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medical insur. mgmt

medical insurance final review

Question	Answer
CPT five-digit codes, indicated by a plus symbol (+), that have been designed to be used with primary procedure codes; descriptions usually start with “each additional,” “list separately,” or “second lesion”	add-on codes
Code that contains a grouping of one or more services that are related to a procedure; coding and billing for these individual services should not be done	bundled code
Broken bone that has not penetrated the skin	closed fracture
Program designed to ensure that national coding guidelines and standards are adhered to	coding compliance program
Software program that uses natural language processing software that automatically assigns codes to clinical procedures and services	computer-assisted coding (CAC)
The provision of similar services (e.g., hospital visits) to the same patient by more than one physician on the same day	concurrent care
Second opinion rendered by a physician in a home, office, hospital, or extended care facility regarding a condition or need for surgery and may initiate diagnostic or therapeutic services; the service must be requested, recorded, and reported	consultations
Discussion with the patient or family member regarding diagnostic results,impressions,and recommended diagnostic studies;prognosis; risks and benefits of treatment options;instructions for treatment and/or followup	counseling
Care of an unstable, acutely ill or injured patient requiring constant bedside attention by a physician requiring high-complexity decision making; most commonly rendered in a critical care area	critical care
Submitted procedure code changed to a lower level by a computer system	downcoding
Computerized or Web-based software program used to search for, locate, and verify code selections	encoder
A second-level coding system used to code those services, products, supplies, drugs, and procedures that are generally not fully listed in the CPT codebook	HCPCS Level II codes
Joint mobilization technique; realigning a fractured long bone using manual pressure, traction, or angulation; also called reduction	manipulated
Coding edits developed by federal legislation that relate to CPT and HCPCS codes for outpatient & physician services;used by Medicare carriers to process claims & detect incorrect reporting of codes, eliminate unbundling,prevent payments from being made	National Correct Coding Initiative (NCCI)
Software program used for transcribing medical records that has artificial intelligence technology built in; it scans a document the physician has input using free-text and singles out key terms, converting them into procedure codes	natural language processing (NLP)
Broken bone in which the bone has penetrated the skin; also referred to as a compound fracture	open fracture
Determination of whether somebody is a new or established patient	patient status (new/est)
Location where a medical service is taking place	place of service (POS)
Laboratory test that determines the presence of an agent within the body	qualitative analysis
Laboratory test that measures how much of an agent is within the body	quantitative analysis
CPT five-digit procedure code that, if not performed separately, is an integral part of another procedure; often bundled into other procedures	separate procedure
Entry point into interior parts of the body that is used by physicians performing surgical procedures, for example, open incision, scope, approaching through a body orifice (ear, nose, vagina)	surgical approach
Kind of service or procedure provided by a medical doctor (e.g., office visit, laboratory test, surgery)	type of service (TOS)
Breaking down a procedure into separate billable codes with charges to increase reimbursement; also known as fragmentation, exploding, or á la carte medicine	unbundling
Practice of coding and billing a health plan for a procedure that reimburses the physician at a higher rate than the procedure actually done; also known as code creep, overcoding, or overbilling	upcoding
Is a computerized or Web-based software program that is used instead of coding books to search for, locate, and verify code selections (e.g., Optum EncoderPro, TruCode, EpiCoder, Flash Code)	An encoder
When a service is rendered and a code number cannot be found for the procedure, check the?	Category III codes found at the end of the other sections.
A complete list can be found in CPT Appendix D.	Add-On Codes
The most common reference used to code procedures is the?	Current Procedural Terminology (CPT) published by the American Medical Association
Uses five-digit code numbers with two-digit modifiers.	CPT Coding
A coding compliance program might include which of the following?	Educating both staff and physicians in coding and compliance.
What is the purpose of the standard code set?	To share health care information in an electronic format.
When searching for a code in the CPT coding manual, where should the coder start?	By searching the index to find the procedure or body part.
What are encoders?	Software programs that are used instead of paper coding books to search for and match the correct code.
