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Group 3 & 4

Medical billing and coding ashworth

Clerk who enters patients demographic information into a computer and obtains signed statement(s) from patients to protect hospitals interests. Who am I? admitting clerk
Specializes in maintaining patient accounting records, filing health insurance claims, working with insurance careers to receive reimbursement on insurance claims filed, and appealing denied claims. Who am I? Centralized billing office (CBO)
Training received in particular fields that acknowledges a medical office specialist expertise. What am I? certifications
Coordinates all financial aspects of patient visits and admission, including insurance verification, precertification information, follow-up of 3rd party payment denials and financial counseling. Who am I? Insurance verification representative
Individual who submits and tracks all insurance companies correctly reimburse the healthcare provider. Who am I? Medical biller
Individual who assigns numerial codes to diagnoses and procedures using the Icd-9(10)- cm & CPT manuals. Who am I? Medical coder
A facility that centralizes the process of billing patients and carriers for treatment received at an inpatient facility. What am I? patient account services (PAS)
Coordinates services related to inpatient medical coding, medical documentation, abstracting data collection, and reimbursement requirements; supervises inpatient medical coding. Who am I? registered health information technician (RHIT)
Request made by a patient to allow the insurance carrier to pay the healthcare professional directly rather than issuing monies to the patient. What am I? assignment of benefits
Authorization by policy holder that allows a payer to pay benefits directly to a provider is called? Assignments of Benefits
Parties responsible for issuing insurance policies are? Carriers
Percentage of the allowed amount that is the patients responsibility. What am I? Coinsurance
A fixed percentage of covered charges applied to the patients bill after the deductible has been met. What am I? Coinsurance
Any type of health insurance not paid for by a government agency. The policy can be based on fee for service or managed care. Also known as private health insurance. What am I? Commercial health insurance (CHI)
A fixed dollar amount the patient pays at each office visit or hospital encounter, as specified in the patients insurance policy. What am I? Copayment
Amount a beneficiary is responsible for before the insurance company pays as stated in the insurance policy. What am I? Deductible
The total amount of covered medical expenses a policyholder must pay each year out-of-pocket before the insurance company is obligated to pay any benefits. What am I? deductible
An individual who takes out an insurance policy in his or her name this is called? Enrollee
An insurance policy offered to groups of employees and often their dependents covered under a single policy & issued by an employer or other group. What am I? group insurance
A medical center or designated group of medical professionals that provide medical services to subscribers for a fixed monthly or annual rate of pay. What am I? Health maintenance organization (HMO)
A form of health insurance combining a range of coverage in a group basis. A group of doctors & other medical professionals offer care though the hmo for a flat monthly rate with no deductibles. What am I? Health maintenance organization (HMO)
A patient who has been admitted to the hospital & is expected to stay 24 hours or more. Who am I? Inpatient
A/An _____ is a person admitted to a hospital or long term care facility for a treatment with the expectation that the patient will remain in the hospital for a period of 24 hours or more. Inpatient
An individual listed as the policy holder an insurance agreement. What/ Who am I? Insured
A system of health care delivery aimed at controlling costs by shifting utilization risk to the provider. Usually requires a gate keeper or primary care physician to approve tests, surgeries and visits to specialist. What am I? Managed care
Organization designed to provide quality health care that is cost effective. Through supervision, monitoring, and advising. _____ seek to ensure a certain standard of care, measure performance, and control costs. What am I? Managed care organization (MCO)
A patient who is treated at a hospital or other medical facility during a stay of less than 24 hrs. Who am I? Outpatient
A type of managed healthcare plan that allows the member to choose between an HMO, PPO, or indemnity plan at the time of service. What am I? point-of-service (POS)
Feature of an insurance plan that allows a patient to chose between in-network care and out-of network care every time he or she sees a doctor. The patient is allowed the freedom to go to whichever doctor is most convenient. What am I? Pont of service (POS)
The owner of an insurance policy is called what? policy holder
Authorizations from an insurance company that allow a patient to receive treatment using their benefits. Some insurance companies require this prior to admission for a hospital stay or outpatient surgery. What am I? preauthorization
A diagnosis or condition for which a beneficiary is treated prior to the effective date of coverage with his or her insurance carrier is called? preexisting condition
Organization that contracts with physicians and facilities to perform services for preferred provide members for specified rates is called what? preferred provider organization (PPO)
A managed care organization that establishes a network of providers who care for their patients is called a/an? preferred provider organization (PPO)
Dollar amounts a person pays for an insurance policy often deducted from an employee's paycheck is what? premium
The charge for keeping the insurance policy in effect is what? premium
___ is similar to an HMO, but care is paid for as received instead of in advance inform of a schedule it may offer more flexibility by allowing for visits to out-of-network professionals, visits within network require only the payment of a small fee. PPO
a review process that compares requests for a medical services to treatment guidelines that are deemed appropriate for such services & includes the preparation of a recommendation based on that comparison is called? utilization
Persons responsible for payment of insurance premiums or persons whose employment or group affiliation is the basis for membership in a health plan is called what? subscribers
Insurance that an individual can purchase to protect against a certain type or accident or illness is called what? special risk insurance.
The transfer of total care or a specific portion of care a patient from one physician to another is called what? referrals
Individuals or facilities providing medical care is called what? providers
A provider who coordinates a patients care is who? primary care provider (PCP)
Physicians who enroll in managed care plans are called ? participating providers
They have contracts with managed care organizations (MCO's) that stipulate their fees. What am I? participating providers
_____ in theory, controls the cost and delivery of health services to members who are enrolled in a managed health care plan. managed care
__1__ when an insurance carrier can state in an insurance contract that it will pay "reasonable and customary fees" or "usual customary, and reasonable fees." This is called? This can also be referred to as _2_ or _3__. 1. discounted fees for services 2. R & C fees 3. UCR fees
____ refers to the base amount that is treated as the standard or most common charge for a particular medical service when rendered in a particular geographic area. usual, customary, and reasonable fee
___ is an individual providers average charge for a certain procedure. Usual fee
____ is determined by what doctors with similar training and experience in a certain geographic location typically charge for a procedure. customary fee
A general practitioner may consistently charge $65.00 for brief office visits. This change would be show on the doctor's fee schedule and charge slip. This is called a _____? usual fee
A Surgeons charge for an appendectomy ranges from 3k-4k. The surgeons charge is $3,364.00 that is considered a ____ fee and is covered. The surgeon who charges $4,200.00 the insurance would only pay 4k. customary fee
Maximum amount an insurance payer considers reasonable for medical services. Providers agree by contract to accept the allowed charge for services they provide. The allowed charge is often paid in part by the insurance company and in part by the patient. allowed charges
Billing a patient for the difference between a higher usual fee and a lower allowed charge is called _____? balance billing
Negative adjustments to patient accounts usually when the provider has a contract with a carrier, the difference between the billed amount and the allowed amount is ___? write offs/ written off
write-of amount is also known as the ____? contractual amount
The portion that the carrier will pay toward the medically necessary procedure is the ____? carriers responsibility
The amount that the patient is responsible for is called ___? patient responsibility
Percentage of the allowed amount that is the patients responsibility is called? coinsurance
A fixed dollar amount the patient pays each office visit or hospital encounter per the insurance policy is called? copayment
Ginger smith was seen in Dr. Sampson's office today for an allergic reaction to a prescribed drug. total CHARGES TODAY ARE $100 allowed amount is $77. what is the discount amount and what does the carrier pay the provider? da- 23 cpp- 77
Wesley camp is having outpatient surgery at the day surgical center. Mr. camp is on a ppo plan. his benefits pay 80% total charges today are $2400.56. allowed amount is $1976.23. What is the discount amount & what does the carrier provider pay? da- $424.33 cpp- 1580.98
A type of managed healthcare plan that allows the member to choose between an hmo, ppo, or indemnity plan at the time of service. this is called? point of service (pos)
An individual who takes out an insurance policy in his or her name. this person is known as the? enrollee
A provider who coordinates a patient's care is known as a? primary care physician (pcp)
The pcp (primary care physician) is also known as the ____ they are mainly used by HMO. gate keeper
The mco will with hold a % of the physicians revenue until end of year. This allows the mco to evaluate the physicians medical management in terms of its cost effective this is known as a __ or ___. withhold program or pay for performance.
