Nationals
Quiz yourself by thinking what should be in
each of the black spaces below before clicking
on it to display the answer.
Help!
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| Accept Assignment | Provider accepts as a payment in full whatever is paid on the claim by the payer(expect for any copayment and or coinsurance amounts
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| Account Receivable | The amount the payer will reimburse for each procedure or service
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| Allowed charges | The maximum amount the payer will reimburse fir each procedure or service according to the patient's policy
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| Bad Debt | Accounts receivable that cannot be collected by the provider or collection agency
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| Beneficiary | The eligible to receive healthcare benefits
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| Charge Master | Term hospitals use to describe a patient encounter form
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| Claim Adjudication | Comparing a claim to payer edits and the patients health plan benefits to verify that the required info is available to process the claim; the claim is not duplicate; payer rules and procedures have been follow
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| Claims attachment | Medical report substantiating a medical condition
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| Claim Processing | Sorting claims upon submission to collect and verify information about the patient
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| Claim Submission | The transmission of claims data (electronically or manually) to payers or clearinghouses for processing
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| Clean claim | A correctly completed standardized claim (e.g., CMS-1500 claim)
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| Clearinghouse | Performs centralized claims processing for providers and health plans.
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| Closed claim | Claims for which all processing, including appeals, has been completed.
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| Coinsurance | Coinsurance payment) the percentage the patient pays for covered services after the deductible has been met and the copayment has been paid.
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| Common data file | Abstract of all recent claims file don each patient
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| Consumer Credit Protection Act of 1968 | Was considered landmark legislations because it launched truth-in-lending disclosures that required creditors to communicate the cost of borrowing money in a common language so that consumers could figure out the charges; compare costs, and shop
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| coordination of benefits (COB) | Provision in group health insurance policies the prevents multiple insurers from paying benefits covered by other policies; also specifies that coverage will be provided in a specific sequence when more than one policy covers the claim
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| Covered entity | Private sector health plan (excluding certain small self-administered health plans), managed care organizations, ERISA-covered health benefit plans
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| Day sheet | Manual daily accounts receivable journal) chronological summary of all transactions posted to individual patient ledger/accounts on a specific day.
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| Deductible | Amount for which the patient is financially before an insurance policy provides coverage.
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| Delinquent claim | Claim usually more than 120 days past due'; some practices establish time frames that is less than or more than 120 days past due.
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| Down coding | Assigning lower-level codes than documented in the record.
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| Delinquent claim cycle | Advances through various aging periods (30 days, 60 days, 90 days, and so on), with practices typically focusing internal recovery efforts on older delinquent accounts
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| Electronic data interchange (EDI) | computer to computer exchange of data between provider and payer
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| Electronic flat file format | Series of fixed records (e.g., 25 spaces patient's name) submitted to payers to bill for healthcare services
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| Electronic Healthcare Network Accreditation Commission (EHNAC) | Organization that accredits clearinghouses
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| Fair Credit Reporting Act | Protects information collected by consumer reporting agencies such as credit bureaus, medical information companies, and tenant screening services; organizations that provide information to consumer reporting agencies also have specific legal obligations
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| Fair Debt Collection Practices Act (FDCPA) | Specifies what a collection source may and may not do when pursuing payment of past due accounts.
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| Guarantor | Person responsible for paying healthcare fees
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| Litigation | Legal action to recover a debt; usually a last resort for a medical practice.
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| Manual daily accounts receivable journal | Also called the day sheet; a chronological summary of all transactions posted to individual patient ledgers/accounts on a specific day.
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| Noncovered benefit | Any procedure or service reported on a claim that is not included on the payer's master benefit list, resulting in denial of the claim
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| Nonparticipating provider (nonPARs) | Does not contract with the insurance plan' patients who elect to receive care from nonPARs will incur higher out-of-pocket expenses.
