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CBCS

Capitation

When the healthcare provider is paid a fixed amount

Service and Procedure Based

The CPT coding system is

5 Digits (282.60)

An ICD-9-CM sublassification code must have?

MM/DD/CCYY

The patients birth date on the CMS-1500 form is entered in which of these formats?

Special Report

A service that is rarely provided, unusual, variable, or new may require a __________ in determining medical appropriateness of the service.

Indemnity

A type of insurance whereby the insured pays a specific amount per unit of service and the insurer pays the rest of the cost is called

Dread Disease Rider

A rider added to a policy to provide additional benefits for certain conditions is called

Stipulations

Rules that insurance companies have that service be outpatient or inpatient are called

Gastrectomy

Gastric resection

Osteitis

Inflammation of a bone

Cystoscopy

Visual examination of the urinary bladder

Hepatoma

Tumor of the liver

Mammary gland

What gland is not an endocrine gland?

Iatrogenic

Pertaining to produced by treatment

Electroencephalogram

Record of electricity in the brain

Diagnosis

Made on the basis of complete knowledge about the patient's condition

Cancerous tumor

Carcinoma

Biopsy

Microscopic examination of living tissue

Cephalic

Pertaining to the largest part of the brain

Adenectomy

Removal of a gland

Arthralgia

Pain in a joint

Leukemia

Increase in numbers of malignant white blood cells

Opthalmoscope

Instrument to view the eye

Thrombocyte

A platelet

Rhinitis

Inflammation of the nose

Cytology

Study of cells

Transhepatic

Pertaining to through the liver

Nephrosis

Abnormal condition of the kidney

Osteotomy

Incision of a bone

Hyperglycemia

High level of sugar in blood

Code of Hammurabi

Earliest written code of ethincal principles for the medical profession

The Principles of Medical Ethics

What is the name of the modern code of ethics that the American Medical Association (AMA) adopted in 1980?

Waiver

An attachment to an insurance policy that excludes certain illnesses or disabilites that would otherwise be covered is referred to as

Name the 6 main sections of CPT code range

Evaluation & Management 99201-99499
Anesthesia 00100-01999 / 99100-99140 (smallest section)
Surgery 10021-69990 (largest section)
Radiology 70010-79999
Pathology / Laboratory 80048-89356
Medicine 90281-99199 / 99500-99602

Semicolon (;)

These symbols are used so that test does not need to be repeated for an entire range of codes

Bullet

This symbol preceding a CPT code means the code is new for that particular year

Triangle

This symbol preceding a code means the code has undergone a revision to the description from the previous year

Double Arrows (<>)

Used to identify new and revised text

A plus sign (+)

indicates an add-on code

Circle with a slash through it

Used to identify codes exempt from modifer 51

Bull's Eye

This symbol was added to indicate those procedures in which the provision of moderate sedation services is considered to be inherent and, therefore, not separetly reported by the same physician performing the primary service.

Lightning Bolt

This convention was added to highlight products that are awaiting U.S. Food and Drug Administration (FDA) approval

21

Prolonged evaluation & Management

Unusual procedural services

22

Unusual aneshesia

23

Unrelated E/M service by the same physician during a post-operative period

24

Significant, separately identifiable E & M service by the same physician on the day of a procedure

25

Professional component

26

Mandated Services

32

Bilateral procedure

50

Multiple procedures

51

Reduced services

52

Decision for surgery

57

Staged or related procedure or service by the same physician during the post-operative period

58

Distinct procedural service

59

Repeat procedure by the same physician

76

Return to the operating room for a related procedure during the post-operative period

78

Unrelated procedure or service by the same physician during the post-operative period

79

Assistant surgeon

80

Reference (outside) laboratory

90

Multiple modifiers

99

A claims assistance professional

Works for the consumer and helps patients file insurance claims

What is the name of the modern code of ethics tha the American Medical Association (AMA) adopted in 1980?

The Principles of Medical Ethics

An attchement to an insurance policy that excludes certain illnesses or disabilities that would otherwise be covered is referred to as a

Waiver

Mrs. Thompsett leaves her place of employment. She is eligible to transfer her medical insurance coverage from a group to an individual contract. This is known as

Conversion privlege

Why would conversion from a group policy to an individual policy be advantageous?

No physician examination required

A patient intake sheet is also called a

Patient registration form

The first document obtained in the initial patient visit is a

Patient information sheet

The source document for insurance claim data is the

Super bill

A medical record is considered

medical information and a health record

A medical report is a

Permanent legal document and part of the medical record

Parts of the small and large intestines, right ovary, right uterine tube, appendix, and right ureter are found in the

Right lower quadrant

Preservation of medical records is governed by

State and local law

When is the principle diagnosis applicable?

Inpatient hospital coding

E codes are used

to show external cuase of injury

What is the name of the book used in the physicians office to code procedures?

Current Procedural Terminology (CPT)

The term "encounter records" means

Claim

Input of data into a computer system requires the use of a

Keyboard

Another name for instructions that make the computer perform a specific task is

Software

The storage capacity of a computer is measured in

Bytes

The smallest unit of storage possible in a computer is the

Bit

Back and forth communicaiton between user and computer that occurs during on-line real time is called

Interactive transaction

What is the name of the act designed to address the collection practices of third-party debt collectors and attorneys who regularly collect debts for others?