There are 3 types of managed care organizations they are? health maintenance org (HMO) preferred provider org (PPO) Point of service plan (POS)
_____ is an organization that contracts with a multispeciality physicians group to provide physician services to an enrolled group. Group model HMO
____ are the most decentralized can involves contracting with individual physicians to create a healthcare delivery system. Individual practice association (HMO)
___ contract with more than 1 community based multi specialty group to provide wider geographical coverage. Network model HMO
____ employee salaried physicians who treat members in facilities owned and operated by the HMO. Staff model HMO
___Do not use gate keepers. There is no requirement to obtain a referral before seeing a specialist. Open access HMO
____ are a type of managed care plan that combines features of HMO & PPO Exclusive Provider Organization (EPO)
A group model HMO aka ___ or _____, represents providers who have formed an organization to provide prepaid health care to individuals and/or groups who purchase the coverage, independent physician association (IPA) Individual physician alliance
___ is another approach to coordinating services for patients. physician hospital org (PHO)
___ is one in which the payer is an employer or other group such as a labor union. self insured plan
___ promotes quality in the delivery of health care in managed care organizations by rating their performance from information obtained from the health care effectiveness data & information set (HEDIS) National committee for quality assurance (NCQA)
____ is an organization of members contracted with a managed care organization. network
___ is a provider who does not have a contract with a designated insurance carrier and is not obligated to offer discounted rates nonparticipating provider (Non-par)
-state licensed, most stringent guidelines, limited network of providers, members assigned to pcp's, members must use network exceot in emergencies or pay a penalty, usually there is a financial reward to providers for managing the cost of care. What am I HMO
limited network of providers but larger than HMO, members may be assigned to pcp's but restrictions on accessing other physicians not as tight as in HMO, financial penalty for accessing non-network providers less severe than in an HMO. what am I? PPO
Hybrid of HMO and PPo networks, members may choose from a primary or secondary network, primary network is HMO-like, What am I? POS
An association formed by physicians with separately owned practices (solo or small group). Hmo may contract with physicians separately or through the IPA. What am I? IPA model HMO
HMO hires the physicians and pays them salaries, HMO owns the network, HMO owns the clinic sites and health centers Staff model HMO
HMO uses two or more group practices or a group practices plus a combination to staff physicians and contracted independent physicians to form a network of providers, Allows members to choose their providers Network model HMO
Doesn't have an HMO license, members are eligible for benefits only when they use network providers, financial penalties for members leaving the network are similar to those of HMO, Priced lower than a PPO but higher than an HMO. What am I? EPO
Hmo contracts with multi-specialty groups, May be open-panel or closed closed-panels Group model HMO
____ is a provider who signs a contract with an insurance carrier to see patients at a discounted rate. PARs are usually listed in a provider book given to beneficiaries at enrollment. participating provider (PAR)
____ is a list of medical services covered under an insurance policy and insurance policy and the amount paid for each treatment schedule of benefits (SOB)
A managed care contract is a ___ or ___ between a healthcare provider and an insurer, HMO, or other network. legal agreement or document
___ is the contract issued by a payer, the plan document, or any other legally enforceable instrument under which a covered person may be entitled to covered services. Benefit plan
___ are those covered services provided by a physician that are consistent with the physicians training, licensure, and scope of practice. contracted services
___ is the determination of which of 2 or more health benefit plans will provide health benefits for a covered person as primary or secondary payers. coordination of benefits (COB)
___ is an individual who is an insured, enrolled participant or enrolled dependent under a benefit plan. covered person
___ are those health care services provided to covered persons under the terms of the benefit plans. covered services
___ is the maximum allowable free payable by the corporation or payer for the provision of a given contracted service by a physician to a covered person. Fee maximum
____ the physician specified by the corporation as its medical director. medical director
___ refers to the use of services or supplies or both, as determined by the corporations medical director medically necessary
___ a state-licensed hospital that has been designated by the corporation as a hospital to which a participating provider may authorize the admission of covered persons for covered services provided. participating hospital
____ is a licensed healthcare professional including the physician, a facility or an entity that has entered into a participation agreement to provide covered services to covered persons. participating provider
____ is a payment structure in which a health maintenance organization prepays an annual set fee per patient to a physician. capitation
___ is an insurance company, 3rd party, or self-insured health benefit plan that is obligated to make payment on behalf of covered persons. payer
__ a punitive five imposed by a civil court on a covered entity that has profiled from illegal or unethical activity. civil money penalty (CMP)
__ is a process of electronic entry of medical instructions for the treatment of patients under the providers care computerized provider order entry (CPOE)
___ are healthcare providers who transmit any health information in electronic form. covered entities (CE)
__ is any medical device equipment, or instrument used in the care of a patient durable medical equipment (DME)
___ is the transfer data between covered entities by electronic means. electronic data interchange (EDI)
__ is an electronic records of patient health information. EHR electronic health records
___ contains health- related information on patients cannot be integrated with other provider systems Electronic medical records (EMR)
___ refers to protected health information of an individual that is transmitted by electronic media or transmitted or maintained in any other form or medium Electronic protected health information (EPHI)
___ Describes information that is scrambled during the time its being transmitted by rotating letters in the alphabet and/or number. Encrypted
___ A federal agency responsible for monitoring trading and safety standards in the food & drug inc. Food and Drug administration (FDA)
___ is the federal department that administers all federal programs dealing with health & welfare health & human services (HHS)
___ is to strengthen HIPAA privacy and security protections enhance enforcement efforts, and provide public education about privacy protections. Health information technology for exonomic & clinical health (HITECH)
___ is a set of requirements that is designed to move the health care industry toward electronic health records and related technologies meaningful use
___ is a unique 10-digit # assigned to providers in the us to identify themselves in all HIPAA transactions national provider identifier # (NPI)
___ enforces the hipaa privacy rule office of civil rights (OCR)
___ is primarily focused on coordination of nationwide efforts to implement and use health efforts to implement and use health information technology & the electronic exchange of health information. office of the national coordinator for health info. (ONC)
___ respobsible for receiving & responding to requests of medical records and receiving complaints privacy compliance officer
___ policies and procedures designed to demonstrate how the entity will comply with the act. administrative safeguards
___ controlling physical access to protect against inappropriate access to protected data. physical safeguards
___ controlling access to computer systems and covered entities, phi by some unauthorized technical safeguards
Dr. Smith doesn’t want to handle the claims process at her office. Instead, she’ll probably use a A. CPT. B. CBO. C. CMBS. D. CCA. B. CBO.
One of your jobs is to make contractual adjustments to patient accounts. You may work as a A. medical office coder. B. RHIT. C. medical collector. D. payment poster. D. payment poster.
