HIT Classification and Reimbursement
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| A payer’s initial processing of a claim screens for | basic errors in claim data or missing information.
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| Some automated edits are for | patient eligibility, duplicate claims, and noncovered services.
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| A claim may be downcoded because | the documentation does not justify the level of service.
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| Payers should comply with the required | claim turnaround time.
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| What is the next step after the primary payer’s RA has been posted when a patient has additional insurance coverage? | billing the second payer
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| Appeals must always be filed | within a specified time.
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| Determine what should be verified after an RA has been checked for the patient’s name, account number, insurance number, and date of service. | that all billed CPT codes are listed
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| If a patient has secondary insurance under a spouse’s plan, what information is needed before transmitting a claim to the secondary plan? | RA data
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| What type of codes explain Medicare payment decisions? | MOA
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| Which of the following appears only on secondary claims? | primary payer payment
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| A payer may __________ a procedure that it determines was not medically necessary at the level reported. | downcode
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| What is the correct order for the basic steps of a payer's adjudication process? | initial processing, automated review, manual review, determination, and payment
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| During the adjudication process, if there are problems during the automated review, the claim is pulled for | development.
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| The __________ verifies the medical necessity of providers' reported procedures. | claims examiner
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| When a claim is pulled by a payer for a manual review, the provider may be asked to submit | clinical documentation.
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| A payer's initial claim review may reject a claim due to | an invalid policy number.
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| A payer's automated claim edits may result in claim denial because of | any of these.
lack of required preauthorization.
lack of medical necessity.
lack of eligibility for a reported service.
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| Medical situations in which a patient receives extensive care from two or more providers on the same date of service are called | concurrent care.
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| Concurrent care is care provided | to a patient on the same date at the same place of service by two or more physicians.
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| A payer's decision regarding whether to pay, deny, or partially pay a claim is called | determination.
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| What is done by a payer to determine the appropriateness of medical services? | utilization review
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| What will a payer do when a claim is submitted with a diagnosis code that is not valid for the date of service? | Payers may deny a claim when outdated codes are used.
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| The payer's processing of claims is called | adjudication.
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| A payer's determination means it is going to | pay, deny, or partially pay the claim.
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| Which of these HIPAA transactions is sent by a payer to answer a question about a submitted claim? | 277
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| The claim turnaround time is the period between | the date of claim transmission and receipt of payment.
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| An __________ code indicates that a request for more information has been sent. | R
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| A(n) __________ claim status category code is an acknowledgment that the claim has been received. | A
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| An insurance aging report lists | unpaid claims transmitted to payers by the length of time they remain due.
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| A list of claims transmitted and how long they have been in process with the payer is shown in the | insurance aging report.
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| Prompt-pay laws govern | insurance carriers' payments of providers' claims.
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| On an aging report, which category describes a current invoice? | 0–30 days
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| A typical aging report groups payments that are due into which of these categories? | 0–30 days, 31–60 days, 61–90 days, 91–120 days, and over 121 days
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| A pending claim is indicated by which claim status category code? | P
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| The payer's RA shows | both the amount the provider is allowed and the amount patient pays.
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| Claim adjustment reason codes are used by payers to explain entries on | RAs.
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| What kind of code appears on payers' electronic reports on the progress of transmitted claims in their adjudication process? | claim status category codes
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| The payer sends the medical practice | an RA that covers a batch of processed claims.
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| A paper explanation of benefits (EOB) is sent to patients by payers after claims | are adjudicated.
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| Remittance advice remark codes are maintained by __________ but can be used by all payers. | CMS
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| RAs generally have information on any | all of these are correct.
errors on the listed claims.
denials to the listed claims
adjustments to the listed claims.
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| The first step the medical billing specialist should check when reviewing RAs is to | match up claims with the RA using the unique claim control number.
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| The advantage(s) of EFT for practices is(are) | funds are available immediately and the transfer is less costly than check deposits.
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| The process of __________ means verifying that the totals on the RA are mathematically correct. | reconciliation
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| What does "reconciliation" mean? | to double-check that totals are accurate and consistent
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| Funds that are electronically transferred from a payer are directly deposited in the | practice's bank account.
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| The person filing an appeal is known as a(n) __________, regardless of whether that individual is a provider or a patient. | either the claimant or the appellant
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| The claimant is the | patient or provider who appeals the claim.
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| The abbreviation MRN stands for | Medicare Redetermination Notice.
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| In general, how many levels are there when pursuing an appeal? | three
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| When is an appeal sent to third-party payers? | after a claim is rejected or paid at less than the expected amount
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| Medicare overpayments must be reported and the amount | must be returned within 60 days.
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| Filing a grievance with the state insurance commission requires the __________ to investigate the complaint. | state
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| If a patient has additional insurance coverage, after the primary payer's RA has been posted, the next step is | billing the second payer.
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| Which of the following statements is true? | Medicaid is the secondary payer to Medicare.
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| If a Medicare beneficiary receives treatment covered by workers' compensation, the Medicare plan is | secondary.
