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What is the table that contains a classification of substances for identifying poisoning states and external causes of adverse effects?
Table of drugs and Chemicals
E codes are used
to show external cause of injury
The term "malignant" in relationship to blood pressure means
Life threatening
CPT publication is updated and revised
annually
Largest section of the CPT book is the
Surgery section
What is the name of the book used in the physician's office to code procedures?
Current Procedural Terminology CPT
Carcinoma in situ is used to describe
cancer that is confined to the site of origin
A working knowledge of ______________ and a course i anatomy and physiology are essential to becoming a topnotch coder of diagnoses
Medical Terminology
Diagnostic codes have from _______ to ______digits
3 to 5
CPT uses a basic ______ digit system for coding services PLUS a _______digit add on modifier
5 and 2
Insurance companies go by the rule "if it is not documented, then it was not
done or performed
Coding and billing numerous CPT codes to identify procedures that are usually described by a single code is called
Unbundling
Deliberate manipulation of CPT codes for increased payment is called
upcoding
A term used as the name of a disease, structure, operation, or procedure usually derived from the name of a place or person who discovered or described it first is called a/an
eponym
Name 6 basic location methods to locate main terms in the index CPT
Service, procedure, anatomic site, disease, synonym, eponym, abbreviation
Medical etiquette refers to
consideration for others
Reporting incorrect information to private insurance carriers is considered
unethical
AHIMA publishes
Diagnostic and procedure training code books and diagnostic coding and reporting requirements
Why are multi-skilled health practitioners MSHP in demand
They are cross trained to provide more than one function
They are often competent in more than one discipline
They offer more flexibility to their employer
Medical ethics include
Standard of conduct
A self employed medical insurance biller that does independent contracting is responsible for
advertising
billing
accounting
When an insurance billing specialist bills for a physician and completes a medicare claim form with information that does not reflect the true situation
he/she may be subject to fines and imprisonment
Billing for services or supplies not provided is
Fraud, illegal
A billing practice such as excessive referrals to other providers for unnecessary services is considered
Medical billing abuse
Stealing money that has be entrusted to one's care is know as
embezzlement
Coined term by AHIMA's eHealth Task Force to describe transactions in which health care information is accessed, processed, stored, and transferred using electronic technologies is usually abbreviated as
eHIM (electronic health information management)
Individual designated to help a provider remain in compliance by setting policies and procedures in place, train staff regarding HIPAA, and act as the contact person for questions and complaints
Privacy officer, privacy official
A health care coverage carrier, clearinghouse, or physician who transmits health information in electronic for in connection with transaction covered by HIPAA is called
Covered entity
Who renders medical services, furnishes bills, or is paid for health care in the normal course of business?
Health care provider
3rd Party administrator who receives insurance claims from physician's office, performs edits, and redistributes the claims electronically to various insurance carriers?
Clearinghouse
Who is hired by medical practice to process claims to 3rd party payer?
Business associate
List 5 disciplinary standards resulting from misconduct
verbal warning, written warning, written reprimand, suspension or probation, demotion, termination
Security rule that addresses electronic protected health information is divided into what 3 main sections?
1. Administrative safeguards
2. Technical safeguards
3. Physical safeguards
PHI
Protected Health Information
CMS
Centers for Medicare/Medicaid Services
CAP
Claims Assistance Professional
AHIMA
American Health Information Management Association
AMA
American Medical Association
E codes are used
to show external causes of injury
In locating a diagnosis, look up the main term, which is the
Condition or disease
Reasons for documentation are
Defense of a professional liability claim.
Insurance carriers require accurate documentation that supports procedure and diagnostic codes.