A patient’s family has a question about a DNR order. Most likely, the family would speak to the hospital’s A. insurance verification specialist. B. admitting clerk. C. medical biller. D. privacy compliance officer. D. privacy compliance officer.
Which one of the following choices was an outcome of managed care for physicians? A. Financial stress B. Less staff C. Higher payments D. Decrease in patients A. Financial stress
Which one of the following credentials is offered by the American Billing Association? A. NCMOA B. CMRS C. OSHA D. CCA B. CMRS
Which one of the following certifications is awarded through know? A. CPC-A B. CMRS C. CMAA D. CCS-P D. CCS-P
Which one of the following professionals probably has the most face-to-face contact with patients? A. Privacy compliance officer B. Refund specialist C. Admitting clerk D. Insurance verification representative C. Admitting clerk
Which one of the following positions requires that you spend most of your day on the telephone? A. Medical biller B. Medical coder C. Payment poster D. Medical collector D. Medical collector
It’s recommended that you join at least _______ professional membership(s) in your field to indicate that you’re involved and dedicated to the profession. A. four B. three C. two D. one D. one
You work in a physician’s office that has three physicians and a couple of different employees. This practice is probably classified as a _______ practice. A. solo B. private C. small-group D. large-group C. small-group
You want to show your dedication and commitment to the industry and your career as a medical biller. Which one of the following certifications will best help you improve your knowledge and skills? A. NCMOA B. CCA C. RHIT D. CMBS D. CMBS
Part of your job duties includes entering patient data & charge information & contacting the insurance carrier when there are ?. You’re probably employed as a A. payment poster. B. medical collector. C. medical biller. D. medical coder C. medical biller.
Which one of the followin choices is a reason to become a member in a profess. org? A. guarantees higher pay B. receive a professional credential C. It gets you published in a professional publication D. It helps keep you current in your field. D. It helps keep you current in your field.
Which one of the following terms refers to monitored health care? A. HIPAA B. Multispecialty practice C. Verification representation D. Managed care D. Managed care
Which one of the following certifications would be good for a student coming out of college and entering the coding field? A. CCA B. CCS-P C. CCS D. CPC A. CCA
Part of your job is to ensure that you determine the patient’s responsibility for charges before the patient receives treatment. You may work as a(n) A. refund specialist. B. insurance verification rep. C. admitting clerk D. medical code B. insurance verification representative.
Which one of the following specialists is the general cashier who must have a complete understanding of the Explanation of Benefits documents? A. Medical biller B. Medical office assistant C. Medical collector D. Payment poster D. Payment poster
If a receptionist and medical biller are cross-trained for different positions, they probably work for a A. large group practice. B. hospital. C. private practice. D. small group practice. C. private practice.
Which one of the following choices is similar to a PAS, except that it focuses on physician offices instead of hospitals? A. CBO B. CCS C. NCMOA D. MAB A. CBO
Which one of the following certifications states that the person is qualified to verify the completeness of patient medical records? A. RHIT B. CCA C. NCMOA D. CPC-H A. RHIT
Which organization has separate exams and certifications based on whether you work at a physician’s office or an outpatient facility? A. AHIMA B. CMBS C. NHA D. AAPC D. AAPC
Which position requires vast knowledge of systems such as CPT and ICD-9-CM? A. Medical biller B. Medical coder C. Payment poster D. Medical collector B. Medical coder
For which of the following certifications must you have graduated from a program or have at least one year of on-the-job training? A. RHIT B. CCA C. CMAA D. CPC-H-A C. CMAA
For which of the following jobs would you need a thorough understanding of HIPAA? A. Privacy compliance officer B. Refund specialist C. Admitting clerk D. Insurance verification representative A. Privacy compliance officer
Physicians and nurses comprise _______ percent of all healthcare providers. A. 20 B. 40 C. 60 D. 80 B. 40
In UCR fees, the portion that’s based on what doctors with similar training charge in a specific area is known as the _______ fee. A. usual B. reasonable C. customary D. medically necessary C. customary
Healthcare plans administered by a TPA are typically which type of plan? A. Physician–hospital organization B. Exclusive provider organization C. Self-insured plan D. Commercial health insurance C. Self-insured plan
In 1982, which one of the following choices made it easier for HMOs to work with Medicare? A. HIPAA B. HMO Act C. NCQA D. TEFRA D. TEFRA
A regularly scheduled payment made to purchase an insurance policy is known as the A. coinsurance. B. copayment. C. premium. D. deductible. C. premium
Mrs. Smith is a widow who had previously received coverage through her husband’s insurance. Mrs. Smith can continue to receive coverage under A. COBRA. B. supplemental insurance. C. long-term care. D. full-service insurance. A. COBRA.
You’re a medical office specialist who just asked a patient if she has health insurance. What is your next step? A Call the insurance company B. Review the Patient Bill of Rights C. Ask to see the patient’s ID card D. Document the conversation C. Ask to see the patient’s ID card.
Which one of the following types of insurance is considered some of the least expensive insurance? A. Medical B. Surgical C. Special risk D. Catastrophic D. Catastrophic
When an MCO keeps a percentage of a physician’s revenue until year end, it’s referred to as A. pay for performance. B. gatekeeping. C. a health savings account provision. D. a preferred provider network. A. pay for performance.
If you want protection against a certain type of accident or illness, which insurance should you get? A. Medical B. Surgical C. Special risk D. Catastrophic C. Special risk
Before 1993, how did many people pay for their healthcare services? A. With managed care B. Through PPO coverage C. With their own private funds D. Through MCOs C. With their own private funds
If negotiated managed care fees are too low, how could a physician make up the difference in payments? A. Change MCOs. B. Hire more employees. C. See more patients. D. Join an EPO. C. See more patients.
Which one of the choices represents a criticism of MCOs? A.can’t appeal the decision if the MCO B. must enter arrangements with providers. C. MCOs employ less-qualified physicians. D. aren’t required to choose primary care physicians A. Patients can’t appeal the decision if the MCO says that a particular treatment isn’t medically necessary.
You have to pay $250 before your insurance begins. This amount is known as the A. premium. B. copay. C. coinsurance. D. deductible. D. deductible.
Which one of the represent a disadvantage of managed care organizations? A. providing services in emergency situations B. difficulty finding patients within the plan C. misunderstandin clearinghouses for payments D. Physicians provide incomplete doc. A. There are issues with providing services in emergency situations.
Which one of the outcomes was a result of physicians being excessively sued? A.ordering of extra tests so the physician could protect themselves. B.creation of copayments C.Lower premiums to prove that physicians were ethical D.Fewer plan enrollees A. The ordering of extra tests and treatments so the physician could protect himself or herself
Which one of the following types of insurance plans is state licensed and has the most stringent MCO guidelines? A. EPO B. HMO C. PPO D. POS B. HMO
You just changed to a plan that’s priced lower than your previous PPO but higher than an HMO. You are probably using a(n) A. POS plan. B. EPO. C. IPA model HMO. D. group model HMO. B. EPO.
The specified amount of out-of-pocket medical expenses that the insured pays annually before the health insurance policy provides coverage is called the A. coinsurance. B. copay. C. deductible. D. premium. C. deductible.
You pay additional expenses to cover the huge medical expenses that aren’t covered by your normal policy. Which type of insurance do you have? A. Catastrophic B. Surgical C. Outpatient D. Major medical D. Major medical
Options available through managed care organizations include the preferred provider organization (PPO), the point-of-service plan (POS), and the A. direct contract agreement. B. (NCQA). C. (HMO). D.Medicare+Choice plan C. health maintenance organization (HMO).
