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Test 5
Question | Answer |
---|---|
After a third-party payer validates a claim what takes place next? | Claims adjudication |
HIPAA transaction standards apply to what entity | Health care clearinghouses |
What is the initial step in processing a Worker’s Compensation claim? | First, report of injury |
The provision of the health insurance policies that specifies which coverage is considered primary or secondary is called | Coordination of benefits |
Medicare enforces mandatory submission of electronic claims for most providers. What provider is allowed to submit paper claims to Medicare? | A providers office with fewer than 10 full-time employees |
When submitting claims, what is the outcome if block 13 is left blank? | The third-party payer reimburses the patient, and the patient is responsible for reimbursing the provider. |
Patient charges that have not been paid it will appear on | Accounts receivable |
I billing and coding specialist needs to know how much Medicare paid on a claim before billing the secondary insurance. What should the specialist refer to | Remittance advice |
A billing and coding specialist should add modifier -50 codes when reporting what | A bilateral procedure |
The symbol “O” in the current procedural terminology reference is used to indicate | Reinstated or recycled code |
In 1995 and 1997, what introduced documentation guidelines to Medicare carriers to ensure that services paid for have been provided and we’re medically necessary? | CMS (The centers for Medicare and Medicaid services) enforce coding requirements. |
What is allowed when billing procedural codes? | Billing using two-digit CPT modifiers to indicate a procedure as performed differs from its usual five-digit code |
The distraction of lesions using cryosurgery would use | Cold treatment |
When a patient has a condition that is both acute and chronic how should it be reported? | Called both acute and chronic, sequencing acute first |
When coding on the UV – 04 form, the billing and coding specialist in a sequence the diagnosis codes according to ICD guidelines. What is the first listed diagnosis code? | Principal diagnosis |
What describes the content of a medical practice aging report? | An overview of the practices outstanding claims |
After reading a providers know about a new patient, a coding specialist decides to code for a longer length of time then the actual office visit. What describes the specialists action? | Fraud. |
A claim is the night because the service is not covered by the insurance company. Upon confirmation of no errors on the claim, what describes the process that will follow the denial? | The claim will not be resubmitted and the patient will be sent a bill |
* A prospective billing account audit prevents run by reviewing and comparing a completed claim form with which documents | A billing worksheet from the patient account |
What should the billing and coding specialist include in an authorization to release information? | The entity to whom the information is to be released |
What security features is required turn transmission of protected health information and medical claims to third-party payers? | Encryption |
What medical term refers to the SAC and encloses the heart? | Pericardium |
* what act applies to the administrative simplification guidelines? | Health insurance portability and accountability act (HIPAA) |
* Z codes are used to identify | Immunizations |
What statement is correct regarding a deductible? | The deductible is the patients responsibility |
A patient presents to the provider with chest pain and shortness of breath. After an unexpected ECG result, the provider calls a cardiologist and summarizes the patient’s symptoms. What portion of Hyppa allows the provider to speak to the cardiologist.. | ..prior to obtaining the patient’s consent.? Title 2 |
What is a verbal or written agreement that gives approval to release protected health information (PHI)? | Consent |
A provider performs an examination of a patient sore throat during an office visit. What describes the level of the examination | Problem focused examination |
A dependent child whose parents both have insurance coverage comes to the clinic. The billing and coding specialist is the birthday Ruth determine which insurance policy is primary. What describes the birthday rule? | The parent whose birth date comes first in the calendar year |
What sections of the medical record is used to determine the correct evaluation and management codes used for billing and coding? | History and principal |
What modifier should be used to indicate if professional service has been discontinued prior to completion? | -53 |
When an electron a claim is rejected due to incomplete information, what action should the billing and coding specialist take? | Complete the information and re-transmit according to the third-party standards |
* what is the purpose of running an aging report each month? | It indicates what claims are outstanding |
Hey physician ordered a comprehensive metabolic panel for a 70-year-old patient who has Medicare as her primary insurance. What form is required for the patient was she may be responsible for payment? | Advanced beneficiary notice |
What describes an obstruction of the urethra? | Urethratresia |
