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BCBS
Billing and Coding Master List
| Question | Answer |
|---|---|
| Medical Ethics are | Standards of conduct based on moral principals. Acting within ethical behavior boundries means carrying out one's responsibilities with integrity, decency, respect, honesty, competence, fairness and trust. Compliance Regulations |
| Modifiers | Reporting indicators that indicate that the procedure or service has been altered by specific circumstance but has not changed in it's definition of code. |
| Parentheses | Used to enclose supplementary words, non-essential modifiers |
| Past, Family and Social History (PFSH) | Consists of patients personal experiences with illnesses, surgeries, and injuries; Information of illnesses predominant in family; Patients educational background, occupation, marital status and other factors |
| Pathology and Laboratory | 80048-89356 |
| Plus sign indicates | add on codes |
| Radiology | 77010-79999 |
| Review of Symptoms (ROS) | Inventory of the constitutional symptoms regarding the various body systems |
| Stand Alone Codes | Contain full description to the procedure for a code. |
| Sideways triangle means | change in wording between triangles |
| Bullet means | new procedure code |
| Circle with a line through it means | modifier 51 exempt code |
| Six sections of CPT | E&M, Anatomical Site, Condition or Disease, Synonym or Eponym, Abbreviation. |
| 3 sections for E&M Codes | 1.History 2.Physical Exam 3.Medical Decision-Making |
| CPT codes 3 categories are what? | Category I: Procedures that are consistent with contemporary medical practice and are widely performed. Category II: Supplementary tracking used for performance measures. Category III: Temporary codes for emerging technology, services & procedures. |
| 4 contributing factors for E&M Codes | New or existing patient, History, Physical Exam, Medical Decision making, Time spent can be a 5th factor |
| Medicare part A | Part A is hospital insurance provided by Medicare. Most people do not pay a premium for this coverage. |
| Medicare part B | Part B is medical insurance to pay for medically necessary services and supplies provided by Medicare. (Doctors, outpatient care, Phys. and Occ. Therapists etc.) |
| Medicare part C | Part C is the combination of Part A and Part B. The main difference in Part C is that it is provided through private insurance companies approved by Medicare. |
| Medicare part D | Part D is stand-alone prescription drug coverage insurance. |
| Medicaid | free or low-cost health insurance coverage through the state |
| Medicaid catagorically needy | A distinction for individuals who fall into a specific category (or criteria)of mandatory Medicaid eligibility established by the federal government. These categories apply to every state Medicaid program. |
| Medicaid Medically Needy | provide Medicaid to certain groups not otherwise eligible for Medicaid.must cover: •Pregnant women •Children under 18.: States have option to cover:•Children up to 21•Parents and other caretaker relatives•Elderly•Individuals with disabilities |
| Who is the Payer of Last Resort? | Medicaid is always the payor of last resort. |
| TRICARE | health care program for Uniformed Service members, retirees and their families |
| TRICARE STANDARD | option that provides the most flexibility to TRICARE-eligible beneficiaries. It is the fee-for-service option that gives beneficiaries the opportunities to see any TRICARE-authorized provider. |
| TRICARE EXTRA (PP0) | A preferred provider option, rather than an annual fee, a yearly deductible is charged. Health care is delivered through a network of civilian health care providers who accept payments from CHAMPUS and provide services at negotiated, discounted rates |
| TRICARE PRIME (HMO) | An HMO type plan in which enrollees receive health care through a Military Treatment Facilities PCM or a supporting network of civilian providers |
| CHAMPVA | comprehensive health care program in which the VA shares the cost of covered health care services and supplies with eligible beneficiaries. |
| Private payer vs Commercial payer | Private individuals are responsible for securing their own health insurance coverage. Commercial Government, Employer, Group health insurance coverage |
| Group Health Plans | An insurance plan that provides healthcare coverage to a select group of people. Group health insurance plans are one of the benefits offered by many employers. These are generally uniform in nature, offering the same benefits to all members of group. |
| Indemnity insurance | Health indemnity insurance is a fee for service insurance that is sometimes used when a person is in between health plans, and will cover some (but not all) expenses |
| HMO | Health Maintenance Organization. A form of health insurance combining a range of coverages in a group basis. A group of doctors and other medical professionals offer care through the HMO for a flat monthly rate with no deductibles. |
