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
NHA BILLING CODING T
| Question | Answer |
|---|---|
| Which of the following information is required to include on an Advance Beneficiary Notice (ABN) form? | The reason Medicare may not pay |
| A billing and coding specialist should identify that which of the following statements is correct regarding the filing limit for Medicaid? | The filing limit is 90 days from the date of service. |
| Which of the following actions by a billing and coding specialist is an example of fraud? | Billing for services not provided to obtain higher reimbursement |
| A patient's employer has not submitted a premium payment for the company's commercial insurance plan. Which of the following is the claim status the provider will receive for any claims sent to the third-party payer? | Denied |
| CPT® codes are used for which of the following concepts? | Revenue |
| A billing and coding specialist is reviewing provider notes to complete a claim. They need clarification on whether the procedure performed was on the left side, right side, or bilaterally. Which of the following indicates laterality of the procedure for | A modifier |
| A billing and coding specialist is contacted by a patient who requests a copy of the remittance advice for a recently adjudicated claim. Which of the following actions should the specialist take? | Remove all information other than what pertains to the patient. |
| Which of the following terms describes the amount the patient must pay for a service when they have an insurance plan benefit that pays 70% of the allowed amount and the patient is responsible for 30% of the allowed amount? | Coinsurance |
| For which of the following is the provider responsible? | Professional courtesy |
| A billing and coding specialist is evaluating code assignments for a batch of claims. Which of the following should the specialist consult as a resource to check for proper code assignment based on procedure-to-procedure (PTP) code pair edits and medicall | National Correct Coding Initiative (NCCI) |
| A billing and coding specialist is reviewing the encounter form for a patient who has type 1 diabetes mellitus and stage III chronic kidney disease (CKD). Which of the following diagnosis codes should be assigned? | E10.22 |
| Which of the following security features is required during transmission of protected health information and medical claims to third-party payers? | Encryption |
| Which of the following is an example of a breach of patient confidentiality? | Discussing patient information in a public space |
| The HIPAA Privacy Rule requires covered entities to track which of the following? | Release of protected health information (PHI) |
| A billing and coding specialist is reviewing an electronic remittance advice (ERA). Which of the following gives additional information about the denial of reimbursement? | Remark code |
| A billing and coding specialist is preparing a list of delinquent accounts over 300 days old that have received telephone calls, letters, and have been referred to a collection agency with no results. Which of the following is the term that describes acco | Bad debts |
| Which of the following do providers use to electronically submit claims? | Clearinghouse |
| Which of the following identifies improper payments made for CMS claims? | Recovery Audit Contractors (RACs) |
| Which of the following procedures refers to the removal of kidney stones? | Nephrolithotomy |
| A surgeon performed a cholecystectomy for a patient. The billing and coding specialist does not know whether to code for an open or laparoscopic cholecystectomy. The specialist should query the provider to prevent which of the following types of fraud or | Upcoding |
| Which of the following processes is used to verify patient benefits and insurance coverage for an outpatient procedure? | Precertification |
| A billing and coding specialist is posting payments from an explanation of benefits (EOB). Which of the following equations determines how patient responsibility is calculated? | Charged amount - Payment amount - Adjustment amount = Patient responsibility |
| A billing and coding specialist is completing a claim to be submitted for Blue Cross Blue Shield by a provider who used to be in private practice but was recently hired by a group practice. Which of the following is true regarding the provider's national | The provider's individual NPI for the group practice is the same as the one from the private practice. |
| Which of the following introduced documentation guidelines to Medicare carriers to ensure that services paid for have been provided and were medically necessary? | CMS |
| A billing and coding specialist is collecting demographic information for a patient who lives in Hawaii and is an active duty service member. The specialist should identify that the insured has which of the following types of insurance? | TRICARE |
| A billing and coding specialist is training a new specialist about submitting claims to a clearinghouse. Which of the following describes the process completed by the clearinghouse before submitting claims to a third-party payer? | Checking claims against payer edits for missing, incomplete, or invalid information |
| A patient is in the third trimester of pregnancy and has developed gestational diabetes mellitus that is diet-controlled. Which of the following ICD-10-CM codes should a billing and coding specialist assign to this patient? | O24.410 |
| A billing and coding specialist is preparing to create patient statements and has been asked to collect finance charges on any late payments. According to the Truth in Lending Act (TILA), which of the following is the way the finance charges must be discl | As an annual percentage rate |
