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Exam 4
HIT Classification and Reimbursement
| Question | Answer |
|---|---|
| A payer’s initial processing of a claim screens for | basic errors in claim data or missing information. |
| Some automated edits are for | patient eligibility, duplicate claims, and noncovered services. |
| A claim may be downcoded because | the documentation does not justify the level of service. |
| Payers should comply with the required | claim turnaround time. |
| What is the next step after the primary payer’s RA has been posted when a patient has additional insurance coverage? | billing the second payer |
| Appeals must always be filed | within a specified time. |
| Determine what should be verified after an RA has been checked for the patient’s name, account number, insurance number, and date of service. | that all billed CPT codes are listed |
| If a patient has secondary insurance under a spouse’s plan, what information is needed before transmitting a claim to the secondary plan? | RA data |
| What type of codes explain Medicare payment decisions? | MOA |
| Which of the following appears only on secondary claims? | primary payer payment |
| A payer may __________ a procedure that it determines was not medically necessary at the level reported. | downcode |
| What is the correct order for the basic steps of a payer's adjudication process? | initial processing, automated review, manual review, determination, and payment |
| During the adjudication process, if there are problems during the automated review, the claim is pulled for | development. |
| The __________ verifies the medical necessity of providers' reported procedures. | claims examiner |
| When a claim is pulled by a payer for a manual review, the provider may be asked to submit | clinical documentation. |
| A payer's initial claim review may reject a claim due to | an invalid policy number. |
| A payer's automated claim edits may result in claim denial because of | any of these. lack of required preauthorization. lack of medical necessity. lack of eligibility for a reported service. |
| Medical situations in which a patient receives extensive care from two or more providers on the same date of service are called | concurrent care. |
| Concurrent care is care provided | to a patient on the same date at the same place of service by two or more physicians. |
| A payer's decision regarding whether to pay, deny, or partially pay a claim is called | determination. |
| What is done by a payer to determine the appropriateness of medical services? | utilization review |
| What will a payer do when a claim is submitted with a diagnosis code that is not valid for the date of service? | Payers may deny a claim when outdated codes are used. |
| The payer's processing of claims is called | adjudication. |
| A payer's determination means it is going to | pay, deny, or partially pay the claim. |
| Which of these HIPAA transactions is sent by a payer to answer a question about a submitted claim? | 277 |
| The claim turnaround time is the period between | the date of claim transmission and receipt of payment. |
| An __________ code indicates that a request for more information has been sent. | R |
| A(n) __________ claim status category code is an acknowledgment that the claim has been received. | A |
| An insurance aging report lists | unpaid claims transmitted to payers by the length of time they remain due. |
| A list of claims transmitted and how long they have been in process with the payer is shown in the | insurance aging report. |
| Prompt-pay laws govern | insurance carriers' payments of providers' claims. |
| On an aging report, which category describes a current invoice? | 0–30 days |
| A typical aging report groups payments that are due into which of these categories? | 0–30 days, 31–60 days, 61–90 days, 91–120 days, and over 121 days |
| A pending claim is indicated by which claim status category code? | P |
| The payer's RA shows | both the amount the provider is allowed and the amount patient pays. |
| Claim adjustment reason codes are used by payers to explain entries on | RAs. |
| What kind of code appears on payers' electronic reports on the progress of transmitted claims in their adjudication process? | claim status category codes |
| The payer sends the medical practice | an RA that covers a batch of processed claims. |
| A paper explanation of benefits (EOB) is sent to patients by payers after claims | are adjudicated. |
| Remittance advice remark codes are maintained by __________ but can be used by all payers. | CMS |
| RAs generally have information on any | all of these are correct. errors on the listed claims. denials to the listed claims adjustments to the listed claims. |
| The first step the medical billing specialist should check when reviewing RAs is to | match up claims with the RA using the unique claim control number. |
| The advantage(s) of EFT for practices is(are) | funds are available immediately and the transfer is less costly than check deposits. |
| The process of __________ means verifying that the totals on the RA are mathematically correct. | reconciliation |
| What does "reconciliation" mean? | to double-check that totals are accurate and consistent |
| Funds that are electronically transferred from a payer are directly deposited in the | practice's bank account. |
| The person filing an appeal is known as a(n) __________, regardless of whether that individual is a provider or a patient. | either the claimant or the appellant |
| The claimant is the | patient or provider who appeals the claim. |
| The abbreviation MRN stands for | Medicare Redetermination Notice. |
| In general, how many levels are there when pursuing an appeal? | three |
| When is an appeal sent to third-party payers? | after a claim is rejected or paid at less than the expected amount |
| Medicare overpayments must be reported and the amount | must be returned within 60 days. |
| Filing a grievance with the state insurance commission requires the __________ to investigate the complaint. | state |
| If a patient has additional insurance coverage, after the primary payer's RA has been posted, the next step is | billing the second payer. |
| Which of the following statements is true? | Medicaid is the secondary payer to Medicare. |