SOAP is
Subjective
Objective
Assessment
Plan
A diseased condition or state is known as
morbidity
According to birth law, if both parents have the same birthday
The hour of birth determines who pays first
What is the correct term to determine if a procedure is covered and medically necessary
Preauthorization
Obtaining and recording patient data before the person's first visit is known as
Preregistration
Discovering the maximum $ amount that the carrier will pay for a procedure is called
predetermination
Criteria used by insurance companies when making decisions to limit or deny payment of medical services or procedures must be justified by the patient's symptoms and diagnosis are called
medical necessity
If husband & wife both have insurance through their employers, and each has added the spouse to their primary insurance plans for coverage. If the wife is seen for treatment then her plan is considered
primary
The Health Insurance Claim Form , also know as universal claim form is often called
CMS-1500
If a professional liability claim is filed by a patient, good____________helps establish a strong defense
documentation
Insurance claim submitted on paper
Paper claim
Insurance claim held in suspense due to review or other reason
Pending claim
Insurance claim that is submitted via a dial-up modem or direct data entry
Electronic claim
Cost pressures on health care providers are forcing employers to reduce personnel costs by hiring
Multi skilled health care practitioners
Claims assistance professional
CAP- works for the consumer, helps patients file insurance claims
In medical practice what is "cash flow"
actual money available to a medical practice
Front office medical duties have become increasingly important because
diagnostic and procedural coding must be review for its correctness and completeness
What level of education is generally required for one who seeks employment as an insurance coder?
Completion of an accredited program for coding certification
What organization published diagnostic and procedure coding competencies for outpatient services and diagnostic coding and reporting requirement for physician billing
AHIMA American Health Information Management Association
Amount of money an insurance billing specialist earns is dependent on what
knowledge
experience
size of employing institution
billing specialist is entrusted with
holding patients medical information in confidence
collecting monies
being a reliable resource for co-workers
Confidentiality between the physician and the patient is automatically waived when the patient is being dreated in a workers' compensation case
True
A patient has the right to obtain a copy of his/her confidential health information
True
Confidential information includes
Everything that is heard about a patient
everything that is read about a patient
everything that is seen regarding a patient
Non-privileged information about a patient consists of the patient's
City of residence
Confidentiality is automatically waived in cases of
gunshot wound, child abuse, extremely contagious diseases
To bill medicare beneficiaries at a higher rate than other patients is considered
abuse
Electronic media refers to
Leased phone or dial-up phone lines
the internet
transmissions that are physically moved from one location to another
MSHP
Multi skilled health practitioner
What year was CPT first developed and published
1966
CMS-1500
Universal claims form
CMS-1500 is divided into what 2 sections
Patient and physician information
What does bundling mean
Grouping codes that are related to a procedure
When is principal diagnosis applicable
Inpatient Hospital coding
It is advisable to process insurance claims
In batches, grouping claims of patients who have the same type of insurance
An insurance claim register facilitates
follow-up of insurance claims
What does co-morbidity mean?
Underlying diseases or other conditions presnet at the time of the visit
The diagnosis listed first in submitting insurance claims for patients seen in a physician's office is the
Primary diagnosis
The International Classification of Diseases, Ninth Revision Clinical Modification was published by the Department of Health Services in what year
1979
The term "malignant" in relation to blood pressure means
Life threatening
When does the physician/patient contract begin?
When the physician accepts the patient and agrees to treat the patient
Most physician/patient contracts are
Implied
When a patient carries private medical insurance, the contract for treatment exists between
the physician and the patient
An emancipated minor is
a person younger than 18 who lives independently
Who does the contract exist between in a workers compensation case?
The physician and the insurance company
In health insurance the insured is also known as
subscriber
member
policyholder
Assignment of benefits (AOB) is
the transfer of one's legal right to collect an amount payable under an insurance contract
Provider who sends the patient for tests or treatment
Referring physician
provider whose opinion is requested by another physician about evaluation and management of a specific problem
Consulting physician
provider who is the medical staff member legally responsible for the care and treatment given to a patient
Attending physician
Services rendered by a physician whose opinion is requested by another physician for evaluating a patient's illness
Consultation
providing similar services to the same patient by more than one physician on the same day
Concurrent care
Intensive care provided during an acute life-threatening condition that requires constant bedside attention by the provider
Critical care
The Healthcare Common Procedure Coding System HCPCS consists of two levels of codes
True
An E code may never be sequenced in the first position
True
When is the principal diagnosis applicable?
