Help
Options
Didn't know it?
click below
click below
Knew it?
click below
click below
Don't Know
Remaining cards (0)
Know
retry
shuffle
restart
0:00
Embed Code - If you would like this activity on your web page, copy the script below and paste it into your web page.
Normal Size Small Size show me how
Normal Size Small Size show me how
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. |
Created by:
shulukong
Popular Medical sets