicare is funded by the payroll taxes in the form of __________ that is paid by employers and employees.

Social Security Tax

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Medicare covers __ percent of covered medical services. Beneficiaries pay __ percent of the cost of covered medical services and an ever-increasing annual deductible.

80, 20

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Those health care providers that have signed an agreement with the Medicare Administrative Contractors (MACs) in which the provider agrees to accept what the MACs pay as payment in full.

Participating providers

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Providers obtain the current reimbursement schedules from the __________ on the Centers for Medicare and Medicaid Services website.

Physician center

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Hospitals submit bills for _______ services by using ICD-9-CM codes and the MS-DRG assignment.

Part A

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Hospitals submit their charges on the:

UB-04

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A patient who receives services in an ambulatory health care facility and is currently not an inpatient.

Outpatient

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There are three coding systems used to report services under Medicare _____: CPT, HCPCS, and ICD-9-CM.

Part B

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The major third-party payer in the United States is the:

government

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The Medicare program was established in what year?

1965

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Hospital Insurance is Medicare, Part:

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Supplemental Medical Insurance is Medicare, Part:

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Medicare Part that covers a semiprivate room.

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Medicare Part that covers physicians services.

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Special dietary charges while in the hospital are covered under Medicare Part:

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Outpatient hospital services are covered under Medicare Part:

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The department responsible for the Medicare program and the delegation of the daily operation of the program to CMS is:

Department of Health and Human Services

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To be a participating QIO provider means that the physician:

accepts assignment

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Medicare beneficiaries are not automatically covered under this part of the Medicare program; instead, they must purchase this coverage and pay a monthly premium.

Part B

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What year was HIPAA established:

1996

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Which edition to the Federal Register is of special interest to hospital facilities?

October

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Which edition of the Federal Register is of special interest to outpatient facilities?

November or December

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What is the issuing office?

Department of Health and Human Services

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What does ARRA stand for?

American Recovery and Reinvestment Act

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The changes in the _______ edition of the Federal Register are implemented the following calendar year.

fall

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The CMS notifies the hospitals of the official policies and rule changes in the __________.

Federal Register

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Scale designed to decrease Medicare expenditures, redistribute physician payment, and ensure quality health care at reasonable rates.

RBRVS (Resource-Based Relative Value Scale)

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Schedules that list the allowable charges for Medicare Services.

MFS (Medicare Fee Schedule)

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Unit value that has been assigned for each service.

RVU (Relative Value Unit)

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What does RBRVS stand for?

Resource-Based Relative Value Scale

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The Medicare Economic Index is published in what publication?

Federal Register

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In 1989, a major change took place in Medicare with the enactment of?

OBRA (Omnibus Budget Reconciliation Act)

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The physician outpatient payment reform was implemented in ______?

1992

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___________________ is provided by congress to convert RVUs to dollars.

Conversion Factor

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A program established by the CMS with the intent of decreasing fraud and abuse of the CMS health care programs.

Medicare Fraud and Abuse

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Assigning multiple CPT codes when one CPT code would fully describe the service or procedure.

Unbundling

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Abuse generally involves impropriety or ________________ for services billed.

lack of medical necessity

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A kickback is a bribe for referring a Medicare patient for any _____.

covered service

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This is the office in which the work plan for the Medicare program is developed and monitored:

OIG

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A health care delivery system in which an enrollee is assigned a primary care physician who manages all the health care needs of the enrollee.

HMO (Health Maintenance Organization)

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A group of providers who from a network and who have agreed to provide services to enrollees as a discounted rate.

PPO (Preferred Provider Organization)

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This group is composed of providers who form a network to offer health care services as a group:

PPO

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This term is the intentional deception or misrepresentation that an individual knows to be false or does not believe to be true and makes knowing that the deception could result in some unauthorized benefit.

fraud

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This organization develops a work plan to identify areas of the Medicare program that will be monitored.

Office of Inspector General

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The physician that is responsible to control and manage the health care of an HMO enrollee is the:

gatekeeper

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What does the abbreviation PACE stand for?

Program for All-Inclusive Care for the Elderly

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This group provides the total package of health care:

HMO

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In the HMO, the physician acts as a/an _____.

gatekeeper

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What two groups of persons were added to those eligible for Medicare benefits after the initial establishment of the Medicare Program?