Inpatient Hospital coding
Why was diagnostic coding developed?
For medical research
for evaluation of hospital service use
for tracking of disease processes
PPO
Preferred Provider Organization
What volumes of ICD-9-CM are used in a physicians office
Volumes 1 and 2
Terms enclosed in parentheses following the main term are referred to as
nonessential modifiers
An insurance policy is a legally enforceable agreement called a/an
Contract
The amount that must be paid each year by the insured before policy benefits begin is known as the
deductible
When the insured is required to pay a percentage of the covered services cost, this is referred to as
Co-insurance
Discovering the maximum DOLLAR amount that the carrier will pay for a procedure is called
predetermination
It is the responsibility of the _____or______ to hand write or dictate the documentation for medical transcription
Physician or provider
Most insurance companies perform routine_____on practices with unusual billing patterns or excessive payment amounts
audits
A reference list of all staff members names, job titles, signatures, and their initials is know as the
signature log
CC
Chief complaint
ROS
review of system
What term describes a disease that persists over a long period of time
Chronic
PFSH
Past Family Social History
Concise statement describing the symptoms, problems, conditions, diagnosis, physician-recommended return, or other factors that is the reason for the encounter is abbreviated as
CC
What is "new patient"
one who has not received any professional services fro the physician within the past 3 years
Medical report is
permanent legal document
part of the health record
When patient fails to return for need treatment, documentation should be made
in the patient's medical record
in the appointment book
on the financial record or ledger card
What is "established patient"
one who has previously received professional services from a physician or another physician of the same specialty who belongs to the group practice within the past 3 years
A health record is considered
medical information
a medical record
A large % of reimbursement in the physician's office is generated from 3 party payers
True
You should not give patients the option of asking if they would like to pay now or have a bill sent
True
All accounts older than 120 days should go to a collection agency
False
Insurance claim register provides
follow up procedure for insurance claims
What is the best way to file pending insurance claims for timely follow up
file by service date
Follow up effort made to an insurance company to locate the status of a insurance claim is called
inquiry or
tracer
An insurance claim with an invalid procedure code would be
denied
What should you do if insurance carrier requests information about another insurance carrier
Provide the information
What should be done to inform a new patient of office fees and payment policies
Send a patient information brochure
send a confirmation letter
discuss fees and policies at the time of the initial contact
Professional courtesy means
Making no charge to anyone, patient or insurance company, for medical care
When collecting fees, your goal should always be
collect the full amount
Most common method of payment in the medical office is
personal check
Accounts receivable are aged in what time periods
30-60-90-120 days
Messages included on statements to promote payment are called
Dun messages
Outsourcing means
Employment of a billing service
Collection calls should be placed
after 8 AM and before 9 PM
Which group of accounts would a collector target when they made telephone calls
Accounts older than 120 days
Documentation from private insurance carriers sent to participating providers that accompanies payment and describes the response to a claim is referred to by the acronym
RA-remittance advice
EOB
Explanation of benefits
Delinquent insurance claim may be easily located by reviewing the
Insurance claim registrar
A suspense or follow up file for pending insurance claims is also called
tickler file
overdue payment on an insurance claim is referred to as
Delinquent claims
If medical practice receives more than contracted rate from an insurance claim that is called
overpayment
Credit comes from a Latin word meaning
to believe or to trust
unpaid balance due from patients for services rendered is called
accounts receivable
relationship of amount of $ owed and the amount of $ collected on the accounts receivable is called
Collection ratio
Patients information sheet is also called
Patients registration form
Assets or debts that have been deemed noncollectable are taken off account books as a loss are called
write offs or courtesy adjustment
An amount due listed on patients financial accounting record is referred to as the account
balance
If endorsement on back of check does not match the name on the front this could be a case of
Check forgery
The procedure of systematically arranging the accounts receivable by age from the date of service is called
aging reports
A patient who owes a balance on their account but leaves no forwarding address is called a
skip
Transferring the sickest high-cost patients to other physicians so the provider appears as a low utilizer
Turfing
In some managed care plans these is an incentive for the gatekeeper to limit patients referrals to specialists
True
A co payment in a managed care plan is usually a fixed dollar amount (predetermined fee)
True
All persons 65 who meet eligibility requirements for medicare receive Medicare Part B (outpatient coverage)
False
Medicare provides insurance for disabled workers of any age
True
Employee and employer contributions help pay for Medicare Part A health services
True
When HMO is paid a fixed amount for each patient served without considering the actual number of services provided to each person, this is called
capitation
What is the name of an organization of physicians sponsored by a state or local medical association that is concerned with the development and delivery of medical services and the cost of health care?
