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Practice Exam Q's 1

TermDefinition
The following describes the reason for a claim rejection because of Medicare NCCI edits Improper coding combinations
The following action should be taken if an insurance company denies a service as not medically necessary Appeal the decision with a provider's report
A coroner's autopsy is compromised of the following examination Gross examination
The following condition is associated with microcephaly Down's syndrome
The following term describes the process used to challenge a payer's decision to deny, reduce, or downcode a claim Appeal
When completing a CMS-1500 paper claim form you should do this use 10-pitch PICA font
In the CPT manual, an esophagectomy can be found in the following subsection Excision
A nurse is reviewing a patient's lab results prior to discharge an elevated glucose level. The following health care providers should be alerted before the nurse can proceed with discharge planning The attending physician
The following section of the CPT manual lists the appropriate code for WBC (white blood cell) with differential, automated Path and Lab
To assign a diagnosis code to the highest level of specificity, a billing and coding specialist should check for a fourth or fifth digit
A patient suffers a second-degree burn of the left axilla and a third-degree burn of the left wrist. Twelve percent was burned, with 3% of the burns designated as third-degree. Which of the following demonstrates the proper coding sequence Third-degree burn of wrist, second-degree burn of axilla, burn involving 10 to 19% of the body surface with less than 10% of that being third-degree burns
The following terms describe when a plan pays 70% of the allowed amount and the patient pays 30% Coinsurance
Representatives from the following accrediting agencies can visit office labs to review manuals and interview staff CLIA (Clinical Lab Improvement Amendments)
CLIA Establish quality standards for all lab testing to ensure the accuracy, reliability, and timeliness of patient test results regardless of where the test was performed
JCAHO Joint Commission, a non-profit organization that accredits and certifies health care organizations and programs in the US. It is a symbol of quality that reflects on an organizations commitment to meeting certain performance standards
NAACLS National Accreditation Agency for Clinical Lab Sciences; the accreditation agency for educational programs
Medicine A patient undergoes hemodialysis. The code for this procedure is found in the following section of the CPT manual
Family history V codes are used as the first-listed diagnosis to indicate
Reporting test results to a family member via phone The following scenario describes a HIPAA violation
Private third-party payers Medigap coverage is offered to Medicare beneficiaries by the following
Endocrinologist A patient has a new onset of diabetes mellitus. The following specialist should be referred to by the primary care provider (PCP)for further treatment
Inform the supervisor A billing and coding specialist observes a coworker drinking alcohol during work hours. The following actions should be taken
Health care clearinghouses The following is a covered entity affected by HIPPA security rules
The claim is overdue for payment The following describes a delinquent claim
Aorta The following transports oxygenated blood form the heart
NPI According to HIPPA standards, the following identifies the rendering provider on the CMS-1500 claim form in Block 24J
Military identification All dependents 10 years of age or older are required to have the following for TRICARE
Subsection of integumentary system The following describes the location for the appropriate code selection for the removal of a malignant lesion of the arm
Coding conventions and instructions The following takes precedence over ICD-9-CM chapter-specific guidelines
Block 24D contains diagnosis code A claim can be denied or rejected for the following reason
Submit an appeal to the carrier with the supporting documentation The following actions should be taken when a claim is billed for a level four office visit and paid at a level three
Invalid A claim is submitted a transposed insurance member ID number and returned to the provider. The following best describes the status that should be assigned to the claim by the carrier
Coccyx Area of the body referred to when a patient presents for an incision and drainage of a pilonidal cyst
When a claim contains unlisted procedure codes Circumstance where a paper claim should be submitted to the insurance carrier
accept the policies and procedures regarding how PHI is handled What is indicated when a patient signs an Acknowledgement of Notice of Policy Practice
anesthesia Time reporting is used as a guideline in this section
Incomplete information The following is a reason for claim rejection
HIPAA The following protects patient confidentiality
Moderate (conscious) sedation Codes indicated with a bulls eye symbol denotes