| PPO is like a HMO but? | PPO is similar to an HMO, but care is paid for as received not in advance in form of a schedule. PPOs may offer more flexibility by allowing for visits to out-of-network professionals. Visits within network require only the payment of a small fee. |
| POINT OF SERVICE | feature of an insurance plan that allows a patient to choose 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, although the cost will vary |
| Disability Insurance | Insurance policy that pays benefits in the event that the policyholder becomes incapable of working. |
| Workman's Comp | Workman's compensation is a job benefit that provides money and services to employees that are injured or become sick on the job. Worker's comp helps injured and sick workers to survive financially as they recover from health problems. |
| Usual Customary and Reasonable | refer 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. |
| Relative Value Payment Method | The payment amount for each service paid under the physician fee schedule is the product of three factors; a nationally uniform relative value for service; a geographic adjustment factor (GAF); a nationally uniform conversion factor for the service. |
| Medicare Resource Based Relative Value Unit (RVU) Payments/Components | The schedule assigns certain values to procedures/costs based upon Total RVUs. The total consists of three components; work, practice expense, and malpractice. Medicare adjusts payment by geographic price cost index (GPCI) and pays depending on locale. |
| Clean Claim | A completed insurance claim form submitted with the program time limit that contains all the necessary information without deficiencies so it can be processed and paid promptly. |
| Dirty Claim | A claim submitted with errors or one that requires manual processing to resolve problems or is rejected for payment. |
| Invalid Claim | Any Medicare claim that contains complete, necessary information but is illogical or incorrect (e.g., listing an incorrect provider number for a referring physician). Invalid claims re identified to the provider and may be resubmitted |
| Rejected Claim | A rejected claim is an electronically submitted claim that is unprocessable due to missing or invalid information required by the payer. |
| ABN / Advance Beneficiary Notice | 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 payment. |
| Paper Claims /CMS 1500 | An insurance claim submitted on paper, including those opticaly scanned and converted to an electronic form by the insurance carrier |
| Electronic Claim | An insurance claim submitted to the insurance carrier via a central processing unit (CPU), tape, diskette, direct data entry, direct wire, dial-in telephone, digital fax, or personal computer download or upload |
| CMS 1500 Universal Claim Form | Developed by the AMA and the Centers for Medicare and Medicaid Services (CMS). Used by physicians and other professionals to bill outpatient services and supplies to Tricare, Medicare, some Medicaid programs, and some private insurance/managed care plans |
| Basic Billing Reimbursement Steps | Patient Info, Verify Ins. Prepare encounter form, Code DX & CPT, Review Linkage Protocol, Calculate physicians charges, Prepare claim, Transmit claim, Follow up on Reimbursement. |
| Review Linkage Protocol | Appropriateness of Codes, Payers rules about linkage, Documentation to support codes, Compliance with regulation and guidelines |
| Life Cycle of a Claim | Submission, Processing, Adjudication, Non-covered, Unauthorized, Medical Necessity Checks, Payment / RA / ERA |
| What does MAC stand for? | Medicare Administrative Contractor |
| "A condition that develops after, the outpatient care has been provided or during an inpatient admission." | Complication |
| "A concurrent condition that coexists with the first-listed diagnosis or principal diagnosis, has potential to affect treatment of the aforementioned diagnosis and is an active condition for which the patient is treated and/or monitored." | Comorbidity |
| The process by which the provider contacts the insurance carrier to see if the proposed procedure is covered by a specific patients insurance policy. | Preauthorization |
| Monies or Funds that are owed to the practice for services provided | Accounts Receivable (A/R) |
| Monies being paid from the medical practice, for instance to pay for supplies, rent, utilities, payroll, etc. | Accounts Payable (A/P) |
| What are the names of the three tables that appear in the Index to Diseases? | Hypertension Neoplasm Table of Drugs and Chemicals |
| The explanation of payments received from the insurance company is often referred to or called the _____________. | Remittance Advice |
| Billing a patient for the difference between a higher usual fee and a lower allowed charge is called _____________. | Balance Billing |
| ___________ is the national health insurance program for Americans aged 65 and older. | Medicare |