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| Past-due account | Delinquent account one that has not been paid within a certain time frame (e.g., 120 days)
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| Patient ledger | (Patient account record) a computerized permanent record of all financial transactions between the patient and the practice.
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| Provider Remittance Notice (PRN) | Remittance advice submitted by Medicare to providers that includes payment information about a claim
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| Source document | The routing slip, charge slip, encounter form, or superbill from which the insurance claim was generated
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| Superbill | Term used for an encounter form in the physician's office
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| Suspense | Pending
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| Truth in Lending Act | Consumer Credit Protection Act of 1968)was considered landmark legislation because it launched truth-in-lending disclosures that required creditors to communicate the cost of borrowing money
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| Unassigned claim | Generated for providers who do not accept assignment; organized by year.
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| Unbundling | Submitting multiple CPT codes when one code should be submitted.
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| Unauthorized service | Services that are provided to a patient without proper authorization or that are not covered by a current authorization
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| Value-added network (VAN) | Clearinghouse that involves value-added vendors, such as banks, in the processing of claims; using a VAN is more efficient and less expensive for providers
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| Electronic remittance advice (ERA) | Remittance advice that is submitted to the provider electronically and contains the same information as a paper-based remittance advice; providers receive the ERA more quickly.
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| Fair Credit Reporting Act | Protect information collected by consume reporting agencies such as credit bureaus, medial information companies and tenant screening services; organizations that provide information to consumer reporting agencies also have specific legal obligations,
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| Fair Credit Billing Act | Federal law passed in 1975 that helps consumers resolve billing issues with care issuers; protect important credit right, including rights to dispute billing errors
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| Fair Credit and Charge Care Disclosure Act | Amended the Truth i Lending Act, requiring credit and charge care issues to provide certain disclousres in direct mail, telephone, and other cirucumstances; this law applies to providers that accept credit cards.
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| Encounter form | Financial record source document used by provider and other personnel to record treated diagnoses and services rendered to the patient during the current encounter
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| Block 1 | This block indicates what kind of insurance is applicable; for example Medicare or Medicaid
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| Block 1A | Medicare health insurance claim number. This number must be recorded whether Medicare is the primary or secondary payer
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| Block 2 | Patients first name, middle initial, and last name, as shown on the patients Medicare card
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| Block 3 | Patients eight-digit date and sex; the birth date
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| Block 4 | Insureds name
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| Block 5 | Patients mailing address and telephone number
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| Block 6 | The patients relationship to the insured
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| Block 7 | Insured's address and phone number
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| Block 8 | Blank
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| Block 9 | Medigap Enrollee name
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| Block 9A | Medigap Enrollee Policy #
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| Block 9B | Medigap Enrollee Birthdate and Sex
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| Block 9C | Blank if block 9d is filled out,
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| Block 9D | Coordination of Benefits agreement Medigap
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| Blocks 10A-C | Block you'll check yes or no to indicate whether employment, auto liability, or other accident involvement applies to one or more of the services
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| Block 11 | It indicates that a good faith effort has been made to determine whether Medicare is the primary insurance
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| Block 11A | Insured's birth date as well as sex
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| Block 11B | Employers name and any change in insurance status
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| Block 11C | 9 digit payer ID # of the primary insurer.
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| Block 12 | Patient or an authorized person signs to authorize the release of medical information
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| Block 13 | Signature authorizes payment of benefits
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| Block 14 | Date of current illness, injury, or pregnancy; it has to have six or eight digits.
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| Block 15 | Blank but only use it if provider is seeing a patient in a facility
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| Block 16 | This is required if the patient is eligible for disability or worker's compensation benefits
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| Block 17 | Has the name of the ordering or physician’s name.
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| Block 17B | The national provider identifier number
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| Block 18 | Hospital dates entered either in a six or eight digit format
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| Block 19 | Dates entered either in a six or eight digit format for when the patient was last seen and the NPI of the attending physician when a physician providing routine foot care submits a claim.