| Which of the following is a specified amount of money that a patient who has a preferred provider organization (PPO) plan is required to pay for each visit or medical service? | Copayment |
| A billing and coding specialist is reviewing a remittance advice for a claim that was denied for medical necessity. Which of the following is an example of this type of error? | The ICD-10-CM code for tonsillitis was listed with the CPT® code for an appendectomy. |
| A billing and coding specialist is reviewing a denied claim for a 19-year-old patient's hysterectomy. The service was coded as 58150-26. Which of the following is the reason for the denial? | The modifier is not valid with the procedure. |
| A billing and coding specialist is reviewing a claim edit report and identifies a rejection for missing patient demographic information. Which of the following missing pieces of patient demographic information would cause a rejection from the clearinghous | Date of birth |
| Which of the following is an example of an informational modifier? | -82 Assistant surgeon (when qualified resident surgeon not available) |
| A billing and coding specialist is reviewing a remittance advice that has a deductible of $100 indicated for one of the claims. The provider asks the specialist to write it off. Which of the following describes this scenario? | Fraud |
| A billing and coding specialist is posting a payment received from Medicare. The specialist should identify that which part of Medicare covers prescription costs? | Part D |
| A billing and coding specialist is reviewing paperwork that indicates overpayment by Medicare for six patients over the past year. Which of the following describes this process? | Audit |
| Which of the following describes the nature of a modifier? | Indicates that an alteration to a service or procedure has occurred |
| A billing and coding specialist is coding a consultation in the provider's office. The provider documented the appropriate history and exam, with low-level medical decision making. Which of the following Evaluation and Management (E/M) codes should the sp | 99243 Office or other outpatient consultation for a new or established patient, which requires a medically appropriate history and/or examination and low level of medical decision making. |
| A married couple each have group insurance through their employers. The patient has an appointment with the provider. Which insurance should be used as primary for the appointment? | The patients |
| A billing and coding specialist is processing a claim for a patient who has Medicare and Medicaid coverage. Which of the following is the type of claim that is automatically adjudicated by Medicare and forwarded to Medicaid? | Crossover |
| In which of the following scenarios is it appropriate to release a patient's psychiatric records without the patient's consent? | When the patient is being investigated by the police |
| A billing and coding specialist is submitting a batch of claims to the clearinghouse and receives a report stating that three claims were rejected. Which of the following actions should the specialist take? | Review the scrubber report. |
| A billing and coding specialist is determining patient financial responsibility for a claim. The billed amount is $1,800, the allowed amount is $750, and the patient paid a $20 copayment. There is a $500 deductible that has not been met, and the plan pays | $570 |
| Which of the following is an electronic form that is used to post reimbursements? | Electronic remittance advice (ERA) |
| Which of the following is a document about patient rights that is required to be signed by the patient to acknowledge receipt and can be provided to the patient upon request? | Notice of Privacy Practices (NPP) |
| A patient who is insulin-dependent is diagnosed with diabetic retinopathy. According to ICD-10-CM coding guidelines, in which of the following orders should the codes be reported on the claim form? | E11.319, Z79.4 |
| A billing and coding specialist is coding a procedure note for a patient who had a diagnostic hysteroscopy that resulted in a hysteroscopic cervical biopsy. Which of the following CPT® codes should the specialist use? | 58558 |
| A billing and coding specialist is coding a laceration repair and needs to determine the type of closure. The specialist queries the provider, who confirms retention sutures were used. The specialist should code which of the following types of closure? | Complex (Layered closure requiring additional corrections) |
| Two providers are having a conversation about a patient's test results at the nursing station. A different patient overhears them talking. This type of privacy exposure is known as which of the following? | Incidental disclosure |
| A patient is covered by Medicare through managed care. Which of the following parts of Medicare includes this coverage? | Part C |
| A billing and coding specialist is performing a coordination of benefits check. The patient has primary and secondary benefits. Which of the following applies to the guarantor? | They are responsible for any charges that are incurred. |
| Many third-party payers require that a patient pay a set amount of eligible charges per year before the patient's health care plan will begin to pay benefits. This refers to which of the following terms? | Deductible |
| A billing and coding specialist is preparing a claim for an esophagectomy. Which of the following types of service is being provided? | Removal |
| A claim was denied due to termination of coverage. The patient had recently obtained new insurance. Which of the following actions should the billing and coding specialist take? | Obtain the patient's updated insurance and submit the claim to the new third-party payer. |
| Chronic kidney disease is included in which of the following code sets? | ICD-10-CM |
