Billing and Coding Errors in Healthcare, Exams of Medicine

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• Medical Billing and Coding Certificate exam questions and answers

Medical Billing and Coding Certificate exam questions and answers 2024 Chief Complaint (element 1 of history) - >>>History of present illness, Review symptom, Past, Family, and Social history History Levels (Element 2 of history) and Examination Levels (Element 3 of History) - >>>Problem focused, expanded problem focused, detailed, Comprehensive Medical Decision Making Complexity Levels (element 4 of history) - >>>Straightforward, Low, Moderate, High straightforward - >>>Minimal diagnosis Minimal risk Minimal complexity of data Low - >>>Limited diagnosis Limited/low risk to patient Limited data Moderate - >>>Multiple diagnosis

Most common billing errors - >>>Billing non-covered services Billing over limit services Upcoding Downcoding Billing without signatures Using outdated codes External Audits Internal Audits Retrospective audits - >>>Types of Audits done to avoid billing and coding errors External Audits - >>>a private payer or government investigator's review of selected records of a practice for compliance Internal Audits - >>>self-audit conducted by a staff member or consultant Retrospective Audits - >>>conducted after the claim has been send the remittance advice has been received Adjustments - >>>amounts added to or taken away from the balance of an account Two methods to determine rates to be paid to providers - >>>Charge; Resource Charge - >>>based fees are established using the fees of providers providing similar services resource - >>>-how difficult is it for the provider to do the procedure

-how much office overhead is involved -the relative risk the procedure presents to the patient and the provider Clearing Houses - >>>Edits and transmits batches of claims to insurance companies Fee schedule - >>>Payment is predetermined according to a table of diagnoses and their eligible fees usual - >>>fee normally charged for a given service Customary fee - >>>fee in the range of usual fees charged by physicians of similar training experience for the same service within the same specific and limited socioeconomic are resonable fee - >>>fee that meets both usual or customary fees or is considered justifiable by responsible medical opinion considering special circumstances of the particular case in question relative value studies (rvs) - >>>a list of 5 digit procedure codes for services with unit values that indicate the value for each procedure Capitation - >>>physician has a contract with an insurance company to be paid whether he sees the patient of not precertification - >>>A process required by some insurance carriers in which the provider must prove medical necessity before performing a procedure. predetermination - >>>finding out the maximum dollar amount insurance will pay for the procedure Preauthorization - >>>Prior approval for treatment and procedures

Medicare Part C (Medicare Advantage Plans) - >>>Health coverage option includes part A & part b & operated by private insurance companies that are approved by & under contract w medicare Medicare part D - >>>Prescription drug coverage participating physician - >>>Accepts assignment payment sent to physician nonparticipating physician - >>>Does not accept assignment payment sent to patient patient pays physician Temporary disability (TD) - >>>patient cannot perform all functions of his or her job for a limited period of time weekly benefits are based on employees earnings Permanent Disability - >>>Injured worker is left with a residual disability Sometimes patient can be rehabilitated in another line of work When a patient case becomes permanent and stationary and no further improvement is expected, the case is rated to the percentage of permanent disability and adjudicated so a monetary settlement can be made. Workers Compensation - >>>A form of insurance paid by the employer providing cash benefits to workers injured or disabled in the course of employment. Allowed amount - >>>the amount insurance companies consider to be an appropriate fee for a given service

Co-insurance - >>>the percentage of the bill for services that the policy holder must pay Self-insurance - >>>employers pay directly for employees' medical bills TRICARE - >>>A government health program that serves dependents of active-duty service members, military retirees and their families, some former spouses, and survivors of deceased military members; formerly called CHAMPUS. CHAMPVA - >>>(Civilian Health and Medical Program of the Veteran Affairs)- was created to provide medical benefits to spouses and children of veterans w/ total, permanent service related disabilities or for surviving spouses and children of a veteran who died as a result of service related disability. It is a service benefit therefore no premiums. Members who receive TRICARE do not qualify for CHAMPVA Member/Subscriber/Insured/ Policyholder - >>>A person who owns the insurance policy Beneficiary - >>>individuals who qualify for the program Dependents - >>>family members covered by the insurance plan Premium - >>>policyholder contributes to their policy by paying a set amount of money Sliding Fee Scale - >>>When offices charge fees based on a patient's financial ability to pay. fee schedule - >>>A list of charges or established allowances for specific medical services and procedures

COBRA - >>>Consolidated Omnibus Budget Reconciliation Act; law to provide terminated employees or those who lose insurance coverage because of reduced work to be able to buy group insurance for themselves and their families for a limited amount of time. Assignment of benefits - >>>reimbursement is sent directly from payer to provider Co-payment - >>>a specific amount of money a patient pays for a particular service Deductible - >>>Amount you must pay before you begin receiving any benefits from your insurance company eligibility - >>>the qualify factor or factors that must be met before a pt receives benefits EIN - >>>Employer Identification Number, also known as a federal tax identification number remittance advice - >>>an electronic paper-based report of payment sent by the payer to the provider encounter form - >>>also called the superbill; it is a listing of all the diagnosis, procedures and charges for a patient visit fiscal intermediary - >>>an insurance company that bids for a contract with Centers of Medicare and Medicaid services to handle the Medicare program in a specific area. joint - >>>arthr/o life - >>>Bi/o

heart - >>>cardi/o cancerous - >>>carcin/o head - >>>cephal/o Cerebrum - >>>cerebr/o Cell - >>>cyt/o teeth - >>>dent/o skin - >>>derm/o electrical activity - >>>electr/o intestines - >>>enter/o fetus - >>>fet/o stomach - >>>gastr/o Uterus - >>>hyster/o

