Final Review-Hospital Billing Ch. 1-4

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Fair Debt Collections Practice Act

The _____ was enabled to protect consumers from unfair collection services.

Certificate insured; Health Insurance Claim #

Reported in FL 60 on the UB-92 is the _____ and _____ assigned by the insurance company or government program to help identify the individual covered under the plan.

Claim form; Reimbursement

_____ and _____ have in common that the claim form is submitted to payers, reimbursement is determined based on information reported on the claim form, and submission of a clean claim can ensure accurate, efficient processing and appropriate reimbursement.

CMS 1500

The _____ claim form is used to submit charges for outpatient professional services provided by hospital employed providers.

Principal diagnosis

The principal procedure is performed as definitive treatment of the _____.

Balance billing

Prohibited under the terms of payer's contracts, _____ refers to the act of invoicing a patient in excess of the payer's approved amount.

A/R Aging report

The _____ is used to identify and analyze outstanding accounts.

Reason

On RA and EOB documents, _____ codes are used as explanations of the claim process.

Electronic Claim Submission

_____ allows tracking, proof of receipt, and reduced processing time.

Contract rates

Commercial payer's commonly use fee schedules, UCRs, case rates, per diems and _____ to reimburse for inpatient hospital services.

Optical Scanning

_____ has improved claim processing b/c data from the claim form no longer needs to be manually input into a computer.

APCs; DRGs; RBRVs

Methods used by the government programs to provide reimbursement to hospitals for outpatient and inpatient services include _____, _____ and _____.

Treatment Authorization Code

The _____ is the payer provided number recorded on the UB-92 when services are authorized.

Value Codes

_____ are 2 digit alphanumeric codes reported in FL 39-41 on the UB-92.

E-Codes

_____ are used to describe external cause of injury or illness.

Significant procedures

_____ are surgical in nature, carry high procedural or anesthetic risk and require specialized training.

Direct transmission

Claims that can be electronically processed using a clearinghouse or _____.

Capitation

Managed care plans commonly use contract rate and _____ to reimburse for outpatient and inpatient hospital services.

Charge Master

The _____ system captures charges for health care services and ites, posts them to the patients account and bills them to the claim form.

Intergrated delivery system; Primary network

The difference between an _____ and a _____ is a network of facilities that best suits ones needs and the other is made up of primary care doctors.

Not for profit organization

A ____ is tax exempt.

UM

_____ refers to procedures implemented to manage health care services.

Primary Care

A primary care network focuses on _____.

True

T/F: Advances in the diagnosis and treatment of medical conditions, technologym standards of medical care and an increase in number of patients seen in hospitals are factors that influence the rise in health care costs in the 1990s.

HIPAA

_____ was implemented to improve continuation of insurance coverage, prevent and detect fraud and abuse, simplify the administration of health insurance and protect the privacy of health information.

Qualtiy Patient care; Public health improvement; Health care costs

Three areas of governmental responsibility related to health care are _____, _____ and ______.

Accreditation

Joint commision and American Osteopathic Association are two organizations involved in the _____ of hospitals.

AHIMA

CCS and CCS-P are coding credentials available through _____.

AAPC

CPC and CPC-H are coding acronyms available through _____.

Health Information Management

_____ is responsible for maintaining records, auditing...ALL OF THE ABOVE.

Clinical; Administrative; Financial; Operational

Hospital functions are generally categorized into _____, _____, _____ and _____.

Outpatient Services

_____ include ambulatory surgery, emergency department and observation.

Utilization Reviews

As related to medical necessity, _____ are conducted to ensure medical necessity.

Written authorization

To avoid breach of confidentiaility, health care providers must have patients approve release of their confidential health information with a _____.

Admission process

The purpose of the _____ is to obtain information for evaluating, billing and treating.

Guarantor

The _____ is responsible for paying for medical services.

ABN

The _____ signed by the patient instructs the insurance company or government plan to forward the benefits to the hospital.

Admiting Physician

Physicians orders outline instructions regarding diagnostic and therapeutic care that the patient is to receive during the inpatient stay according to the treatment plan. The _____ writes the order.

Coded health care data

_____ are the primary key to reimbursement, used for statistical analysis by hospitals, insurance companies, & health care facilities, used for research and study.

Death and disease

Define "Mortality and Morbidity"

Primary diagnosis

The most significant outcome of patient care services rendered in a physician's office is the _____.

Volume 1

The tabular list of diseases, two supplemental classifications, and appendices of the ICD-9-CM manual can be found in _____.

Significant procedures

Volume 3 of the ICD-9-CM is used by hospitals and other facilities to code _____.

Volume 3

The ICD-9-CM's alphabetic and tabular listings of procedures are contained in _____.

Conventions

The terms, punctuation marks, abbreviations and symbols used in a coding system to communicate special instructions are collectively referred to as _____.

Volume 1,2,3

Trick question: ICD-9-CM's numeric listing of patient signs, symptoms, injury, illness, disease, and other reasons for the visit are contained in _____.

Primary diagnosis

The condition determines after study is the _____.

ICD-9-CM

Volume 1,2,3 of the _____ is used for coding diagnosis and inpatient procedures.

Procedure coding

The CMS and other payers like blue cross/blue shield use ICD-9-CM for _____.

Volume 3 procedure coding system

Developed for submitting claims to Medicare carriers, the ICD-9-CM _____ is used to describe services, procedures, and items when a code cannot be found in the CPT.

Diagnosis codes

Providers use _____ on the claim form to explain why procedures and services are required.

HCPCS level 1

The _____ and/or HCPCS level 2 procedure coding system is used to report procedures, services, and items for hospital outpatient services.

CMS 1500

The _____ claim form is used to submit hospital outpatient professional services.

CMS-1450 (UB-92)

The _____ claim form is used to submit hospital inpatient services.

Category 1 Codes

_____ are found in the CPT in sections titles "E/M," "Anesthesia," "Surgery." "Radiology," "Pathology/Laboratory," and "Medicine."

Category 3 codes

Found after the "Medicine" section in CPT, _____ represent new procedures or services and emerging technology.

HCPCS Level 1; CPT; HCPCS Level 2

The guideline for determining whether to use a _____, _____, or _____ code...use a CPT code unless a code that adequately describes the service, procedure, or time cannot be found in CPT, When a code cannot be found in CPT, refer to HCPCS Level 2 manual, use HCPCS codes when required by the payer.

HCPCS Level 2 codes

_____ are five-digit alphanumeric codes that start with a letter.

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