How do you determine how much a carrier is responsible for? A.-allowable amt from the billed amt. B.-unpaid deductible or copay form the write-off amount. C.+ patient payment to the write-off amount. D.+ unpaid deductible to the allowable amount. B. Subtract the unpaid deductible or copay form the write-off amount.
Which one of the following is an important reason for offices to understand the history of healthcare? A.help w/ employment opp. B.help them communicate w/ patients. C.impossible to code & bill w/o this D.helps them to write patient premiums B. It will help them better communicate with patients.
When multiple doctors become employees of a group practice and contract with an MCO to deliver health care to members of the network, they’re probably participating in a(n) _______ model. A. open-access B. network C. staff D. group D. group
Delivering high-quality care that manages costs is a goal of A. carriers. B. withholding programs. C. supplemental insurance. D. managed care. D. managed care.
Which one of the following types of insurance plans combines features of a health maintenance organization and a preferred provider organization where the employers don’t contract with other plans? A. EPO B. IPA C. PHO D. HMO A. EPO
When a physician agrees to accept a payment directly from the patient’s insurer, it’s called A. the copayment. B. MCO care. C. assignment of benefits. D. point-of-service care. C. assignment of benefits.
1. You work in a hospital and you’re speaking with the person responsible for receiving complaints from patients about their health information. You may be speaking to the A.medical coder B.preferred provider C.HITECH rep. D.privacy compliance offi. D. privacy compliance officer.
3. After the provider credentialing process, the MCO A.physicians are better than those not included in an MCO B.demonstrates the credentialing process C.decides if it wants to contract w/ the provider D.documents, signs, and dates the paper C. decides if it wants to contract with the provider.
4. Resources that are required for adequate health care are referred to as A. medically efficient. B. covered services. C. emergency services. D. contracted services. A. medically efficient.
5. The security sections of HITECH were meant to prevent PHI from A. standardization. B. fraud and hacking. C. CPOE. D. ONC. B. fraud and hacking
patient is in a coma & can’t consent to or authorize release of info. physician may disclose relevant infor 2 fam or close friend A.fam signs a release B.falls under HITECH C.physician deems the disclosure is in the best interest D.is usin EPHI C. the physician deems the disclosure is in the patient’s best interest.
7. Which one of the following choices requires that an MCO plan being reviewed for accreditation demonstrates that it has done a thorough credentialing process for providers? A. PPO B. NCQA C. PMPM D. RBRVS B. NCQA
8. You had an appointment with Dr. Smith for an illness, but Dr. Smith isn’t a provider within the MCO. Dr. Smith is known as a(n) A. PAR. B. PPO. C. RBRVS. D. non-PAR. D. non-PAR
9. You work in a health care organization where you see the Privacy Rule repeatedly being violated. You can file a complaint with the A. CMS. B. OCR. C. EDI. D. DHHS. B. OCR.
10. Which one of the following choices was created to simplify submitting insurance claims electronically? A. CDT-2 B. HCPCS C. Uniform Code Sets D. Administrative safeguards C. Uniform Code Sets
Which one of the following is one of the main reasons that privacy complaints are filed A.No insurance benefit is recorded in record B.isn’t issued the Bill of Rights C.patient can’t gain access to record D.Reimbursement codes are inaccurately assign. C. A patient can’t gain access to his or her record.
12. What is the key element of any managed care contract? A. EOB B. Network C. Compensation for services D. Non-PAR C. Compensation for services
13. Which one of the following choices could present an increased financial risk to a physician? A. Capitation B. Schedule of benefits C. NCQA D. Participating provider requirements A. Capitation
14. The primary intent of HIPAA is to provide better access to health insurance, to reduce administrative costs, and to A. limit fraud and abuse. B.governmental health care coverage C.privatize health care industry D.insurance premiums A. limit fraud and abuse.
Under HIPAA, which one of the following choices can be given to a patient’s friend or relative without a signed authorization? A. DME B. EDI C. EMR D. PHI A. DME
A policyholder may also be called a A. member. B. provider. C. payer. D. medical director. A. member.
Which one of the following choices may use PHI to better understand and review product recall situations A. CMS B. HIPAA C. HITECH D. FDA D. FDA
Each managed care contract has its own autho&claims req, as well as A.list of participatin providers B.confidential policies C.codes 4 diagnosing & treating patient health issues D.regulations 4 transmitting patient health information electronically A. list of participating providers.
A hospital has just signed a contract with a managed care organization. The hospital is known as the A. PMPM. B. HMO. C. NPI. D. PAR. D. PAR.
Ethically, all providers and MCOs must abide by the A. schedule of benefits. B. Patient’s Bill of Rights. C. non-PAR document. D. CBO. B. Patient’s Bill of Rights.
If someone obtains PHI under false pretenses, he or she may receive a penalty of up to A. $100 per violation. B. $50,000 and 1 year in prison. C. $100,000 and 5 years in prison. D. $250,000 and 10 years in prison. C. $100,000 and 5 years in prison.
Which one of the following choices identifies employer-sponsored health insurance? A. NPI B. EIN C. CMP D. NDC B. EIN
Under HIPAA, which one of the following choices can be given to a patient’s friend or relative without a signed authorization? A. DME B. EDI C. EMR D. PHI B. EDI
Which one of the following choices was created to improve HIPAA privacy and security? A. CMS B. NCQA C. EPHI D. HITECH D. HITECH
Which part of an MCO contract should contain a list of CPT codes and the rate for those services? A. Payment B. Covered medical expenses C. Network D. Fee maximum B. Covered medical expenses
Electronic data interchange is the A.process of reporting services to payers as numeric codes B.trans of protected health info to Medicare C.Web-based submission of encrypted data to beneficiaries D.mutual exchange of data between the provider D. mutual exchange of data between the provider and payer.
As a medical office specialist, you may be required to A. write MCO contracts. B. decide on PARs. C. review MCO contracts. D. work as a CBO. C. review MCO contracts.
____ An addition made to a book or publication, normally at the end, to document a change or revision. addenda
___ is an undesired condition that results from use of a medication or drug given in correct dosage. adverse affect
____ a single code that classifies more than one condition, such as both the etiology and the manifestation of an illness or injury. combination code
___ A diagnostic code that defines a complication that occurs when a patient suffers a problem resulting directly from a procedure that was performed from a procedure that was performed by a physician. complication code
___ formatting used in coding books that is exclusive to each volume & publisher. conventions
__ the process of determining by examination the nature and circumstances of a diseased condition. diagnosis
__ The main reason for the patient encounter a long with the descriptions of additional conditions or symptoms that have been treated or related to the patients current illness. diagnostic statement
__ A procedure or diagnosis name derived from the name of a person. eponym
___ the cause or origin of a disease. etiology
__ abbreviation for international classification if diseases, ninth revision clinical modification. a coding system used to code signs, symptoms, injuries, diseases and conditions. icd-9-cm
___ A condition that remains after a patients acute illness or injury. late effect
___ the term used when searching for a specific diagnosis code. is usually the chief complaint. main term
__ A designation used in the icd-9-cm coding manual that indicates a more specific code is not available to describe the condition, even through there is a detailed info in record. nec (not else where classified)
___ A symptom related to the patients condition manifestation
___ the study of the structure of words morphology
A designation used in the icd-9-cm coding manual that indicates there is a lack of sufficient details in the medical record to assign a more specific code. NOS (not otherwise specified)
___ The patients main reason for the outpatient visit or encounter primary diagnosis
___ the condition established, after all tests and procedures are completed to chiefly responsible for the admission of a patient to a hospital for care, the 1st listed diagnosis can also be referred to as principal diagnosis
___ A condition that remains after a patients acute injury or illness residual effect
__ A designation (R/0) for an uncertain diagnosis. when coding outpatient services r/0 diagnoses are not to be coded; rather, the presenting signs and symptoms should be coded. rule out
___ An indication of a particular disorder that can be observed or measured by a physician sign
___ Coding terms that provide more specific information that the main term. they also provide the anatomic site affected by the disease or injury sub terms
___ nonessential words or phrase that help to define a code in the icd-9-cm; it is usually enclosed in parentheses or brackets supplementary terms
___ used in the cpt book to show changes and alert the reader to new codes, deletions or alternations to a code. The symbol is located before the code number for 1 year, after which it becomes part of the next annual printing. symbols
__ An indication of a disorder or disease that the patient reports to the physician, but that the physician can not observe or measure. symptoms
___ supplementary classification of factors influencing health status and contact w/ health services (v01-v91) v codes
___ supplementary classification of external causes of injury and poisoning (e000-e999) e codes
patient comes in for a physical examination (check up) what is primary diagnosis- main term- subterm- pd- physical examination m-examination s-physical
the main term will be in ___ type & followed by a code. (#) bold face
triangle symbol- dot- 4 (circled) or 5 (circled)- triangle- there is a revision to the text of the existing code dot- means that the code is the new to this revision 4or5- code must be coded either to the 4th or 5th level of specificity.
