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Certified Billing and Coding Specialist
(CBCS) Study Guide
Which of the following accurately describes the difference between informed and implied consent? A) Informed consent is required after a procedure, while implied consent is required before a procedure. B) Informed consent only refers to electronic documents, while implied consent refers to written and electronic documents. C) Informed consent is required in writing after explanation of a procedure, with time to ask questions, while implied consent is assumed. D) Informed consent applies to hospitals, while implied consent applies to physicians'' offices. - CORRECT ANSWER C) Informed consent is required in writing after explanation of a procedure, with time to ask questions, while implies consent is assumed. The correct distinction between informed consent, which requires the patients' signature, and implied consent What is documentation? - CORRECT ANSWER Documentation is a complete, accurate, up-to-date record of care a patient receives at a health care facility. Disclosure refers to the way health information is: A) Handled by doctors B) Given to an outside person or organization C) Stored D) Organized - CORRECT ANSWER B) Given to an outside person or Organization Disclosure refers to the dissemination of personal health information, which is covered by the HIPAA Privacy Rule What is the difference between consent and authorization? - CORRECT ANSWER Authorization: Permission granted by the patient or the patient's representative to release information for reasons other than treatment, payment, or health care operations Consent: Is used only when the permission is for treatment, payment, or health care operations True or False: Physicians have the option to decide whether to explain privacy rules to their patients. - CORRECT ANSWER False Physicians are legally obligated to explain privacy rules to their patients Auditing refers to which of the following? A) Writing claims B) Signing off on claims C) Sending claims to third-party payers D) Reviewing claims for accuracy and completeness - CORRECT ANSWER D) Reviewing claims for accuracy and completeness
Many facilities have internal auditing systems to review claims for accuracy and completeness. One of the main things an audit looks for is nonspecific or inaccurate use of diagnosis and procedure codes. True or False: Fraud is intentional misrepresentation of information for the purposes of receiving higher payments, while abuse happens unintentionally, often because of poor business practices. - CORRECT ANSWER True An example of fraud is knowingly billing for services or supplies that were not provided. Abuse includes any practice that is not consistent with the goals of providing patients with services that are medically necessary, meet professionally recognized standards, and are fairly priced. Which of the following accurately defines upcoding? A) Assigning a code that will deliberately result in a higher payment B) Using a shorthand code system C) Including more than one procedure in one code D) Using multiple codes when a comprehensive code is available - CORRECT ANSWER A) Assigning a code that will deliberately result in a higher payment Assigning a cough with the code for pneumonia is an example of upcoding, and it is fraud The Stark Law states that: A) Debt collection agencies can't use abusive or unfair practices to collect payment B) The government can't be charged for substandard goods or services C) Physicians can't refer patients to practitioners with whom they have a financial relationship D) Private health information must be kept secure - CORRECT ANSWER C) Physicians can't refer patients to practitioners with whom they have a financial relationship Also referred to as the Physician Self-Referral Law, the Stark Law also prohibits the referred practitioner from presenting claims to Medicare The Office of the Inspector General is responsible for A) Protecting health information B) Fighting fraud C) Helping health care professionals stay compliant with the laws D) Disclosing health information - CORRECT ANSWER B) Fighting fraud HIPAA established a comprehensive programs to combat fraud called the Health Care Fraud and Abuse Control (HCFAC) program, which is run by the OIG What is a claim? - CORRECT ANSWER Claims are a complete record of the services provided by the health care professional, along with appropriate insurance information Identify two items of information that need to be on a claim - CORRECT ANSWER Patient name, Patient's health record number, Patient's account number, Patient's demographic information, Subscribe, Subscriber (member) number, Group or plan number, Prior approval number, Provider name, National Provider Identifier (NPI),
Describe when Medicare is the secondary insurance for a patient - CORRECT ANSWER Medicare is the secondary insurance for a patient when she has a group health insurance plan, is covered by workers' compensation, or is on disability By signing block 12 on the CMS-1500 form, a patient is doing which of the following? A) Authorizing the release of funds to a provider B) Authorizing the provider to perform a procedure C) Authorizing the release of medical information needed to process a clam D) Authorizing hospice care - CORRECT ANSWER C) Authorizing the release of medical information needed to process a claim Block 12 is an important field where the patient or an authorized person signs to authorize the release of medical information. The field must be dated and entered as a six- or eight digit date. A signature on file or a computer-generated signature can also be used. The patient's signature authorizes release of information necessary to process the claim Name the kinds of insurance information that needs to be collected from the patient - CORRECT ANSWER Correct policy number and group number, Policy effective dates, Type of policy, Which benefit covers the primary treatment, Policy limitations, Deductible amounts Coordination of benefits involves which of the following: A) Double-checking each patient's insurance information B) Collecting demographic information C) Determining which insurance is the primary and which is secondary D) Submitting a claim - CORRECT