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| Block 20 | If lab tests were done by an entity other than the one doing the billing, the box should be marked YES
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| Block 21 | The diagnosis codes
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| Block 22 | Empty
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| Block 23 | Prior authorization number
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| Block 24A | Contains the dates of service
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| Block 24B | The places of service codes
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| Block 24C | Medicare providers do not have to fill out this block
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| Block 24D | CPT or HCPCS codes will be used
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| Block 24E | The diagnosis reference code. It also matches the date of service to the procedures performed under the primary diagnosis code
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| Block 24F | Providers billed charges for each service
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| Block 24G | The number of days or units
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| Block 24 I | ID qualifier will go in the shaded portion of this block
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| Block 24J | The rendering provider's NPI goes in the unshaded portion
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| Block 25 | the provider's or suppliers ID number or social security number
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| Block 26 | Patients account number as assigned by the provider or supplier goes in this block
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| Block 27 | Will be checked yes or no if the provider accepts assignment of Medicare benefits
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| Block 28 | Will have total charges for all services
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| Block 29 | The total amount the patient paid for covered services only
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| Block 30 | Blank
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| Block 31 | Signature of the provider or the signature of the authorized representative
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| Block 32 | Name, address, and ZIP code of the facility
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| Block 32A | National provider Identifier
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| Block 33 | The providers or suppliers billing name, address, ZIP code, and telephone number
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| How many dates of service can blocks include for a same procedure code? | 02
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| How are codes shown for place of service? | Two digit codes
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| What is the code used for a pharmacy? | 01
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| What is 02 used as? | Unassigned number
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| What is the code used for a school? | 03
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| What is the code used for a homeless shelter? | 04
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| What should be done if a claim involves more than one referring, ordering, or supervising physician? | A Separate claim must be submitted for each physician
Referring provider
The physician who requests the service for the patient
Ordering provider
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| A physician or other licensed health care professional who prescribes services for a patient | Supervising provider
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| What are the entities covered under HIPAA? | The physician monitoring a patient’s care
Individuals, organizations, home health agencies, clinics, nursing homes, residential treatment homes, laboratories, ambulances, group practices, and health maintenance organizations
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| What is block 24g mostly used for? | Multiple visits, units of supplies, anesthesia minutes, oxygen volume
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| Why is block 11 important? | This is the place to indicate that a good faith effort has been made to determine which the primary insurance is and which is secondary
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| Patients demographic for the Claims Form? | 2,3,5,7
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| Left Blank? | 8, 9b, 11d, 17a, 22, 24h, 30
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| What does a group health plan cover? | Workers compensation, black lung, veteran’s benefits
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| What are the other blocks that can be listed for block 19? | Name and date of drugs listed as not otherwise classified, Homebound, Patient refuses to sign benefits, testing for hearing aids
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| What also should be used in block 23 when an investigation device is used in an FDA approved clinical trial? | Investigational device exemption
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| What’s the other information included in block 23? | National provider identifier of a home health agency or hospice, 10 digit clinical laboratory improvement act certification number for laboratory services billed by any entity performing CLIA covered procedures
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| What needs to be done if more than one condition applies to a claim? | Separate claims need to be submitted for each condition
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| What takes place when a work related illness or injury occurs? | Group health plan coverage, no fault and or other liability, work related illness or injury
These are instances when Medicare is the secondary insurance
Working aged, disability, end-stage kidney disease
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| A claim rejected because of Medicare NCCI edits? | Because of improper code combination
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| A claim is submitted with transposed insurance member ID # and returned because? | An Invalid claim contains illogical or incorrect information and returned to the provider unprocessed
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| DENIED CLAIM | Is returned to the provider after it has been processed
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| Medigap coverage ID offered to Medicare beneficiaries by which of the following? | Private 3rd party payer
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| Medicaid’s supplement coverage | Called Medi Medi and it picks up Medicare premium to qualified applicants
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| Release of Patient Records 1 | All request for patient records must be in writing and have signed authorization from the patient, parent, legal guardian
