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Various topics related to medical billing and coding practices, including medicare and medicaid guidelines, insurance coordination, claim submission, coding rules, and compliance. It addresses scenarios involving patient demographics, insurance coverage, billing procedures, and coding for medical services. Insights into the knowledge and skills required for effective medical billing and coding, which are essential for healthcare providers and administrative staff to ensure accurate reimbursement and compliance with regulatory requirements. The information presented can be useful for university students studying healthcare administration, medical coding, or related fields, as well as for healthcare professionals seeking to enhance their understanding of medical billing and coding best practices.
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A Medicare card will list which of the following: I. Effective date of coverage II. Home address III. Telephone Number IV. Entitled to Part A and/or Part B V. When coverage ends VI. Name of Primary Care Physician A. I - VI B. I, IV C. I-III, VI D. I, II, IV, V - Answer: B. I, IV
In which of the following scenarios is Medicare the secondary payer? I. A 65 year-old patient who is collecting her deceased spouse's Medicare benefits and has a supplemental insurance II. A 72 year-old patient who participates in the group health insurance of his employer III. A 66 year-old patient is injured at work and the employer does not offer health insurance as a benefit of employment IV. A 55 year-old patient who is on disability through Social Security and qualifies for Medicaid and Medicare A. I-IV B. II and III C. I and IV D. None - Answer: B. II and III When a patient has Medicare primary and AARP as Medigap, what is entered on the CMS-1500 claim form in item 9d for the Insurance Plan Name or Program Name for Medicare to cross over the claim? A. Plan name followed by "MEDIGAP" B. Plan Payer ID followed by "MEDIGAP" C. COBA Medigap claim-based identifier (ID) D. Leave blank - Answer: C. COBA Medigap claim-based identifier (ID)
V. Capitation A. II B. IV C. II and IV D. II, III, and V - Answer: C. II and IV A patient covered by a PPO is scheduled for knee replacement surgery. The biller contacts the insurance carrier to verify benefits and preauthorize the procedure. The carrier verifies the patient has a $500 deductible which must be met. After the deductible, the PPO will pay 80% of the claim. The contracted rate for the procedure is $2,500. What is the patient's responsibility? A. $ B. $ C. $ D. $1,600 - Answer: C. $ When a nonparticipating provider files a claim for a patient to BC/BS, how is the payment processed? A. The payment is sent to the patient and the patient must pay the provider.
B. The payment is sent to the provider if the provider agrees to accept assignment. C. The payment is sent to the provider regardless if he accepts assignment. D. The claim is not paid because the provider is not participating in the plan. - Answer: A. The payment is sent to the patient and the patient must pay the provider. Which of the following TRICARE options is/are available to active duty service members? A. TRICARE Select B. TRICARE Prime C. TRICARE For Life D. TRICARE Young Adult - Answer: B. TRICARE Prime Which of the following services is covered by Early and Periodic Screening, Diagnostic, and Treatment (EPSDT)? A. Family planning B. Obstetric care C. Pediatric checkups D. Emergency department visits - Answer: C. Pediatric checkups A female patient who was involved in an auto accident presents to the emergency department (ED) for evaluation. She does not have any complaints. The provider evaluates her and determines there are no injuries. The provider informs the
C. Insurance waiver D. Explanation of Benefits - Answer: B. Advance Beneficiary Notice What is an Accountable Care Organization (ACO)? A. Groups of doctors, hospitals, and other health care providers who coordinate high quality care to Medicare patients. B. An insurance carrier that provides a set fee based on the diagnosis of the patient. C. A group of providers who contract with a third party administrator to pay fee for service for services. D. Hospitals who see a subset of patients for cost efficiency. - Answer: A. Groups of doctors, hospitals, and other health care providers who coordinate high quality care to Medicare patients. A new patient presents for her annual exam and has no complaints. She is scheduled to see the physician assistant (PA). How should services be billed? A. Bill under the PA. B. A new patient can be billed incident to the physician. C. The PA cannot see new patients. D. Reschedule the patient with the physician - Answer: A. Bill under the PA. CPT® codes 12032 and 12001 were reported together for a 2.6 cm intermediate repair of a laceration to the right arm and a 2.5 cm simple repair of a laceration to
the left arm. 12001 was denied as a bundled service. What action should be taken by the biller (following the CPT® guidelines)? A. Write-off the charge for 12001 as it is a bundled procedure. B. Resubmit a corrected claim as 12032, 12001-59. C. Transfer the charge to patient responsibility. D. Resubmit a corrected claim as 12032, 12001-51. - Answer: B. Resubmit a corrected claim as 12032, 12001-59. According to CMS, which of the following services are included in the global package for surgical procedures? I. Surgical procedure performed II. E/M visits unrelated to the diagnosis for which the surgical procedure is performed III. Local infiltration, digital block, or topical anesthesia IV. Treatment for postoperative complication which requires a return trip to the operating room (OR)V. Writing Orders VI. Postoperative infection treated in the office A. I, III, V, VI B. I, IV, V C. I, II, III, V D. I-VI - Answer: A. I, III, V, VI Which CPT® code below can be reported with modifier 51?