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| If a Medicare beneficiary is employed and covered by the employer's group health plan, the Medicare plan is | secondary.
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| The abbreviation MSP stands for | Medicare Secondary Payer.
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| If a Medicare beneficiary is covered by a spouse's employer group health plan, the Medicare plan is | secondary
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| The Medicare Secondary Payer program coordinates the benefits for patients who have both Medicare and | any other insurance coverage.
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| When talking with someone other than the patient about an overdue bill, collections specialists will | not discuss the patient’s debt.
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| The day sheet produced by the practice management program shows | the payments and charges that occurred on that date.
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| During collections, most practices use | letters and calls.
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| Credit bureaus keep records about a patient’s | credit information.
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| Collection calls are regulated by the guidelines set by | FDCPA.
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| Accounts might be considered uncollectible when a patient | files for bankruptcy.
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| Skip tracing increases the practice’s chances of | locating a patient with an overdue bill.
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| The practice will need to pay patient refunds if it has | overcharged the patient for a service.
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| The patient aging report is used to | collect overdue accounts from patients.
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| Bad debt is defined as | uncollectible A/R.
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| Effective patient billing begins with | sound financial policies.
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| A good financial policy is clear to | both patients and the practice staff.
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| When a practice accepts a credit card payment in advance for payments billed after treatment, what does the practice send the patient? | zero-balance statement
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| A patient statement is | a bill that is sent to a patient for medical services that have been provided.
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| Which of the following shows a particular day's transactions? | day sheet
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| What document is used by the medical insurance specialist to update the patient billing program with the payer's payments and the amount due from the patient? | RA
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| The __________ totals the transactions that were posted to all patient ledgers on a particular business day. | day sheet
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| The day sheet in a medical office summarizes | all the transactions that were posted to all patient ledgers on a particular business day.
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| What is a printed bill that shows the amount a patient owes? | patient statement
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| The patient statement shows | all of these
the balance that a patient owes the practice.
the services provided to the patient.
how much the insurance paid.
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| The type of patient billing that spreads out the workload of mailing statements is called | cycle billing.
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| In cycle billing, how often does the practice mail all patient statements? | at intervals during the month
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| Patients are grouped under the insurance policyholder in what type of billing? | guarantor billing
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| Under the Federal Trade Commission's rules, it is illegal to | call multiple times daily.
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| For most patients, their first notice that their bill is past due is a | collection letter.
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| The law that regulates calling hours and collections methods is | Telephone Consumer Protection Act.
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| The __________ report is the start of the process of collecting payments due from patients. | patient aging
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| The law that regulates collection practices is | FDCPA.
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| Who is responsible for regulating the hours during which collection calls may be made? | both the FDCPA and the Telephone Consumer Protection Act
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| Collections from patients are classified as consumer collections and are regulated by __________ and state laws. | federal
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| Under the Federal Trade Commission's rules, it is not illegal to | call a patient at 8 p.m.
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| FDCPA is the abbreviation for | Fair Debt Collection Practices Act.
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| The job of creating and implementing the practice's collections policies is done by | the billing/collections manager.
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| Embezzlement is a form of | stealing.
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| What term refers to the stealing of funds? | embezzlement
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| What term refers to all the activities that are related to patient accounts and follow-up? | collections
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| The process of following up on overdue accounts is called | collections.
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| The job of accurately recording the funds coming into and going out of the practice is done by | the bookkeeper.
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| Which of the following employees learns and applies the correct techniques for effective follow-up of overdue accounts, as well as is most likely to work directly with patients? | collections specialist
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| Patients may agree to a(n)__________ for expensive procedures before the date of service. | prepayment plan
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| Which of the following is the cost of a borrower's credit calculated as an annual rate? | annual percentage rate
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| When patients are scheduled to have major, expensive procedures, the practice's policy may be to set up | prepayment plans.
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| The __________ process is used to locate a patient who owes an account balance to the practice. | skip tracing
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| Which law modified the Fair Credit Reporting Act to protect the accuracy and privacy of credit reports? | FACTA
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| A collection agency is usually | an outside firm the medical practice hires.
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| FACTA is the acronym for | Fair and Accurate Credit Transaction Act.
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| FCRA is the abbreviation for | Fair Credit Reporting Act.
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| Credit bureaus supply information about | how well patients pay their bills.
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| Collection agencies are outside services that are hired to | collect overdue accounts.
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| Which law required consumer reporting agencies to have reasonable and fair procedures? | FCRA
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| The __________ helps a practice decide whether patients are indigent. | means test
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| __________ is a legal declaration of a person's inability to pay his or her debts. | Bankruptcy
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| Which of the following requires a practice to follow a specific series of steps before an account can be written off? | both Medicaid and Medicare
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| Uncollectible accounts refer to | monies owed by patients and payers.
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| When a person receives a legal declaration of the inability to pay debts, it is called | bankruptcy.
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| What is the term for monies owed to a patient from the provider? | patient refund
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| Bad debt includes all collections that are | classified as uncollectible accounts.
