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MED112 CODE/BILL
MED112 CH 06 VISIT CHARGES AND COMPLIANT BILLING SB
| Question | Answer |
|---|---|
| MED112 CH 06 SB | |
| Code linkage ensures which of the following? A. Charges are for medically necessary services. B. Services were within the patient’s scope of benefits. C. Patient is insured under a health plan. D. Diagnosis and procedure codes are inaccurate. | Charges are for medically necessary services. |
| To correctly prepare claims, it is important to know the payers' billing rules that are stated in which of the following? A. Patients' medical charts B. Patients' medical insurance policies C. Fee schedules D. Participation contracts | B. Patients' medical insurance policies D. Participation contracts |
| Which of the following are examples of CCI edits? A. Prevents female-specific and male-specific codes for the same patient B. Prevents billing two procedures that could not possibly have been performed together C. Tests for unbundling of CPT codes D. Prevents billing for noncovered services | A. Prevents female-specific and male-specific codes for the same patient B. Prevents billing two procedures that could not possibly have been performed together C. Tests for unbundling of CPT codes |
| What does a CCI modifier indicator of 1 represent? A. A CPT modifier cannot be used B. A CPT modifier may be used to bypass an edit C. A CPT modifier is invalid and could not have reasonably been done during the service D. A CPT modifier will not change the edit, or mutually exclusive code edits will not be bypassed | A CPT modifier may be used to bypass an edit |
| What is the purpose of medically unlikely edits? A. To identify codes that are not medically necessary B. To identify instances in which no procedure code should be used for an encounter C. To identify clerical errors or services that require a modifier D. To identify when a modifier can bypass a CCI edit | To identify clerical errors or services that require a modifier |
| The term used to describe when the diagnosis supports the billed services necessary to treat or investigate a patient’s condition is called ________. A. granularity B. coordination of benefits C. code linkage D. assignment of benefits | code linkage |
| In which of the following ways could a medical insurance specialist find information about changed contracts and updated rules? A. Review payer websites B. Monitor payer bulletins C. Track patient activity D. Communicate with payer representatives E. Ask patients if they have received any new information | A. Review payer websites B. Monitor payer bulletins D. Communicate with payer representatives. |
| What does the OIG Work Plan address? A. It sets forth various projects to address particular types of billing. B. It lists initiatives for Medicare to offer more extensive benefits and coverages. C. It offers legal advice for providers who violate Medicare regulations. D. It reports fraudulent providers who have violated Medicare policies. | It sets forth various projects to address particular types of billing. |
| When is the OIG Work Plan issued? A. Bimonthly B. Annually C. Quarterly D. Biannually | Annually |
| When a medical coder selects a procedure code that provides higher payment, it is called ____. A. downcoding B. upcoding C. unbundling D. truncating | upcoding |
| Major procedures have global periods containing a ____-day postoperative period with a ____-day preoperative period. A. 180; two B. 120; three C. ninety; one D. forty-five; zero | ninety; one |
| What are the newly mandated HCPCS modifiers that are a subset of modifier 59? A. Y modifiers B. O modifiers C. X modifiers D. Z modifiers | X modifiers |
| In which of the following ways do private payers relay information about payment policies? A. Federal Register B. Bulletins C. Handbook D. Contract | B. Bulletins C. Handbook D. Contract |
| Reporting items or services that are not actually documented but the coder assumes were performed is called ________ coding. A. unbundling B. upcoding C. truncated D. assumption | assumption |
| Which of the following are examples of compliance errors? A. Incorrect code selection B. Incorrect billing practices C. Use of appropriate code linkage D. Accuracy of claim form completion E. Errors related to medical necessity | A. Incorrect code selection B. Incorrect billing practices E. Errors related to medical necessity |
| Which of the following are reasons claims may be denied for a lack of medical necessity? A. The reported services are not consistent with the diagnosis. B. The reported services do not meet generally accepted professional medical standards of care. C. The reported services provided were not a covered benefit under the patient's health plan. | A. The reported services are not consistent with the diagnosis. B. The reported services do not meet generally accepted professional medical standards of care. |
| Medicare has computer programs to profile average billing patterns for E/M codes. This practice is known as ________. A. graphing B. predicting C. charting D. benchmarking | benchmarking |
| What does modifier 25 state when appended to an E/M code? A. E/M service was significant and clearly separate but performed by the same physician who performed the procedure within the postoperative period. B. E/M service was reduced or limited by the same physician on the same day as the procedure. C. E/M service was significant and clearly separate but performed by the same physician on the same day as the procedure. | E/M service was significant and clearly separate but performed by the same physician on the same day as the procedure. |