| A billing and coding specialist is reviewing a Medicare remittance advice (RA) and discovers a denial due to medical necessity. Which of the following actions should the specialist take? | Check the local and national coverage determination policies for diagnosis requirements. |
| Which of the following is proper supportive documentation for reporting CPT® and ICD-10-CM codes for the removal of a skin lesion? | Operative report |
| Which of the following does a patient sign to allow payment of claims directly to the provider? | Assignment of benefits statement |
| Which of the following modifiers indicates that a patient has signed a Medicare Advance Beneficiary Notice (ABN)? | -GA Waiver of liability statement issued as required by payer policy |
| Which of the following is the purpose of coordination of benefits? | To prevent multiple third-party payers from paying benefits covered by other policies |
| Vaccine products are included in which of the following code sets? | CPT® |
| A billing and coding specialist is analyzing the health of a practice's revenue cycle using an aging report. Which of the following categories of the report should contain the lowest percentage of accounts receivable? | Greater than 120 days |
| A billing and coding specialist is appealing a Medicare denial. Which of the following is the first step in the appeals process? | Redetermination |
| Which of the following are used to code provider and outpatient services? | CPT® codes |
| A provider orders a comprehensive metabolic panel for a 70-year-old patient who has Medicare as their primary insurance. Which of the following is required to inform the patient they may be responsible for payment? | Advance Beneficiary Notice |
| Which of the following is the type of service code that can have three to five levels of service and covers office visits, hospital visits, and consultations? | Evaluation and Management |
| A billing and coding specialist is processing a claim for a new patient who came to the office for a sore throat. The provider diagnosed the patient with tonsilitis and wrote a prescription for antibiotics. Which of the following codes should the speciali | 99203 Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and low level of medical decision making. |
| A billing and coding specialist is reviewing a letter from a patient's third-party payer about an emergency procedure that was performed for the patient. The letter states that preauthorization requirements were not met and the claim was denied. Which of | Send an appeal letter to the third-party payer. |
| Which of the following actions should a billing and coding specialist take when submitting a claim to Medicaid for a patient who has primary and secondary insurance coverage? | Attach the remittance advice from the primary insurance along with the Medicaid claim. |
| A billing and coding specialist is preparing a claim for a participating provider whose billed amount is $175.00 for an encounter. The third-party payer's allowed amount is $90.00 for the service rendered, including a $20.00 copay. The specialist should r | $85.00 |
| Which of the following types of diagnosis code is to identify the presence of a pacemaker? | Status |
| A billing and coding specialist is verifying coverage for a Medicare beneficiary. Which of the following determines Medicare coverage of services on a national level? | NCD |
| A billing and coding specialist is coding a claim for a provider who performed a hysterectomy and needs to determine whether the procedure was done by an excisional or laparoscopic procedure. Which of the following actions should the specialist take to de | Review the operative report. |
| A patient presents to a provider with chest pain and shortness of breath. After an unexpected EKG result, the provider calls a cardiologist and summarizes the patient's symptoms. Which of the following is a portion of HIPAA that allows the provider to spe | Title II: Administrative Simplification |
| A patient has a new diagnosis of hypothyroidism. In which of the following body systems is the thyroid gland located? | Endocrine system |
| A billing and coding specialist is submitting claims through a clearinghouse. The specialist should identify that which of the following actions is performed by the clearinghouse? | Scrubbing claims, translating them to a standard format, then sending them to various third-party payers |
| Which of the following describes the term "crossover" as it relates to Medicare? | When a third-party payer transfers data to allow coordination of benefits for a claim |
| A patient is preauthorized to receive vitamin B12 injections from January 1 to May 31. On June 2, the provider prescribes an additional 6 months of injections. In order for the patient to continue with coverage of care, which of the following should occur | The provider should go ahead with the injections due to medical necessity. |
| In which of the following departments should a patient be seen for a furuncle? | Dermatology |
| A billing and coding specialist is reviewing a denied claim for a patient who was diagnosed with an upper respiratory infection and had a benign lesion removed. The codes listed on the claim were 99213 and 17000. Which of the following actions should the | Add modifier -25 to the claim. |
| A provider documents a patient's response to questions about various parts of the body. A billing and coding specialist should identify that this information is included in which of the following sections of the note? | Review of systems |
| A billing and coding specialist is reviewing a claim for services provided on November 30. In reviewing the insurance information, the specialist notes the patient's eligibility date began on December 1. The specialist changing the date of service to Dece | Fraud |