-oma - >>>tumor, mass -osis - >>>condition -pathy - >>>disease condition -sis - >>>state, condition ante- - >>>before, in front of anti- - >>>against brady- - >>>slow dia- - >>>through end, endo - >>>within epi- - >>>above, upon hyper- - >>>excessive hypo- - >>>deficient, below, under, less than normal

peri- - >>>surrounding, around sub- - >>>under, below -ectomy - >>>excision, removal -graphy - >>>process of recording -metry - >>>process of measuring -scopy - >>>visual examination -stomy - >>>new opening -tomy - >>>incision -tripsy - >>>crushing Anterior - >>>front of the body Posterior - >>>back of body deep - >>>away from the surface proximal - >>>Nearer to the trunk of the body

history of present illness - >>>description of its development from the first sign or symptom that the patient experienced to the present time past medical history - >>>The past history explains the patient's experiences with illnesses, injuries, and treatments in addition to operations, injuries and hospitalizations. It also covers current medications, allergies, immunization status and diet expressed consent - >>>consent given by adults who are of legal age and mentally competent to make a rational decision in regard to their medical well-being Implied consent - >>>Type of consent in which a patient who is unable to give consent is given treatment under the legal assumption that he or she would want treatment. Respondeat Superior - >>>let the master answer HIPAA - >>>Health Insurance Portability and Accountability Act of 1996 empathy - >>>having an understanding and compassion for what they may be experiencing Establised patient - >>>patient who has been seen multiple times by this facility New Patient - >>>Individual who has not received any professional services from the physician or another physician of the same specialty who belongs to the same group practice within the past 3 years. advantages of electronic health records - >>>*Safety *Quality of Care *Efficiency *Cost Reduction

HIPAA Security Rule - >>>regulations outlining the minimum administrative, technical, and physical safeguards required to prevent unauthorized access to protected health care information HIPAA National Identifiers - >>>Employers Healthcare providers Health plans Patients Patient Encounter - >>>any personal contact between a patient and a physician or other person authorized to furnish healthcare services for the diagnosis or treatment of the patient day sheet - >>>a report that provides information on practice activities for a twenty-four-hour period 3 steps to establish financial responsibility - >>>Verify the patient's eligibility for insurance benefits. Determine pre authorization and referral requirements. Determine the primary payer if more than one insurance plan is in effect Patient is covered under two group plans - >>>Plan that has been effect for the longest period of time is the primary, unless that employee has been laid -off or retired, the original plan in existence is then the primary. patient is covered under a group plan and an individual plan - >>>group plan is the primary Patient's plan is the primary - >>>Patient is covered as a dependent under another insurance policy employer's plan is the primary - >>>patient is covered under an employer plan and a government sponsored plan.

Instruction module-Volume 2 Alphabetical list-Volume 3 main term - >>>bold-faced term located in the ICD-10-CM index; listed in alphabetical order with subterms and qualifiers indented below each main term sub terms - >>>also known as essential modifiers, qualify the main term by listing alternate sites, etiology, or clinical status. Nonessential modifiers - >>>1) Are in parentheses;

2. Follow main terms;
3. May follow sub-terms eponym - >>>a disease, structure, operation, or procedure named for the person who discovered or described it first NEC (not elsewhere classified) - >>>- no code is specific for that condition NOS (not otherwise specified) - >>>used when a condition is not completely described in the medical record Code also - >>>Used when more than one code is necessary to fully identify a given condition, "code also" or "use additional code" is used. category - >>>three-character code for classifying a disease or condition sub-category - >>>Four or five character alphanumeric subdivision of a category

Inclusion Notes - >>>Headed by the word "includes" and refine the content of the category appearing above them Exclusion Notes - >>>Headed by the word "excludes" and indicates conditions that are not classifiable to the preceding code excludes 1 - >>>used when two conditions could not exist together excludes 2 - >>>"Not included here" Note includes that the condition excluded is not part of the condition represented by the code, but a patient might have both conditions. brackets - >>>enclose synonyms, alternative wording, or explanatory phrases Parentheses - >>>used in both the index and tabular list to enclose supplementary words. non essential modifiers Colons - >>>Used in Tabular list after an incomplete term which needs one or more of the modifiers following the colon to make it assignable to a given category. Sequelae - >>>condition that remains after an illness has ended Providers - >>>Physicians, hospitals, and other suppliers that furnish care or supplies to Medicare patients Beneficiary Pays - >>>deductible, premiums, co-insurance (20%) non-covered services Medicare pays - >>>covered services (80%)