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Comprehensive Health Insurance

Mid-term study guide
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HCPCS
The acronym for Healthcare Procedure Coding System
Level I HCPCS codes
the 5 digit CPt codes used to report services performed by health care providers are referred to as:
HCPCS was developed in order to achieve all of the following goals:
allowing providers & suppliers to communicate their services in a consistient manner, ensuring the validity of profiles & fee schedules through standardized coding, & coordinating goverment programs by uniform application of the Center for medicare & medicaid Services policies.
Level I HCPCS codes are also known as the:
AMA's CPT codes
Level I HCPCS codes are developed by:
American Medical Association(AMA)
Level II HCPCS codes are updated annually by the:
Centers for Medicare & Medicaid Services(CMS)
The code for durable medical equipment (DME) would be found in the:
Level II HCPCS code book.
If a medical office assistant wanted to find the code for prosthetic procedures, they would find it in the:
Level II HCPCS code book.
Level II HCPCS codes would include all of the following:
dental procedures, ambulance services, & medical & surgical supplies.
HCPCS national codes consist of:
one alaphbetic character & 4 digits.
An example of an HCPCS Level III code is:
Z0000
HCPCS Level IIcodes range D0000-D9999 would be used for:
dental procedures
Drugs administered other than oral method would be coded begining with the following letters:
J
The National Panal that maintains Level II HCPCS codes includes represenatives from:
the Blue Cross/Blue Sheild Association, The Centers for Medicare & Medicaid Services & the Health Insurance Association of America.
The HCPCS national codes are manages by:
Public & private insurers
Level III HCPCS codes are maintained & managed by:
individual state medicare carriers.
If a medical office assistant wanted to find the code for a new procedure, they would find it in the:
Level III codebook.
HCPCS modifiers are codes that consist of:
2 letters or 1 letter & 1 number
To identify that a procedure was preformed on the left hand thumb, the medical office assistant would select the modifier:
FA
The HCPCS modifier GA indicates:
an advanced beneficiary notice has been signed by the patient, a waiver of liability statement is on file, & the procedure billed may not be covered by Medicare.
The written notification that must be signed by a medicare patient as a warning that a services may not be medically necessary is called a:
advanced beneficiary notice
Inaccurate coding & incorrect billing can result in:
prison sentences, delays in receiving payments, & loss of the providers license to practice medicine.
When each reported service is connected to a diagnosis that supports the procedure as necessary, the claim is referred to as:
clean
Code linkage refers to a connection between the:
CPT & ICD-9-CM codes
Services can be denied for all of the following reasons:
there is a cap on the number of services allowed, the procedure is considered expermental, & the service was not preformed at an appropriate location.
Procedure & didiagnostic codes should be appropriate to the patient's:
age & gender
THe act that prohibits submitting a fraudulent claim or making a false statement in connection with a claim is called:
Federal Civil False Claims Act
Individuals suspected of medical fraud & abuse can be investicated & prosecuted by all of the following:
Office of Inspector General (OIG), Federal Bureau of Investigation (FBI), & U.S. Department of Justice.
The Healthcare Fraud & Abuse Control Program was created by the:
Health Insurance Portability & Accountability Act (HIPPA)
In physical therapy cases, if a coder bills for supervised attendance:
one-on-one direct contact is not required by the provider.
The Stark Law was enacted to govern the practice of:
physician refferals to medical facilities in which they have a financial interest.
Under civil law, the maximum penalty for medical fraud is:
$10,000.00
An action that misused the money that the government has allocated is considered:
abuse
To bill for a procedure that was not preformed is considered:
Fraud
Misusing Medicare funds is considered:
abuse & fraud
To bill for a procedure that was not medically necessary is considered:
abuse
Using a procedure code that provides a higher reimbursement rate than the code that actually reflects the services provided is referred to as:
upcoding
Billing the parts of a bundled procedure as separate procedures for higher reimbursement is referred to as:
unbundling
The types of edits for National Correct Coding Initiative (NCCI) errors include all of the following:
mutually exclusive edits, comprehensive versus componets edits, & modifiers indicators.
2 codes that could not have both been reasonably performed during a single patient encounter are referred to as:
mutually exclusive codes
Healthcare payers base their decision to pay or deny claims on the:
diagnosis & procedure codes
The best way to be sure that an intended action will not be subject to investigation as fraud is to:
obtain an advisory opinion from the Office of Inspector General & Centers for Medicare & Medicaid Services.
Compliance Program Guidance for Individual & Small Group Physician Practices can be found in the:
Federal Register
The Compliance Program Guidance suggest that a physician's office implement a plan that includes all of the following:
developing open lines of communication, conducting appropriatetraining& education of staff, & conducting internal monitoring & suditing claims.
a compliance plan for the physician's office is:
not mandatory but suggested.
The Federal Register is published by the:
Centers for Medicare & Medicaid.
Benefits of voluntary compliance plan include:
reducing the chances that an audit will be conducted by the Office of Inspector General, minimizing billing mistakes, & avoiding conflicts with the anti-kickback statue.
If a provider requests an advisory opinion & fails to follow the advise if The Inspector General, the provider:
could be prosecuted.
