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Chapter 7 Coding
| Term | Definition |
|---|---|
| Clean claim | Claim was submitted within the program or policy time limit and contains all necessary information |
| Physically clean claim | Has no staples or highlighted areas; bar code area has not been deformed |
| Rejected claim | Not processed or cannot be processed |
| Pending claim | Held in suspense because of review or other |
| Incomplete claim | Missing required information |
| Invalid claim | Contains complete, necessary information but is illogical or incorrect |
| Dirty claim | Submitted with errors, requiring manual processing for resolution, or rejected for payment |
| Deleted claim | Canceled, deleted, or voided by a Medicare fiscal intermediary |
| Reasons for abstracting from medical records | To complete insurance claim forms When sending a letter to justify a health insurance claim after professional services are rendered When a patient applies for life, mortgage, or health insurance |
| Basic Guidelines for Submitting a Claim | Individual insurance Group insurance Secondary insurance |
| Paper claim | Submitted on paper or optically scanned Typed or computer-generated |
| Electronic claim | Submitted via electronic method Digital file not printed on paper |
| Do | Use original claim forms printed in red ink Align printer Keep characters within border of each field Complete new form for additional services Enter 6or 8digit date formats Keep signature within block Enter information via computer keyboard |
| Don’t | Handwrite information on document Allow characters to touch lines Use specialized characters and fonts Strike over errors |
| Don’t | Use highlighter pens or colored ink Use decimals in Block 21 or dollar signs in money column. Use N/A or DNA when information not applicable Use paper clips, cellophane tape, stickers, rubber stamps, or staples Fold or spindle forms when mailing |
| What legislation required all claims sent to the Medicare Program be submitted electronically, effective October 16, 2003? | Administration simplification compliance act |
| State the name of the health insurance claim form that was required for use effective October 1, 2013. | 1500 Claim Form (02-12) |
| Does Medicare accept the CMS-1500 (02-12) claim form? | yes |
| What is a pended claim? | Claim that is held in suspense for review or other reason by third party payer |
| How many days will it take for processing of a Medicare claim which is submitted electronically | About 14 days of receipt |
| If a claim is submitted on behalf of the patient, and coverage of the services is denied, what is the most effective way to present the situation to the patient? | with a rejection from the insurance company |
| What is dual coverage? | Patient is covered under 2 or more insurance policies |
| The insurance company with the first responsibility for payment of a bill for medical services is known as the | Primary carrier |
| The CMS-1500 (02-12) claim form allows for reporting of a maximum of _____ diagnosis codes per claim form | 12 |
| What Internet resource can be used to find physician provider numbers? | NPI Registry |
| For electronic submission of claims, what allows the physician’s name to be printed in the signature block where it would normally be signed? | The participating contract with the third party payer that the physician previously signed. |
| When preparing a claim that is to be optically scanned, birth dates are keyed in with how many digits? | 8 |
| Exchange of data in a standardized format through computer systems is a technology known as | Electronic Data Interchange |
| The act of converting computerized data into a code so that unauthorized users are unable to read it is a security system known as | Encryption |
| Payment to the provider of service of an electronically submitted insurance claim may be received in approximately | 2 weeks or less |
| Medical practices which do not use the services of clearinghouses submit claims through a _________to the insurance company. | direct links |
| list the benefits of using HIPAA standard transactions and code sets: | reduction in office expenses, reliable and timely , improved accuracy, easier and more efficient,better tracking of transactions , reduction of manual labor. |
| Dr. Morgan has 10 or more full-time employees and submits insurance claims for his Medicare patients. Is his medical practice subject to the HIPAA transaction rules? | Yes |
| Dr. Maria Montez does not submit insurance claims electronically and has five fulltime employees. Is she required to abide by HIPAA transaction rules? | No |
| Name the standard code sets used for the following: physician services | CPT 4 |
| Name the standard code sets used for the following:diseases and injuries | ICD9-CM |
| Name the standard code sets used for the following:pharmaceuticals and biologics | NDC - national drug codes |
| The staff at College Clinic submits professional health care claims for each of their providers and must use the industry standard electronic format called _____________________to transmit them electronically. | ASC X12N 837P |
| The billing department at College Hospital must use the industry standard electronic format called ______________________to transmit health care claims electronically | ASC X12N 837I |
| The Medicare fiscal intermediary (insurance carrier) uses the industry standard electronic format called ___________________________to transmit payment information to the College Clinic and College Hospital | ASC X12N 835 |
| It has been 3 weeks since Gordon Marshall’s health care claim was transmitted to the XYZ insurance company, and you wish to inquire about the status of the claim.The industry standard electronic format that must be used to transmit this inquiry is called | ASC X12N 276 |
| Dr. Practon’s insurance billing specialist must use the industry standard electronic format called ______________________to obtain information about Beatrice Garcia’s health policy benefits and coverage from the insurance plan | ASC X12N 270 |
| The American National Standards Institute formed the ________________________ _____________________which developed the electronic data exchange standards | accredited standards committee X 12 |
| The __________________________ is an all numeric 10-character number assigned to each provider and required for all transactions with health plans effective May 23, 2007. | NPI |
| The most important function of a practice management system is | Accounts recievable |
| Much of the patient and insurance information required to complete the CMS-1500 form can be found on the ___________________ form that is used to post charges | encounter Form |
| Add-on software to a practice management system that can reduce the time it takes to build or review a claim before batching is known as a/an ________________ | encoder |
| Software that is used in a network that serves a group of users working on a related project allowing access to the same data is called a/an | grouper |
| The medicare electronic remittance advice was previously referred to as | EOMP explanation of medicare benefits |
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lin_linxo