Medical Billing Final Exam - Multiple Choice

The office of civil rights enforces rules of privacy and security.
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Terms in this set (74)
The office of civil rights enforces rules of privacy and security.
Privacy and Security Rules
Fraud is unbundling or exploding of charges.
Fraud
In cases of divorce, the decision as to responsibility for a child's medical costs should be made by the court.
In cases of divorce
An attachment to an insurance policy that excludes certain illnesses that would otherwise be covered is called a waiver.
Waiver
Why would conversion from a group policy to an individual policy be advantageous?
Because no physician examination is required
A type of managed care plan created by the Tax Equity and Fiscal Responsibility Act (TEFRA) that allows for enrollment of Medicare beneficiaries into managed care plans is a competitive medical plan.
Competitive Medical Plan
When the physician's services have been submitted to the patient's insurance company by the physician's office, the patient should be sent a monthly statement indicating that the insurance company has been billed.
Monthly statement indicating that the Patient's insurance company has been billed.
An advantage of electronic medical records is greater standardization in clinical medical terminology.
Greater standardization in clinical medical terminology
Under the Medicare incentive program for implementation of the electronic health record, eligible providers will be penalized through payment adjustments starting in 2015 if they have not demonstrated meaningful use.
Penalized through payment adjustments starting in 2015
a) defense of a professional liability claim,
b) insurance carriers require accurate documentation.
both answers are correct
The reasons for documentation are:
Levels of Evaluation & Management services are based on types of physical examinations that may be problem-focused.Problem-focusedA co-morbidity is an underlying disease or condition present at the time of the visit.Co-morbidityYour physician has been to the hospital providing constant bedside attention and treating a patient in respiratory failure. These services are considered critical care.Critical CareIn the ICD-10 Clinical Modification, a code with a 9 as the fourth digit or a 10 as the fifth digit means that the information in the health record is unspecified.UnspecifiedThe ICD-10 code Z79.4 refers to a patient who routinely takes insulin.ICD-10 code Z79.4What table contains classifications of substances for identifying poisoning states? The Table of Drugs and Chemicals.The Table of Drugs and Chemicals.What book is used in a physician's office for coding medical procedures? CPTCPT or Current Procedural TerminologyThe CPT is updated and revised every year.Every yearWhen a service rendered is not listed in the CPT, use an "unlisted" code for your procedure.Unlisted CodeBundling is the grouping together of codes related to a specific procedure.What does "bundling" mean?When completing a form, if any question is unanswerable, leave the space blank.When a question is unanswerableThe NPI is a 10-digit identification number that replaces all numbers assigned by health plansNational Provider Identifier (NPI)A clearinghouse receives transmission of insurance claims, separates claims and sends them electronically to the correct insurance payer.ClearinghouseThe IRS assigns the employers identification number.Employers Identification Number (EIN)The HIPAA security rule addresses security of electronic patient health information in which of the following areas: 1) Administrative safeguards, 2) Technical safeguards, 3) Physical safeguards, 4) All of the AboveAll of the AboveHow often should you post payments in the practice management system?DailyHow often should you batch scrub, edit and transmit claims?Daily or WeeklyHow often should you audit claims batched and transmitted with confirmation reports?DailyHow often should you make follow up calls to resolve reasons for rejection?WeeklyHow often should you correct rejections and resubmit claims?DailyThe document, together with the payment voucher, that is sent to a physician who has accepted assignment of benefits is called the explanation of benefits (EOB).Explanation of Benefits (EOB)Pending or resubmitted insurance claims may be tracked through a tickler file.Tickler FileThe first level of appeal in the Medicare program is called redetermination.RedeterminationTri-Care appeals are normally resolved within 60 days.60 daysIn a Tri-Care case, a request for an independent hearing may be pursued if the amount in question is $300 or more.