| A provider documents a simple repair of a superficial wound that is 2.5 cm long on a patient's hand. A billing and coding specialist reports the code for a 5 cm simple repair. Which of the following describes the specialist's action? | Upcoding |
| Which of the following should be included on a claim form that is sent from a specialist to a managed health care organization? | The referring provider's national provider identifier (NPI) |
| Which of the following documents should a billing and coding specialist use to ensure that all payers are sending reimbursement within 45 days of claim submission? | Aging report |
| A billing and coding specialist is using an accounts receivable aging report to determine which accounts should be sent to collections. According to best practices, which of the following accounts should the specialist send to collections? | An account that has a balance of $600 and is 135 days old |
| Which of the following prohibits a provider from referring Medicare patients to a clinical laboratory service in which the provider has a financial interest? | Stark Law |
| A patient was seen in an outpatient clinic for a cough, chest congestion, and a low-grade fever and was given the diagnosis of possible pneumonia. How should a billing and coding specialist code this encounter using ICD-10-CM? | Cough, chest congestion, and low-grade fever |
| Which of the following is the structure used for ICD-10-CM codes? | 3 to 7 alpha-numeric characters |
| A billing and coding specialist is preparing a claim for an outpatient encounter. The patient was last seen in the office 2 years ago. Which of the following Evaluation and Management (E/M) codes should the specialist use? | 99203 Office or other outpatient visit for the evaluation and management of a new patient |
| Which of the following requires companies with 20 or more workers to offer employees who are laid off the ability to buy into the company's health insurance coverage for 18 months? | Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA) |
| Which of the following positions is required in a provider's office to comply with HIPAA regulations? | Privacy officer |
| Claims that are submitted without an NPI number will delay payment to the provider due to which of the following? | The number is needed to identify the provider. |
| Which of the following are required for professional services claims to specify the type of organization for the services rendered? | Place of service codes |
| A billing and coding specialist in an internal medicine practice is assisting a patient who is already collecting Social Security but will be turning 65 in the next year and has questions about what Medicare will cover. The specialist should know that whi | Medicare Part A |
| HCPCS codes are used in which of the following health care settings? | Physician clinics |
| A billing and coding specialist is preparing a claim for a colonoscopy. At the start of the procedure, the provider determined that the patient had not properly prepared for the procedure, so the procedure was immediately stopped. Which of the following m | -53 |
| A patient has a history of breast cancer that has metastasized to the liver and is undergoing chemotherapy today for the liver cancer. Which of the following ICD-10-CM codes should be sequenced first? | C78.7 Secondary liver cancer |
| Which of the following describes an insurance company that offers plans that pay health care providers who render services to patients? | Third-party payer |
| Which of the following statements is true when determining patient financial responsibility by reviewing the remittance advice? | Any coinsurance, copayments, or deductibles should be collected from the patient. |
| A billing and coding specialist is reviewing a patient's account and notes there is an outstanding balance that is 45 days old after third-party payer reimbursement. Which of the following actions should the specialist take? | Send the patient an itemized statement to collect the outstanding balance. |
| A billing and coding specialist is posting payments to accounts based on a remittance advice and discovers a denial of payment. Which of the following codes indicates why reimbursement was denied? | Claims adjustment reason code |
| When coding for outpatient and professional services and procedures, a billing and coding specialist must sequence the diagnosis codes according to ICD-10-CM guidelines. Which of the following describes the first listed diagnosis code on a claim? | Primary diagnosis |
| A billing and coding specialist is billing for services provided by an assistant surgeon. Which of the following modifiers should the specialist use? | -80 |
| A patient has health coverage through multiple third-party payers. A billing and coding specialist should identify that which of the following is the payer of last resort? | Medicaid |
| Which of the following is issued to active duty uniformed service personnel for access to TRICARE benefits? | Common access card |
| Which of the following is a covered entity affected by HIPAA security rules? | A health care clearinghouse |
| Which of the following government agencies is responsible for combating fraud and abuse in health insurance and health care delivery? | Office of Inspector General (OIG) |
| An internal retrospective billing account audit prevents fraud and abuse by reviewing and comparing completed claim forms with which of the following? | Documentation from patient encounters |
| Which of the following is a document used to analyze accounts receivable based on dates of service? | Explanation of benefits (EOB) |
| Which of the following is a valid type of authorization used to release medical information to the judicial system? | Subpoena duces tecum |
| A provider accepts assignment for a patient who has a $10 copayment and has already met $100 of their $150 deductible. The office charge is $100 and the allowed amount is $70. How much should the provider's office adjust off the patient's account? | $30 |