| A health-benefit program designed for low-income, blind, or disabled patients; needy families; foster children; and children born with birth defects. | Medicaid "payer of last resort" |
| What is the single largest healthcare program in the United States? | Medicare |
| Signed into law in 2010, an act that resulted in improved access to affordable healthcare coverage and protection from abusive practices by healthcare insurance companies is what? | Affordable Care Act (ACA) |
| Person who is responsible for a patients debt is called? | Guarantor |
| Medicare beneficiaries can also obtain supplemental insurance called what? | Medigap |
| What does Medigap do? | Helps cover costs not reimbursed by the original Medicare plan. |
| A writ requiring the appearance of a person at a trial or other proceeding is a ___ | ________. subpoena |
| When does the tertiary insurance pay? | After the primary and secondary insurers. |
| Healthcare Common Procedure Coding System (HCPCS) | A numeric and alphabetic coding system used for billing/pricing of procedures, medical supplies, medications, and durable medical equipment (DME). |
| A managed care organization that establishes a network of providers who care for their patients is called a/an _________. | Preferred Provider Organization (PPO) |
| A group that takes nonstandard medical billing software formats and translates them into the standard Electronic Data Interchange (EDI) formats is called a/an? | Clearinghouse |
| The out-of-pocket payment amount that a policyholder must meet before insurance covers the service(s) is called? | Deductible |
| National Provider Identifier (NPI) number | A unique 10-digit number assigned to providers in the U.S. to identify themselves in all HIPAA transactions. |
| What is a capitation? | A payment structure in which a health maintenance organization prepays an annual set fee per patient to a physician. |
| A fixed fee collected at the time of the patients visit. | Copayment |
| A fixed percentage of covered charges applied to the patients bill after the deductible has been met. | Coinsurance |
| The charge for keeping the insurance policy in effect. | Premium |
| Coding and billing that is inconsistent with typical coding and billing practices. | Abuse |
| How does HIPAA define fraud? | An intentional deception of misrepresentation. |
| "The difference between fraud and abuse is _______." | Intent |
| Current Procedural Terminology (CPT) codes | Numeric codes developed by the American Medical Association (AMA) to standardize medical services and procedures. |
| Is Abuse intentional? | No |
| What simplified process was developed to enable Medicare beneficiaries to participate in mass pneumococcal pneumonia virus (PPV) and influenza virus vaccination programs offered by public health clinics? | Roster Billing |
| A person filing an appeal is called? | Claimant |
| Covers injuries caused by insured that occurred on the insured's property. | Liability Insurance |
| A detailed accounting of the claims for which payment is being made by an insurance company. The __________ accompanies the payment from the insurance company. | Remittance Advice (RA) |
| Authorization by a policyholder that allows a payer to pay benefits directly to a provider is called? | Assignment of Benefits |
| A/An ___________ is a person admitted to a hospital or long-term care facility(LTCF) for treatment with the expectation that the patient will remain in the hospital for a period of 24 hours or more. | Inpatient |
| What is confidentiality? | Involves restricting patient information access to those with proper authorization and maintaining the security of patient information. |
| The first listed diagnosis can also be referred to as _____ | _________. Principal diagnosis |
| Physicians who enroll in managed care plans are called ______________. They have contracts with Managed Care Organizations (MCO)s that stipulate their fees. | Participating Providers |
| A formal, written document that describes how the hospital or physician's practice ensures rules, regulations, and standards that are being followed is known as a/an _______________. | Compliance Plan |
| What act mandated the reporting of ICD-9-CM diagnosis codes? | The Medicare Catastrophic Coverage Act of 1988 |
| Transmitting electronic medical insurance claims from providers to payers using the necessary information systems is called ______________. | Electronic Data interchange (EDI) |
| "A severe form of hypertension with vascular damage and a diastolic pressure reading of 130 mm hg or greater." | Malignant |
| "Mild and/or controlled hypertension, with no damage to the patient's vascular system or organs." | Benign |
| "No notation of benign or malignant status is found in the diagnosis or in the patient's chart." Would require what type of coding? | Unspecified |
| For Inpatient coding, the initials CC mean? | Comorbidities and Complications |
| What does policy mean? | Insurance |
| A person who receives a check in payment is the _________. | Payee |
| Insurer/Insured, Subscriber, Member, Recipient are all terms that apply to the? | Policyholder |
