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Mid-term study guide


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:


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:


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:


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:


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:


An action that misused the money that the government has allocated is considered:


To bill for a procedure that was not preformed is considered:


Misusing Medicare funds is considered:

abuse & fraud

To bill for a procedure that was not medically necessary is considered:


Using a procedure code that provides a higher reimbursement rate than the code that actually reflects the services provided is referred to as:


Billing the parts of a bundled procedure as separate procedures for higher reimbursement is referred to as:


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:

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:


If documnetation in the patient chart supports a lower level of service than coded. the error would be coded.


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:


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:


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:


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:


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:


If a patient presents with one self-lmited or minor problem, the level of risk involved with the medical decsion making would be considered:


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:


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

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