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.
Which of the following conditions must be met before payment is made under an indemnity plan?
payment of premium, deductible and coinsurance
In the United States, rising medical costs are primarily due to:
advances in technology and aging population.
Under an insurance contract, the physician is the first party and the patient is the second party. Who is the third party?
When a provider injures a patient due to failure to follow medical standards of care, this is called:
An important part of a compliance plan is a commitment to keep both physicians and medical office staff current by providing:
What is the single most important strategy for achieving compliance in medical practice:
having a compliance plan in place.
Disguising an electronic message so that only recipients with the correct key can read it is called:
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
If a retired patient with Medicare also has coverae under a working spouse's plan, the primary plan is
the spouse's plan.
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
An important initial step in extablishing inancial responsibility is to:
verify the payer's rules for the medical necessity of the planned service.
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?
In the diagnostic statement "peripheral polyneuropathy due to pellagra" what is the SECONDARY term?
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
Guidelines for HCPCS can be found in both
the Medicare Carriers Manual (MCM) and the Coverage Issues Manual (CIM)
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
In the CCI, which type of codes cannot both be billed for a patient on the same day of service?
Which member of the medical practice is ultimately responsible for proper documentation and correct coding?
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.
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?
Some possible consequences of inaccurate coding and incorrect billing in a medical practice are
- denied claims
- delays in processing claims & receiving payments
- reduced payments
- loss of hospital privileges
- exclusion from payers' programs
- prison sentence
- loss of license
What type of audit do payers routinely condict to ensure that claims are compliant?
The provider who provides the procedure on a claim if other than the pay-to provider is called the:
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