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87 terms

exam 567 hit yellow mod

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Preauthorization 7
A procedure required by third-party payers that requires permission before a provider can carry out specific procedures and treatments is:
POS plan 7
A plan that allows patients to use the HMO provider or go outside the plan and pay a higher copayment and deductible is a(n):
Open-panel IPA 7
A managed care system composed of individual healthcare providers who offer healthcare services for HMO and non-HMO patients, but maintain their own offices and identities, is called a(n):
Network 7
An organized, interrelated system of people and facilities that communicate with one another and work together as a unit is commonly referred to as a(n):
Enrollees 7
Individuals belonging to a managed healthcare plan are referred to as:
HMOs and PPOs 7
The two most common types of MCOs are:
Primary care physician (PCP) 7
A specific provider who ovesees an HMO member's total healtcare treatment is called a(n):
Copayment 7
The amount of money a patient has to pay out-of-pocket per visit is referred to as a(n):
PCP 7
When an individual first enrolls in an HMO, he or she chooses a(n):
Preventive healthcare 7
Most managed healthcare plans emphasize:
Staff model 7
A multispecialty group practice where all healthcare services are provided within the building(s) owned by the HMO is called a :
Group model 7
An HMO that contracts with independent, multispecialty physician groups that provide all healthcare services to its members and usually share the same facility, support staff, medical records, and equipment is called a:
Capitation 7
A reimbursement system in which healthcare providers recieve a fixed fee for every patient enrolled in the plan, regardless of how many or few services the patient uses, is called a(n):
Utilization 7
A system designed to determine the medical necessity and appropriateness of a requested medical servce, procedure, or hospital admission prior, concurrent, or retrospective to the event is called:
Grievance 7
If a particular medical service or procedure is determined not to be "medically necessary," a patient may file a(n):
Indemnity plan, FFS plan
d. b or c ch6
The type of health insurance that offers the most choices of providers, in which patiets can choose any provider they want and can change providers at any time is a(n):
A commercial insurance company, Blue Cross and Blue Shield, Medicare/Medicaid all of the above ch6
An example of a third-paty payer is:
A contract between an insurance company and an employer 6
Group insurance typically is :
Managed care plan 6
The best type of insurance that comprises a group of providers who share the financial risk of the plan or who have an incentive to deliver cost-effective, but quality, service is a(n):
No one type is universally best 6
The best type of healthcare plan is a(n):
Periodic payment (premium), Yearly deductible, Per-visit coinsurance all of the above 6
Most FFS plans include the patient paying a:
Basic/major medical/comprehensive 6
The typical levels of coverage in an FFS plan include:
The higher the deductible, the lower the premium 6
With FFS insurance, which of the following is typically true:
Insurance cap 6
the amount of money the policyholder has to pay out-of-pocket for any one incident or in any 1 year is limited by:
Reasonable and customary 6
When the fee charged by a provider falls within the parameters of the fee commonly charged for that particular service within a specific geographic area, it is said to be:
Participating provider (PAR) 6
A provider who signs a contractual arrangement with a third-party insurance contractor and agrees to accept the amount paid by the carrier as payment in full is referred to as a:
Federal Employees Health Benefits (FEHB) Program 6
The government health insurance program that provides coverage for its own civilian employees is called:
Self-insured program 6
When the employer--not an insurance company--- is responsible for the cost of its employees' medical services, the employer has a:
Employee Retirement Income Security Act (ERISA) 6
The federal law designed to protect the rights of beneficiaries of employee benefit plans offered by employers and that sets minimum standards for pension plans in private industry is called:
Third-party administrator (TPA) 6
A person or organization that processes claims and performs other contracted administrative services is commonly referred to as a:
FALSE 6
With managed healthcare, patients can choose any physician they want and can change physicians any time?
FALSE 6
Group insurance is generally more expensive because it covers more individuals?
FALSE 6
FFS plans all have the same deductible amount?
TRUE 6
With FFS insurance, the policyholder controls the choice of physician and facility?
TRUE 6
Blue Cross policies cover inpatient hospital care: Blue Shield covers physicians's services?
FALSE 5
The CMS-1500 form is in two parts. The top portion is for the physician/supplier information, and the bottom portion for the patient/insured information?
TRUE ?
fee-for-service and indemnity insurance are the same?
TRUE?
The portion of the medical fee that the patient is responsible for is called coinsurance?
TRUE?
individual health insurance policies historically have higher premiums than employer group policies?
FALSE?
Under no circumstances will an insurance policy cover services rendered for "preexisting condition?"
TRUE 7
An HMO provides its members basic healthcare services for a fixed price and for a given period of time?
TRUE 7
PPOs typically do not require authorization from a PCP for a referral to a specialist?
TRUE 7
HMOs typically have no deductibles or plan limits?
TRUE 7
Precertification involves collecting information before inpatient admissions or performances of selectd ambulatory procedures and services?
TRUE 7
A referral is a request by a healthcare provide for a patient under his or her care to be evaluated or treated or both by another provider?
FALSE 7
In all managed care situations, for the healthcare plan to recognize the referral, it must come from the patient's designated PCP?
a universal form 5
a major innovation that made the process of health insurance claims submission simpler was the development of
ORC scannable red ink 5
The front side of the CMS-1500 claim form is printed in
ASCII ch5
the most common format used for text files in computers and on the internet is
OCR formatting rules specify 5
all entries in upper case letters , no puncutation, MM/DD/YYYY birthdate format,
once a year 5
the patient information form should be updated no less than
demographic information
a patient's name, address, social security #, and employment data is commonly referred to as
beneficiary 5
an individual covered under Medicare is referred to as a(n)
super bill, encounter form, routing form all of the above 5
a multipurpose form used by most medical practices for billing is called a(n)
family plan 5
an insurance policy that covers an individual, their spouse, and eligible dependents is referred to as a
patient ledger card 5
in non-computerized practices, patient charges and payments can be tracked manually on a
33 ch 5
the CMS-1500 claims form has ____ seperate blocks
proofread
after the health insurance professional has completed the claims form, it should be
Insurance log, Insurance register 5
an example of a method for manual claims follow-ups is using a
claims clearinghouse 5
A company that receives claims, consoidates them and transmits them in batches to third-party payers is called a
Give 3 definitions of arthrocentesis sbs14
puncture of a joint cavity to remove fluid, injection in the joint, aspiration of a joint.
Name three treatment methods for a dislocation
apply gentle traction, elevate and rotate the limb while applying pressure.
A fracture to be exposed to view or opened at a remote site for nailing across the fracture is what kind of treatment of a fracture?
Open treatment
Define Segmental instrumentation
The attachment of a fixative device at each end of the area being repaired and at least 1 other attachment in the spinal area being fixed. Attached at multiple vertebral bodies ex. Using a rod.
What is the difference between the code for a soft tissue abscess in the Musculoskeletal System subsection?
the code in the musculoskeletal subsection is associated with deep tissue possibly to the bone
What kind of correction is a bunionectomy?
hallux valgus correction
Name three kinds of fracture treatment
open, closed, percutaneous
Manipulation means?
reduction?????
the restoration of a fracture or dislocation to its normal anatomic alignment by the application of manually applied force is known as
Manipulation
The application of a cranial halo is a form of?
(device that holds a bone in place, and is place on the outside of the body with pins or wires are placed into the bone from the outside)
external fixation
which of the following terms describes traction by use of strapping,elastic wraps,or tape
skin traction
Silver, Keller and Mitchell are all types of? (These are listed in the CPT book under bunion)
bunionectomy
What two items are needed to correctly code for local treatment of burns?
percentage of body surface and the depth of the burn
An excision defined as full thickness would be through the?
dermis
define intermediate repair
single layer closure of heavily contaminated wounds that require extensive cleaning or removal of particular matter
Narrowest margin refers to?
When an excision is being performed, the "margins" refer to the __________ required to adequately excise the lesion based on the physician's judgment.