| Which of the following is used to communicate why a claim line item was denied or paid differently than it was billed? | Claims adjustment reason codes |
| Coding manuals use which of the following conventions? | Icons |
| Which of the following is a HIPAA compliance guideline affecting electronic health records? | The electronic transmission and code set standards require every provider to use the health care transactions, code sets, and identifiers. |
| Which of the following is the filing limit for claim submission for an outpatient service with TRICARE? | Within 1 year from the date of service |
| A billing and coding specialist is reviewing an operative report for a patient who had a graft. Which of the following is a tissue transplanted from one person to another? | Allograft |
| Which of the following physical status modifiers should a billing and coding specialist use for anesthesia services performed to reduce a traumatic fracture in an otherwise well 4-year-old patient? | -P4 |
| A patient has managed care insurance and has been referred to a specialist for gastric bypass surgery. Which of the following is needed to ensure payment? | Preauthorization |
| Which of the following requires an authorization to release protected health information (PHI)? | Processing an insurance claim |
| A billing and coding specialist is preparing a small claims court case against a patient for a delinquent account in the amount of $6,500. Which of the following is a court order that allows payments on unsecured debt to be made directly from a defendant' | Garnishment |
| A billing and coding specialist is submitting an electronic claim for a procedure with modifier -22 for increased procedural services. Which of the following actions should the specialist take? | Include an attachment to the claim. |
| A patient's portion of the bill should be discussed with the patient before a procedure is performed for which of the following reasons? | To ensure the patient understands how much they are responsible to pay |
| A billing and coding specialist is coding a claim for an autopsy. Which of the following CPT® codes should be included on the claim? | 88000 Necropsy (autopsy), gross examination only; without central nervous system |
| A patient had an x-ray for a fractured arm. The documentation does not indicate if the x-ray was performed on the right or left arm. Which of the following actions should a billing and coding specialist take? | Query the provider. |
| A billing and coding specialist is reviewing modifier use with a new employee. Which of the following scenarios warrants the use of a modifier? | Splinting of the fourth digit on the left foot |
| Which of the following statements is true regarding the release of patient records? | Patient access to psychotherapy notes is restricted. |
| Which of the following provisions ensures that an insured patient's benefits from third-party payers do not exceed 100% of allowable medical expenses? | Coordination of benefits |
| A patient presents to a provider's office with difficulty speaking, facial drooping, and an inability to close their left eye. They are diagnosed with Bell's palsy. A billing and coding specialist should report which of the following ICD-10-CM codes? | G51.0 |
| Which of the following pieces of guarantor information is required when establishing a patient's financial record? | Phone number |
| A billing and coding specialist observes a colleague perform an unethical act. Which of the following actions should the specialist take? | Report the incident to a supervisor. |
| On a remittance advice form, which of the following is responsible for writing off the difference between the amount billed and the amount allowed by the agreement? | Provider |
| A billing and coding specialist is reviewing the procedure notes from a provider who selected a code indicating an incisional biopsy when the entirety of the patient's lesion was removed. The specialist should verify with the provider that which of the fo | Excisional procedure |
| A billing and coding specialist is reviewing a report from the clearinghouse after submitting electronic claims and notices that one claim was rejected due to missing demographic information. Which of the following actions should the specialist take? | Resubmit an updated claim. |
| A billing and coding specialist is preparing a claim for a patient who had a procedure performed on their left index finger. Which of the following CPT® modifiers indicates the correct digit? | -F1 Left hand, second digit |
| In the ICD-10-CM code set, which of the following characters is the placeholder? | X |
| A patient who recently received care from an endocrinologist is being referred to an infectious disease specialist. Which of the following types of referral does the patient need from the endocrinologist? | Tertiary care referral |
| A billing and coding specialist is preparing a claim for a provider. The operative note indicates the surgeon performed a CABG. The specialist should identify that CABG stands for which of the following? | Coronary artery bypass graft |
| A billing and coding specialist should identify that which of the following is used to improve the efficiency and effectiveness of the health care system as mandated by HIPAA for providers? | ANSI ASC X12N 837P format |
| A billing and coding specialist is reviewing a claim for a patient who presented to the provider's office for an upper respiratory infection. During the encounter, the patient also received the influenza vaccine. Which of the following modifiers should be | 25 |
| A billing and coding specialist is posting a Medicare remittance advice and identifies an overpayment of $15. Which of the following actions should the specialist take? | Notify Medicare about the overpayment within 60 days. |