* which of the following is an example of electronic claim submission? | Claim submitted via a secure network |
Test results indicated that no abnormalities were found in the brain and the brains electrical activity patterns are normal. What test was used to conduct this exam? | ECG An electroencephalography |
The standard abbreviation ECG refers to a test used to assess which body system? | Cardiovascular system checks for problems with the electrical activity of the heart |
When billing is secondary insurance company, what block should the billing and coding specialist fill out on the CMS-1500 claim form? | 9a |
What actions should the billing and coding specialist take to effectively manage accounts receivable? | Collect copayment from the patient at the time of service |
A participating Blue Cross Blue Shield provider receives an exclamation of benefits for a patient account. The charged amount was $100. Bcbs allowed $80 and applied $40 to the patient’s annual deductible. | Bcbs paid the balance at 80% how much should the patient expect to pay? $48.00 |
What is the maximum number of ICD codes that can be entered on a CMS 1500 claim form as of February 2012? | 12 |
What is considered the final determination of the issues involving settlement of an insurance claim? | Adjudication |
What statement is true regarding the release of patient records? | Patient access to psychotherapy notes may be restricted |
What action should the billing and coding specialist take to prevent fraud use in the medical office? | Internal monitoring and auditing |
Why does correct claim processing rely on accurately completed encounter forms? | They streamline patient billing by summarizing the services rendered for a given date of service. |
For what time period Should the billing and coding specialist track unpaid claims before taking follow up actions? | 30 days |
When posting payment accurately, what items should the billing and coding specialist include? | Patients responsibility |
* A beneficiary of a Medicare or Medicaid crossover claim submitted by a participating provider is responsible for what percentages? | 0% When services are covered by both Medicare and Medicaid, the beneficiary is not responsible for payment |
A biller will electronically submit a claim to the carrier via what? | Direct data entry |
The physician bills $500 to a patient. After submitting the claim to the insurance company the claim is sent back with no payment. The patient still owes $500 what is this called | Deductible |
When I physician documents a patient’s response to symptoms and various body systems, the results are documented by | Review of systems |
What is a correct entry of a charge of $150 in black 24F of the CMS 1500 claim form | 150 00 |
On the CMS 1500 claim form, box 1- through 13 include | The patient’s demographics |
* what situations constitutes a consultation? | Services rendered by physician whose opinion or advice is requested by another physician or agency. |
If a patient has osteomyelitis, he has a problem with what area? | Bones and bone marrow |
What form must the patient or representative sign to allow the release of protected health information | An authorization |
* Block 17 be on the CMS 1500 claim form should list what information* | Referring physicians national provider identifier(NPI) number |
What was developed to reduce Medicare program expenditures by detecting in appropriate codes and illuminating improper coding practices? | NCCI |
What describes the status of a claim that does not include required pre-authorization for a service? | Denied |
What parts of the body system regulates immunity | Lymphatic system |
What is used by providers to remove errors for claims before they are submitted to third-party payers? | Clearinghouses |
What information should the billing and coding specialist and put into black 33A on the CMS 1500 claim form? | National provider identification number |
* A provider receives a reimbursement from a third-party payer accompanied by what document? | Explanation of benefits |
What is the third stage of the lifecycle of a claim | Claims adjudication |
What block on the CMS 1500 claim form is required to indicate a Worker’s Compensation claim? | Block 10 A |
Two providers from the same practice visit a patient in the emergency department using the same CPT code. The claim May be Denied due to | Duplication of services |
If patient has had an emergency appendectomy while on vacation the claim is rejected due to patient updating services out of network. What information should be included in the claim appeal? | The patient was out of town during the emergency |
* what is a type of claim that will be denied by a third-party payer? | Incomplete claim |
What steps would be part of a physicians practice compliance program | Internal monitoring and auditing |
A patient has met a Medicare deductible of $150. The patient’s coinsurance is 20% and the allowed amount is $600. What is the patients out-of-pocket expense | $120 |
What is the primary information to use to determine the priority of collection letters to patient’s? | The age of the account |
What claims would appear in the aging report | A claim that is delinquent for 60 days |
What is the portion of the account balance that patient must pay after services are rendered and the annual deductible is met? | Coinsurance |