| True or False, Preferred Provider Organizations (PPO)s never allow members to receive care from physicians outside the network. | False, Policyholders may choose to go out of network, but the may have to pay greater expenses. |
| Everything a medical claims specialist learns about a patient's condition must remain _____________. | Confidential |
| Medicaid Card | A common method for verifying the patient's Medicaid eligibility is the ID card. This card provides important information regarding eligibility date and type shown on the face of the card. |
| Birthday Rule | The birthday rule determines which plan is primary(usually children) are listed as dependents on more than one health plan. It states that the health plan of the parent whose birthday comes first in the calendar year will be considered the primary plan. |
| Group Health Plan | Covers eligible employees and an employer or member. Employees employed full-time (or for a specific number of hours, 30 or 35 hours per week. |
| Diagnosis | The detemination of the nature of a cause of disease or the art of distinguishing one disease from another. |
| ICD-9-CM | International Classification of Disease 9th Revision, Clinical Modification |
| E-Codes | The Supplementary Classification of External Causes of Injury and Poisoning (codes E800-E999). |
| V-Codes | The Supplementary Classification of Factors Influencing Health Status and Contact with Health Services. V-Codes are used when circumstances other than a disease or injury are recorded as a diagnosis or problem. |
| Evaluation and Management Codes | Found in the beginning of the CPT manual. The E&M section of the CPT is divided into broad catergories, including office visits, hospital visits, and consultations. Coded 99201 and 99499). |
| TRICARE | Is the U.S. military's comprehensive healthcare program for active duty personnel and eligible family members, retirees and family members younger than age 65, and survivors of all uninformed services (i.e., Army, Air Force, Marines, Navy). |
| Referral/Authorization | Provided by the PCP to visit any physician, hospital, or other healthcare provider who belongs to the network. Authorization is a procedure required by most managed healthcare and indemnity plans before a provider carries out specific procedure/treatment |
| Allowable Charge | Are the fees Medicare permits for a particular service or supply. |
| Upcoding | Billing for a more expensive service or procedure than what was provided. |
| Workers' Compensation | Insurance that pays workers who are injured or disabled on the job or have job-related illnesses. |
| Federal Registry | A daily publication that provides a uniform system for publishing federal regulations, legal notices, presidential proclamations, and executive orders. |
| Insurance Log | Tracks the status of insurance claims. |
| Cafeteria Plan | A plan falls under the cafeteria category when the cost of the plan (premium) is deducted from the employee's wages before withholding taxes are deducted. |
| OCR | Means "Optical Charter Recognition". OCR is the recogntion of printed or written text charters by a computer. |
| POS | Is a "hybrid" type of managed care (also referred to as an open ended HMO) that allows patients to use the HMO provider or go outside the plan and use any provider they choose. |
| NON Par | A provider that has no contractual agreement with the insurance carrier; the provider does not have to accept insurane company's reimbursement as payment in full. |
| Examples of Medicaid Fraud | (1). Billing for medical services not actually performed (2). Billing for a more expensive service than was rendered (3). Billing separately for several services that should be combined into one billing (4). Billing twice for the same medical service |
| Examples of Medicaid Fraud | (5). Dispensing generic drugs and billing for brand name drugs (6). Giving or accepting something in return for medical services (kickbacks). (7). Bribery (8). Providing unnecessary services (9). False cost reports |
| Examples of Medicaid Fraud | (10). Billing for ambulance runs when no medical service is provided (11). Transporting multiple passengers in an ambulance and billing a run for each passenger. |
| Preventive Services Covered by Medicare | (1). Bone mass measurements (2). Colonrectal cancer screening (3). Diabetes services (4). Glaucoma testing (5). Pap tests, pelvic examinations, clinical breast examinations (6). prostate cancer screening (7). screening mammograms (8). certain vaccinations |
| Durable items | Pieces of equipment used indefinitely, such as telephones or computers. |
| Expendable Items | Items used and then restocked |
| Invoice | Describes amount due. |
| Disbursment | Cash amounts that are paid out. |
| Account Balance | The debit or credit amount remaining in an account. |
| Accounts Recievable | Amounts owed to your business for the service of goods supplied. |
| Accounts payable | amounts owed by your business to suppliers and creditors. |