(extra tissue taken from around the lesion)
Incision and drainage codes are divided into subcategories according to the?
condition for which the procedure is performed.
Define Shaving of Epidermal or Dermal Lesions
the shaving of a lesion (11300-11313) can be performed by using a scalpel blade or other sharp instrument. The blade is held horizontal to the skin and an epidermal or dermal lesion is sliced off.
The removal of a lesion by transverse incision that did not require sutured closure is reported using codes from which subsection?
An excision of the left great toe nail and matrix, complete for permanent removal - CPT code?
11750 TA
dermabrassion of the segmental face - CPT CODE
11781
Removal of 37 skin tags be electrosurgical destruction
11200+11201x3
Exsicion of 3 malignant lesions: a 2.4-cm lesion of the leg, a 3.2-cm lesion of the back, and a 1.6-cm lesion of the lip.
11603 - leg
11604 - back or trunk
11642 - lip
look up excision, lesion, skin, malignant 11600-11646
A patient presents to the orthopedic office complaining of pain in the wrist. Upon examination, the physician determines that the patient has a ganglion cyst. the physician injects the ganglion cyst with Xylocaine to reduce the pain
20612 look up gangloin then cyst
Wound closure requiring the use of adhesive strips as the sole repair material should be coded with:
AN appropriate E/M CODE
Destruction of 7 actinic keratoses:
.
Fine needle aspiration of the breast without imaging:
.
When coding 3 biopsies of the skin, performed at the same visit, the reporting would be:
.