If the coder determines that the code checked off by the physican on the encounter form does not match the medical record, the coder should:
inform the physician of the issue & dtermine the correct code.
A medical coder can receive information about coding & governmental regulations from:
national speciality medical societies, local carriers, & the American Medical Society.
The types of claims sudits include all of the following:
accreditation audit, internal audit, & external audit.
a prepayer audit would be conducted to verify:
the identification number of the patient
A postpayment audit would be conducted to verify all of the following:
patient progress notes, lab results, & date of services.
a postpayment audit would be conducted to verify:
sign-in sheet
an internal audit can be conducted:
either prospectively or retrospectively
An internal prospective audit would most likely be preformed on:
a workers compesation claims
An internal audit would determine:
if training is needed for office staff, whether procedures were coded correctly, the coders' skill & knowledge.
Phsician office should audit their charts
asses the completness of medical records, determine the accuracy of the physicians documentaition, & discover lost revenue.
The following are advantages of a prospective internal audit:
it insures compliance, it decreases the wrk load of the medical office assistant, & it decreases the risk of errors.
An indepentant audit should be preformed a minimum of:
twice a year
If dicumentation in the patient chart supports a higher level of service than coded, the error would be called:
downcoding
If documnetation in the patient chart supports a lower level of service than coded. the error would be coded.
upcoding
When auditing a medical chart, the medical office assistant should verify that all documentation is initaled or signed by:
the provider only
Key componets for selecting evaluation& management codes include all of the following:
extent of the exam documented, extent of the history documented, & complexity of the medical decision.
If medicare determines that an evaluation & management services excedes the patients documented need, Medicare could:
deny service
Medical necessity of evaluation & management services is based on all of the following factors:
physical scope encompassed by the problems, acuity & severity of the problems addressed, & complexity of documented comorbidities.
The most widely used CPT codes are:
evaluation & management
The most extensive type of history is called:
comprehensive
Documentation of a review of systems is required in all levels of histories except:
problem focused
An expanded problem-focused history requires all of the following elements:
history of present illness, review of systems, & chief complaint
If a patient states that the present illness atarted 3 days ago, the element he would be describing is the:
duration
If a patient states that the pain he is experiencing is burning, the element he would be describing is the:
associated signs & symptoms
If a patient states that the pain he is experiencing is in his right arm, the element that he is describing is the:
location
Documentation o an extended history of present illness include at least:
4 history of present illness(HPI)
If a patient complains of a dull ache in the left ear over the past 24 hours, he would be describing :
3 History of present illness(HPI)
Tyoes of history of present illness(HPI) categories include:
brief or extended
All of the following are types of review of systems(ROS):
problem pertinent, extended, & complete
If a physician examines the system directly related to the problem plus 2-9 additional systems, the review of systems would be considered:
extended
If a PFSH includes a review of the patient's past, family, & social history, it would be an example of the patient's:
past history
If a chart note documents that the patient is status post-thyroid resection 10 years ago, this would be an example of the patient's:
past history
If a chart note documents that the patient has smoked 2 packs of cigarettes everyday for the past 10 years, it woul be an example of the patients:
social history
In documentsing a medical exam, all of the following are recognized body area:
back, abdomen, & neck
In documenting a medical exam, all of the following are recognized organ systems:
ear, nose, mouth, & throat, eyes, & skin
An exam tat involves one or more organ systems or body areas is called a:
general multisystem exam
In documntation of a medical exam, the terms musculoskeletal, respiratory, & gastrointestinal would refer to:
organ systems
If a physician documents that an exam included the measurement of patient's blood pressure, the system reviewed would be the:
cardiovascular system
An exam that documents a limited exam of the affected body area or organ system & any other symptomatic or related body areas would be considered a:
a problem-focused exam
an exam that documents a general multisystem exam would be considered:
comprehensive exam
Elements of medical decsion making include all of the following:
number of diagnoses or management options, risk of significant complications, morbidity, or mortality, amount & complexity of data to be reviewed.
In documenting the patient chart, a diagnosis
can be implied
If physician who ordered a test personally reviews the image to supplement information from the physician who prepared the test report, the work would add to the level of the:
amount &/or complexity of data to be reviewed
If the level of risk of morality is very high, the medical decsion making would be considered:
high
If a patient presents with one self-lmited or minor problem, the level of risk involved with the medical decsion making would be considered:
minimal
If a patient presents with an acute or chronic illness that poses a threat to life or body function & requires emergency major surgery, the level of risk involved with the medical decsion making would be considered:
High
The risk of significant complication, morbidity, &/or mortality is based on the risk of:
the diagnostic procedures, the presenting problem, & the possible management options.
In order to consider time as the key factor in determining the level of evaluation & management services, the counseling &/or coordination of care must make up:
50% of the encounter
A medical office assistant is unsure which evaluation & management code to use, they should:
not code the procedure
A medical office assistant can find clinical examples for documenting medical necessity is the:
CPT Appendix C
An example of an evaluation & management code that requires 3 key compenets documented & comprehensive history & comprehensive exam is:
a new patient office visit
Medical records documents work that is more intense than the work of other evaluation & management services & involves frequent personal assessment by the physician would be coded as:
critical care