burns % head and neck 9%
burns % each arm- each leg- a-18% (9 each) l- 36% (18 each)
burns % anterior & posterior- genitalia- a&p- 36% (18 each) g- 1%
diabetes type 1- type 2- gestational diabetes- 1- insulin dependent 2- non-insulin dependent 3- during pregnancy
diabetes- 0-type- 1-type- 2-type- 3-type- 0-2 1-1 juvenile 2-2 3-1 juvenile
___ a committee that reviews proposals regarding diagnostic codes & determines if a code in modified, added, or deleted coordination & maintenance (c&m) committee
___ reassignment of gaps in coverage that elimates the need for a beneficiary to file a separate claim w/ his or her medigap insurer. it usually requires the beneficiary to sign release- of information and assignment of benefit forms with their providers. crossover
___ Tool to assist with the conversion of icd-9 and icd-10 general equivalence mapping (GEM) files
___ A department in a healthcare facility that maintains patients medical records health information management (HIM)
___ a system of medical classification used for procedural codes that track various health interventions taken by medical professionals. it is referred to as volume 3 in a coding manual icd-10 procedure coding system (icd-10-pcs)
___ reflects the complexity of the code sets rather than over simplifying mapping
___ an organization component of the centers for disease control and prevention, charged w/ providing statistical information that will guide actions & policies to improve the health of the American people national center for health statistics (NCHS)
___ a specialized agency of the united nations (UN) that is concerned with international public health. world health organization (WHO)
icd 9 # of digits- # or letters- 3-5 all #
icd 10 # of digits- # or letters- 3-7 1 is a letter 2 is a # 3-7 is ether
icd 9 code elements decimal point- supplemental codes- decimal after 3rd character -1st digits are letters (V&E codes)
icd 10 code elements decimal point- supplemental codes- decimal after 3rd character -combination codes include the external/ supplemental causes
character 1-7 for coding 1. section 2. body system 3. root operation 4. body part 5. approach 6. device 7. qualifer
___ professional society that assists patients and physicians by creating a sense of unity in the medical industry. American medical association (ama)
___ The department of the federal government responsible for administering Medicare & Medicaid. formerly the health care financing administration. centers for Medicare and Medicaid services (CMS)
___ concise statement describing the symptom, problem, condition, diagnosis, or other factor that is the reason for the patient encounter. chief complaint (CC)
____ service by a physician whose opinion or advice regarding a patients condition & your treatment is requested by another physician consultation
___ a method of a health care professional providing advice and guidance to a patient counseling
___ a system of 5-digit codes used to describe what procedures were performed current procedural terminology (CPT)
___ cpt code # 99201 to 99499 e/m codes
___ one who has received professional services from a physician or another physician of the same specialty established patient
___ an evaluation performed by a physician by a physician who is involved in a patient care. examination
___ information gained by a health care professional by asking the patient specific questions history
___ the process of establishing a diagnosis & selecting a management option as measured by the # of diagnosis or treatment options medical decision making (MDM)
___ 2 digit #'s placed after the 5-digit cpt code to indicate that the description of the service or procedure has been altered modifiers
___ describes how severe the patients disease, condition, illness, injury, symptom, sign, complaint, or other reason for encounter w/ or w/out a diagnosis is at the time of the encounter nature of the presenting problem
___ a person who has not received any professional services w/in the past 3 years new patient
__ a listing of descriptive terms, guidelines, and identifying codes for reporting medical services & procedures. nomenclature
___ a review of the past medical experiences and patients families history. past ,family, and social history (PFSH)
___ an inventory of body systems obtained through a series of questions asked by the physician, who seeks to identify signs or symptoms that the patient may be experiencing. review of systems (ROS)
triangle- dot- bowtie- +- 1. revised code 2. new code 3. new or revised code 4. add-on code
category 1 cpt codes medical
category 2 cpt codes supplemental codes for performance measures
category 3 cpt codes emerging technologies
___ 00100-01999 or 99100-99140 anesthesia
___ used to enclose synonyms, alternative wording or/and explanatory phrase. brackets
___ represents a new procedure or service code added since the previous edition of the manual. bullets
___ exemption from modifiers 51 0 with a line through it
___ used to report services and procedures by physicians cpt
___ are at the beginning of each section and used to provide specific coding rules for that section guidelines
___ the procedure was unusually complicated and took more time than the general cpt code allows. 22
___ more than one surgical procedure was performed during the same operation 51
___ the doctor performed the same procedure more than once during the visit (same patient) 76
___ the doctor repeated the same diagnostic test, usually the same day 91
___ references to information found else where cross reference
___ all current procedural terminology codes are 5 digits followed by a descriptor descriptor
___ occurs when procedures are reported separately that should have been included under a bundled code fragmented billing
___ a group of related procedures covered by a single code bundled care
___ an act passed by congress establishing quality standards for all laboratory testing to ensure the accuracy, reliability, and timelessness of patient test results clinical laboratory improvement amendment (CLIA)
___ mandated service is used when it is requested by the payer 32
___ reduced service us when an e/m service is less extensive than the description indicates 52
__ is used on e/m services the day before or day major surgery when the initial decision to perform the surgery is identified modifier 57
___ physician must return the operating room to address complication stemming from initial procedure modifier 78
___ procedure or service provided during postoperative period not associated with initial procedure modifier 79
___ bilateral procedure modifier 50
___ attach to e/m service code when service is provided during postoperative period to indicate the service is not part of the postoperative care and not included in the surgical package modifier 24
___ provider only provided the professional component modifier 26
___ used more than on procedure during the same surgical episode modifier 51
__ codes found in the cpt manual level 1 codes
___ national codes for physician and non-physician service not found in the cpt level 1 level 2 codes
___ used locally or regionally and have been eliminated by the cms since the implementation of HIPAA level 3 codes
__ appendix a and in front of the book the list of modifiers
___ listed under associate and stand alone codes indented codes
__ used to enclose supplementary words, non-essential modifiers parentheses
___ coding and billing that is inconsistent with typical coding and billing practices abuse
how does hipaa define fraud? intentional deception of misrepresentation
the difference between fraud & abuse is? intent
