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Ethics are standards of behavior for licensed medical staff and other employees of medical practices


The deductible is the amount the insured must pay for each health care encounter, such as an office visit.


A health plan is a plan, program, or organization that provides some form of medical insurance.


Fee-for-service contracts establish capitated payments for patients' charges.


A capitated payment is made to a provider prospectively to cover a plan member's health services for a specified period.


Under an indemnity plan, an insurance company agrees to cover the financial losses of a medical practice.

False (it covers the "risk" of the patient)

The amounth that an insured person must pay for each office visit is called the copayment.

True (due at time of service)

A managed care system combined the financing and the delivery of health care services.

True (managed care systems i.e. PPO; HMO)

A preexisting condition is an illness or disorder that existed before insurance coverage.


coinsurance is usually stated as a percentage.

True i.e. 80/20

A compliance plan extablished which particular ICD-9-CM and CPT codes should be used by the medical practice when reporting services and procedures.

False - a compliance plan is a medical office's written plan to adhere to code of conduct for physician's and also to properly prepare and use updated coding, documentation and claim preparation etc...

When information is released, only facts pertinent to the specific request should be provided.


An encounter is usually defined as a face-to-face meeting with a patient.


NPI is the abbreviation for National Provider Identifier


Documentation is a systematic, logical and consistent recording of a patients' health status in a medical record.


Under HIPAA, patients PHI (protected health information) may NOT be shared for Treatment, Payment and Health care Operations without their authorization.

False - Information may be shared for TPO

At the first encounter, covered entities are required to give patients their Notice of privacy practices.


The HIPAA Privacy Rule regulates the use and disclosure of patients' protected health information.


As long as a sercie was actually done for a patient, it can be billed, even if it is not documented in the patients' record.

False. Every service MUST be documented!!

The HIPAA Electronic Health Care Transaction and Code Sets standards create a standard paper form for each payer transaction.


A patient may have coverage under more than one health plan.


The insurance plan that pays benefits after the primary payer is referred to as secondary insurance.


The policyholder is always the patient.

False. Someone else may be the policyholder.... i.e. father for kids or spouse.

The birthday rule is used to determine which of two parents with medical coverage has the primary insurance for a child.

True Birthday Rule states that the spouse with the birthday that comes FIRST in the calendar month is the responsible party, even if they are not the older of the 2 people.

Medical offices cannot treat a patient who refuses to sign their Acknowledgment of Receipt of Notice of Privacy Practices.


A coordination of benefits clause is included in medical insurance policies to explain how the policy will pay if more than one plicy applies to a claim.


The superbill, charge slip, or routing slip are other terms for the patient information form.


The medical insurance specialist verifies patients' insurance coverage by contacting their employers.


A nonparticipating provider must follow the plan's rules regarding fees for service.


Under an assignment of benefits, a payer can make payments directly to a policyholder.

False - Assignment of Benefits is authorization by a POLICYHOLDER that allows a payer to make payments directly to a PROVIDER.

When new ICD-9-CM codes are issued, they must be used as of their effective date.


To select a correct diagnosis code in the ICD-9-CM, first look up the medical term in the Alphabetic Index and then verify the indicated code in the Tabular List


The Alphabetic index of the ICD-9-CM presents diseases and injuries with corresponding codes in numeric order.

False - the Alphabetic Index lists diseases and injuries with corresponding diagnosis codes in ALPHABETICAL ORDER. The Tabular Index lists them in Numerical order.

The addenda to the ICD-9-CM list new, revised, and deleted diagnostic codes.


In physician practices, all three volumes of the ICD-9-CM are used for diagnostic code assignment

False - only the first two... the Alphabetical Index and Tabular List are used for diagnostic code assignment; the 3rd Volume is for procedures done in hospitals.

An E code in the ICD-9-CM identifies encounters for other than treatment of illness or injury

Fals - E code is an alphanumeric ICD code for an external cause of injury or poisoning

The Tabular List in the ICD-9-CM presents diagnosis codes in numerical order


A late effect occurs some period of time after the acute disease is resolved.