The number is needed to identify the provider Claims that are submitted without and NPI number will delay payment to the provider because
Medicaid A patient's health plan is referred to as the "payer of last resort" which means the patient is covered by this insurance
encounter form A form that contains charges, DOS, CPT codes, ICD-9-CM, fees, and copayment information is on this form
Privacy officer To be complaint with HIPAA every office needs this
HCPCS Level II(2) #forkim National Codes HIPAA requires standard transactions and code sets include the following
Urinary The following system in the surgical section of the CPT manual lists the correct code for ablation of renal cysts by laparscopy
6 This many behavior classifications are included in the Table of Neoplasms
This block on the CMS 1500 form requires the patient's authorization to release medical information to the process a claim. For Medicare claims this block acts as assignment of benefits. 12
This code includes a comprehensive history, examination, and medical decision making of high complexity. 99205
implied contract does not require written of verbal consent. Example: patient schedules appointment with a new provider's office
this should be obtained from a Medicare patient when services for a diagnostic test is not covered ABN form (advanced beneficiary notice)
these are valid ICD-9-CM principles (guideline) code signs and symptoms in the absence of an established diagnosis code the first-listed diagnosis, followed by additional diagnoses Code to the highest level of specificity code to the highest level of certainty; never code inconclusive diagnoses
CMS-1500 claim form used to submit professional outpatient services and procedures
if an insurance company denies a claim the appropriate way to communicate this with the patient is inform the patient of the reason for the denial
solid circle symbol for new CPT code
nephrolithiasis condition of having stones in the kidneys
A provider charged $500 to a claim that had an allowable amount of $400. In which of the following columns should the billing and coding specialist apply the non-allowed charge? adjustment column of the credits
this encourages claims to be submitted electronically HIPAA guidelines
It is not appropriate to submit an electronic claims when submitting to a secondary payer claim is submitted to a third-party liability payer when an accident or injury has occurred claim contains an unlisted procedure **Note these all situations all require attachments to a paper claim to be sent)
this valve controls the opening between the right atrium and the right ventricle tricuspid valve
congenital condition in which the urethra opens on the lateral aspect of the penis paraspadias
coordination of benefits provision of health insurance that specifies which coverage is considered primary or secondary
financial record source generated by a providers office patient ledger account
patient develops a rash after taking a medication his provider prescribes for him. what type of code should be assigned to the reaction? E code
protein associated with a PSA screening test protein produced by prostate gland. **PSA stands for Prostate Specific Antigen test
-right to: considerate and respectful care-relevant, current, and understandable information- make decisions about the plan of care -refuse treatment -have advance directives- every consideration of privacy- right to "every consideration of privacy" Patient Bill of Rights (1)
Right to: -expect confidentiality -be informed of hospital policies that relate to patient care Patient Bill of Rights (2)
medical term for fainting syncope
medical term for the body's inability to compensate for position change orthostatic hypotension
these are used in electronic claims transmission for provider services CPT
first section of the small intestine duodenum
skin, hair, nails, and glands parts of the integumentary system
Accepts electronic and paper claims on behalf of Medicare MAC's (Medicare Administrative Contractors)
patella kneecap
an appropriate diagnosis for the application of a long leg cast is patella fracture
when a patient is being seen for chemotherapy treatments, should the biller sequence the relevant cancer code first or the V code for chemotherapy? V code for chemotherapy. V58.11
What color format is acceptable on the CMS-1500 claim form red
organization that developed and updated the CPT code book annually AMA
modifier required by CLIA when billing Medicare for a waived laboratory test QW
horizontal triangles symbolize this in CPT (HCPCS Level I) new or revised text
When assigning CPT code for wounds how do you calculate total size of wound add together all measurements on same body part
Claim control number can be used to expedite (speed up) a phone appeal or claim question when speaking to the insurance company
category code 3 digits to the left of the decimal
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. This action is considered. fraud
What font is required for claims to be processed via OCR (optical character recognition) 12 pitch PICA
Created by: tina.reynolds