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HIT 130 Midterm Exam
| Question | Answer |
|---|---|
| Determines which insurance is primary when two policies are valid for a dependent. | Birthday rule |
| A claim that is incorrect or is missing information when submitted. | Dirty claim |
| Any insurance a patient may have in addition to the primary insurance. | Supplemental insurance |
| Provides coverage for medical services not covered by the primary plan such as a Medigap policy. | Secondary insurance |
| When a patient has more than one insurance policy, insurance carriers work together to determine insurance benefit. | Coordination of benefits |
| What would an internal audit determine? | A coder's skill and knowledge |
| True or False? Claims may require three provider identification numbers. | True |
| On the CMS-1500 claim form, what is the meaning of the abbreviation EIN? | Employer Identification Number |
| The use of the CMS-1500 claim form is | mandatory for all Medicare claims but optional for private insurance carriers. |
| When a private payer or government investigator reviews a selection of patient records for compliance, it is called a(n) ______ audit. | external |
| Which term identifies when documentation in the patient chart supports a higher level of service than that coded? | Downcoding |
| HCPCS is the acronym for the: | Healthcare Common Procedure Coding System. |
| HCPCS Level I codes were developed by the: | American Medical Association (AMA). |
| The notice that alerts a Medicare beneficiary that a service may NOT be medically necessary and is, therefore, NOT covered. | Advance Beneficiary Notice |
| Intentional acts of deception used to take advantage of another person or entity. | Fraud |
| When diagnosis and procedures codes are aligned to justify medical necessity. | Code linkage |
| Billing for procedures or services that were NOT necessary. | Abuse |
| Billing for reasonable undocumented services presumably performed by healthcare professionals as part of the documented procedure. | Assumption coding |
| What document lists the year's planned projects for sampling types of billing to see if there are any problems? | OIG Work Plan |
| True or false? Fraud is knowingly billing for services that were never provided. | True |
| True or false? The purpose of the Office of the Inspector General(OIG) is to fight waste, fraud and abuse in Medicare, Medicaid and more than 3000 other HHS programs. | True |
| All services or procedures coded must be ... | performed by the provider who is billing for the charge and documented in the patient's medical record |
| Which type of procedure is reported as an additional procedure performed in addition to a main procedure? | Secondary procedure |
| True or false? All coded and billed services or procedures must be documented in the patients' medical record. | True |
| True or false? Unbundling will result in higher reimbursement for the physician and should be done in as many circumstances as possible. | False |
| Who published the Current Procedural Terminology (CPT®)? | AMA |
| When a second physician examines a patient and renders an opinion, the service is referred to as a(n): | consultation |
| A statement, usually in the patient's words, describing the symptom, problem, condition, or other factor that is the reason for the encounter is called the: | chief complaint |
| What is the term for a chronological description of the patient's illness from the first sign or symptom to the present? | History of present illness |
| What is another word for etiology? | Cause |
| The main reason for the services provided is known as the ________ diagnosis. | first-listed |
| ICD-10-CM codes submitted on insurance claim forms are used to: | determine medical necessity for covered procedures and services. |
| A condition that occurs when a patient suffers a problem resulting directly from a procedure that was performed by a physician. | Complication |
| One or more diseases or disorders that presents in addition to the primary disease or disorder. | Comorbidity |
| A sign or symptom of a disease | Manifestation |
| A late effect, also referred to as a residual effect | Sequela |
| A group of symptoms that together are characteristics of a specific disorder. | Syndrome |
| Violating HIPAA laws that protect the privacy of patient information can result in a jail term of up to ________ years. | 10 |
| What is the most restrictive type of healthcare? | HMO |
| A _____ includes a contracted network of providers. | PPO (Preferred Provider Organization) |
| Group insurance is issued to an employer to provide coverage for: | employees and all their dependents. |
| These are examples of individuals who would qualify for COBRA | employees who are laid off from their jobs, employees quit their jobs and children of covered employee who are no longer full time students |