* What do you physicians use to electronically submit claims | Clearinghouse |
* what is a requirement of some third-party payers before a procedure is performed? | Pre-authorization form |
What indicates a claim should be submitted on paper instead of electronically | The claim requires an attachment |
What coding manual is used primarily to identify products, supplies, and services? | HCPCS level two manual |
* A billing and coding specialist should enter the prior authorization number on the CMS 1500 claim form and what block | Block 23 |
What documents is required to disclose in adult patients information? | A signed release from the patient |
A provider performs an examination of a patient sore throat during an office visit. What describes the level of the examination | Problem focused examination |
A dependent child whose parents both have insurance coverage comes to the clinic. The billing and coding specialist is the birthday Ruth determine which insurance policy is primary. What describes the birthday rule? | The parent whose birth date comes first in the calendar year |
What sections of the medical record is used to determine the correct evaluation and management codes used for billing and coding? | History and principal |
What modifier should be used to indicate if professional service has been discontinued prior to completion? | -53 |
When an electron a claim is rejected due to incomplete information, what action should the billing and coding specialist take? | Complete the information and re-transmit according to the third-party standards |
* what is the purpose of running an aging report each month? | It indicates what claims are outstanding |
Hey physician ordered a comprehensive metabolic panel for a 70-year-old patient who has Medicare as her primary insurance. What form is required for the patient was she may be responsible for payment? | Advanced beneficiary notice |
What describes an obstruction of the urethra? | Urethratresia |
* which of the following is an example of electronic claim submission? | Claim submitted via a secure network |
Test results indicated that no abnormalities were found in the brain and the brains electrical activity patterns are normal. What test was used to conduct this exam? | ECG An electroencephalography |
The standard abbreviation ECG refers to a test used to assess which body system? | Cardiovascular system checks for problems with the electrical activity of the heart |
When billing is secondary insurance company, what block should the billing and coding specialist fill out on the CMS-1500 claim form? | 9a |
What actions should the billing and coding specialist take to effectively manage accounts receivable? | Collect copayment from the patient at the time of service |
A participating Blue Cross Blue Shield provider receives an exclamation of benefits for a patient account. The charged amount was $100. Bcbs allowed $80 and applied $40 to the patient’s annual deductible. | Bcbs paid the balance at 80% how much should the patient expect to pay? $48.00 |
What is the maximum number of ICD codes that can be entered on a CMS 1500 claim form as of February 2012? | 12 |
What is considered the final determination of the issues involving settlement of an insurance claim? | Adjudication |
What statement is true regarding the release of patient records? | Patient access to psychotherapy notes may be restricted |
What action should the billing and coding specialist take to prevent fraud use in the medical office? | Internal monitoring and auditing |
Why does correct claim processing rely on accurately completed encounter forms? | They streamline patient billing by summarizing the services rendered for a given date of service. |
For what time period Should the billing and coding specialist track unpaid claims before taking follow up actions? | 30 days |
When posting payment accurately, what items should the billing and coding specialist include? | Patients responsibility |
* A beneficiary of a Medicare or Medicaid crossover claim submitted by a participating provider is responsible for what percentages? | 0% When services are covered by both Medicare and Medicaid, the beneficiary is not responsible for payment |
A biller will electronically submit a claim to the carrier via what? | Direct data entry |
The physician bills $500 to a patient. After submitting the claim to the insurance company the claim is sent back with no payment. The patient still owes $500 what is this called | Deductible |
When I physician documents a patient’s response to symptoms and various body systems, the results are documented by | Review of systems |
What is a correct entry of a charge of $150 in black 24F of the CMS 1500 claim form | 150 00 |
On the CMS 1500 claim form, box 1- through 13 include | The patient’s demographics |
* what situations constitutes a consultation? | Services rendered by physician whose opinion or advice is requested by another physician or agency. |
If a patient has osteomyelitis, he has a problem with what area? | Bones and bone marrow |
What form must the patient or representative sign to allow the release of protected health information | An authorization |
* Block 17 be on the CMS 1500 claim form should list what information* | Referring physicians national provider identifier(NPI) number |
