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CBCS studyguide book

Test/Quiz questions

QuestionAnswer
Chapter 1: Regulatory Compliance (19 scored questions) Appropriate Documentation
1. Which of the following accurately describes the difference between informed and implied consent? Informed consent is required in writing after explanation of a procedure, with time to ask questions, while implied consent is assumed.
2. What is documentation? Documentation is a complete, accurate, up-to-date record of the care a patient receives at a health care facility.
3. Disclosure refers to the way health information is Given to an outside person or organization.
4. What is the difference between consent and authorization? Authorization is permission granted by the patient or their representative to release information for other than treatment, payment, or health care operations. Consent is used only when the permission is for treatment, payment, or health care operations.
5. True or False: Physicians have the option to decide whether to explain privacy rules to their patients. False. Physicians are legally obligated to explain privacy rules to their patients.
Billing Audits
6. Auditing refers to which of the following? Reviewing claims for accuracy and completeness.
7. True or False: Fraud is intentional misrepresentation of information for the purposes of receiving higher payments, while abuse happens unintentionally, often because of poor business practices. True. Fraud is knowingly billing for services or supplies not provided. Abuse is any practice inconsistent with the goals of providing patients with services that are medically necessary, meet professionally recognized standards, and are fairly priced.
Laws, Regulations, and Administering Agencies
8. Which of the following accurately defines upcoding? Assigning a code that will deliberately result in a higher payment.
9. The Stark Law states that Physicians can’t refer patients to practitioners with whom they have a financial relationship.
10. The Office of the Inspector General is responsible for Fighting fraud.
Chapter 2: Claims Processing (28 scored questions) Transmitting Claims
1. What is a claim? A claim is a complete record of all the services provided to a patient.
2. Identify two items of information that need to be on a claim. Possible answers include the patient’s name, health record number, account number, and demographic information, the subscriber number, group or plan number, and the provider’s name.
3. Which of the following describes a clean claim? All the necessary data elements are completed.
4. True or False: In 2012, the Administration Simplification compliance Act (ASCA), part of HIPAA, mandated that health care claims be submitted electronically, with some exceptions. True. One exception is if a provider uses a clearinghouse to submit claims. In this case, the draft sent to the clearinghouse may be completed on paper, and the correct form to use is the CMS-1500.
CMS-1500 Form
5. The primary insurance plan does which of the following? Pays first.
6. What is an NPI number? Where does it go on the CMS-1500? NPI is a unique id number for all HIPAA-covered entities, (individuals, orgs., home health agencies, clinics, LT care facilities, residential treatment centers, labs, ambulances, group practices, and HMOs). NPIs go in blocks 17b, 19, 24J, 32A, and 33A.
7. True or False: Misspelling a patient’s name is a common processing error. True. Nicknames and hyphenated last names can complicate the task of getting the patient’s name correct. Based on 2011 results, the average claims processing error rate was 19.3%.
8. True or False: You are allowed to use both six and eight digits for the date on one claim. False. You need to pick one style and use it throughout the claim.
9. Describe when Medicare is the secondary insurance for a patient. Medicare is the secondary insurance for a patient when he/she has a group health insurance plan, is covered by workers’ compensation, or is on disability.
10. By signing block 12 on the CMS-1500 form, a patient is doing which of the following? Authorizing the release of medical information needed to process a claim.
Chapter 3: Front-End Duties (10 scored questions) Collecting Patient Information
1. Name three kinds of insurance information that needs to be collected from the patient. Among the correct responses are the correct policy number and group number, if applicable; policy effective dates; and type of policy.
Insurance Eligibility
2. Coordination of benefits involves which of the following? Determining which insurance is primary and which is secondary.
3. True or False: The birthday rule is a way to mark how long a patient has had his insurance policy. False. The birthday rule is a way to determine primary insurance if both parents have insurance and list their children as dependents. The insurance of the parent whose birthday is first in the calendar year is considered the primary insurance.
Government and Commercial Insurance
4. What is the difference between Medicare and Medicaid? Medicare is a government-based insurance plan that covers people older than 65, those younger than 65 with disabilities, and those with end-stage kidney disease. Medicaid covers low-income families and individuals.