| True or false? If a physician has ordered surgery for a patient, a managed care organization (MCO) case manager may disallow an inpatient stay if the MCO guidelines designate the procedure as best suited for outpatient care. | True |
| True or false? Point-of-service (POS) plans are becoming more popular because they offer more flexibility and freedom of choice than do standard health maintenance organizations (HMOs). | True |
| True or false? If a member in a health maintenance organization (HMO) sees a specialist without a referral from his or her PCP, the HMO will not pay for the service. | True |
| The schedule of benefits section of a managed care contract lists the: | medical services covered under the managed care plan. |
| What was formed under ACA to provide comprehensive, coordinated, and seamless, high-quality medical care to patients? | ACO |
| One aspect of healthcare reform that most people agree on is that: | reform needs to address issues of cost, access, and quality of care. |
| The organization that awards accreditation to managed care organizations is the: | National Committee for Quality Assurance (NCQA). |
| An individual who is an insured, enrolled subscriber or dependent under the terms of a health benefit plan is a(n): | covered person. |
| Some principles adopted in the Patient's Bill of Rights include ... | accurate and easily understood information, a sufficient choice of healthcare providers and receive emergency services without prior authorization. |
| In the Patient's Bill of Rights, the provision regarding choice of providers allows patients the right to: | a network with access to appropriate high-quality health care. |
| The typical time limit for a medical office specialist to submit claims to a managed care organization is __________months after the date of service. | 6 to 12 |
| An insurance company, third-party administrator, or self-insured health benefit plan that is contractually obligated to make payments on behalf of covered persons. | Payer |
| A licensed healthcare professional who has entered into an agreement to provide covered services to covered individuals. | Participating provider |
| The determination of which health plan will pay for covered services as primary or secondary payer. | Coordination of benefits |
| Contract issued by a payer under which a covered person may be entitled to covered services. | Benefit plan |
| A provider who is not under contract with a managed care plan. | Nonparticipating provider |
| A compensation arrangement in which a provider is paid a per-member-per-month fee. | Capitation |
| Under HIPAA, health plans, providers, and clearinghouses are considered____________________. | covered-entities |
| The person in medical practice who handles requests for medical records and serves as the primary contact person in regard to HIPAA confidentiality issues is the____________________. | privacy-compliance officer |
| The electronic transfer of information in a standardized format between trading partners is called____________________. | electronic-data-interchange |
| The Department of Health and Human Services agency that handles privacy complaints is the Office for____________________. | Civil Rights |
| Data that has been scrambled and/or encoded to prevent it from being readable by unauthorized users is____________________. | encrypted |
| The three types of protections of electronic data that must be in place to be in compliance with the HIPAA Security Rule are administrative, physical, and technical____________________. | safeguards |
| Under HIPAA, any information related to patient identity, patient health status, the provision of care, or payment for services is considered____________________. | protected-health-information |
| HIPAA provision that deals with protecting the confidentiality of electronically stored and transmitted patient health data. | Security Rule |
| Legally mandated policies, procedures, and actions that protect the privacy of patient health information. | HIPAA compliance |
| HIPAA provision that deals with protecting the confidentiality of patient health information, regardless of its format. | Privacy Rule |
| Legislation enacted to strengthen HIPAA privacy and security protections and enhance enforcement efforts. | HITECH Act |
| HIPAA provision that deals with establishing standards for electronic data interchange (EDI) and for reporting diagnosis, procedure, and drug information. | Transactions and Code Set Rule |
| Requirements established by the HITECH Act for the implementation of standardized electronic health records and related technologies. | Meaningful use |
| HIPAA privacy protections apply to which type of healthcare data? | Paper and electronic records |
| A(n) ____________________ practice usually consists of three to nine physicians of the same specialty. | small-group |
| What percentage of all healthcare providers are allied health professionals? | 60% |
| A(n) ____________________contacts patients or insurance carriers to collect money owed to the facility or practice. | medical collector |
Created by:
Prof Clark