| If a Medicare beneficiary receives treatment covered by workers' compensation, the Medicare plan is | secondary. |
| If a Medicare beneficiary is employed and covered by the employer's group health plan, the Medicare plan is | secondary. |
| The abbreviation MSP stands for | Medicare Secondary Payer. |
| If a Medicare beneficiary is covered by a spouse's employer group health plan, the Medicare plan is | secondary |
| The Medicare Secondary Payer program coordinates the benefits for patients who have both Medicare and | any other insurance coverage. |
| When talking with someone other than the patient about an overdue bill, collections specialists will | not discuss the patient’s debt. |
| The day sheet produced by the practice management program shows | the payments and charges that occurred on that date. |
| During collections, most practices use | letters and calls. |
| Credit bureaus keep records about a patient’s | credit information. |
| Collection calls are regulated by the guidelines set by | FDCPA. |
| Accounts might be considered uncollectible when a patient | files for bankruptcy. |
| Skip tracing increases the practice’s chances of | locating a patient with an overdue bill. |
| The practice will need to pay patient refunds if it has | overcharged the patient for a service. |
| The patient aging report is used to | collect overdue accounts from patients. |
| Bad debt is defined as | uncollectible A/R. |
| Effective patient billing begins with | sound financial policies. |
| A good financial policy is clear to | both patients and the practice staff. |
| When a practice accepts a credit card payment in advance for payments billed after treatment, what does the practice send the patient? | zero-balance statement |
| A patient statement is | a bill that is sent to a patient for medical services that have been provided. |
| Which of the following shows a particular day's transactions? | day sheet |
| What document is used by the medical insurance specialist to update the patient billing program with the payer's payments and the amount due from the patient? | RA |
| The __________ totals the transactions that were posted to all patient ledgers on a particular business day. | day sheet |
| The day sheet in a medical office summarizes | all the transactions that were posted to all patient ledgers on a particular business day. |
| What is a printed bill that shows the amount a patient owes? | patient statement |
| The patient statement shows | all of these the balance that a patient owes the practice. the services provided to the patient. how much the insurance paid. |
| The type of patient billing that spreads out the workload of mailing statements is called | cycle billing. |
| In cycle billing, how often does the practice mail all patient statements? | at intervals during the month |
| Patients are grouped under the insurance policyholder in what type of billing? | guarantor billing |
| Under the Federal Trade Commission's rules, it is illegal to | call multiple times daily. |
| For most patients, their first notice that their bill is past due is a | collection letter. |
| The law that regulates calling hours and collections methods is | Telephone Consumer Protection Act. |
| The __________ report is the start of the process of collecting payments due from patients. | patient aging |
| The law that regulates collection practices is | FDCPA. |
| Who is responsible for regulating the hours during which collection calls may be made? | both the FDCPA and the Telephone Consumer Protection Act |
| Collections from patients are classified as consumer collections and are regulated by __________ and state laws. | federal |
| Under the Federal Trade Commission's rules, it is not illegal to | call a patient at 8 p.m. |
| FDCPA is the abbreviation for | Fair Debt Collection Practices Act. |
| The job of creating and implementing the practice's collections policies is done by | the billing/collections manager. |
| Embezzlement is a form of | stealing. |
| What term refers to the stealing of funds? | embezzlement |
| What term refers to all the activities that are related to patient accounts and follow-up? | collections |
| The process of following up on overdue accounts is called | collections. |
| The job of accurately recording the funds coming into and going out of the practice is done by | the bookkeeper. |
| Which of the following employees learns and applies the correct techniques for effective follow-up of overdue accounts, as well as is most likely to work directly with patients? | collections specialist |
| Patients may agree to a(n)__________ for expensive procedures before the date of service. | prepayment plan |
| Which of the following is the cost of a borrower's credit calculated as an annual rate? | annual percentage rate |
| When patients are scheduled to have major, expensive procedures, the practice's policy may be to set up | prepayment plans. |
| The __________ process is used to locate a patient who owes an account balance to the practice. | skip tracing |
| Which law modified the Fair Credit Reporting Act to protect the accuracy and privacy of credit reports? | FACTA |
| A collection agency is usually | an outside firm the medical practice hires. |
| FACTA is the acronym for | Fair and Accurate Credit Transaction Act. |
| FCRA is the abbreviation for | Fair Credit Reporting Act. |
| Credit bureaus supply information about | how well patients pay their bills. |
| Collection agencies are outside services that are hired to | collect overdue accounts. |
| Which law required consumer reporting agencies to have reasonable and fair procedures? | FCRA |
| The __________ helps a practice decide whether patients are indigent. | means test |
| __________ is a legal declaration of a person's inability to pay his or her debts. | Bankruptcy |
| Which of the following requires a practice to follow a specific series of steps before an account can be written off? | both Medicaid and Medicare |
| Uncollectible accounts refer to | monies owed by patients and payers. |
| When a person receives a legal declaration of the inability to pay debts, it is called | bankruptcy. |
| What is the term for monies owed to a patient from the provider? | patient refund |