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| HIPAA compliance records must be retained for how many years? | six
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| A __________ is a log of how long various types of documents must be stored for a particular practice. | retention schedule
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| The practice's policy about keeping records is summarized in a __________, a list of the items from a record that are retained and for how long. | retention schedule
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| When the hospital staff collects data on a patient who is being admitted for services, the process is called | registration
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| Which of the following hospital departments has different procedures for collecting patients’ personal and insurance information? | emergency department
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| Patient charges in hospitals vary according to | their accommodations and services.
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| Which of these rules governs the reporting of hospital inpatient services on insurance claims? | UHDDS
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| Conditions that arise during the patient’s hospital stay as a result of surgery or treatments are called | complications.
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| In inpatient coding, the initials CC mean | comorbidities and complications.
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| The code 02103D4 is an example of which type of code? | ICD-10-PCS
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| Under a prospective payment system, payments for services are | set in advance.
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| The UB-04 form locator 4 requires the | type of bill.
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| Under Medicare rules for patients in car accidents, the automobile insurance is | primary
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| In medical insurance terminology, an emergency is a | situation in which delaying the treatment of a patient would result in a significant increase in the threat to life or to the viability of the body part.
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| Ambulatory care refers to which kind of care? | outpatient
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| What is a special approach to caring for people with terminal illnesses? | hospice care
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| ASU is the abbreviation for | ambulatory surgical unit.
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| __________ involves a situation that is life-threatening. | Emergency care
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| What involves a situation in which a delay in treatment would lead to a significant increase in the threat to a patient's life or body part? | emergency care
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| __________ is palliative care for terminally ill patients. | Hospice care
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| What type of facility is equipped for patients to stay overnight? | inpatient
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| A(n) __________ is a person admitted for services that require a stay spanning two midnights. | inpatient
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| Hospice care is provided | either in a special hospice facility or a patient's home.
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| ASC is the abbreviation for | ambulatory surgical center.
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| HHA is the abbreviation for | home health agency.
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| What category of services includes care given at home, such as physical therapy or skilled nursing care? | home health care
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| SNF is the abbreviation for | skilled nursing facility.
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| What type of care covers all types of health services that do not require an overnight hospital stay? | ambulatory care
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| An ambulatory surgical center is a clinic that provides | outpatient surgery.
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| At-home recovery care refers to assistance with which of the following? | the activities of daily living, such as bathing and eating
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| Ambulatory care is provided in a(n) | outpatient facility or setting.
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| The__________ is the main database of a hospital's patients. | master patient index
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| Inpatients are admitted to hospitals in a process called | registration.
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| A charge master contains a hospital's list of all of the following except | staff.
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| patient's personal and insurance information is gathered before or during hospital admission through which process? | registration process
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| Patients are listed in a patient register under a unique number, which makes up the | master patient index.
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| A __________is the hospital's list of the codes and charges for its services | charge master
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| HIM is the abbreviation for | health information management.
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| The HIM department in hospitals conducts which of the following | organizes and maintains patient medical records
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| The major steps related to hospital claims processing are | admission, treatment, and discharge.
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| Which term is generally used for the hospital admission process? | registration
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| HINN is the abbreviation for | Hospital-Issued Notice of Noncoverage.
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| CC is the abbreviation used by the inpatient coder on the medical record for _________. | complications and comorbidities
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| A patient's other conditions at admission that affect care during the hospitalization being coded are called __________, meaning coexisting conditions. | comorbidities
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| Which term describes the patient's condition that, after study, is established as the main reason for a hospital admission? | principal diagnosis
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| Which of these terms refers to coexisting conditions? | comorbidities
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| UHDDS is the classification system for | inpatient health data.
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| Which term describes the patient's condition upon hospital admission? | admitting diagnosis
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| Which term describes the main service performed for the condition listed as the principal diagnosis for a hospital inpatient? | principal procedure
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| The principal procedure is assigned by the | inpatient medical coder.
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| MS-DRG is the abbreviation for | Medicare-Severity Diagnosis Related Group.
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| APC is a __________ payment system. | Medicare
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| __________are complications caused by avoidable conditions that will not be reimbursed. | Never events
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| Each MDC is subdivided into __________ MS-DRGs. | medical and surgical
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| APC is the abbreviation for | ambulatory payment classifications.
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| DRG is the abbreviation for | diagnosis related group.
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| The DRG system is now called which of the following | MS-DRGs
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| The IPPS is the Medicare system for payments to institutions for | inpatients.
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| Each hospital's __________ is an average of the DRG weights handled for a specific period of time. | case mix index
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| Each hospital negotiates a rate for MS-DRGs based on which of the following? | all of these are factors in the rate
supply costs
geographic location
labor
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| A grouper is software used to help calculate and assign | DRGs.
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| The UB-04 form is also identified as the __________ form. | CMS-1450
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| Hospitals must submit electronic claims for Medicare Part A reimbursement to MACs using the HIPAA health care claim called | 837I.
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