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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
What is the name of the book used in the physician's office to code procedures?
Current Procedural Terminology CPT
A working knowledge of ______________ and a course i anatomy and physiology are essential to becoming a topnotch coder of diagnoses
CPT uses a basic ______ digit system for coding services PLUS a _______digit add on modifier
5 and 2
Coding and billing numerous CPT codes to identify procedures that are usually described by a single code is called
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
Name 6 basic location methods to locate main terms in the index CPT
Service, procedure, anatomic site, disease, synonym, eponym, abbreviation
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
A self employed medical insurance biller that does independent contracting is responsible for
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
A billing practice such as excessive referrals to other providers for unnecessary services is considered
Medical billing abuse
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
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?
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
Reasons for documentation are
Defense of a professional liability claim.
Insurance carriers require accurate documentation that supports procedure and diagnostic codes.
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
Discovering the maximum $ amount that the carrier will pay for a procedure is called
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
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
If a professional liability claim is filed by a patient, good____________helps establish a strong defense
Cost pressures on health care providers are forcing employers to reduce personnel costs by hiring
Multi skilled health care practitioners
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
size of employing institution
billing specialist is entrusted with
holding patients medical information in confidence
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
Confidential information includes
Everything that is heard about a patient
everything that is read about a patient
everything that is seen regarding a patient
Confidentiality is automatically waived in cases of
gunshot wound, child abuse, extremely contagious diseases
Electronic media refers to
Leased phone or dial-up phone lines
transmissions that are physically moved from one location to another
It is advisable to process insurance claims
In batches, grouping claims of patients who have the same type of insurance
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
The International Classification of Diseases, Ninth Revision Clinical Modification was published by the Department of Health Services in what year
When does the physician/patient contract begin?
When the physician accepts the patient and agrees to treat the patient
When a patient carries private medical insurance, the contract for treatment exists between
the physician and the patient
Who does the contract exist between in a workers compensation case?
The physician and the insurance company
Assignment of benefits (AOB) is
the transfer of one's legal right to collect an amount payable under an insurance contract
provider whose opinion is requested by another physician about evaluation and management of a specific problem
provider who is the medical staff member legally responsible for the care and treatment given to a patient
Services rendered by a physician whose opinion is requested by another physician for evaluating a patient's illness
providing similar services to the same patient by more than one physician on the same day
Intensive care provided during an acute life-threatening condition that requires constant bedside attention by the provider
Why was diagnostic coding developed?
For medical research
for evaluation of hospital service use
for tracking of disease processes
The amount that must be paid each year by the insured before policy benefits begin is known as the
When the insured is required to pay a percentage of the covered services cost, this is referred to as
Discovering the maximum DOLLAR amount that the carrier will pay for a procedure is called
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
A reference list of all staff members names, job titles, signatures, and their initials is know as the
Concise statement describing the symptoms, problems, conditions, diagnosis, physician-recommended return, or other factors that is the reason for the encounter is abbreviated as
What is "new patient"
one who has not received any professional services fro the physician within the past 3 years
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
You should not give patients the option of asking if they would like to pay now or have a bill sent
Follow up effort made to an insurance company to locate the status of a insurance claim is called
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
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
If medical practice receives more than contracted rate from an insurance claim that is called
relationship of amount of $ owed and the amount of $ collected on the accounts receivable is called
Assets or debts that have been deemed noncollectable are taken off account books as a loss are called
write offs or courtesy adjustment
If endorsement on back of check does not match the name on the front this could be a case of
The procedure of systematically arranging the accounts receivable by age from the date of service is called
Transferring the sickest high-cost patients to other physicians so the provider appears as a low utilizer
In some managed care plans these is an incentive for the gatekeeper to limit patients referrals to specialists
All persons 65 who meet eligibility requirements for medicare receive Medicare Part B (outpatient coverage)
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
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
what is correct procedure to collect copayment on a managed care plan
Collect the copayment when the patient arrives for the office visit
process of evaluation of quality and efficiency of services rendered by a practicing physician or physicians within the specialty group
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
Health benefit program that enrollees may choose any physician or hospital but get greater benefits if preferred providers are used.
3 choices of coverage for families of active duty personnel, military retirees and their dependents
Tricare standard, Tricare prime, Tricare extra
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
Primary Care Manager-physician responsible for coordinating and managing all of the health care for the Tricare prime (HMO) patient
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 service for prevention, early detection and treatment for welfare children is know as
the health maintenance organization provided for dependents of active duty military personnel is called
Tricare prime (HMO)
Participating (network) provider
physician who provides medical care at contracted rates to beneficiaries under the Tricare Extra (PPO) program is called
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
Time limits for Medicaid claim submission can vary from state to state but are generally.
2 months to 1 year from date of service
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
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
"Doing Business As" form must be filed if self employed insurance specialist palns to use a business name
For coding purposes, diagnoses that relate to a previous medical problem and have no bearing on the present condition are
Whick of the following is not one of the Alpha Sections in the HCPCS level II system
When converting drugs know by a brand name to generic names a convenient resource is
Physicians Desk Reference
Malignant neoplasms may be located in the ICD-9-CM Neoplasm Table by anatomic site and
status-primary, secondary, CA in situ
Coding of late effects requires a code for the residual condition and a
late effects code indicating the cause
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