| Which of the following examples is related to truncated coding? A. Diagnosis codes are not as specific as possible. B. Match between the gender or age of the patient and the selected code C. Coding a unilateral service twice instead of choosing the bilateral code D. Altering documentation after services are reported | Diagnosis codes are not as specific as possible. |
| Using a procedure code that provides a higher reimbursement rate than the correct code may lead to the payer ________. A. modifying B. downcoding C. unbundling D. packaging | downcoding |
| When is it appropriate to append modifier 91 to a CPT code? A. When a repeat procedure or test is performed on the same day for patient management purposes B. When a significant, clearly separate E/M service is performed by the same physician on the same day as the procedure C. When a procedure that is distinct or independent from other services are performed on the same day D. When a repeat service is performed by a different physician | When a repeat procedure or test is performed on the same day for patient management purposes |
| What does Medicare use to inform medical insurance specialists about global periods? A. Global period status indicators B. Global period maps C. Global periods notices D. Global period bulletins | Global period status indicators |
| When a physician reports only the top two of the five-level E/M code range for established patients, this coding practice could be seen as ________. A. patterning B. fraudulent C. benchmarking D. unbundling | fraudulent |
| Which of the following are true about attaching modifier 25? A. The diagnosis code must be different than the diagnosis code linked to the procedure code. B. The E/M service must be significant and clearly separate. C. Modifier 25 can only be attached to an E/M code. D. Both an E/M code and a procedure code must be submitted by the same physician on the same day as the procedure. | B. The E/M service must be significant and clearly separate. C. Modifier 25 can only be attached to an E/M code. D. Both an E/M code and a procedure code must be submitted by the same physician on the same day as the procedure. |
| Which modifier should be used when a physician performs a simple repair of a superficial wound to the right leg and performs a partial thickness skin debridement of another site on the same leg? A. 57 B. 25 C. 59 D. 26 | 59 |
| Which modifier should be appended to a laboratory test that was distinct or separate from a lab panel performed on the same day? A. 57 B. 59 C. 91 D. 25 | 91 |
| What are global periods based upon? A. Health status of the patient after the procedure B. Level of medical necessity of the procedure performed C. Cost of the procedure performed D. Complexity of the procedure performed | Complexity of the procedure performed |
| The practice of routinely waiving deductibles or copayments violates ________ rules. A. licensing B. antikickback C. CPT D. AMA | antikickback |
| What is the term for the aids that list the procedures and CPT codes that are most frequently billed by the practice? A. Master aids B. Help aids C. Template aids D. Job reference aids | Job reference aids |
| A(n) ________ is a formal exam or methodical review of something such as billing compliance. A. audit B. determination C. review D. compliance waiver | audit |
| Which of the following items may be requested for a private-payer audit? A. Progress notes B. Laboratory test results C. Malpractice insurance D. Referrals | A. Progress notes B. Laboratory test results D. Referrals |
| When is it appropriate to append modifier 91 to a CPT code? A. When a procedure that is distinct or independent from other services are performed on the same day B. When a significant, clearly separate E/M service is performed by the same physician on the same day as the procedure C. When a repeat service is performed by a different physician D. When a repeat procedure or test is performed on the same day for patient management purposes | When a repeat procedure or test is performed on the same day for patient management purposes |
| Which of the following are goals of an internal coding audit? A. Analyze the skills and knowledge of the medical coders in the practice B. Locate areas in which training or additional review is needed C. Increase the cost of overhead expenses D. Determine if new procedures or treatments are correctly coded and documented E. Decrease patient satisfaction | A. Analyze the skills and knowledge of the medical coders in the practice B. Locate areas in which training or additional review is needed D. Determine if new procedures or treatments are correctly coded and documented |
| What is the meaning of professional courtesy? A. A physician waives the charges for services to any patient. B. A physician waives the charges for services to other physicians and their families. C. A physician provides services for a patient who is employed by the provider. D. A physician provides discounted services for his office staff. | A physician waives the charges for services to other physicians and their families. |
| Which of the following are key components for selecting E/M codes? A. Complexity of the medical decision making B. Extent of the history documented C. Extent of the exam documented D. Extent of the patient's insurance coverage | A. Complexity of the medical decision making B. Extent of the history documented C. Extent of the exam documented |
| Which of the following are found on job reference aids? A. ICD codes B. CCI edits C. CPT codes D. Modifiers | A. ICD codes C. CPT codes |
| Workers' compensation patients often must be charged according to a(n) ________ fee schedule. A. employer-mandated B. Medicare-mandated C. city-mandated D. state-mandated | state-mandated |