$300 or moreThe average amount of accounts receivable should be 1.5 to 2 times the charges of 1 month of services.1.5 to 2 times the charges for 1 month of servicesThe patient is most likely to be cooperative in furnishing details necessary to complete the registration process before any services are provided.before any services are providedA professional courtesy means charging nothing, either of a patient or an insurance company, for medical care.Professional courtesyWhat is the type of billing system in which management software is used? Computer BillingComputer billingEmployment of billing services is called outsourcing.OutsourcingIn a bankruptcy case, most medical bills are considered unsecured debt.Unsecured debtWhich type of bankruptcy is considered "wage earner's" bankruptcy? Chapter 13Chapter 13America's oldest privately owned, prepaid medical group is the Ross-Loos Medical Group.Ross-Loos Medical GroupCapitation is when an HMO is paid a fixed amount for each patient served without considering the actual number of services or nature of services provided.CapitationWhat does one call an organization of physicians sponsored by a state or local medical association concerned with the development and delivery of medical services and the cost of health care? Foundation for Medical CareFoundation for Medical CareIn an independent practice association (IPA), physicians are not employees and are not paid salaries.Independent Practice Association (IPA)A program that combines an HMO-style cost management with a PPO-style freedom of choice is called a Point-of-Service plan.Point-of-Service PlanMedicare is a Federal Health Insurance plan.MedicarePAP Smears for a Medicare patient with low risk may be billed once every 24 months.PAP SmearsSome senior HMOs may provide services not covered by Medi-Care, such as eyeglasses and prescription drugs.Eyeglasses and prescription drugsThere is a mandatory assignment in Medi-Care for clinical laboratory tests.Clinical laboratory testsWhen a Medicare patient signs an advanced beneficiary notice of non coverage, the procedure code for services provided must include the HCPCS modifier GA.HCPCS Modifier GAPayments to hospitals for MediCare services are classified according to Diagnostic Related Groups (DRGs).Diagnostic Related Groups (DRGs)A claims assistance professional (CAP) may act as a client representative on behalf of a MediCare beneficiary.Claims Assistance Professional (CAP)If an obvious overpayment by check is received from Medicare, the insurance billing specialist should deposit the check, then write Medicare to acknowledge the overpayment.Medicare overpaymentIn the Medicaid program, Congress has authorized vendor payments, which are payments from the welfare agency directly to the physician.Medicaid vendor paymentsMedically needy individuals, including the blind, the disabled, the elderly and the poor, require help in meeting costs of medical care.Medically needyMedicaid (Medi-Cal in California) is administered by the state government with partial federal funding.MedicaidMedi-Caid (Medical) is available to low income folks and the Medically needy, including the blind, the disabled and the elderly.Medically NeedyMedicaid eligibility must always be checked for the month and type of service.Month and type of serviceMedicaid managed care patient claims should be sent to the managed care organization and not to the Medicaid fiscal agent.Managed care organizationThe physician responsible for managing Tri-Care Prime patients is referred to as the Primary Care Manager (PCM).Primary Care Manager (PCM)TriCare outpatient claims must be filed within one year of service.TriCare outpatient claimsTriCare Prime and TriCare Extra claims are filed by the provider to the TriCare subcontractor.TriCare Prime and TriCare ExtraState compensation laws that require an employer to accept certain provisions and specified benefits are called compulsory laws.Compulsory lawsIn many states, Worker's Comp laws exempt certain occupations such as Domestic Employees, Gardeners and BabysittersWorker's Comp Law exemptionsIf a worker has a work related injury and is unable to perform their job for two months, then returns to modified work for one month before returning to full work, the claim is referred to as temporary disability claim.Temporary disability claimA procedure in which an attorney asked a sworn witness a series of questions regarding a legal case in a setting other than a courtroom.DepositionWhat is the correct procedure for maintaining an industrial patient's financial and health records when the same physician is seeing a patient as a private patient? Separate financial and health records.Separate financial and health recordsSupplemental reports for patients on temporary disability should be sent to the insurance carrier after every visit.Supplemental reportsIn a Worker's Comp case, a contract and financial relationship exists between the physician and the insurance company, not the patient.Worker's Comp responsibility"Guaranteed Renewable" means a policy must be renewed so long as the premiums are paid on time; premiums may be increased.Guaranteed RenewableState Disability Insurance is also known as: A) Unemployment Compensation Insurance (UCD), B) Temporary Disability Insurance (TDI), Both A & B are correctState Disability Insurance (SDI)State Disability Insurance benefits begin after the seventh consecutive day of disability.State Disability Insurance benefits