| Which of the following parts of Medicare is managed by private third-party payers that have been approved by Medicare? | Medicare Part C |
| A billing and coding specialist is preparing a claim for a procedure with a prolonged operative time that has modifier -22 attached. Which of the following actions should the specialist take? | Include an attachment to the claim. |
| Which of the following is the third stage of a claim's life cycle? | Adjudication |
| A billing and coding specialist is preparing an accounts receivable aging report. The specialist should expect the report to include which of the following? | Outstanding balances organized by date |
| Which of the following should a billing and coding specialist complete to be reimbursed for a provider's outpatient services? | CMS-1500 claim form |
| A billing and coding specialist is assisting a patient who has a capitated health maintenance organization (HMO) and presents to the office with a sinus infection. The specialist should identify that which of the following statements is true regarding a c | Payment for the encounter is based on a flat rate. |
| A billing and coding specialist is preparing a claim for an appendectomy and reports it with two units. The claim is then denied. Which of the following coding edits should the specialist have reviewed prior to submitting the claim? | Medically unlikely edits |
| Which of the following code sets is used to report inpatient procedures? | ICD-10-PCS |
| HIPAA transaction standards apply to which of the following entities? | Health care clearinghouses |
| Which of the following information is required on a patient account record? | Name and address of guarantor |
| A patient presents to a primary care provider for a closed right index finger fracture. The provider is a non-participating provider for a private payer and does not accept assignment of benefits. The provider's charge for the service is $135. The third-p | $39 |
| When a patient has a condition that is both acute and chronic, how should it be coded? | Code both the acute and chronic conditions, sequencing the acute condition first. |
| A billing and coding specialist is determining coordination of benefits for a patient who has health insurance coverage from both parents. The patient's father's birthday is May 18, 1982 and their mother's birthday is May 18, 1984. Which of the following | The parent whose insurance policy has been active the longest will be the primary insurer. |
| Which of the following is true regarding Medicaid eligibility? | Patient eligibility is determined at each visit. |
| A billing and coding specialist is filing a CMS-1500 claim form for a patient who has private insurance. The specialist should recognize that a signature approving assignment of benefits indicates which of the following? | The payer should send reimbursement directly to the provider with the exception of copays and deductibles. |
| Medigap coverage is offered to Medicare beneficiaries by which of the following? | Private third-party payers |
| A billing and coding specialist is reviewing a delinquent claim. Which of the following actions should the specialist take first? | Verify the age of the account. |
| A provider's office fee is $100, and the Medicare Part B allowed amount is $85. Assuming the beneficiary has not met any deductible amount, the patient should be billed for which of the following amounts? | $85 |
| A patient has a resection of the intestines with anastomosis through the abdominal walls. Which of the following is a type of anastomosis? | Colostomy |
| A billing and coding specialist identifies a CPT® code that is routinely being denied by a third-party payer. Which of the following types of review should the specialist perform? | Retrospective review |
| Which of the following is the purpose of running an insurance aging report each month? | To determine which claims are outstanding from third-party payers |
| A billing and coding specialist is determining the level of service for an office visit for a new patient. Which of the following codes represents a moderate level of medical decision-making? | 99204....Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. |
| Which of the following is a ICD-10-CM category code? | A 3-character code |
| Which of the following is an advantage of electronic claim submission? | Claims are expedited. |
| Which of the following is the provision of health insurance policies that specifies which coverage is primary or secondary? | Coordination of benefits |
| Which of the following actions by a billing and coding specialist ensures a patient's health information is protected? | Using data encryption software on office workstations |
| A billing and coding specialist is reviewing a remittance advice from Medicare and notices that the amount paid for a procedure is less than the contracted amount. Which of the following is a potential reason for the reduced amount of payment? | The claim indicated an incorrect place of service. |
| A billing and coding specialist discovers that one private payer has not reimbursed the provider for any claims submitted in the past year. Clean claims have been submitted to the payer and have been acknowledged. Which of the following entities should th | State Insurance Commissioner's office |
| Outstanding patient balances will appear on which of the following? | Accounts receivable |
| A child is brought into a facility by their mother. The child is covered under both parents' insurance policies. The child's father was born on 10/1/1980 and their mother was born on 10/2/1981. Which of the following statements is true regarding the prima | The father is the primary policy holder because his birthday falls first in the calendar year. |