| What is the purpose of a billing compliance audit in a physician's practice? A. Determines whether the practice has the staff needed to comply with state licensing regulations B. Reveals discrepancies in following HIPAA guidelines C. Reviews the efficiency of resource use in the practice D. Judges whether the practice's physicians and coding and billing staff comply with regulations for correct billing and coding | Judges whether the practice's physicians and coding and billing staff comply with regulations for correct billing and coding |
| If the provider's fees are always paid in full, the fees may be set ________. A. below the payers' maximum allowable charges. B. at the incorrect geographical area. C. within the normal range of UCR. D. above the payers' maximum allowable charges. | below the payers' maximum allowable charges. |
| What may result when problems are found during a payer postpayment audit? A. A HIPAA grievance is filed. B. The investigation proceeds further. C. Penalties or fines are issued. D. Charges of fraud or abuse may be filed against the practice. | B. The investigation proceeds further. D. Charges of fraud or abuse may be filed against the practice. |
| Which of the following are the factors used to build a resource-based fee structure? A. How difficult it is for the provider to do the procedure B. The relative risk that the procedure presents to the patient and to the provider C. How much office overhead the procedure involves D. The fees that providers of similar training and experience have charged for similar services | A. How difficult it is for the provider to do the procedure B. The relative risk that the procedure presents to the patient and to the provider C. How much office overhead the procedure involves |
| UCR fees may not be available for new or ____ procedures. A. preventive B. obsolete C. deleted D. rare | rare |
| What must the coder determine as part of selecting the correct E/M code? A. Physician's NPI B. Patient's health plan C. Extent of history D. Patient's age and gender | Extent of history |
| Under the RVS system, every ________ is assigned a relative value unit. A. minute of service B. procedure C. supply D. diagnosis | procedure |
| What are usual fees? A. The charges that physicians require patients to pay for making copies of medical records B. The charges that physicians charge to most of their patients most of the time under typical conditions C. The copayment or coinsurance charges payers charge patients to receive benefits D. The charges that physicians charge to patients under health plans in which they are participating | The charges that physicians charge to most of their patients most of the time under typical conditions |
| Which of the following are parts used in determining the RBRVS fee? A. GPCI B. UCR C. RVU D. Conversion factor | A. GPCI C. RVU D. Conversion factor |
| Which of the following payment databases should be used to set practice fee schedules? A. Medicare B. OIG Workplan C. National databases D. Medicaid | A. Medicare C. National databases |
| What are the two main fee structures that payers use to establish payer fee schedules? A. Specialty-based B. Facility-based C. Charge-based D. Resource-based | C. Charge-based D. Resource-based |
| Which of the following are relative values for the Medicare Physician Fee Schedule? A. Malpractice B. Practice expense C. Work D. Physician expertise | A. Malpractice B. Practice expense C. Work |
| How are UCR fees set? A. By comparing utilization fees, customary fees, and related fees B. By comparing usual fees, collected fees, and revised fees C. By comparing unique fees, complicated fees, and resource fees D. By comparing usual fees, customary fees, and reasonable fees | By comparing usual fees, customary fees, and reasonable fees |
| The three main methods payers use to pay providers are allowed charges, contracted dee schedules, and ____. A. contracted clauses B. fee maintenance sheets C. fixed income payments D. capitation | capitation |
| What is the name of the Medicare payment system? A. RBRVS B. GPCI C. UCR D. COLA | RBRVS |
| With RVS, each procedure in a group of related procedures is assigned a ________ in relation to a ________. A. relative value B. usual value C. base unit D. cost unit | A. relative value C. base unit |
| What is an allowed charge? A. A maximum charge a plan pays for a service or procedure B. A charge that exceeds the approved amount C. A charge or service that is precertified by the health plan D. A fixed dollar amount reimbursed to the provider for capitated services | A maximum charge a plan pays for a service or procedure |
| A PAR provider must ________ the amount of the difference from the provider's fee and the allowed charge. A. write off B. balance bill C. collect D. discount | write off |
| What is the name of the payment arrangement made by payers for participating members? A. Contracted fee schedule B. Percentage of billed charges C. Usual and customary D. Reasonable and customary | Contracted fee schedule |
| Which of the following influence the GPCI? A. Local taxes B. Average physician salaries C. Rental prices D. Number of patients in a practice | A. Local taxes B. Average physician salaries C. Rental prices |
| A fixed plan payment for each plan member is called ________. A. bundled rate B. benefit payment C. capitation rate D. subrogation payment | capitation rate |
| If a provider's fee is lower than the allowed charge, the payer reimburses ________. A. the higher amount B. 60 percent of the allowed charges C. the difference between the allowed charge and the provider's fee D. the lower amount | the lower amount |
| What is the term used for collecting the difference between a PAR provider's usual fee and a payer's lower allowed charge? A. Coinsurance B. Deductible C. Write off D. Balance billing | Balance billing |