A. I and IV B. II, III, and V C. II, III, and IV D. II and IV - Answer: A. I and IV Which of the following indicates the frequency of care on a UB-04 claim form? A. Revenue code B. Type of Bill C. MSDRG D. Condition code - Answer: B. Type of Bill Pam works for a medical practice. She discovered a claim was overpaid by Medicare. What Act requires the money to be refunded? A. Health Insurance Portability and Accountability Act B. The Stark Act C. False Claims Act D. Consumer Credit Protection Act - Answer: C. False Claims Act Security involves the safekeeping of patient information by: I. Setting office policies to protect PHI from alteration, destruction, tampering, or loss II. Allowing full access to all employees to the electronic medical records
III. Giving employees a policy on confidentiality to read IV. Requiring employees to sign a confidentiality statement that details the consequences of not maintaining patient confidentiality, including termination A. I and IV B. I, II, and IV C. II, III, and IV D. II and III - Answer: A. I and IV Dr. Taylor's office has a new medical assistant (MA) who is responsible for blood collection for lab specimens. Because the MA is new, she often misses when obtaining blood on the first stick. To be sure the office is billing for all services, the office now has a rule that all patients will be billed a minimum of two blood draws to demonstrate the work that is being done for lab collection. Which statement is true regarding this rule? A. The rule covers the office and allows them to get paid for all services performed. B. The rule is fraudulent because the office is billing for services not performed and services that are a result of provider error. C. The rule would be legal if changed to only bill for two blood draws on the patients the MA misses on the first stick. D. The rule is only legal if the clinic is in a hospital-based office. - Answer: B. The rule is fraudulent because the office is billing for services not performed and services that are a result of provider error.
There is a written office policy to write off patients co-insurance and copayment amounts as a professional courtesy. Is this appropriate? A. Yes, if it is a policy in writing it must be followed. B. Yes, if it is a written policy and everyone in the office adheres to it. C. No, it is considered fraud to write off the patients' responsibility for all patients. D. No, it is a violation of Stark law to write off patients' responsibility. - Answer: C. No, it is considered fraud to write off the patients' responsibility for all patients. Which statement is TRUE regarding the Fair Debt Collection Practices Act (FDCPA)? A. Collectors are allowed to threaten legal action even if it will not be pursued. B. The FDPCA does not apply to medical practices. C. Collectors are allowed to contact debtors repeatedly. D. Collectors are not allowed to contact debtors at odd hours. - Answer: D. Collectors are not allowed to contact debtors at odd hours. Which of the following is an allowed collection policy after a patient files for bankruptcy? A. Unpaid insurance claims for dates of service occurring after the date of the bankruptcy can be collected. B. Any co-payments or deductibles that are past due and owed by the patient can be collected.
C. Unpaid claims for dates of service occurring before the date of the bankruptcy and any co-pays or deductibles adjudicated on that same claim. D. Discuss a payment arrangement with the patient to settle the past due account.
A dermatologist performed an excision of a squamous cell carcinoma from the patients forehead with a 1.2 cm excised diameter. The excision site required an intermediate wound closure measuring 1.8 cm. What is/are the correct code(s)? A. 11642 B. 11442 C. 11642, 12051- D. 11442, 12051-51 - Answer: C. 11642, 12051- 55-year-old female presents to the office with ongoing history of type I diabetes which has been controlled with insulin. During the exam the physician notes that gangrene has set in due to the diabetic peripheral angiopathy on her left great toe. Patient is recommended to see a general surgeon for treatment of the gangrene on her left great toe. A. I96, E10.9, Z79. B. E11.52, I96, Z79. C. E10. D. I96, E11.52 - Answer: C. E10. What is the correct HCPCS Level II code for Depo-Provera (medroxyprogesterone acetate) injection of 100 mg? A. J B. J1050 x 100 C. J1020 x 5
D. J1030 x 3 - Answer: B. J1050 x 100 The provider performs an office visit with an expanded problem focused history, expanded problem focused exam and low MDM to manage the patient's hypertension. The provider also destroys two plantar warts. How is this reported? A. 99213-25, 17110 B. 99213-25, 17110- C. 99213, 17110- D. 99213, 17110-59 - Answer: A. 99213-25, 17110 Incorrect entry of the patient demographics can have an effect on many areas of the practice. What documents are necessary to verify demographics? I. Photo Identification II. Insurance card III. Credit card information IV. Social Security card V. Patient completed demographic form A. I and V B. II and IV C. II, IV and V D. I, II, and V - Answer: D. I, II, and V
C. No, report code 99024 instead of the E/M service for all services provided in the post-operative period. D. Yes, the E/M can be reported with modifier 25 to indicate a separate procedure or service was performed. - Answer: A. Yes, the E/M service can be reported with modifier 24 to indicate it is unrelated to the surgery. When you respond to a patient with "How may I help you, Mrs. Jones?", the use of the patient's name: A. Is too familiar B. Violates HIPAA C. Indicates to the caller you are interested and listening D. Is too formal for an existing patient - Answer: C. Indicates to the caller you are interested and listening