| An employer's workers' compensation payer requires bloodwork for an employee who experienced a work-related injury. Which of the following modifiers should a billing and coding specialist use? | -32 Mandated services |
| A billing and coding specialist is reviewing a claim for an established patient who arrived at the office with an upper respiratory infection. Which of the following codes should the specialist use for this encounter? | 9921.... Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and low level of medical decision making. 3 |
| Which of the following actions should a billing and coding specialist take to assign a diagnosis code to the highest level of specificity? | Apply characters four through seven to a claim. |
| A billing and coding specialist is training a new employee on a claim for a consultation. The new employee asks, "What is a consultation?" Which of the following responses should the specialist make? | "It's when a provider requests medical advice from a specialist." |
| A billing and coding specialist discovers suspicious billing activity that may be fraudulent in the workplace. Which of the following actions should the specialist take? | Call the U.S. Department of Health and Human Services' (DHHS) anonymous hotline. |
| A billing and coding specialist is preparing to appeal a partially paid claim due to an incorrect procedure code. Which of the following steps of the appeal process includes the review of the claim adjustment reason code? | Identification |
| In ICD-10-CM, Z codes are used to identify which of the following? | Immunizations |
| Which of the following editing systems should a billing and coding specialist reference to determine if a supplies and materials code should be assigned to report a surgical tray used during an ambulatory procedure? | National Correct Coding Initiative (NCCI) |
| In which of the following sections of a SOAP note does a provider indicate a patient's reported level of pain? | Subjective |
| For which of the following reasons should a billing and coding specialist follow the guidelines in the CPT® manual? | The guidelines define items that are necessary to accurately code. |
| Which of the following is a federal government health insurance program? | TRICARE |
| A billing and coding specialist is working on a claim in which reimbursement was reduced due to two surgical services performed during the same encounter being bundled together. Which of the following modifiers should be assigned to indicate the procedure | -59 Distinct procedural service |
| Which of the following qualifies a patient for eligibility under Medicare as the primary third-party payer? | Individuals who are under age 65 and have a disability |
| Which of the following CPT® codes should a billing and coding specialist use to bill for a 5-year-old child who had an initial repair of a 2.5 cm abdominal hernia? | 49591....Repair of anterior abdominal hernia(s) (i.e., epigastric, incisional, ventral, umbilical, spigelian), any approach (i.e., open, laparoscopic, robotic), initial, including implantation of mesh or other prosthesis when performed, total length of de |
| Which of the following codes are included in the ICD-10-CM code set? | Acquired absence of limb |
| Which of the following is an example of a violation of an adult patient's confidentiality? | Patient information was disclosed to the patient's parent without consent. |
| A patient has a breast biopsy with the placement of a clip. After the biopsy is determined to be malignant, the patient elects for a mastectomy during the global period of the biopsy. Which of the following modifiers should a billing and coding specialist | -58..... Staged or related procedure by the same physician or other qualified health care professional during the postoperative period. |
| A billing and coding specialist is reviewing a remittance advice and encounters a denial of payment for CPT® code 44950 (appendectomy). The specialist discovers the ICD-10-CM code assigned to the claim was J32.1 (chronic frontal sinusitis). Which of the f | Incorrectly linked codes were reported on the claim |
| Which of the following are included in surgery service codes? | Preoperative history and physical |
| In an outpatient setting, which of the following forms is used as a financial report of all services provided to patients? | Encounter form |
| An explanation of benefits states the amount billed was $80. The allowed amount is $60, and the patient is required to pay a $20 copayment. Which of the following describes the insurance check amount to be posted? | $40 |
| A billing and coding specialist is reviewing a patient's encounter progress note. Which of the following modifiers indicates the patient received general anesthesia from a surgeon? | -47 Anesthesia by surgeon |
| Which of the following is a correct rule when using CPT® add-on codes? | They are exempt from the multiple procedure concept. |
| A patient is upset about a bill they received because their third-party payer denied the claim. Which of the following actions should a billing and coding specialist take? | Inform the patient of the reason for the denial. |
| Which of the following is part of a provider's practice compliance program? | Internal monitoring and auditing |
| A provider's office receives a subpoena requesting medical documentation from a patient's medical record. After confirming the correct authorization, which of the following actions should a billing and coding specialist take? | Send the medical information pertaining to the dates of service requested. |
| A new patient presents for an urgent care encounter. Which of the following code sets should be used to report this encounter? | Office or other outpatient services |
| When a patient signs an Acknowledgement of Notice of Privacy Practice, it indicates which of the following? | The patient accepts the policies and procedures regarding how protected health information (PHI) is handled. |