___ a notice that a doctor, supplier, or provider gives a Medicare beneficiary before furnishing an item or service if the doctor, supplier, or provider believes that Medicare may deny payments. advance beneficiary notice (ABN)
__ a numeric and alphabetic coding system used for billing, pricing of procedures, medical supplies, medications, and durable medical equipment (DME) health care common procedure coding system (HCPCS)
___ developed by the cms to promote national correct coding methodologies and to control improper coding that leads to inappropriate payment of part & health insurance claims national correct coding initiative (NCCL)
___ a formal examination of patients medical records and accounts audit
___computer program function that screens for improperly or incorrectly reported procedure codes code edits
__ occurs when the procedure that is less involved than the procedure actually documentation in the chart. carriers will down code or deny payment when the documentation fails to justify the level of service billed. down code
___ an investigation performed by an external party to review patient documentation and records. external audit
___ a review of claims that is performed by a facility to protect against submitting dirty claims internal audit
___ completed b4 the claim is submitted for payment. prospective audit
___ audit completed after payments has been received from a carrier retrospective audit
__ occurs when the procedure code stated is for a procedure that is more involved than the one actually documentation in the chart. up code
1. a combination code in the icd-9-cm covers the: a. coexisting condition b. etiology and manifestation c. chronic and acute illness d. none of the above b
2. comparison of two coding systems that shows which codes are used for similar classifications is a: a. convention b. category c. crosswalk d. manifestation c
3. a disease or procedure that is named for a person is a(n) a. eponym b. e code c. etiology d. manifestation a
4. a 5-digit code in the icd-9-cm is called a a. category b. sub classification c. subcategory d. v codes b
5. a personal history of cancer is reported with a(n) a. e code b. v code c. combination code d. none of the above b
which one of the following icd-9-cm sections is used to find codes for use on medical forms and documents? a. volume 1 b. volume 2 c. volume 3 d. appendix a
to assign the correct code to a neoplasm (tumor), you should carefully study the ____ report to determine the type, site, and organ involved. a. pathology b. original lab 3. patient lesion d.cbc a
when coding multiple injuries, how do you determine what's sequenced 1st a.injury that the physician lists 1st b.injuries must be listed alphabetical, accordin to the code index c.no rule 4 sequencing mult injuries d.most severe injury always 1st d
patient came into the hosp w/ pain&tightness in the chest for 3 days, upon further exam,the patient had a myocardial infarction, also has diabetes&dehydrated. what are the complication codes? a.786.59, 410 b.410,250 c.250,276.51 d.276.51,786.59 a
patient came into the hosp w/ pain&tightness in the chest for 3 days, upon further exam,the patient had a myocardial infarction,also has diabetes&dehydrated. What Is the principal? a. heart attack b. chest pain/tightness c.dehydration d.diabetes a
your reviewin patient doc. to learn why a patient is bein seen. which step r u probably performin in the coding process a.determinin the reason 4 encounter b.locatin term in volume 2 c.verifyin code in volume 1 d.assignin code to patient acct. a
a patient has a keloid scar due to a laceration, which requires 2 separate codes. the keloid is known as a(n) a. late effect b. adverse reaction c. metastatic condition d. perinatal condition a
a woman in her 6 month preg comes into the office. she has had 0 check ups and insufficient weight gain. the primary diagnosis is? (icd-9) a. e codes b.v codes c.icd-9 # diagnosis code d. icd-9 # procedure code b
e codes r always used as 2nd, never 1st, codes in case of poisonin/adverse effects cuz a.external result of injury, not diag b.temp indication until lab reports have been studied c.identified w/ specific types of drugs cause illness d.insurance no pay a
nec is used at the 4th-digit level to indicate a. that 2 codes are req to adequately describe the illness b.the diag statement bein coded is a nonspecific condition c.subcategory that cant be classified to a more specific code d.nonessential modifer c
youre looking up a code in volume 1 & notice that the description includes a tem in square brackets the info in the bracket could be a. modifier b. supplementary words c. nec info d. synonyms d
which one of the following choices may be used to be determine medical necessity for services a.ub-04 b.icd-9 cm c.cms-1500 d.nec b
when u see the instructional note code 1st underlying disease as u know that the code cant be used as the a.admitting diagnosis b.primary diagnosis c.principal diagnosis d.procedure c
to ensure accurate icd-9-cm coding and billing, code books should be purchased a. once a year b. as coding updates are released c. every 2 years d. 2x yearly a
a patient is diagnosed w/ brain cancer that has metastasized to the lymph nodes. the brain cancer is called a. primary diagnosis b. 2nd diagnosis c. the in situ diagnosis d. benign a
which one of the following choices is required providers to submit a diagnosis code to be reimbursed a. who b. London bills of mortality c. icd-9-cm d. medicare catastrophic coverage act of 1988 d
undercoding conventions Edward syndrome is an example of a. sign b. synonym c.eponym d. symptom c
in a working diagnosis, terms such as rule out, possible and suspected a. may be used as principal diagnosis codes b. should not be coded c. may not be used on any claim form d. are called 2nd diagnosis b
a patient complaint of pain and tightness in the chest is referred to as a. sign b. symptom c. probable cause d. suspected cause b
a patient record has the code 47.01 for laparoscopic appendectomy. this coder probably used which part of the icd-90cm coding book to assign this code a. icd-9 volume b.icd-9 volume 2 c.icd-9 volume 3 d.icd-9 appendix c
important role does 3M play in the new ICD-10? A.# of new codes 4 ICD-10 B.to help translate complexity between ICD-9&ICD-10 C.board that will be responsible for releasing ICD-10 updates D.working on an ICD-10-PCS procedure coding software system. b
What are the correct ICD-9-CM and ICD-10-CM codes for acute pharyngitis? (Use the conversion tool located at www.aapc.com/ICD-10/codes/index.aspx.) A. 462.0 and J02.9 B. 462 and J02.9 C. 462.0 and J12.9 D. 462 and J12.9 b
Incorporating standardized terminology, completeness, expandability, and multiaxiality are all goals of A. HCPCS. B. CPT. C. ICD-9-CM. D. ICD-10-PCS. d
What is the correct ICD-10-CM code for the ICD-9-CM code 496, Chronic Obstructive Pulmonary Disease? (Use the conversion tool located at www.aapc.com/ICD-10/codes/index.aspx.) A. J44.1 B. J44.9 C. J44.2 D. J44.8 b
In ICD-10-CM, when are three-character codes used? A. When there are no further subdivisions B. When adding the body or direction code information C. When billing for E/M codes D. When creating a crosswalk from ICD-9-CM to ICD-10-CM a
In ICD-10-CM, an “X” is used as the fifth character in some codes to A. indicate the reimbursement amount. B. document the episode of care. C. specify the location on the body. D. act as a placeholder for future code expansion. d
Which one of the following choices is a disadvantage of ICD-9-CM procedure codes? A.too specific and hard to work with. B.place limitations on DRG assignment. C.descriptions are too detailed. D.7-character codes are too long for most systems b
Code 428.0 is an example of an A. ICD-9-CM diagnosis code. B. ICD-9-CM procedure code. C. ICD-10-CM code. D. ICD-10-PCS code. a
Which outcomes is expected to happen after ICD-10 is implemented in the US? A.Payments&reimbursement will decrease. B.Software systems will be unable to map codes. C.Health info details will improve. D.Coding efficiency will increase c
Which choices is a disadvantage of using crosswalks in coding? A.too specific. B.don’t take into consideration the complexity of ICD-10. C.hard to understand under the new coding system. D.no software systems to assist with crosswalks b
