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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):
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):
Primary care physician (PCP) 7
A specific provider who ovesees an HMO member's total healtcare treatment is called a(n):
The amount of money a patient has to pay out-of-pocket per visit is referred to as a(n):
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:
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):
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:
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:
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):
Periodic payment (premium), Yearly deductible, Per-visit coinsurance all of the above 6
Most FFS plans include the patient paying a:
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:
With managed healthcare, patients can choose any physician they want and can change physicians any time?
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?
individual health insurance policies historically have higher premiums than employer group policies?
Under no circumstances will an insurance policy cover services rendered for "preexisting condition?"
An HMO provides its members basic healthcare services for a fixed price and for a given period of time?
Precertification involves collecting information before inpatient admissions or performances of selectd ambulatory procedures and services?
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?
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
OCR formatting rules specify 5
all entries in upper case letters , no puncutation, MM/DD/YYYY birthdate format,
a patient's name, address, social security #, and employment data is commonly referred to as
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
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?
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
the restoration of a fracture or dislocation to its normal anatomic alignment by the application of manually applied force is known as
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)
which of the following terms describes traction by use of strapping,elastic wraps,or tape
Silver, Keller and Mitchell are all types of? (These are listed in the CPT book under bunion)
What two items are needed to correctly code for local treatment of burns?
percentage of body surface and the depth of the burn
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?
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
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