What is considered critical care when coding in the CPT manual?	The care of unstable, acutely ill, or injured patients requiring constant bedside attention by a physician.
Which of the following symbols in the CPT codebook indicates a new code that has been added?	A circle
What is upcoding?	Reporting a code at a higher rate or value than the procedure actually done.
How is the CPT codebook organized?	In 6 sections, including surgery, E/M, and medicine.
What is the purpose of a global surgical package?	To include most surgical expenses including preoperative and postoperative care into one CPT code.
What is a code modifier used for?	To indicate circumstances that are different in some way from the five-digit CPT code.
When would add-on codes be used?	To indicate a qualifying circumstance such as both sides of the body were affected (both arms or both legs).
In which appendix are the codes for products pending FDA approval located?	Appendix K
A medical assistant is confused by the information the physician has provided and cannot find the proper CPT code. How would they tactfully ask the physician for clarification?	Find the physician when they have a break in their schedule.
When coding procedures or services are performed, which codebook should be used?	Current Procedural Terminology (CPT)
In what section of the CPT manual would a coder find the proper code for an established patient office visit who has come in for a sore throat and fever?	Evaluation and Management Codes
A coding compliance program is:	voluntary.
Current Procedural Terminology codebook, used to code procedures and services, consists of:	five-digit code numbers with two-digit modifiers.
An encoder is a:	software program used to search for, locate, and verify code selections.
Concurrent care is:	the provision of similar services to the same patient by more than one physician on the same day.
Care of an unstable, acutely ill, or injured patient requiring constant bedside attention by a physician is referred to as:	critical care.
The "three Rs" to remember when coding consultation services are:	request, record, and report.
Consultation codes are no longer used by:	Medicare.
When a computer system changes a submitted code to a lower level code, it is referred to as:	downcoding.
How many sections are there in Current Procedural Terminology?	6
when coding Evaluation and Management services, first determine:	place of service, type of service, patient status.
What is the largest section in CPT?	Surgery section
When coding from the surgery section of CPT, the first thing you should do is:	go to the index.
According to CPT, a surgical package:	includes the operation, certain types of anesthesia, and normal uncomplicated postoperative care within designated follow-up days.
The Medicare Global Surgical Package includes:	removal of sutures, staples, wires, casts, etc.
When coding from an operative report, the first step is to:	identify the type of surgery.
For wound repairs, how many types of closures are there?	3
In a "laparoscopy," the scope enters the body through the:	abdomen.
Starting at the beginning of the following subsections in the Surgery section (Musculoskeletal, Respiratory, Cardiovascular, Digestive, and Urinary), codes are arranged by:	anatomic site.
Injections are found in the:	Medicine Section.
The codebook appendices are located:	after Category II and III codes.
Neoplasms (growths) that are noninvasive and do not metastasize (spread to other tissue); noncancerous	benign
Connecting the diagnostic code to the procedure code on the insurance claim so that the procedure or service is justified	code linkage
Single diagnostic code used to classify (1) two diagnoses, (2) a diagnosis with a secondary process, or (3) a diagnosis with an association complication	combination code
Coexisting medical conditions	comorbidity
The underlying cause (etiology) of a disease or condition and the characteristics, signs, or symptoms (manifestation) associated with that disease/condition that occur due to the underlying condition	etiology/manifestation
The condition, problem, or other reason for the health encounter that is chiefly responsible for the services provided; also referred to as the primary diagnosis	first-listed condition
Harmful neoplasm (new growth) that has the capability of spreading and invading other tissue; often called cancer	malignant
Diseased condition or state; number of sick people in relation to a population	morbidity
Cause of death	mortality
Spontaneous new growth or formation of tissue; often referred to as a tumor	neoplasm
The character (x) used as a fourth, fifth, or sixth digit in diagnostic coding with certain seven-digit codes to allow for future expansion of the ICD-10-CM codebook; if it exists, it must be used or the code is invalid	placeholder
Condition, problem, or other reason for the health encounter that is chiefly responsible for services; also referred to as the first-listed condition	primary diagnosis
Condition established after study that prompted the hospitalization; used only in an inpatient setting	principal diagnosis
Final medical impression made by a physician using the terms rule-out, suspected, suspicion of, questionable, likely, probably, or possible, as if they existed or were established but have not been; also called working diagnosis	qualified diagnoses
Coders who work at locations other than in the physician’s office (e.g., home or billing service)	remote coders
How is the ICD-10-CM codebook organized?	In chapters of related body part, body system, or diagnosis.