ANSWER C) Determining which insurance is the primary and which is secondary The coordination of benefits process, which determines primary and secondary insurance, ensures that there is no duplication in the payment of benefits. The primary insurance pays first, up to its coverage limits, and the secondary insurance pays second True or False: The birthday rule is a way to mark how long a patient has had his insurance policy - CORRECT ANSWER False The birthday rule is a way to determine primary insurance if both parents have insurance and list their children as dependents. The insurance of the parent whose birthday is first in the calendar year is considered the primary insurance What is the difference between Medicare and Medicaid? - CORRECT ANSWER Medicare is a government-based insurance plan that covers people older than 65, those younger than 65 with disabilities, and those with end-stage kidney disease. Medicaid covers low-income families and individuals What is the advantage of employer=based self-insured health plans? - CORRECT ANSWER Due to economies of scale, employer-based self-insured health plans are more reasonably priced than private insurance Which of the following accurately describes a deductible? A) The cost of a health insurance premium B) A patient's share of the cost of health insurance
C) The fee a patient pays for a doctor's visit D) The amount the patient must pay before the insurance company will start to provide benefits - CORRECT ANSWER D) The amount the patient must pay before the insurance company will start to provide benefits This correctly describes deductibles, which vary considerably from plan to plan. The deductible ,must be met for each calendar year. Any expenses not covered will be applied to the deductible True or False: A copay is the patient's share of the insurance premium - CORRECT ANSWER False Insurance premium is a weekly, monthly, or annual cost for the plan or insurance coverage. Copayment is the out-of-pocket cost Name one advantage and one disadvantage of a PPO - CORRECT ANSWER PPOs generally provide greater choice in health care professionals patients can choose to see. Patients do not need a referral from the provider to see a specialist. A disadvantage is that cost-control measures, such as coinsurance and copayments, are usually in place What is the coinsurance percentage? - CORRECT ANSWER The coinsurance percentage is the amount the provider is allowed for the service and the amount her was paid. The patient has coinsurance responsibility to what provider was allowed. A common percentage split is 80% for insurance carrier and 20% for the patient. What is the role of the account receivable department? - CORRECT ANSWER The account receivable department manages follow-up to the billing process for a provider's office What two kinds of information the CDM stores? - CORRECT ANSWER Descriptions of service, CPT/HCPCS code, Revenue code, Charge amount, Charge or service code, General ledger key, Activity/ status date An aging report refers to which of the following? A) The length of time the report has been in the CDM B) The ages of all patients in a provider's practice C) The claims that are outstanding D) The amount of money the provider's office has received in the last 6 months - CORRECT ANSWER C) The claims that are outstanding Aging reports refer to paid or unpaid status of invoices True or False: An RA is sent to policyholders - CORRECT ANSWER False RA is sent to the provider, not to policyholders The allowable charge is which of the following? A) Amount the provider charges for a service B) Amount the patient agrees to pay C) Amount the health insurance company will pay providers D) Amount set by hospitals - CORRECT ANSWER C) Amount the health insurance company will pay providers
health care services, such as the addition of information relevant to ambulatory and managed care encounters and expanded injury codes. It also has updated medical terminology and classification of diseases and codes that allow comparison of mortality and morbidity True or False: The following represents a disease coded under ICD-10-CM: E10.2 - CORRECT ANSWER True For ICD-10-CM codes, the first character is a letter, followed by digits. Characters three through seven can be numbers or letters What are the goals of ICD-10-PCS? - CORRECT ANSWER The goals of ICD-10-PCS are to improve accuracy and efficiency of coding, reduce training effort, and improve communication with physicians What character of ICD-10-PCS for medical or surgical procedure would identify the body part? A) Character 1 B) Character 2 C) Character 3 D) Character 4 - CORRECT ANSWER D) Character 4 Character 1 identifies the site Character 2 identifies the body system Character 3 identifies the root operation Character 4 identifies the body part CPT codes are used to describe which of the following? A) Supplies used during surgery B) Type of insurance a patient has C) Services rendered by the provider D) Payments received from third-party payers - CORRECT ANSWER C) Services rendered by the provider Physicians use CPT codes for hospital inpatient and outpatient services and for those performed in other facilities What is the purpose for using modifiers? - CORRECT ANSWER Modifiers provide the means to report or indicate a service or procedure that has been altered by some specific circumstance but not changed in its definition or code What are HCPCS Level II codes used for? - CORRECT ANSWER HCPCS Level II codes were establish to report services, supplies, and procedures not represented in CPT Abstracting involves which of the following? A) Writing notes about codes B) Selecting relevant information from the health record C) Coding physicians' notes D) Answering questions form insurance companies - CORRECT ANSWER B) Selecting relevant information from the health record
Abstracting involves reviewing the health record and or encounter form and translating the medical documentation into the specific code sets Abstracted information is which of the following? A) Sent to the physician B) Sent to the patient C) Coded D) Sent to the insurance company - CORRECT ANSWER C) Coded Abstracted information is coded, often using computer-assisted coding to generate codes for each episode of care
