75 terms

Study for Medical Billing Midterm Exam

Under a written Insurance contract, the policyholder pays a premium, and the insurance company provides:
Payments for medical services
Under a capitated rate for each plan member, which of the following does a provider share with the third-party payer?
Under a fee-for service plan, the third-party payer makes a payment:
after medical services are provided.
Patients who enroll in an HMO may use the services of:
only HMO network providers.
Which of the following conditions must be met before payment is made under an indemnity plan?
payment of premium, deductible and coinsurance
Under an indemnity plan, a patient may use the services of:
any provider
In the United States, rising medical costs are primarily due to:
advances in technology and aging population.
The capitated rate per member per month covers:
services listed on the schedule of benefits.
Under an insurance contract, the physician is the first party and the patient is the second party. Who is the third party?
The provider
A capitated rate is called a :
Prospective payment
The HIPAA Privacy Rule is enforced by:
the OCR
When a provider injures a patient due to failure to follow medical standards of care, this is called:
When personal identifiers have been removed, protected health information is called:
The types of covered entities are:
health plans, clearinghouses, and providers
An important part of a compliance plan is a commitment to keep both physicians and medical office staff current by providing:
ongoing training
What is the single most important strategy for achieving compliance in medical practice:
having a compliance plan in place.
The federal agency that runs Medicare and medicaid is:
Disguising an electronic message so that only recipients with the correct key can read it is called:
EDI is the abbreviation for:
Electronic Data Interchange
Which of the following is NOT part of usual Evaluation and Management services:
Surgical procedure
If a patient has coverage under two insurance plans, the primary plan is the one that
has been in effect for the patient the longest
If an employed patient has coverage under two insurance plans, one from a current employer and one from a previous employer, the primary plan is:
The current employer's plan
If an employed patient has coverage under two insurance plans, one the employer's plan and the other a government plan, the primary plan is:
the employer's plan
patients may have fill-in-the gap insurance called:
Supplemental Insurance (i.e. AARP)
If a retired patient with Medicare also has coverae under a working spouse's plan, the primary plan is
the spouse's plan.
Another term for prior authorization is:
If a patient has coverage under two insurance plans, one under which the patient is the policyholder and one under which the patient is a dependent, the primary plan is:
The patient's plan
Insurance Information is found on the
Patient Information form
An important initial step in extablishing inancial responsibility is to:
verify the payer's rules for the medical necessity of the planned service.
NonPAR stands for
A fracture that is not described as either closed or open is coded as:
A closed fracture
If a patient is treated for both an acute and a chronic condition, and each has a code, which is reported first?
the acute condition
What is the main term in the diagnostic statement "allergic rhinitis in the fall due to ragweed"?
After surgery, the patient's diagnosis is different from the preoperative primary diagnosis. Which diagnosis is reported?
the preoperative diagnosis.
What is the main term in the diagnostic statement "localized salmonella infection, unspecified" ?
In the diagnostic statement "tuberculous rheumatism", which is the main term?
either tuberculous or rheumatism
The diagnostic statement is "patient has found a mass in the upper quadrant of the left breast; carcinoma is suspected and an immediate workup is scheduled." What main term is coded?
An adverse effect is the result of
unintentional poisoning
In the diagnostic statement "peripheral polyneuropathy due to pellagra" what is the SECONDARY term?
What is the main term in the diagnostic statement "profound impairment of both eyes"?
The temporary national HCPCS codes are updated annually
False- they are updated quarterly
Which is the correct process for selecting CPT codes?
determine the procedures and services to report, edentify the correct codes, and determine the need for modifiers
Codes in CPT's Anesthesia section generally cover:
codes are used to Report Anesthesia services performed or supervised by a physician.
- 2 types of modifiers used w/ anesthesia codes:
1. Modifier that describes patient's health status
2. standard modifiers
In CPT, Category II codes report
services to track performance measurement
In CPT, a thunderbolt symbol (~) next to a code indicates a(n)
code pending FDA approval
Guidelines for HCPCS can be found in both
the Medicare Carriers Manual (MCM) and the Coverage Issues Manual (CIM)
In CPT, a plus sign (+) next to a code indicates a (n)
add-on code
Coding a procedure may require:
both a CPT and an HCPCS code
In CPT, facing triangles that appear in front of a code indicate a(n)
new text other than a code descriptor
CPT codes from the Anesthesia section have two types of modifiers:
standard CPT modifiers
physical status modifiers
Permanent national HCPCS codes are
updated annually
HCPCS codes may be
permanent or temporary
In CPT, a triangle next to a code indicates a(n)
revised code
in CPT, a bullet (a black circle) next to a code indicates a(n)
new code
In the CCI, which type of codes cannot both be billed for a patient on the same day of service?
mutually exclusive
What type of audit is performed internally beore claims are reported?
prospective audit
Which member of the medical practice is ultimately responsible for proper documentation and correct coding?
the physician
If a payer judges that too high a code elvel has been assigned by a a practice for a reported service, the usual action is to
downcode the reported procedure code.
What type of audit is performed internally after claims are submitted?
retrospective audit
What type of external audit is performed by payers before claims are processed?
prepayment audit
In the CCI, which type of code cannot be billed together with a column 1 code for the same patient on the same day of service?
column 2
Some possible consequences of inaccurate coding and incorrect billing in a medical practice are
- denied claims
- delays in processing claims & receiving payments
- reduced payments
- fines
- loss of hospital privileges
- exclusion from payers' programs
- prison sentence
- loss of license
Correct Coding Innitiative - includes Edits that ensure proper coding and billing procedures
What type of audit do payers routinely condict to ensure that claims are compliant?
postpayment audits
The national Correct Coding Initiative (CCI) is a program of:
A data element that HIPAA always mandates reporting is called a
required data element
A non-NPI ID (other ID number) has two parts, the number itself as well as a:
Which is associated with payers?
National Payer ID
The provider who provides the procedure on a claim if other than the pay-to provider is called the:
rendering provider
A physician's state license number is an example of a(n)
secondary identification number
Assume that three providers are indicated for a claim for lab services. A clearinghouse is the billing provider and the physician practice is the pay-to provider. What type of provider is the laboratory?
Rendering provider because it is not the pay-to provider
On a HIPAA claim, which of these is assigned to a claim by the sender?
claim control number AND line item control number
A data element that HIPAA mandates reporting under certain conditions is called a:
situational data element
Correct medical code sets for claims are those that are:
valid at the time the service is provided.
Correct administrative code sets for claims are those that are;
valid at the time the claim is prepared.