What is a primary diagnosis?	A diagnosis used in an outpatient or office visit setting; the main reason for the patient's visit.
What is morbidity?	Diseased condition.
What does the abbreviation NOS in the ICD-10-CM codebook stand for?	Not Otherwise Specified
What do brackets [ ] used in tabular list indicate?	Synonyms or alternative wording.
To properly code from the ICD-10-CM codebook, once you have determined the main term that relates to the patient's condition, what is the next step?	Locate the main term in the alphabetic index.
Most burns are classified by what features?	Depth, extent, agent.
Which of the following best describes using medical necessity in diagnostic coding?	The physician must match all diagnosis codes to the codes for the procedure performed.
Which of the following would be a tactful way to ask for additional information in a physician query?	Could you confirm that the reason for the additional procedure was due to a complication or whether it was a part of the original procedure?
The term acute is often used in medical coding to describe symptoms, for example, acute pain. What does acute mean?	Sudden onset.
Coexisting medical conditions are referred to as:	comorbidity.
Checking a diagnostic code against a procedure code to ensure medical necessity is referred to as:	code linkage.
When a single code exists that can classify two diagnoses, a diagnosis with a secondary process or a diagnosis with an associated complication, it is referred to as a:	combination code.
A "qualified diagnosis" is a:	condition coded as if it existed but has not been proven.
An "NEC" code is a code number for a diagnosis that the coder uses:	when a complete description cannot be found in the codebook.
If a patient has had a condition for a long time, it is referred to as:	chronic.
The coding rule for "etiology and manifestations" is to:	code the etiology in the first position and the manifestation in the second position.
A complication or condition that arises as a direct result of an injury is called a:	sequela.
All categories in ICD-10-CM have:	three alphanumeric digits.
To start coding, you need to turn to the Alphabetic Index and look up the:	main term.
In diagnostic coding, the following symbol is used as a "placeholder" when a subcategory does not have a fourth, fifth, or sixth digit and a seventh digit needs to be applied.	x
A carcinoma in situ is a tumor:	localized or confined to the site of origin.
To look up a tumor using the Neoplasm Table, you would first:	look for the site of the tumor.
When a patient presents with influenza, the type of flu documented in the medical record:	does not have to be verified by positive laboratory serology.
If documentation in a patient's medical record does not state "open fracture," code it as:	closed
When a patient with a fracture comes into the physician's office to have an internal fixation device removed, select the diagnostic code for the encounter as a/an:	subsequent encounter.
Even though coding rules are the same, ICD-10-CM makes a distinction between burns that come from:	heat source and corrosions.
Burns are classified by:	depth, extent, agent.
When a wrong substance is given or taken in error, it is coded as a/an:	poisoning.
Factors Influencing Health Status and Contact with Health Services codes are:	Z codes.