5. What is the advantage of employer-based self-insured health plans? Due to economies of scale, employer-based self-insured health plans are more reasonably priced than private insurance.
Patient Authorization and Referral Forms
6. Which of the following accurately defines preauthorization? A health plan gives approval for an inpatient hospital stay or a surgical procedure.
Determining Balance Due
7. Which of the following accurately describes a deductible? The amount the patient must pay before the insurance company will start to provide benefits.
8. True or False: A copay is the patient’s share of the insurance premium. False. Insurance premium is a weekly, monthly, or annual cost for the plan or insurance coverage. Copayment is the out-of-pocket cost.
9. Name one advantage and one disadvantage of a PPO. They generally provide greater choices in healthcare, patients can choose who they and don’t need a referral from the provider to see a specialist. A disadvantage is that cost-control measures, such as coinsurance and copayments, are usually in place.
10. What is the coinsurance percentage? It is the amount the provider is allowed for the service and the amount he was paid. The patient has coinsurance responsibility to what provider was allowed. A common percentage split is 80% for the insurance carrier and 20% for the patient.
Chapter 4: Payment Adjudication (23 scored questions) Analyzing Aging Reports
1. What is the role of the accounts receivable department? The accounts receivable department manages follow-up to the billing process for a provider’s office.
2. What are two kinds of information the CDM stores? Among the correct responses are description of service, CPT/HCPCS code(s), revenue code, charge amount, charge or service code, general ledger key, and activity/status date.
3. An aging report refers to which of the following? The claims that are outstanding.
Interpreting Remittance Advice
4. True or False: An RA is sent to policyholders. False. An RA is sent to the provider, not the policyholders.
5. The allowable charge is which of the following? Amount the health insurance company will pay providers.
Posting Payments
6. Which of the following is NOT a charge the patient is expected to pay? Difference between a provider’s charges and what the insurance company will pay.
7. The term reconciliation means which of the following? Determining how much the provider has been reimbursed and how much the patients owe.
Determining Reasons for Insurance company Denial
8. What are the four types of nonmedical codes used by Medicare to explain claims? Group codes, claims adjustment reason codes (CARCs), remittance advice remark codes (RARCs), and provider-level adjustment reason codes aren’t related to a specific claim. These adjustments are made by the provider’s office.
9. Who benefits from the new appeals process, and why? The patient benefits because the new process lays out steps the insurance company must follow and make sure that the tasks get done in a timely fashion.
10. When can a patient request an external independent review? The patient can request an external independent review after an internal appeal has been denied.
Chapter 5: Apply Knowledge of Coding (20 scored questions) Coding Guidelines and Conventions for Diagnoses and Procedures
1. List three purposes of ICD-10-CM. Reporting national morbidity/mortality data, indexing records by disease/operations, reporting dx, storing/retrieving data, DRG assignments, reporting/compiling hc data, determining patterns of care, analyzing payments and conducting research.
2. True or False: The following represents a disease coded under ICD-10-CM: E10.2. True. For ICD-10-CM codes, the first character is a letter followed by digits. Characters three through seven can be numbers or letters.
3. What are the goals of ICD-10-PCS? The goals of the ICD-10-PCS are to improve accuracy and efficiency of coding, reduce training effort, and improve communication with physicians.
4. What character of ICD-10-PCS for medical or surgical procedure would identify the Medical/Surgical section’s body part? Character 4.
Healthcare Common Procedure Coding Systems (HCPCS)
5. CPT codes are used to describe which of the following? Services rendered by the provider.
6. What is the purpose for using modifiers? Modifiers provide the means to report or indicate a service or procedure that has been altered by some specific circumstance but not changed in its definition or code.
7. What are HCPCS Level II codes used for? HCPCS Level II codes were established to report services, supplies, and procedures not represented in the CPT.
Abstracting Medical Documents
8. Abstracting involves which of the following? Selecting relevant information from the health record.
9. Abstracted information is which of the following? Coded.
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