Fair Debt Collection Practices Act

America's oldest privately owned, prepaid medical group is the

Ross-Loos Medical Group

Kaiser Permanente's medical plan is a closed panel program, which means

It limits the patient's choice of personal physicians

When an HMO is paid a fixed amount for each patient serviced without considering the actual number or nature of services provided to each person, this is known as

Capitation

How are physicians paid who work for a prepaid group practice model?

Salary paid by independent group

The letters preceding the number on the patients Medicare identification card indicate

Railroad retiree

Medigap insurance may cover

the deductible not covered under Medicare

Under the prospective payment system (PPS), hospitals treating Medicare patients are reimbursed according to

Preestablished rates for each type of illness treated based on diagnosis.

The 1987 Omnibus Budget Reconciliation Act (OBRA) established the

MAAC

RBRVS was established as a means to

redistribute Medicare dollars among physicians more equitably

Organizations handling claims from hospitals, nursing facilities, intermediate care facilities, long-term care facilities, and home health agencies are called

Fiscal intermediaries

The Medicaid program was a direct result of

a law passed by Congress in 1950

The medically needy aged

require help in meeting costs of medical care

The federal aspects of Medicaid are the responsibility of

CMS

The Omnibus Budget Reconciliation Act

Provided assistance for the aged and diabled who are receiving Medicare and whose incomes are below the poverty level.

TRICARE, formerly known as CHAMPUS, is funded through

Congress

People NOT entitled to benefits under TRICARE are

CHAMPVA beneficiaries

What is the system called that TRICARE claims processors use to verify beneficiary eligibility?

TRI-CHECK

A physician who chooses not to participate in TRICARE bills

no more than 115% of the Tricare allowable charge.

The time limit within which a TRICARE inpatient claim must be filed is within

one year from a patients discharge from an inpatient facility.

The statutes for workers compenatjion laws fall under

Federal and state compensation laws

When a case is rated for permanent disability and settled, this is called

Compromise and release

In a PD (permanent disability) claim, the physicians final report must include the words

Permanent and stationary

The code book used to list procedures on outpatient hospital claims is

CPT

The form that accompanies the billing claim form for inpatient hospital services is called a

Detail statement

A claims assistance professional should promote and market to

Medicare receipients

What association maintains and publishes CPT coding guidelines, codes, and descriptions?

AMA

What are the three categories of CPT codes?

Category I, II, III

What are three methods procedural main terms are listed in the CPT manual alphabetical index?

Condition, synonyms, abbreviations

What three components are used to configure Relative Value Units?

Malpractice insurance cost, physician work, practice expense

What are the definitions for facility and non-facility RVU expenses for calculating physician fee schedule payment amounts?

Non-Facility includes privately owned physician practices
Facility includes skilled nursing facilities, nursing homes, hospitals

Which CPT code set is used voluntarily by physicians to report quality patient performance measurements?

CPT Category II Codes.

CPT category III codes are reported to indicate which type of service or procedure?

New and emerging

Which CPT Appendix lists clinical examples for E/M coding?

Appendix C

Neurectomy

Resection of a nerve

Pericardium

Membran surrounding the heart

What is the correct term used to determine if a procedure is covered and medically necessary

Preauthorization

The computer output device is the

Printer

The type of memory in which data may be stored and read but not changed is

ROM

An ECP is

an individual who converts insurance claims to standardized electronic format and transmits electronic claims data.

A computer printout that is used to look for errors before an insurance claim is transmitted electronically is called

an insurance billing worksheet

The _______ describes whether specific medical items, services, treatment procedures, or technologies are considered medically necessary under Medicare.

National Coverage Determinations

LCDs only have jurisdiction in their ______area.

Regional

A covered entity does not include

Patient

Arthritis is an inflammation of what?

Joint

A procedure that widens a narrowed vessel or obstructed blood vessel is name an

Angioplasty

A patient is diagnosed with inflammation of the testis and epididymis. The medical term for this condition is called

Orchiepididymitis

Adrenomegaly is defined as

Enlargement of the adrenal gland

What is the Rhinne test?

Test that measures hearing using bone conduction and air conduction

A sialography is an x-ray of

Salivary glands

In an independent practice association (IPA), physicians are

not employees and are not paid salaries

A program that offers a combination of HMO-style cost management and PPO-style freedome of choice is a

Point of service (POS) plan

The frequency of Pap tests that may be billed for a Medicare patient who is not at risk is

Once every 3 years

A state-based group of doctors working under government guidelines reviewing cases for hospital admission and discharge is known as

PRO

RVU component consists of a

RVU component, GAF component, and CF component

Medical care that is cost-shared by both Tricare Standard and a civilian source is known as

Cooperative care

A health care professional usualy a registered nurse who helps the patient work with his or her primary care manager to locate a specialist or obtain a preauthorization for care is referred toas a

HCF

The Veterans Health Care Expansion Act of 1973 authorized the

CHAMPVA program

RICARE Prime and TRICARE Extra claims are

filed by the provider to a TRICARE subcontractor

If a Tricare Extra claim is submitted with several items and several dates of service, the time limit that would apply to the claim for filling would be

Individual time limits for each item on the claim.

Cyst/o

Urinary bladder

Ped/o

Child

Patho

genic

Neuralgia

Pain of nerves

Ertythrocyte

Blood cell that carries oxygen

Nephrectomy

Resection of a kidney

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