To settle judicially as in a determination of payment for an insurance claim	adjudicated
Employee of an insurance carrier to whom a case is assigned and who follows the case until it is adjusted, or settled; grants verbal authorization in workers’ compensation cases for testing, procedures, surgeries, and referrals	adjuster
One who qualifies for health insurance to receive medical benefits	beneficiary
List of benefits, that is, services and procedures that are covered under the insurance plan or program	benefit list
Informal procedure adopted by the health industry, which is used to determine the primary insurance plan when both parents cover a child. The plan of the person whose birthday (month and day, not year)falls earlier in the calendar year will pay first	birthday rule
Method of payment for health services by which a health group is prepaid a fixed, per capita amount for each patient served, without considering the actual amount of service provided to each patient	capitation
Request for payment under an insurance contract or bond	claim
Cost-sharing requirement under a health insurance policy that stipulates the insured assumes a percentage of the costs of covered services	coinsurance
offer a tiered benefit structure with low premiums, high-deductible catastrophic insurance, and a number of different types of prespending tax-savings accounts in which money may be rolled-over from year to year.	consumer-directed health plans (CDHPs)
Clause in a group insurance policy that allows the insured to continue the same or lesser coverage under an individual policy	conversion privilege
Provisions and procedures used by insurers to avoid duplicate payment for losses insured under more than one insurance policy	coordination of benefits (COB)
Type of cost-sharing whereby the insured pays a specified amount per unit of service and the insurer pays the rest of the cost; in managed care, flat fee that is owed prior to receiving services	copayment
Amount the insured must pay in a calendar or fiscal year before policy benefits begin	deductible
Under an insurance contract, the spouse and children of the insured; in some cases, domestic partners	dependents
Specific hazards, perils, or conditions listed in an insurance policy for which the policy will not pay	exclusions
Managed care plan operating with a limited network of physicians and a designated primary care physician for each subscriber; governed by state health insurance laws	exclusive provider organization (EPO)
Managed care plan offering prepaid health care for a fixed fee to subscribers in a designated geographic area; enrollees receive benefits when they obtain services provided or authorized by selected providers, generally with a primary care physician	health maintenance organization (HMO)
Group of individual health care providers who contract with managed care plans to provide care at a discounted rate in their own office setting	independent (or individual) practice association (IPA)
Individual or organization who contracts for a policy of insurance and is protected in case of loss of property, life, or health under the terms of the insurance policy	insured
Provision of an insurance policy that lists exceptions or reductions to specific coverage	limitations
Insurance policy especially designed to offset heavy medical expenses resulting from catastrophic or prolonged illness or injury	major medical
Illness or injury that prevents a person from performing one or more of the functions of a regular job; may be temporary or permanent	partial disability
Illness or injury that is not resolved and prevents an insured person from performing all the functions of a regular job	permanent disability (PD)
Managed care plan that contracts with independent providers at a discounted rate. Members have choice at time services are needed of receiving services from an HMO, PPO, or fee-for-service plan; patient can self-refer self for a higher coinsurance payment	point-of-service (POS) plan
Process of requesting permission to render a service/procedure to the patient in which the insurance plan determines the medical necessity and appropriateness of the service; also called prior authorization or prior approval	preauthorization
To determine whether services (surgery, tests, hospitalization) are covered under a patient’s health insurance policy	precertification
Finding out the maximum dollar amount that will be paid for specific services and procedures; also called preestimate of cost or pretreatment estimate	predetermination
An injury that occurred, a disease that was contracted, or a physical condition that existed before the issuance of a health insurance policy	preexisting conditions
Type of health program in which enrollees receive the highest level of benefits when obtaining services from a physician, hospital, or other called preferred providers, enrollees may receive reduced benefits when obtaining care from provider of own choice	preferred provider organization (PPO)
Payment made on a regular schedule to keep an insurance policy in force	premium
Person or institution that gives medical care	provider
Procedure followed when a primary care physician recommends and sends the patient to another physician for further medical treatment	referral
A “marketplace” where individuals may search for and purchase affordable health insurance that meets their needs	state insurance exchanges
Illness or injury that temporarily prevents an injured person from performing the functions of a regular job	temporary disability (TD)
Federal legislation that allows employees to continue their group health insurance after leaving their employment by paying the entire premium	The Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA)
Party (insurance carrier or medical assistance program) other than the physician or patient who intervenes to pay hospital or medical expenses; also known as third-party carrier	third-party payer
Illness or injury that prevents a person from performing the duties of his or her occupation or from engaging in any other type of work for remuneration	total disability
Evaluation process performed by qualified health care professionals to determine the quality, appropriateness, and medical necessity of medical care	utilization review
One who has served in the United States Armed Forces and has received an honorable discharge	veteran
Time that must elapse before a benefit is paid; also known as excepted period	waiting period (w/p)
Attachment to an insurance policy that excludes certain illnesses or disabilities that would otherwise be covered	waivers
Which of the following describes group insurance?	Insurance policies obtained through an employer.