| Which of the following is the purpose of an internal review in a provider's office? | To verify that the medical records and the billing record match |
| When should a billing and coding specialist initiate the collection of the information needed to process a patient's insurance claim form? | When the patient contacts the provider's office and schedules an appointment |
| A billing and coding specialist is processing a claim for a patient who broke their arm while repairing cars at their workplace. There is no nerve damage, the arm is placed in a cast for 6 weeks, and the patient is cleared to return to work in 6 weeks. Wh | Temporary disability |
| A claim is submitted with a transposed insurance member ID number and returned to the provider. Which of the following describes the status that will be assigned to the claim by the third-party payer? | Invalid |
| A billing and coding specialist should add a modifier in which of the following scenarios? | A bilateral procedure was performed. |
| A billing and coding specialist is preparing an appeal letter in response to a denial by a third-party payer for lack of medical necessity. Which of the following should the specialist include with the letter to indicate medical necessity? | Medical record documentation |
| A patient is diagnosed with pneumonia during a follow-up encounter for a knee joint replacement surgery performed 2 weeks previously. Which of the following CPT® modifiers should the specialist add to the claim prior to resubmitting? | -24 Unrelated evaluation and management service by the same physician or other qualified health care professional during a postoperative period |
| Which of the following terms describes the removal of the eye, adnexa, and bony structure? | Exenteration |
| A patient has met an in-network PPO deductible of $150. The patient's coinsurance is 20%, and the allowed amount is $600. Which of the following is the patient's out-of-pocket expense? | $120 |
| Which of the following entities are required to follow HIPAA rules and regulations? | Clearinghouses, health insurance companies, and billing services |
| Which of the following links the ICD-10-CM and CPT® codes for claims processing? | Diagnosis pointer |
| Which of the following is a valid ICD-10-CM principle? | Code signs and symptoms in the absence of a definitive diagnosis. |
| CPT® Evaluation and management codes are used for which of the following? | Critical care services |
| A billing and coding specialist is arranging a payment plan with a patient who wants to leave postdated checks with the office. The patient proposes leaving one check postdated for 3 months, one for 4 months, and another one for 5 months in the future. Ac | Notify the patient between 3 and 10 days prior to depositing each check on the indicated date. |
| For which of the following reasons should a claim be resubmitted? | The claim requires an attachment to support medical necessity. |
| When reviewing an established patient's insurance card, a billing and coding specialist notices a minor change from the existing card on file. Which of the following actions should the specialist take? | Photocopy both sides of the new card. |
| A patient wants to see an endocrinologist for a consultation about their diabetes mellitus, but they must see their primary care provider (PCP) for a referral to an in-network specialist first. Which of the following types of insurance does the patient ha | Health maintenance organization (HMO) |
| A billing and coding specialist is preparing a claim for an established patient who arrived for an annual exam. During the examination, the provider treated the patient's sinus infection and prescribed medication for it. Which of the following Evaluation | 99213.. Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and low level of medical decision making. |
| Anesthesia codes from the CPT® manual require which of the following on the claim form? | Physical status modifiers |
| A billing and coding specialist is determining third-party payer responsibilities for a 70-year-old patient who has Medicare coverage. The patient's spouse has insurance with Blue Cross Blue Shield through their employer. Which of the following actions sh | Establish coordination of benefits. |
| Which of the following is used by Medicare to determine if an item or service is covered? | National Coverage Determination (NCD) |
| A billing and coding specialist is reviewing an encounter note that indicates a biopsy was performed. The specialist requires which of the following additional details to fully code this procedure? | Benign vs. malignant status |
| A billing and coding specialist is collecting demographic information from a patient. Which of the following pieces of information should the specialist expect the Medicaid eligibility verification system (MEVS) to provide? | Dates of coverage |
| A billing and coding specialist is reviewing delinquent claims and discovers that a third-party payer paid a claim but applied it to the incorrect provider. The third-party payer will reimburse the payment once the improperly paid funds are recouped. Whic | Suspended |
| A billing and coding specialist is submitting a claim for a school-age child who was brought to the clinic by their maternal grandmother. The child's parents are divorced and remarried, and the child's mother has legal custody of the child. The specialist | Biological mother |
| A billing and coding specialist receives a denial for payment from TRICARE for services provided in the emergency department while a provider was on call. The provider is not a participating TRICARE provider. Which of the following actions must the specia | Contact the patient for assistance. |
Created by:
SHAMCK9388