Persons eligible for disability benefits from Social Security and persons with permanent kidney failure.

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What government organization handles the funds for the Medicare Program?

Social Security Administration

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Medicare publishes the Medicare fee schedule and usually pays what percentage of the amounts indicated for services?

80%

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According to the filing guidelines, providers must file claims for their Medicare patients within _____ months of the date of service.

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Under what act was a major change in Medicare in 1989 made possible?

OBRA

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Individuals covered under Medicare are termed:

beneficiaries

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Medicare Part C is also known as

Medicare Advantage

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The most major change to the health care industry as a result of HIPAA was a result of what portion of the act?

Administrative Simplification

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The number that is assigned to all providers as a result of HIPAA:

National Provider Identification

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The _____ charge historically was specific for each physician, but in 1993, the charge for a service was the same for all physicians withing a locality, regardless of the specialty.

limiting

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Specific regulations for Medicare are contained in the

Internet only manual

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In this model of HMO, the HMO directly employs the physicians ______ Model.

Staff

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An all inclusive care program for the elderly that provides a comprehensive package of services that permits the client to continue to live at home is known as:

Program for All-Inclusive Care for the Elderly (PACE)

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What is the correct way of writing the abbreviations for the two coding systems that translate medical services into codes?

CPT/HCPCS

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What is the correct abbreviation for the coding system used to translate medical diagnoses into codes?

ICD-9-CM

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The CPT manual was developed by the:

American Medical Association

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CPT stands for:

Current Procedural Terminology

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Providers of health care are paid based on the codes submitted for __________ or procedures provided to the patient.

services

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The first CPT was published in this year:

1966

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In which year were CPT codes incorporated as Level 1 codes into the Healthcare Procedure Coding System (HCPCS)?

1983

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Which of the following is the correct title of the insurance form developed by the Centers for Medicare and Medicaid Services on which outpatient services are reported?

CMS-1500

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In what block on the CMS-1500 form do you place the CPT code?

24D

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This Act requires the Secretary of Health and Human Services to adopt national uniform standards for the electronic transmission of financial and administrative health information.

HIPAA

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Special guides that help the coder compare codes and descriptors with the previous edition.

Symbols

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A _____ is used to indicate a new procedure or service coded added since the previous edition of the CPT manual.

bullet

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A _____ placed in front of a code number indicates that the code has been changed or modified since the last edition.

solid triangle

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A _____ is used to indicate an add-on code.

plus

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A _____is used to identify a modifier -51 excempt code.

circle with a line through it

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_____ indicate the beginning and end of text changes.

Right and left triangles

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A _____ indicates procedures that include moderate sedation.

bullseye

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A ______ identifies codes that are being tracked by the AMA to monitor FDA status for approval of a drug.

lightning bolt symbol

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Where is a complete list of additions, deletions, and revisions located in the CPT manual?

Appendix B

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Which CPT manual appendix contains a complete list of all modifier -51 exempt codes?

Appendix E

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Which CPT manual appendix contains a complete list of add-on codes?

Appendix D

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What symbol would indicate that the CPT code can only be used with another CPT code?

Plus

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A revised code description within the CPT manual is indicated with what symbol?

Triangle

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In which CPT appendix would you find clinical examples for E/M codes?

Appendix C

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In which CPT appendix would you find a summary of add-on codes?

Appendix D

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To what extent do the codes in Appendix D have the code description listed?

No description

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To what extent do cross references for added, deleted, or revised codes appear in Appendix B?

No cross references appear

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Using the CPT manual code the following unlisted procedure. Radiology: Miscellaneous procedures, diagnostic nuclear medicine

78999

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With the use of the CPT manual section guidelines, identify the following unlisted code. Pathology: Chemistry procedure

84999

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With the use of the CPT manual section guidelines, identify the following unlisted code. Medicine: Special service, procedure, or report

99199

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Which term reflects the technologic advances made in medicine that are incorporated into the CPT manual?

Revisions

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Which appendix of the CPT manual contains a complete list of the additions to, deletions from, and revisions of the previous edition of the CPT manual?

Appendix B

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Which appendix of the CPT manual contains a complete list of the modifier -51 exempt codes?