Which one of the following choices is a disadvantage of ICD-9-CM? A. It’s too specific. B. The volume of codes is difficult to manage. C. It makes it difficult to analyze data. D. It provides too much information on laterality. c
Which one of the following ICD-10-CM codes correlates to ICD-9-CM code 733.91, arrest of bone development of the humerus, unspecified? (Use the conversion tool located at www.aapc.com/ICD-10/codes/index.aspx.) A.M89.169 B.M89.16 C.M89.192 D.M89.13 a
Which one of the following organizations maintains the ICD-10? A. WHO B. AMA C. CMS D. NCHS d
The ICD-10-CM diagnosis code H65.119, acute and subacute allergic otitis media (mucoid)(sanguinous)(serous), unspecified ear, translates to how many ICD-9-CM code choices? (Use the conversion tool A. Two B. Three C. Four D. Five d
You just assigned the code A02.21 for acute myeloid leukemia in remission. Which coding classification system are you using? A. ICD-9-CM B. ICD-10-CM C. HCPCS D. CPT b
Code I50.9 translates to how many ICD-9-CM code choices? (Use the conversion tool located at www.aapc.com/ICD-10/codes/index.aspx.) A. One B. Two C. Three D. Zero b
Which one of the following organizations created the ICD-10-PCS? A. WHO B. CMS C. AMA D. NCHS d
When coding with ICD-10-CM, which step should you perform first? A. Locate the term in the alphabetic index. B. Read all notations. C. Verify the code in the tabular list. D. Assign the code to the account. a
Which one of the following choices is not used in ICD-10-PCS? A. Letters A–H B. Numbers 0–9 C. Letters P–Z D. Letters O and I d
Which one of the following choices can assist coders with translating and analyzing the differences between an ICD-9-CM code and ICD-10-CM code? A. Crosswalk B. Mapping C. GEM D. HCPCS c
A patient has carpel tunnel syndrome on her right hand. She had a release of the carpal via a percutaneous approach. The correct ICD-10-PCS diagnosis code is probably A. 0PNM4ZZ. B. 0PNM4TZ. C. OPNN4ZZ. D. OPNM4ZZ a
Which of the following procedures has an open approach? A. 3E03316 B. 3E0336Z C. 3E033WL D. 3E030WK d
If you were looking for the root operation of an ICD-10-PCS code, you would look at position A. 1. B. 2. C. 3. D. 4. c
In code 02703ZZ for PTCA, which of the following characters tells us that it was a percutaneous approach? A. 2 B. 7 C. 0 D. 3 d
The first digit of an ICD-10-PCS code always reflects the A. surgical procedure. B. device. C. qualifier. D. category. d
Which one of the following groups was required to have ICD-10-PCS implemented by October 1, 2015? A. American Hospital Association members B. HIPAA-covered entities C. Nursing home residents D. All physician offices b
An ICD-10-PCS code that starts with “0” tells the coder that A. the procedure is a medical or surgical procedure. B. the procedure is an open approach. C. there’s no qualifier for the procedure. D.procedure affected the respiratory system a
A coder looked up reduction of fracture in the coding book index. Where was the coder redirected? A. Release B. Reposition C. Exploration D. Excision b
In the code 0T910ZX, which character tells us that it is a code about the urinary system? A. 0 B. T C. 9 D. 1 b
In code 02703ZZ for PTCA of one coronary artery, which of the following characters tells us that there was no device and no qualifier for this procedure? A. 03 B. 27 C. 3Z D. ZZ d
A code that begins with OHT tells us that the procedure A. is a medical or surgical resection of the skin or breast. B. doesn’t have a device. C. has no qualifier listed. D. is a radiological procedure. a
Which of the following is a valid ICD-10-PCS code? A. OBT74ZZ B. 0BT74ZZ C. OBT74 D. 0BT74 b
The first three digits of the code for a hysterectomy that was a resection of the uterus is A. 0U99. B. 0UB9. C. 0UT9. D. 0US9. c
What was one reason that ICD-10-PCS was created? A. The American Hospital Association mandated a new system. B.no valid procedure codes for hospital inpatient coding C.old system was becoming outdated. D.no physician-based coding system c
ICD-10-PCS codes are A. alphabetical. B. numeric. C. alphanumeric. D. sometimes alphabetical and sometimes numeric. c
Which of the following is the correct code for destruction of the prostate via natural opening? A. 0V507ZZ B. 0V503ZZ C. 0V508ZZ D. 0V504ZZ a
In the code 0T910ZX, which character tells us that the procedure is on the left kidney? A. 0 B. T C. 9 D. 1 d
If you want to look up an ICD-10-PCS code alphabetically, you would use the A. Table. B. Index. C. List of Codes. D. Category. b
Referring to the index of the coding book, what page references specifically left breast repair? A. 694 B.507 C. 556 D. 513 a
A coder needs to provide the updated ICD-10-PCS code for an ICD-9-CM code. What should the coder use? A. Mapping software B. A medical dictionary C. ICD-9-CM coding book D. ICD-10-PCS coding book a
What other terms could a coder use for graft when using the ICD-10-PCS coding book index? A. Excision B. Replacement C. Fragmentation D. Decompression b
The code for laparoscopic (percutaneous endoscopic approach) appendectomy is A. 0DTJ4ZZ. B. 0D9J0ZZ. C. 0D9J3ZZ. D. 0DTJ7ZZ. a
GEMS helps healthcare facilities A. train coders on the new system. B. identify incorrect code assignment. C. understand the “Section-Body System-Operation” section of ICD-10 D.translate old ICD-9-CM procedure codes into the new ICD-10 d
A patient had a closed percutaneous liver biopsy for the purpose of helping diagnose a disease. Which code should be assigned? A. 0FB00ZX B. 0FB03ZX C. 0F903ZX D. 0F904ZZ b
The code for excision of thoracic vertebral disc starts with A. 0RB3. B. 0RB5. C. 0RB9. D. 0RBB. c
A patient had his left ethmoid sinus drained. To look up the code in the coding book, which terms should the coder start with first? A. Ethmoid B. Sinusectomy C. Drainage D. Left c
What modifier should be used if a service required significantly greater effort or complexity than normal? A. -22 B. -47 C. -57 D. -50 a
In terms of E/M codes, which one of the following choices could have the most significant impact on reimbursement? A. Place of service B. Date C. AMA D. Nomenclature use a
Which of the following organizations first developed and published the CPT? A. CMS B. HCFA C. AMA D. HIPAA c
Extent of history doc, the extent of the examination doc, and the complexity of the medical decision making documented are key components for A.gettin the office reimbursed. B.understandin new CPT codes. C.E/M code assignment. D.codin nomenclature c
Which one of the following codes is an example of a CPT code? A. 428.0 B. H65.119 C. 96.20 D. 97010 d
You’re coding from the CPT book and notice a triangle next to a code. This symbol means A. it’s a new code. B. it can’t be used as a primary code. C. the description has changed. D. it’s an add-on code. c
You code for an emergency department. You probably code mainly from which one of the following CPT code ranges? A. 99221–99239 B. 99241–99245 C. 99251–99225 D. 99281–99288 d
Biopsies are performed on three separate skin lesions. How many CPT codes would be reported? A. One B. Two C. Three D. Four c
The number of days for a surgical package with all other services and procedures relating to that surgery is referred to as A. modifiers. B. fragmented billing. C. the global period. D. unbundling c
CPT descriptive terms, guidelines, and the identifying codes are referred to as A. symbols. B. nomenclature. C. modifiers. D. consultations. b
Which one of the following tasks helps establish medical necessity for procedures? A. Updating codes in coding software annually B. Linking diagnosis and procedure codes C.alphanumeric codes for reporting D.Gainin FDA approval of the codes b
Before you submit a medical claim with the modifier -57, you should A. assign the secondary code that goes with it. B. review the guidelines from the specific payer. C. request additional documentation. D. get a second opinion. b