What was developed to reduce Medicare program expenditures by detecting in appropriate codes and illuminating improper coding practices? | NCCI |
What describes the status of a claim that does not include required pre-authorization for a service? | Denied |
What parts of the body system regulates immunity | Lymphatic system |
What is used by providers to remove errors for claims before they are submitted to third-party payers? | Clearinghouses |
What information should the billing and coding specialist and put into black 33A on the CMS 1500 claim form? | National provider identification number |
* A provider receives a reimbursement from a third-party payer accompanied by what document? | Explanation of benefits |
What is the third stage of the lifecycle of a claim | Claims adjudication |
What block on the CMS 1500 claim form is required to indicate a Worker’s Compensation claim? | Block 10 A |
Two providers from the same practice visit a patient in the emergency department using the same CPT code. The claim May be Denied due to | Duplication of services |
If patient has had an emergency appendectomy while on vacation the claim is rejected due to patient updating services out of network. What information should be included in the claim appeal? | The patient was out of town during the emergency |
* what is a type of claim that will be denied by a third-party payer? | Incomplete claim |
What steps would be part of a physicians practice compliance program | Internal monitoring and auditing |
A patient has met a Medicare deductible of $150. The patient’s coinsurance is 20% and the allowed amount is $600. What is the patients out-of-pocket expense | $120 |
What is the primary information to use to determine the priority of collection letters to patient’s? | The age of the account |
What claims would appear in the aging report | A claim that is delinquent for 60 days |
What is the portion of the account balance that patient must pay after services are rendered and the annual deductible is met? | Coinsurance |
* What do you physicians use to electronically submit claims | Clearinghouse |
* what is a requirement of some third-party payers before a procedure is performed? | Pre-authorization form |
What indicates a claim should be submitted on paper instead of electronically | The claim requires an attachment |
What coding manual is used primarily to identify products, supplies, and services? | HCPCS level two manual |
* A billing and coding specialist should enter the prior authorization number on the CMS 1500 claim form and what block | Block 23 |
What documents is required to disclose in adult patients information? | A signed release from the patient |
What billing patterns is a best practice action? | Documenting the patient’s chief complaint, history, exam, assessment, and plan for care |
Behavior plays an important part of being a team player in the medical practice. What is an appropriate action for the billing and coding specialist to take? | Communicating with the front desk staff during a team meeting about information missing in patient files |
A billing and coding specialist is reviewing a CMS 1500 claim form. The a OB box has been checked yes. The check box indicates | The provider receives payment directly from the payer |
What is the correct term for an amount that has been determined uncollectible | Bad debt |
* accepting assignments on the CMS 1500 claim form indicates what | The physician agrees to except payment under the terms of the payers program |
* What statement is true when determining patient financial responsibility by reviewing the remittance advice? | Any coinsurance, copayments, or deductibles can be collected from the patient |
What is an example of a violation of an adult patient confidentiality? | Patient information was disclosed to the patient’s parents without consent |
What is the function of the respiratory system? | Oxygenating blood cells |
What is a private insurance carrier | Blue Cross/Blue Shield |
What insurance carriers is considered the pair of last resort? | Medicaid |
What is the purpose of an internal auditing program in a physicians office? | Verifying that the medical records and billing records match |
* in an outpatient setting, what form is used as a financial report of all services provided to patients? | Patient account record, (also known as the patient ledger it contains all the transactions between a patient and the practice.) |
What is the appropriate diagnosis for a patient who has an abnormal accumulation of fluid in her lower leg that has resulted in swelling? | Edema |
What type of health insurance plans best describes a government sponsored benefit program? | Tricare prime |
* What organizations identifies improper payments made on CMS claims? | Recovery audit contractor(RAC) BRAC programs mission is to identify and correct improper agreements through the efficient detection and collection of overpayments made on CMS claims for healthcare services |
* What information is required to include on an advanced beneficiary notice (ABN) form? | The reason Medicare may not pay |
What block on the CMS 1500 claim form is used to build ICD codes? | Black 21- The ICD indicator |
What is the advantage of electronic claim submission? | Claims are expedited |