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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.

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