When should physicians code&report supplies&materials used to treat patients? A.Never—included w/ reg billin B.when the use is above what would normaly be used C.with separate codes for the CPT codes D. when the payer indicates it’s okay b
You see a CPT code with -TC as a modifier. This designation tells you that it probably is a _______ code. A. surgical B. laboratory C. radiology D. diagnosis c
If you’re coding for ear procedures, you’re probably using which CPT code range? A. 10021–19499 B. 33010–39599 C. 60000–60699 D. 6900–69979 d
Youre placin codes in order so the code with the highest reimbursement is 1st. What step r u on? A.Determinin the procedures and services to report B.Identifyin the correct codes C.Determinin the need for modifiers D.Reportin the codes b
Which one of the following code systems is an optional system developed mainly for performance tracking? A. ICD-9-CM B. E/M C. CPT Category II D. HCPCS c
Which one of the following categories is the largest section in the CPT book? A. Integumentary B. Surgical C. Anesthesia D. Laboratory b
What is one benefit of using correct CPT modifiers? A. Shorter codes B. Updated information C. Faster claims processing D. Better documentation c
You look up a CPT code that lists see also under it. What does this not mean? A.Use mult codes B.Look under the other main term if u dont see what u need C.Use the other code listed instead of the one u searched on D.Look for a code in a diff range. b
A concise statement describing a patient’s problem or condition is known as the A. CC. B. HPI. C. ROS. D. PRSH. a
Which one of the following categories is reimbursed based on time? A. Surgery B. Anesthesia C. Maternity care and delivery D. Operating microscope b
CPT is part of A. ICD-9-CM. B. ICD-10-CM. C. HCPCS. D. HIPAA. c
Dr. Smith has asked Dr. Brown to take a look at his patient and give an opinion. Dr. Smith is probably asking Dr. Brown for a A. referral. B. consultation. C. transfer. D. chief complaint. b
Where is the primary procedure code listed on the CMS-1500? A. First B. Second C. Third D. In the order required by the payer a
Which one of the following organizations defines anesthesia services and procedures, including publishing updates? A. ASA B. AMA C. AHA D. AHIMA a
A patient comes to the physician’s office. It has been a year since the doctor has seen her. The patient should be classified as a(n) A. inpatient. B. new patient. C. referral. D. established patient. d
Which one of the following tasks can be considered fraud? A. Reporting more than one CPT code B. Using outdated codes C. Not submitting supportive documentation when needed D. Performing fragmented billing d
The practice of grouping related procedures into one code is known as A. a modifier group. B. improper nomenclature. C. fragmented billing. D. bundling. d
Appliances or products used to assist in treating a patient are coded under A. HCPCS Level I. B. HCPCS Level II. C. CPT Level I. D. CPT Level II. b
If you’re assigning the Level II HCPCS from the code range M0064–M0301, you’re probably working with A. medical and surgical supplies. B. medical services. C. a state Medicaid program. D. orthotic procedures. b
Healthcare organizations are required to develop and implement compliance programs due to A. OIG. B. CMS. C. PPACA. D. AMA b
HCPCS was created in 1983 by the A. HIAA. B. HCFA. C. AMA. D. AHIMA. b
Each year the federal government announces billing codes that it will focus on to ensure that there are no occurrences of fraud. This strategy is known as the A. NCCI. B. HIPAA. C. OIG Work Plan. D. Federal Civil False Claims Act. c
How do payers know that the procedures being billed are medically necessary? A. The provider codes them B. Through code linkage C. By paying them D. From HINNs b
Which one of the following parties has the ultimate responsibility for proper documentation in the patient’s record? A. CMS B. Payer C. Patient D. Provider d
A coder doesn’t see a certain procedure performed, but the other items performed & doc infer that particular procedure was performed. The coder codes it anyway. This act is A.clinical modification B.assumption coding C.codin compliance D.code linkage b
Which one of the following choices occurs when a procedure that’s coded and reported is lower in reimbursement than the code that should have been reported? A. Unbundling B. Upcoding C. Downcoding D. Editing c
The complexity of establishing a diagnosis, including considering the number of management options, is known as A. medical necessity. B. medical decision making. C. coding. D. morbidity. b
Which one of the following choices is a key element of service? A. Coding B. Transmission to the payer C. Examination of documentation D. Consultation c
A coder reports a procedure that has a higher reimbursement than the code supported by the documentation. This act is known as A. upcoding. B. unbundling. C. bundling. D. assumption coding. a
Reducing the chance that a physician’s office will be audited is just one benefit of A. the Federal Civil False Claims Act. B. a compliance program. C. HIPAA. D. billing information. b
When coding, which one of the following documents is one of the most important items you can reference in a patient’s record? A. Surgery report B. Laboratory results C. Progress notes D. The claim c
A patient presents to a physician’s office and says, “I’ve had a cough and fever for three days.” In the documentation, this statement from the patient is known as the A. HPI. B. ROS. C. PFSH. D. CC. d
The law that states that the maximum penalty for fraud is $10,000 for each instance is an example of _______ law. A. administrative B. criminal C. OIG D. civil d
Knowingly submitting incorrect information to a payer is in violation of A. HIPAA. B. the Advance Beneficiary Notice. C. HCPCS. D. the Federal Civil False Claims Act. d
What is the ultimate goal of submitting claims? A. To be audited B. To be paid C. To get patients D. To code records b
When is an ABN required? A. Anytime a physician performs a procedure B. When resubmitting denied claims C. When assigning HCPCS codes D. Before providing treatment to a Medicare patient d
A government investigator is performing an audit at a physician’s office to ensure that documentation and codes are complete. This procedure is known as A. accreditation. B. an internal audit. C. PPACA compliance. D. an external audit. d
Which one of the following outcomes could be a consequence of inaccurate coding? A. Cancellation of codes B. Inability to subscribe to software systems C. Loss of patients D. A prison sentence d
What kind of code is J0290? A. CPT B. HCPCS Level I C. ICD-10-CM D. HCPCS Level II d
Which one of the following choices is a common error encountered with code linkage and medical necessity? A. The procedures aren’t coded at the correct E/M level. B.There’s no code. C.insurance provider isn’t stated. D.too many procedure codes a
Which one of the following choices is a reason that physicians’ offices should regularly perform internal audits? A. To gain new patients B.ensure accuracy of documentation C.stay out of prison D.allow coders to upcode for the best reimbursement b
The HCPCS modifier -TA tells the payer that the procedure is on the A. upper left, eyelid. B. right hand, second digit. C. left foot, great toe. D. right foot, fifth digit. c
Which one of the questions will help a physician better submit a clean claim? A.Do the procedures coded meet all regulations? B.Will this claim be denied? C.the office knowingly committing fraud? D.Will this claim reduce payments for the office a
If a physician office coder needs clinical examples for the correct way to code E/M, where is the first place he or she should go? A. The provider B. Old patient records C. The payer’s reimbursement software D. CPT book, Appendix C d
A patient has an eye infection, but the provider also inquires about ten other body systems to gain a complete picture.What type of ROS is this? A.Problem pertinent B.Extended C.Complete D.Pertinent c
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