| Assets | Total value of all cash and property. |
| Liabilities | Amounts owed to creditors. |
| Balance sheet | A financial statement for a specific date or period that indicated the total assets, liabilities, and capital of the business. |
| Single entry bookkeeping | Debit and charges in the same entry. |
| Double entry bookkeeping | Based on the equation assets=liabilities+owner equity |
| Accounts receivable ledger | Contains records of patient charges, payments, and adjustments. |
| Posting | The process of copying an amount from one record to another. |
| Trial balance | A method of checking the accuracy of accounts. Makes sure that numbers were not mistyped into the system. Example 3+4+7+8 = 22 3 +19 = 22 |
| Equity | The net worth of the medical office. |
| Balance | The different between the debit and credit totals. |
| Adjustment Column | Used to write off amounts, enter discount, debits, credits, or refunds. |
| Best Column | Used to record the difference between the debit and credit columns. |
| Debit | A charge; an amount representing things acquired for the intended use of the practice. |
| Credit | Money coming into your account. |
| Credit balance | Money owed to the patient in the event of an over payment. |
| Refund | Debit adjustment. |
| Receipts | Money received. |
| Petty Cash Fund | A fund maintained to pay small cash expenses and incidentals. |
| Reconciliation of bank accounts | The process of verifying that the bank statement and the checkbook balance is are in agreement |
| Superbill | A combination charge slip statement and insurance reporting form |
| NSF | Non sufficient funds |
| Balance billing | Billing the patient for the difference between the fee and the amount the insurance company allows |
| Statement | Shows the service rendered on each date what the charge was for each service the date the claim was submitted to the insurance company the date of payment and the balance due from the patient |
| Cycle billing | Bills each patient at the 30 60 90 days or 15 30 45 days |
| Fair Credit billing Act | A federal law mandating that billing for a balance due or reporting a credit balance for $1 or more must occur every 30 days |
| Hardship cases | Accounts of patients who are poor uninsured underinsured elderly or on a limited income |
| Age analysis | The process of classifying and reviewing delinquent accounts by age from the first day of billing |
| Payroll deductions | Accounts regularly withheld from a paycheck |
| Net earnings | Gross earnings minus total deductions |
| Receptionist | Makes the first impression for the facility and its employees |
| Double booking | Scheduling two patients at the same time |
| Wave scheduling | Appointments are scheduled based on average appointment time |
| Modified wave scheduling | Appointments for two or more patients are scheduled at the beginning of each hour followed by single appointment every 10 to 20 minutes |
| Grouping | Reserving certain days or times of day for scheduling specific types of appointments |
| S o a p | Subjective objective assessment plan |
| Numeric filing | Filing of a patient's chart by their patient or account number |
| An insurance company is also known as | insurance carrier or insurer or third-party payer |
| A policyholder is also known as | first party, insured , member , enrollee , subscriber , and beneficiary |
| A healthcare provider is also known as | second party, doctor's office or hospital |
| Family members of the policyholder who are also covered under the policy, such as spouses, children, and partners are known as? | dependents |
| The policyholder of an insurance policy makes the insurance primary, secondary, or tertiary? | primary insurance |
| A dependent on insurance policy makes the insurance primary, secondary, or tertiary? | secondary insurance |
| A patient covered under a third insurance policy makes the insurance primary, secondary, or tertiary? | tertiary insurance |
| Birthday Rule | If a child is eligible for coverage through both parents, the Birthday Rule determines which health insurance coverage is the primary payer. The first birthday month and day determines the primary payer. |
| Guarantor | Someone who agrees to be financially responsible for the patient's bill. The guarantor is always the patient, unless the patient is a minor (under 18 years of age). |
| Emancipated minor | Someone under 18 who is no longer dependent on his or her parents because of a court order, getting married, or entering military service |
| Uninsured | patient without health coverage (aka self-pay patient) |
| Deductible | amount of money that the patient must pay for covered medical expenses before insurance reimbursements begin |
| co-payment | fixed dollar amount that the patient must pay for each healthcare visit |
| co-pay | fixed dollar amount that the patient must pay for each healthcare visit |
| Coinsurance | patient's share of the costs of a covered healthcare service (after the deductible) |