What does the policy number on an insurance card represent?	The specific plan or policy so that coverage can be determined.
Which of the following defines precertification?	Determination of whether a service or procedure is covered by a specific patient's policy.
What is a deductible?	The amount of money the insured must pay each calendar year before benefits begin.
What does Medicare Part A cover?	Hospital costs, nursing facilities, and home care.
If a patient is covered by TRICARE Extra, what type of coverage does that indicate?	A preferred provider organization (PPO)–type coverage.
What type of coverage does a managed care health maintenance organization offer?	A prepaid plan offering service by member physicians stressing preventative care for individuals in a designated area.
In a managed care setting, which of the following describes a direct referral?	A simplified authorization request completed by the physician and given to the patient at the time of referral.
What does coordination of benefits involve?	Preventing duplication of benefits if a patient has more than one insurance policy.
Which of the following best describes Medicaid?	An assistance program that covers certain lower-income individuals.
According to the Gallup-Healthways Well-Being Index, the majority of health insurance coverage in the United States is provided by:	employers.
The term third-party payers indicates that the following entities are involved in health care reimbursement:	patient, provider, and payer.
Aetna Casualty, Allstate, BlueCross/Blue Shield, Farmers Insurance, and United American are all examples of:	commercial insurance companies.
Traditional indemnity insurance is more commonly referred to as:	fee-for-service plans.
In a Health Savings Account (HSA), unused funds:	may be carried over, without limits from year to year.
HDHPs have a:	high deductible and annual out-of-pocket limits.
COBRA:	is an extension of group health insurance for employees who have left their job.
The birthday rule states that when a child is covered by both parents the health plan of the parent:	whose birthday, by month and day, falls earlier in the calendar year will pay first.
With managed care insurance plans, you:	may be required to file insurance claims.
Medicaid is sponsored by:	federal, state, and local governments.
In the Medicaid program, if a patient needs prior authorization for services, use a:	treatment authorization request form.
A Medicare hospital benefit period:	begins the day a patient enters a facility and ends when the patient has not been a bed patient in any facility for 60 consecutive days.
To determine if a service or procedure is a covered Medicare benefit in your region, you would look at Medicare's:	LCDs
Traditional Medicare prescription drug program is covered through Medicare:	Part D.
To contain costs and improve the value received for health care, CMS has requested the reporting of "quality measures" through the:	Physician Quality Reporting System.
Insurance through the TRICARE preferred provider organization is called:	TRICARE Extra.
TRICARE providers who see TRICARE-eligible persons must obtain preauthorization for certain procedures, or the amount of payment may be reduced by:	10%.
When the physician accepts an assignment for a CHAMPVA patient, the payment from CHAMPVA will be:	75% of the allowable fee.
In a workers' compensation case, who does the medical assistant communicate with?	Adjuster
In workers' compensation, when no further improvement is expected for the patient, the industrial case is considered:	P & S.