| Bad debt includes all collections that are | classified as uncollectible accounts. |
| HIPAA compliance records must be retained for how many years? | six |
| A __________ is a log of how long various types of documents must be stored for a particular practice. | retention schedule |
| The practice's policy about keeping records is summarized in a __________, a list of the items from a record that are retained and for how long. | retention schedule |
| When the hospital staff collects data on a patient who is being admitted for services, the process is called | registration |
| Which of the following hospital departments has different procedures for collecting patients’ personal and insurance information? | emergency department |
| Patient charges in hospitals vary according to | their accommodations and services. |
| Which of these rules governs the reporting of hospital inpatient services on insurance claims? | UHDDS |
| Conditions that arise during the patient’s hospital stay as a result of surgery or treatments are called | complications. |
| In inpatient coding, the initials CC mean | comorbidities and complications. |
| The code 02103D4 is an example of which type of code? | ICD-10-PCS |
| Under a prospective payment system, payments for services are | set in advance. |
| The UB-04 form locator 4 requires the | type of bill. |
| Under Medicare rules for patients in car accidents, the automobile insurance is | primary |
| In medical insurance terminology, an emergency is a | situation in which delaying the treatment of a patient would result in a significant increase in the threat to life or to the viability of the body part. |
| Ambulatory care refers to which kind of care? | outpatient |
| What is a special approach to caring for people with terminal illnesses? | hospice care |
| ASU is the abbreviation for | ambulatory surgical unit. |
| __________ involves a situation that is life-threatening. | Emergency care |
| What involves a situation in which a delay in treatment would lead to a significant increase in the threat to a patient's life or body part? | emergency care |
| __________ is palliative care for terminally ill patients. | Hospice care |
| What type of facility is equipped for patients to stay overnight? | inpatient |
| A(n) __________ is a person admitted for services that require a stay spanning two midnights. | inpatient |
| Hospice care is provided | either in a special hospice facility or a patient's home. |
| ASC is the abbreviation for | ambulatory surgical center. |
| HHA is the abbreviation for | home health agency. |
| What category of services includes care given at home, such as physical therapy or skilled nursing care? | home health care |
| SNF is the abbreviation for | skilled nursing facility. |
| What type of care covers all types of health services that do not require an overnight hospital stay? | ambulatory care |
| An ambulatory surgical center is a clinic that provides | outpatient surgery. |
| At-home recovery care refers to assistance with which of the following? | the activities of daily living, such as bathing and eating |
| Ambulatory care is provided in a(n) | outpatient facility or setting. |
| The__________ is the main database of a hospital's patients. | master patient index |
| Inpatients are admitted to hospitals in a process called | registration. |
| A charge master contains a hospital's list of all of the following except | staff. |
| patient's personal and insurance information is gathered before or during hospital admission through which process? | registration process |
| Patients are listed in a patient register under a unique number, which makes up the | master patient index. |
| A __________is the hospital's list of the codes and charges for its services | charge master |
| HIM is the abbreviation for | health information management. |
| The HIM department in hospitals conducts which of the following | organizes and maintains patient medical records |
| The major steps related to hospital claims processing are | admission, treatment, and discharge. |
| Which term is generally used for the hospital admission process? | registration |
| HINN is the abbreviation for | Hospital-Issued Notice of Noncoverage. |
| CC is the abbreviation used by the inpatient coder on the medical record for _________. | complications and comorbidities |
| A patient's other conditions at admission that affect care during the hospitalization being coded are called __________, meaning coexisting conditions. | comorbidities |
| Which term describes the patient's condition that, after study, is established as the main reason for a hospital admission? | principal diagnosis |
| Which of these terms refers to coexisting conditions? | comorbidities |
| UHDDS is the classification system for | inpatient health data. |
| Which term describes the patient's condition upon hospital admission? | admitting diagnosis |
| Which term describes the main service performed for the condition listed as the principal diagnosis for a hospital inpatient? | principal procedure |
| The principal procedure is assigned by the | inpatient medical coder. |
| MS-DRG is the abbreviation for | Medicare-Severity Diagnosis Related Group. |
| APC is a __________ payment system. | Medicare |
| __________are complications caused by avoidable conditions that will not be reimbursed. | Never events |
| Each MDC is subdivided into __________ MS-DRGs. | medical and surgical |
| APC is the abbreviation for | ambulatory payment classifications. |
| DRG is the abbreviation for | diagnosis related group. |
| The DRG system is now called which of the following | MS-DRGs |
| The IPPS is the Medicare system for payments to institutions for | inpatients. |
| Each hospital's __________ is an average of the DRG weights handled for a specific period of time. | case mix index |
| Each hospital negotiates a rate for MS-DRGs based on which of the following? | all of these are factors in the rate supply costs geographic location labor |
| A grouper is software used to help calculate and assign | DRGs. |
| The UB-04 form is also identified as the __________ form. | CMS-1450 |
| Hospitals must submit electronic claims for Medicare Part A reimbursement to MACs using the HIPAA health care claim called | 837I. |
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