Foundation for medical care
When a physician sees a patient more than is medically necessary, it is called
Churning
Referral of a patient recommended by one specialist to another specialist is known as
Tertiary care
what is correct procedure to collect copayment on a managed care plan
Collect the copayment when the patient arrives for the office visit
Medicare Part A is run by
CMS Center for Medicare/Medicaid Services
Medicare is a
Federal health insurance program
Medicare Part A covers
Hospital and hospice care
Medicare Part B covers
physician outpatient medical services, diagnostic tests
Medigap
Insurance that may cover the deductable not covered under Medicare
MSP-Medicare Supplemental Payer
When a Medicare beneficiary has employer supplemental coverage.
HCPCS are referred to as
Level II codes
What year was CPT first developed?
1966
Primary care physician who controls patient access to specialists is called
gatekeeper
Peer review
process of evaluation of quality and efficiency of services rendered by a practicing physician or physicians within the specialty group
UR
Utilization Review
Utilization review
necessary to control costs in the health care setting
when managed care plan requires primary care physician to seek approval before referring a patient to a specialist, it is called
preauthorization or prior approval
NEMB
Document given to a patient when a service is never covered
Notice of Exclusions from Medicare Benefits
NEMB
ABN
Advanced Beneficiary Notice
PPO
Health benefit program that enrollees may choose any physician or hospital but get greater benefits if preferred providers are used.
ESRD
end stage renal disease
Medicaid
is an assistance program
Tricare
Formerly known as CHAMPUS is funded through Congress
3 choices of coverage for families of active duty personnel, military retirees and their dependents
Tricare standard, Tricare prime, Tricare extra
Tricare Standard
fee for service
Tricare Prime
HMO
Tricare Extra
PPO
Tricare for Life
(Tricare Senior Life) Tricare pays secondary to Medicare 65 and over
DEERS
System used that Tricare claims processors use to verify beneficiary eligibility
HCF
health care finder-usually a registered nurse, how helps patient work with primary care manager to locate a specialist or obtain a preauthoization for care
PCM
Primary Care Manager-physician responsible for coordinating and managing all of the health care for the Tricare prime (HMO) patient
CHAMPVA
service benefit program
CHAMPVA
authorized by Veterans Health Care Expansion Act of 1973
Time limit within a Tricare inpatient (hospital)claim must be filed is within
1 yr from a patient's discharge from an inpatient (hospital) facility
Medicaid
direct result of a law passed by Congress in 1950
Medicaid is administered by
State government with partial federal funding
Federal aspects of Medicaid are the responsibility of
CMS
Medicaid is available to needy and low-income people such as
blind
disabled
65 and older
EPSDT
Early & Periodic Screening, Diagnosis and Treatment Service
Medicaid service for prevention, early detection and treatment for welfare children is know as
EPSDT
Time limit to appeal a claim varies from state to state, but it is usually
30 to 60 days
the health maintenance organization provided for dependents of active duty military personnel is called
Tricare prime (HMO)
Active duty service member whose family members are covered under Tricare is called the
Sponsor
Participating (network) provider
physician who provides medical care at contracted rates to beneficiaries under the Tricare Extra (PPO) program is called
Veteran
Person who has served in the Armed Forces of the United States, especially in time of ware, who is no longer in the service and has received an honorable discharge
Medi-Cal
Medicaid medical assistance program in California
Two Medicare eligibility classifications are
Categorically needy group
Medically needy class
Medicaid identification cards are usually issued
monthly
Time limits for Medicaid claim submission can vary from state to state but are generally.