| what form used to post payments? | remittance advice |
| the authorization number for a service approved before service was rendered is indicated in which block on cms-1500 claim form? | block 23 |
| which block of cms-1500 form if the federal tax ID entered? | block 25 |
| which block of cms-1500 form indicates an ICD diagnosis code? | block 21 |
| which block of cms-1500 form is additional claim information entered? | block 18 |
| what standardized format is used in the electronic filing of claims? | HIPPA standard transactions |
| which block of cms-1500 form is used to accept assignment of benefit? | block 27 |
| on cms-1500 claim form, blocks 14 - 33 contain what information | patients condition and provider's information |
| the EOB states the amount billed was $80. the amount allowed is $60, and the patient is required to pay a $20 copayment. what insurance check amount should be posted? | $40 |
| what should a billing and coding specialist use to submit a claim with supporting documents? | claim attachment |
| what medicare policy determines if a particular item or service is covered by medicare? | National Coverage Determination (NCD) |
| what is an example of a remark code from EOB document? | contractual allowance |
| what form should a billing and coding specialist transmit to the insurance carrier for reimbursement of inpatient hospital services? | UB-04 |
| a claim is denied due to termination of coverage (TOC). what action should the billing and coding specialist take next? | follow up with the patient to determine the current name, address, and carrier for resubmission |
| In what block of the CMS1500 do you put the billing provider? | in block 33a of cms-1500 claim form |
| what reason a claim would be denied? | incorrectly linked codes |
| when the remittance advice is sent from third-party payer to provider; what action should the billing and coding specialist perform first? | ensure the proper payment has been made |
| How often does Medicaid determine eligibility? | monthly |
| which of the following describes a key component of E/M service | history, physical exam, and medical decision making |
| which of the following is considered a fraud | a billing and coding specialist unbundles a code to receive higher reimbursement |
| which of the following is an example of medicare abuse? | charging excessive fees |
| what organization fights waste, fraud, and abuse in medicare and Medicaid | OIG - Office of the Inspector General |
| medicare part D | prescription services |
| what part of medicare insurance program is managed by private, third-party insurance providers approved by medicare | medicare part C |
| what block on cms-1500 claim form should a billing and coding specialist complete for procedures, services, or supplies? | block 24d |
| what describes an insurance carrier that pays the provider who rendered services to a patient? | third-party payer |
| what format is used to submit electronic claims to a third-party payer? | 837 |
| what entity defines essential elements of a comprehensive compliance program? | OIG |
| what causes a claim to be suspended? | services required additional information |
| a medicare non-participating (non-PAR) provider's approved payment amount is $200 for a lobectomy and deductible has been met. what amount is the limiting charge for this procedure? | $230 |
| for non-crossover claims, the billing and coding specialist should prepare a copy of what form? | primary insurance card |
| a billing and coding specialist can ensure insurance coverage for an outpatient procedure by using what process? | precertification |
| when a third-party payer requests copies of patient information related to claim, billing and coding specialist must include what document from patient's file? | signed release of information form |
| in the anesthesia section of CPT manual, what is considered a qualifying circumstance | add-on codes |
| what describes the term "crossover" relating to medicare? | when insurance company transfers data to allow (COB) coordination of benefits of a claim |
| a provider performs an examination of patient's knee joint via small incisions and optical device. what term describes this procedure? | arthroscopy |
| a billing and coding specialist has 4 past-due charges: $400 - 10 weeks past due; $800 - 6 weeks past due; $1,000 - weeks past due; and $2,000 - 8 weeks past due. what charge should be sent to collections first? | $2000 Many experts recommend waiting 90 days after your invoice's due date to send someone to collections. |
| the EOB states the amount billed was $170. The allowed amount is $150. The patient has an unmet deductible of $50 and a copayment of $20. what dollar amount is the patient responsible for? | $70 |
| what term refers to difference between billed & allowed amounts? | adjustment |
| these <> symbols are used to indicate new and revised text of what description? | procedure descriptors |