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| Release of Patient Records 2 | ID is required in order to maintain patient confidentiality and privacy
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| ABUSE | Submitting a claim for services that are not medically necessary
Violating participating provider
Billing no covered service as covered
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| Fraud | Is billing for a service that was never provider
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| NPI | National Provider ID #
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| Fee schedule | Are a list of the provider’s service fee
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| HCPCS | Healthcare Common Procedure Coding System
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| CPT | Current Procedural Terminology is used for procedure coding
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| ICD | International Classification of Disease
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| Preventing Fraud | Performing periodic audit
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| Medicare part A | Inpatients
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| Medicare part B | Outpatients
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| Medicare part C | Both in and out patients
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| Medicare part D | Prescription
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| Anesthesia section of the CPT manual (qualifying circumstances is? | ADD-ON Codes
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| > | Symbol is used for procedure descriptions
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| Prospective review | Ensure the appropriateness and necessity of care provided
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| Coding Compliance Plan contains | Rules, procedures and best practice
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| Procedures and best practice for correct coding is? | Coding Compliance Plan
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| Health Care clearinghouses is covered by HIPAA regulations included? | Providers of health care services and health 3rd party payers who submit
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| Insurance company denies a service as not medically necessary? | Appeal the decision with providers report
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| Blood cells | Are generated in BONE MARROW
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| Assignment benefits | Is a required for Medicare recipients
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| Retrospective | Audit ensure correctness of billing documents
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| Endo | mean inside
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| Cardium | means pertaining to heart
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| Epi | means top
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| My | means Muscle
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| Peri | means around
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| Uretharatresia | mean Obstruction of the Urethra
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| Urethrism | mean Irritability or spasmodic stricture
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| Urethralgia | means Pain
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| Urethritis | mean inflammation
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| Ambulatory, Surgery centers, Hospice form is? | UB-04
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| HIPAA transaction standards apply to which? | Health Care Clearinghouse
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| algia | means pain
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| emia | means blood condition
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| itis | means inflammation
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| megaly | means enlargement
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| meter | means measure
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| oma | means tumor, mass
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| osis | means abnormal condidtion
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| a, an | means not, without, less
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| pathy | means disease condition
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| rrhagia | means bursting forth of blood
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| rrhea | means discharge
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| sclerosis | means hardening
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| scopy | means to view
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| centesis | means surgical puncture
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| ectomy | means removal, resection, excision
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| gram | means records
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| graphy | means process of recording
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| lysis | means separation, breakdown, destruction
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| pexy | means surgical fixation
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| plasty | means surgical repair
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| rrhaphy | means suture
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| scopy | means visual examination
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| stomy | means opening
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| therapy | treatment
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| tomy | means incision, to cut into
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| ante | means before
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| anti | means against
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| brady | means slow
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| dys | means painful, difficult
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| endo | means inside, within
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| epi | means upon
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| Claim Life Cycle 1 | Submission
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| Claim Life Cycle 2 | Processing
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| Claim Life Cycle 3 | Adjudication
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| Claim Life Cycle 4 | Payment
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| What would cause a claim to be suspended? | Service required additional information
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| Left Upper Quadrant | Left lobe of the liver, the stomach, the spleen, part of the pancreas, and part of the small and large intestines
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| Right Upper Quadrant | Right lobe of the liver, the gallbladder, part of the pancreas, part of the small and large intestines