2 months to 1 year from date of service
Who determines eligibility in the CHAMPVA program
Department of Veteran Affairs
If a physician accepts Medicaid patients, physician must accept
Medicaid allowed amount
Medigap insurance may cover
the deductible not covered under Medicare
Churning
when physician sees a patient more than is medically necessary
If a problem develops with an insurance company and the company ignores claims and exceeds time limits to pay a claim who should be contacted
state insurance commissioner
DRG
classification of payment to hospitals for Medicare services
The law states that an employer employing how many persons may offer the services of an HMO clinic as an alternative health treatment plan for employees
25 or more
If inadequate payment was received from an insurance company for a complicated procedure the insurance billing specialist should, on behalf of the physician, file
an appeal
Lien
a claim on the property of another as security for a debt
MAC
Medicare Administrator Contractor
subpoena
writ requiring the appearance of a person at a trial or other proceeding
OCR
Optical Character Reader-Directly reads claims into a computer memory
who should interpret reports and laboratory tests to the patient
physician
Accounting records should be kept
4 years
When physicians evaluate other physicians process is called
peer review
RAM and ROM refer to a computer's
Memory
transmission device for sending electronic data is called
modem
Backing-up refers to
saving data
1099 form is used to report income to the
IRS
computer memory can be measured in
bytes
Virus
destructive computer program that attaches itself to other programs
DBA form
"Doing Business As" form must be filed if self employed insurance specialist palns to use a business name
CPU
brains of the computer-Central Processing Unit
Fraud
Intentional misrepresentation of facts in order to deceive or mislead others
memory
Storage in a computer
Menu
list of items displayed on a computer screen from which the operator can choose a function
First 8 weeks, myocardial infartions ar coded
Acute
When coding neoplasm of the skin, it is important to
wait for the pathology report
highest degree of certainty means
coding only what is know as fact
When using E codes to code accidents, it is important to
identify where accident happened
In the Healthcare Common Procedure Coding System, Level I codes are
CPT codes
In the Healthcare Common Procedure Coding System J codes are found in which Level
Level II
J codes describe
injectable and chemotherapy drugs
Who is responsible for the annual updates to HCPCS Level II codes
CMS
For coding purposes, diagnoses that relate to a previous medical problem and have no bearing on the present condition are
never coded
Hospitals in the US began using ICD in
1950
Update of ICD-9-CM is published each
October 1
DSM III is used to code
psychiatric disorder
First step in coding diagnoses is to locate the
main term Volume 2
For outpatient services, ruled out conditions are
not coded and listed on claim forms
2 diagnoses are sometimes classified with a
Combination code
3 digit codes are used only if
there are no 4 or 5 digit subdivisions
Always sequence the code for underlying disease
first
The first code listed for a burn is the exact site and
degree
HCPCS Level II codes
start with a letter and have 4 numeric digits
HCPCS level II codes should be used to indicate
specific supplies
Whick of the following is not one of the Alpha Sections in the HCPCS level II system
Physical Therapy
When converting drugs know by a brand name to generic names a convenient resource is
Physicians Desk Reference
"rule of nines"
estimate the percentage of the body surface in a burn
Malignant neoplasms may be located in the ICD-9-CM Neoplasm Table by anatomic site and
status-primary, secondary, CA in situ
Diagnostic codes must be used at their
highest level of specificity
Coding of late effects requires a code for the residual condition and a
late effects code indicating the cause
When coding an acute and chronic condition
sequence the acute code first
What degree of burn is sequenced first
3rd degree
PHI
protected health information