| what HIPAA compliance guideline affects electronic health records? | electronic transmission & code set standards require every provider to use healthcare transactions, code sets, & identifiers |
| what describes a code that would be denied? | an italicized code as the primary diagnosis |
| what does HMO managed care services require to see a specialist? | a referral |
| what explains why medicare will deny a service / procedure? | |
| which block of cms-1500 form should a billing & coding speacialist enter the referring provider's NPI | |
| what action should billing & coding specialist take when submitting a claim to medicaid for a patient that has primary & secondary insurance coverage? | attach remittance advice from primary insurance along w/ medicaid claim |
| what term is used to communicate why a claim line item was denied or paid differently than billed? | claim adjustment codes |
| two surgeon successfully performed closure of a vaginal fistiula thru patient's abdomen. for both providers' claims, the billing & coding specialist should use what cpt codes & modifiers? | 57305-62 |
| in 1996, cms implemented which entity to detect inappropriate & improper codes? | National Correct Code Initiative (NCCI) |
| a billing & coding specialist is preparing a claim form for a provider from a group practice. the billing & coding specialist should enter the rendering providers NPI in which block on cms-1500 form? | 24j |
| on a remittance advice form, who is responsible for writing off difference between amount billed and the amount allowed by agreement? | the provider |
| what is the purpose of coordination of benefits (COB)? | prevent multiple insurers from paying benefits covered by other policies |
| which block of cms-1500 claims form is the report modifiers section? | 24d |
| as of april 1, 2014 what is the maximum number of diagnoses that can be reported on CMS-1500 claim form before a further claim is required? | 12 |
| what best describes medical ethics? | medical standard of conduct |
| a patient has AARP as secondary insurance. what block on cms-1500 claim form should enter information? | block 9 |
| External cause code | An alphanumeric code used to identify the external cause of an injury or poisoning |
| Unspecified | Refers to a code that should be used for an incompletely described condition |
| Addenda | Annual updates to the ICD-10-CM diagnostic coding system |
| Category = how many digits and relates to how many diseases or condition per code? | A three-digit code that covers a single disease or related condition |
| Z-Code | An alphanumeric code used for an encounter that is not due to illness or injury |
| Convention | Typographic technique or standard practice that provides visual guidelines for understanding printed material |
| Main term | The medical term that identifies a disease or condition in the alphabetic index |
| Supplementary | A nonessential word or phrase that helps define a diagnosis coCOde |
| GEMs | An acronym for reference tables of related ICD-10-CM and ICD-9-CM codes.C |
| Main term | Word that identifies a disease or condition in the Alphabetic Index. |
| The __________ provides an index of the disease descriptions that are found in the second major part of ICD-10-CM. | Alphabetic index |
| The ICD-10-CM updates released by the National Center for Health Statistics are called __________. | Addenda |
| The ICD-10-CM code set contains approximately __________ codes, making it much larger than ICD-9-CM. | 70,000 |
| __________ are used to report encounters for circumstances other than a disease or injury in ICD-10-CM. | Z codes |
| ICD-10-CM uses __________ to indicate an incomplete term. | Colons |
| Which of the following is not a further breakdown of a disease that may be provided by a subcategory? | Sequela |
| Tay-Sachs disease is an example of a(n) __________. | Eponym |
| The abbreviation ______ is used with a term when there is no code that is specific for the condition. | NEC |
| What are the steps involved in coding? | 1. REVIEW COMPLETE MEDICAL DOCUMENTATION 2.ABSTRACT MED. CONDITIONS FROM THE VISIT DOCUMENTATION 3.IDENTFITY THE MAIN TERM FOR EACH CONDITION 4.LOCATE MAIN TERMS IN ALPHABETIC INDEX 5.VERIFY CODE IN TABULAR LIST |
| STEP 6 IN CODING STEPS | CHECK COMPLIANCE WITH APPLICABLE OFFICAL GUIDELINES AND LIST CODES IN ORDER |
| ICD-9 how many chapters and characters | CONTAINS 17 CHAPTERS INJURIES GROUPED BY CATEGORIES COES CONTAIN 3-5 CHARACTERS |
| ICD-10 CONTAINS __ CHAPTERS INJURIES GROUPED BY___ CODES ARE ALPHA NUMERIC WITH ___ to ___ DIGITS | CONTAINS 21 CHAPTERS INJURIES GROUPED BY ANATOMICAL SITE CODES ARE ALPHA NUMERIC WITH 5,6,7 DIGITS |
| SUBTERM | Word or phrase that describes a main term in the Alphabetic Index. |
| Excludes 1 | Exclusion note used when two conditions could not exist together, such as an acquired and a congenital condition; means “not coded here.” |
| Excludes 2 | Exclusion note meaning that a particular condition is not included here, but a patient could have both conditions at the same time. |
Created by:
ericmichaelperkins