Typographic conventions include a symbol used in ICD-9-CM to show the fifth-digit requirement.

True - indicated by a 5 in a circle

The primary diagnosis represents the patient's most serious condition, regardless of the reason for the current encounter.

False - the primary diagnosis is that patient's cheif complaint or main reason for a specific ENCOUNTER

An add-on code in CPT describes a procedure that is performed only in addition to a primary procedure


CPT is the abbreviation for Current procedural Teminology


In CPT, evaluation and management codes E/M, are used to report most surgical procedures.

False E/M codes are used to report Evaluation and Management codes; they cover physicians' services performed to determine the optimum course for patient care

The term "global period" in CPT refers to the national average length of time required for each surgical procedure.

False - Global Period = days surrounding a surgical procedure when all services relating to the procedure are considered part of the surgical package.

Use of a modifier often affects a payer's reimbursement level for a CPT code.

True, because the modifier adds conditions

If a procedure that is designated a separate procedure in CPT is performed for a different purpose than usually done, it may be reported.


A surgical package code in CPT covers a combination of surgical procedures and services.


CPT is used to report the medical, surgical and diagnotic procedures and services of physicians.


Assigning Category II codes can increase reimbursement


Under CPT guidelines, all services related to a surgical procedure are not additionally reimbursed.

during the global period

There are no modifiers in the HCPCS coding system


HCPCS codes are used when reporting services and procedures for Medicare patients.


There are two levels of HCPCS codes.


HCPCS modifiers are made up of two letters or a letter with a number.


HCPCS Level II code set contains the national codes for products, supplies, and those services not included in CPT.


Coding a procedure may require both a CPT and an HCPCS code.


DME is the abbreviation for durable Medicare equipment.

False, it's for Durable MEDICAL equipment

HCPCS is the abbreviation for Healthcare Common Procedure Coding System.


HCPCS codes are maintained by CMS.


HCPCS is a mandated HIPAA code set.


Most payers reimburse cosmetic procedures only when medical necessity is proved.


Medical insurance specialists help ensure maximum appropriate reimbursement for services by submitting claims that are correct and compliant.


The term "external audit" may refer to an audit conducted by a consultanat that the medical practice has hired.

False - it is conducted by an organization ourside of the practice, such as a Federal Agency. (non-hired)

Downcoding refers to a coding method in which lower-level codes are selected.

True - A payer's review and reduction of a procedure code (often an E/M code) to a lower level than reported by the provider.

It is acceptable to alter documentation after an encounter so that the record matches the descriptor of a reported procedure code.


An internal audit is conducted to verify that a medical practice is in compliance with reporting regulations.


Reporting more than one diagnosis code indicates that the procedures are medically necessary.


The term "code linkage" refers to the connection between a service that is provided and the patient's condition, illness or diagnosis.


The conversion factor is a dollar amount


CCI code editis screen for improperly or incorrectly reported procedure codes.


Place of service (POS) codes are HIPAA administrative codes


A clean claim is one that has been accepted for adjudication by a payer


The claim control number should be the same as the patients' account number in the medical billing system.

It is a Unique number assigned to a health care claim by the sender.

Electronic claim submission is the leading method of transmitting insurance claims.


The provider reported on HIPAA claims is called the destination payer.

The person or organization to receive payment for services reported on a HIPAA claim is the PAY-TO PROVIDER. may be the same as or different from the billing provider. DESTINATION PAYER is the health plan receiving the claim

if payment is due on a health care claim, the billing provider always receives it.

False - the Pay-to provider may be the same as or different from the billing provider.

The various units of information on HIPAA claims are called data elements.


A taxonomy code is used for rederal tax returns.

False - it is a HIPAA code set used to describe physician's specialty.

Claim attachments often contain documentation that supports the medical necessity of the claim.

True - claim attachments may be lab reports etc...

A POS (place of Service) code on HIPAA claims indicates where medical services were proveded.


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