Waiver of liability form provided by the physician’s office and given to Medicare beneficiaries to be signed prior to services being rendered that may be deemed not medically necessary and therefore not paid by Medicare	Advance Beneficiary Notice (ABN)
A completed insurance claim submitted within the program time limit that contains all necessary data to process and pay promptly	clean claim
Centralized location where claims are received, edited, and distributed electronically to insurance companies	clearinghouse
An insurance claim that was received by the payer, but payment was rejected because of a technical error or payment policy issue (e.g., noncovered benefit)	denied claim
An insurance claim that was submitted with errors or one that requires manual processing	dirty claim
Contractor that processes and pays provider claims on behalf of state or federal agencies or insurance companies; also called fiscal agent	fiscal intermediary
Specified time interval after a premium payment is due in which the policyholder may make such payment and during which the protection of the policy continues	grace period
An insurance claim that is missing required information. It may be resubmitted after correction	incomplete claim
An insurance claim that contains complete, valid information but is illogical or incorrect. It may be resubmitted after correction	invalid claim
Insurance carriers who contract to pay Medicare Part B claims; formerly called fiscal agents	Medicare Administrative Contractor (MAC)
Ten-digit number, mandated by HIPAA and issued on a lifetime basis as a standard unique health identifier for health care providers, clearinghouses, and plans who conduct electronic transactions (may be used on paper claims)	National Provider Identifier (NPI)
An insurance claim that is held in suspense pending a review or other reason. It may be paid or denied after the review	pending claim
A group that reviews Medicare claims on a post-payment basis to recover overpayment, identify underpayments and develop methods to prevent future improper payments	Recovery Audit Contractors often called RAC’s
An insurance claim that is submitted but discarded by the system because of technical errors. It may be returned to the provider for investigation, correction, reprocessing, or resubmission	rejected claim
An insurance claim that is being held by the insurance company or third-party payer as pending due to an error or because additional information is needed	suspended claim
How is the Advance Beneficiary Notice used?	To inform patients that a service or procedure will probably not be covered by Medicare by getting their signature and possibly collecting payment.
Which of the following is a good way to show professionalism and tact when interacting with a third-party representative?	Ask specific questions in order to get specific answers.
In the Medicare claims appeal process, what is the final or highest level of appeal?	Federal Court Review
Which of the following describes a denied claim?	A claim that has been received but payment is rejected because of a technical error or payment policy issue.
According to the False Claims Act, which of the following categories would constitute fraud and abuse?	Billing for services not medically necessary.
To properly follow up on unpaid claims, how should the claims be logged or sorted?	By the date of service.
What is an advantage of using electronic claims filing over using a paper claims filing?	Electronic claims increase cash flow.
What is the time limit for filing a Medicare claim?	Within 1 year from the date of service.
If a workers' compensation claim is filed, which of the following is true?	Physicians accept payment from the workers' compensation carrier as payment in full.
On the CMS-1500 claim form, what is the National Provider Identifier?	A number that identifies physicians when they are exchanging electronic transactions.
The CMS-1500 claim form has an assignment of benefits for government programs in:	Field 12.
The four main stages in the life cycle of an insurance claim are:	claim submission, claim processing, adjudication, payment.
The reason that the CMS-1500 claim form is printed in red ink is:	to comply with OCR machines.
Standards for electronic transmission of protected patient information, developed by the Health Insurance Portability and Accountability Act, is called the:	Transaction Code Set.
The physician’s signatures on an electronic agreement or paper insurance claim are accepted in which of the following format?	First and last name, with credential.
A unique health identifier for health care providers is called a/an:	NPI.
A code that represents the physician’s Internal Revenue service employer identification number is called the:	EIN
The format used to transmit electronic insurance claims was developed by the:	ANSI.
Medicare Part B claims are submitted to:	MACs.
An Advance Beneficiary Notice:	must be completed when it is suspected that Medicare may not deem a service or supply medically necessary.
Timely filing rules for Medicare claims state that claims must be submitted:	1 year from the date of service.
State disability claims are filed using:	individual state forms.
Physicians accept payment from workers’ compensation insurance carriers:	as payment in full.
A suspended claim is a:	claim held by the insurance company as pending because of an error or the need for additional information.
A dirty claim is a claim that:	is submitted with errors or one that requires manual processing.
Paid paper claims are filed according to:	dates of service.
The Medicare CERT program is used to:	audit claims to determine if claim submission and payment are correct.
A Medicare RAC auditor may go back _____________ and examine claims from the date of original determination.	3 years
Which of the following is considered fraud and abuse under the False Claims Act?	Billing separately for bundled services
What percent does an appeal have of being overturned?	50%

Created by: Diamond87

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