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| Right Lower Quadrant | Part of the small and large intestines, and appendix, and the right ureter
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| Left Lower Quadrant | Part of the small and large intestines, and the left ureter
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| Medicaid for a patient who had primary and secondary insurance coverage what do you do? | Attach the remittance advice from the primary insurance along with the Medicaid
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| Who Fights waste, fraud, and abuse in Medicare and Medicaid? | Office of Inspector General (OIG)
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| Medigap coverage is offered to which Medicare beneficiary? | Private 3rd party payer
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| Financial record source is? | Patient ledge account
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| Encounter Form | Is used for billing
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| Examination of a sore throat is ? | Problem-Focus examination
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| What Final determination of the issue involving settlement? | Adjustication
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| A transmit to the insurance carrier for reimbursement of inpatient Hospital service is? | UB-04
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| A form that contains charges DOS CPT ICD code fee and copayments is | Encounter Form
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| A unlisted codes can be found where in the CPT manual? | Guidelines prior to section each section
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| Psoriasis | Dermatology
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| Valvuloplasty | Open stenotic heart valve
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| Angioplasty | A balloon is threaded into the artery and expanded
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| Ablation | Ablation therapy
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| + | Add-on codes
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| A Triangle | Means revised code
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| Encounter Form | Is a form that includes info about past and current history, inpatient record, discharge in and out
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| Pediatric | Is for infants, children and teens
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| Pathology | Is disease
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| Integumentary | Is body temp
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| HCPS LEVEL 2 | Appendix's
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| Appendix A | Has a complete list of modifiers and their description
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| Appendix B | Is a summary of the addition, deletion, and revision that has been put into use in the current CPT edition
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| Appendix C | Has clinical example for codes in evaluation and management section of the CPT book
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| Appendix D | Is a list of CPT add-on codes
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| Appendix E | Is a summary of CPT codes that are exempt from modifier 51
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| Appendix F | Is a summary of CPT codes exempt from modifier 63
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| Appendix G | Has a codes that include conscious/moderate sedation
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| Appendix H | Is an alphabetic index of performance measures by clinical conditions or type but was removed from CPT
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| Appendix I | Has genetic testing code modifiers used for reporting with lab procedures
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| Appendix J | Includes a list of sensory, motor, and mixed nerves that are useful for nerves conduction studies
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| Appendix K | List procedure included in the CPT codebook that are not yet approved
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| Appendix L | Is a reference of the vascular families, including which are considered first-, second-, and third-order vessels
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| Appendix M | Shows a table of deleted CPT codes and crosswalks to current codes
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| Appendix N | Is a listing of codes that have been re-sequenced
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| ICD-9-CM VOLUME 1 | Tabular List of Disease and Injuries
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| ICD-9-CM VOLUME 2 | The Alphabetic Index to Diseases and Injury
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| ICD-9-CM VOLUME 3 | The Classification for Procedures for Reporting Hospital Procedures
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| HCPCS LEVEL 2 A codes | Is Ambulance and transportation service, medical and surgical supplies
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| HCPCS LEVEL 2 B codes | Is Enteral and parenteral therapy
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| HCPCS LEVEL 2 D codes | Is Dental
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| HCPCS LEVEL 2 E codes | Is Durable medical equipment
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| HCPCS LEVEL 2 G codes | Is Procedures/professional service (temporary)
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| HCPCS LEVEL 2 J codes | Is Drugs that are not self-administered (such as chemotherapy
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| HCPCS LEVEL 2 L codes | Is Orthotic and prosthetic procedure
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| HCPCS LEVEL 2 M codes | Office services and cardiovascular
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| HCPCS LEVEL 2 P codes | Is Pathology
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| HCPCS LEVEL 2 Q codes | Is Temporary codes
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| HCPCS LEVEL 2 R codes | Is Domestic radiology
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| HCPCS LEVEL 2 V codes | is Vision, hearing, and speech-language pathology service
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|
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You may also shuffle the rows of the table by clicking on the "Shuffle" button.
Or sort by any of the columns using the down arrow next to any column heading.
If you know all the data on any row, you can temporarily remove it by tapping the trash can to the right of the row.
Embed Code - If you would like this activity on your web page, copy the script below and paste it into your web page.
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Created by:
kayymoore
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