Appendix E

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With the use of the CPT manual index, locate the term indicated and enter what the cross reference term "See" directs you to: Antigen, CD8 See

CD8

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With the use of the CPT manual index, locate the term indicated and enter what the cross reference term "See" directs you to: FSP, See

Fibrin Degradation Products

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With the use of the CPT manual index, locate the term indicated and enter what the cross reference term "See" directs you to: PRA, See

Cytotoxic Screen

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With the use of the CPT manual index, locate the term indicated and enter what the cross reference term "See" directs you to: Repeat Surgeries, See

Reoperation

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The six major areas into which all CPT codes and descriptions are categorized.

Sections

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Provide specific instructions about coding for each section of the CPT manual; they contain definitions, terms, applicable modifiers, explanation of notes, subsection information, unlisted services, special reports information, and clinical examples.

Guidelines

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The further division of sections into smaller units, usually by body systems.

Subsections

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Surgically cutting into.

Incision

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The full thickness removal of a lesion that may include simple closure.

Excision

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Break in a bone.

Fracture

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Placement in a location other than the original location.

Dislocation

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In front of.

Anterior (ventral)

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What is the title of the section that contains the 80000 range of CPT codes?

Pathology and Laboratory

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What is the title of the section that contains the 10000 range of codes?

Surgery

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A concise statement describing the symptom, problem, condition, diagnosis, or other factor that is the reason for the encounter, usually stated in the patient's words.

Chief complaint

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According to the Surgery Guidelines, surgical destruction is a part of a surgical procedure and _____ methods of destruction are not ordinarily listed separately.

different

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According to the Radiology Guidelines, who must sign a written report to have the report considered part of the radiologic procedure?

Interpreting physician

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Under whose supervision are Pathology and Laboratory services provided?

Physician

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What is the code listed in the Medicine Guidelines that is to be used to identify materials supplied by the physician that are beyond those ordinarily included in the service provided?

99070

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Guidelines contain information that is applicable to codes in one_____________ of the CPT manual.

section

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Those codes that have full description (or similar wording)

Stand-alone codes

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Those codes that include their own description as well as that portion of the stand-alone code description found before the semicolon in a preceding code (or similar wording)

Indented codes

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Words following the semicolon in stand-alone codes can indicate that following three things:

alternative anatomic site, alternative procedure, or description of the extent of service

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What is the name of the code that depends on a preceding code for the full description?

Indented

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How many digits is a CPT modifier?

Two

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In which Appendix of the CPT manual can a list of all modifiers be found?

Appendix A

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Procedures that are considered unusual, experimental, or new and do not have a specific code number assigned; they are located at the end of the subsections or subheadings and may be used to identify any procedure that lacks a specific code.

Unlisted procedures

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Surgery: Unlisted procedure; middle ear:

69799

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Surgery: Unlisted procedure; arthroscopy

29999

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Surgery: Unlisted procedure; esophagus

43499

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Pathology and Laboratory: Unlisted procedure; cytogenetic study

88299

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Pathology and Laboratory: Unlisted procedure; urinalysis procedure

81099

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Pathology and Laboratory: Unlisted procedure; chemistry procedure

84999

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Medicine: Unlisted special service, procedure, or report

99199

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Radiology: Unlisted procedure; clinical brachytherapy

77799

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Radiology: Unlisted miscellaneous procedures; diagnostic nuclear medicine

78999

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What is the name of the report that must accompany the use of an unlisted code?

Special

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What category of codes identify temporary codes in the CPT manual?

Category III

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What is the highest numbered modifier in Appendix A of the CPT manual?

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The Surgery Guidelines give directions on the use of a code to use when the physician supplies materials during a patient service. What is the code indicated in the Surgery Guidelines?

99070

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Using the CPT manual, identify the correct section, subsection, and subheading for code 99201.

Evaluation/Management, Office or Other Outpatient Services, New Patient

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The words following the semicolon in a code description are what three types of statements?

Alternative anatomic site, alternative procedure, description of extent of the service

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-RC is what type of modifier?

HCPCS

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he six items that must be included in a special report are:

Nature, extent, need, time, effort, and equipment

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What is the name for the location method that involves use of words with similar meanings?

Synonym

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What type of term is "See" in the CPT index?

Cross reference

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