| What is the term for the amount withheld from a participating provider's payment by an MCO? A. RBRVS B. Capitation C. Provider withhold D. Subcapitation | Provider withhold |
| Adjustments to a patient's account can be ________ or ________. A. authorized; unauthorized B. contracted; non-contracted C. PAR; nonPAR D. positive; negative | positive; negative |
| Participating providers that are contracted directly with payers agree to accept the plan's ________. A. professional guidelines B. benefit plan C. fee schedule D. compliant policies | fee schedule |
| What must a practice follow if it accepts credit and debit card payments. A. UHDDS B. HIPAA C. FERPA D. PCI DSS | PCI DSS |
| Which of the following are acceptable methods of patients' payment? A. Credit or debit card B. Electronic fund transfer C. Check D. Cash | A. Credit or debit card C. Check D. Cash |
| Who determines the cap rate for healthcare plans? A. Managed care organization B. CMS in the Federal Register C. OIG D. Physician | Managed care organization |
| When a patient makes a payment at the time of an office visit, the patient is given a(n) ________. A. explanation of benefits B. receipt of payment C. walkout receipt D. remittance advice | walkout receipt |
| Which of the following services are typically included in the cap rate? A. Preventive care B. Counseling and telephone calls C. Office visit D. Surgical services performed in a hospital | A. Preventive care B. Counseling and telephone calls C. Office visit |
| What is the purpose of a provider withhold? A. To set aside money in a fund to cover the plan's unanticipated medical expenses B. To offer an incentive to participating providers C. To set up a fund to cover malpractice claims D. To cover administrative expenses in managing a health plan | To set aside money in a fund to cover the plan's unanticipated medical expenses |
| When the medical insurance specialist makes a change to a patient's account, it is called a(n) ________. A. PMPM B. cap rate C. adjustment D. provider withhold | adjustment |
| What is the purpose of a walkout receipt? A. It identifies the prior authorizations and precertifications for services rendered. B. It lists the laboratory tests that are ordered to an outside laboratory. C. It estimates the amount the health plan will pay for services. D. It summarizes the services and charges for the day as well as any payment the patient made. | It summarizes the services and charges for the day as well as any payment the patient made. |
| In calculations of RBRVS fees, the three relative value units are multiplied by A. the national conversion factor. B. the neutral budget factor. C. the UCR factor. D. their respective geographic practice cost indices. | their respective geographic practice cost indices. |
| Medicare typically pays for what percentage of the allowed charge? A. 70 percent B. 80 percent C. 50 percent D. 60 percent | 80 percent |
| If a participating provider’s usual fee is $400 and the allowed amount is $350, what amount is written off? A. $25 B. zero C. $75 D. $50 | $50 |
| If a nonparticipating provider’s usual fee is $400, the allowed amount is $350, and balance billing is permitted, what amount is written off? A. $75 B. $25 C. zero D. $50 | zero |
| If a nonparticipating provider’s usual fee is $400, the allowed amount is $350, and balance billing is not permitted, what amount is written off? A. $50 B. $25 C. zero D. $75 | $50 |
| Physicians establish a list of their usual fees for A. the procedures and services they frequently perform. B. workers’ compensation patients. C. their Medicare patients. D. the charges they have written off. | the procedures and services they frequently perform. |
| An encounter form containing E/M codes should list A. the practice’s professional courtesy policies. B. the most frequently billed codes. C. just blanks, so the correct E/M code can be entered. D. the complete ranges of codes for each type or place of service listed. | the complete ranges of codes for each type or place of service listed. |
| In calculations of RBRVS fees, the three relative value units are multiplied by A. the national conversion factor. B. the neutral budget factor. C. the UCR factor. D. their respective geographic practice cost indices. | their respective geographic practice cost indices. |
| Medicare typically pays for what percentage of the allowed charge? A. 70 percent B. 80 percent C. 50 percent D. 60 percent | 80 percent |
| If a participating provider’s usual fee is $400 and the allowed amount is $350, what amount is written off? A. $25 B. zero C. $75 D. $50 | $50 |
| If a nonparticipating provider’s usual fee is $400, the allowed amount is $350, and balance billing is permitted, what amount is written off? A. $75 B. $25 C. zero D. $50 | zero |
| If a nonparticipating provider’s usual fee is $400, the allowed amount is $350, and balance billing is not permitted, what amount is written off? A. $50Correct B. $25 C. zero D. $75 | $50 |
| Physicians establish a list of their usual fees for A. the procedures and services they frequently perform. B. workers’ compensation patients. C. their Medicare patients. D. the charges they have written off. | the procedures and services they frequently perform. |
| An encounter form containing E/M codes should list A. the practice’s professional courtesy policies. B. the most frequently billed codes. C. just blanks, so the correct E/M code can be entered. D. the complete ranges of codes for each type or place of service listed. | the complete ranges of codes for each type or place of service listed. |
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