MEDICAL BILLING FINAL EXAM STUDY GUIDE WITH VERIFIED SOLUTIONS, Exams of Nursing

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MEDICAL BILLING FINAL EXAM STUDY GUIDE WITH

VERIFIED SOLUTIONS

1. Privacy and Security Rules: The office of civil rights enforces rules of privacy

and security.

2.Fraud: Fraud is unbundling or exploding of charges.

3. In cases of divorce: In cases of divorce, the decision as to responsibility for a

child's medical costs should be made by the court.

4. Waiver: An attachment to an insurance policy that excludes certain illnesses

that would otherwise be covered is called a waiver.

5. Because no physician examination is required: Why would conversion from a group

policy to an individual policy be advantageous?

6. Competitive Medical Plan: A type of managed care plan created by the Tax

Equity and Fiscal Responsibility Act (TEFRA) that allows for enrollment of Medicare beneficiaries into managed care plans is a competitive medical plan.

7. Monthly statement indicating that the Patient's insurance company has been billed.:

When the physician's services have been submitted to the patient's insurance company by the physician's office, the patient should be sent a monthly statement indicating that the insurance company has been billed.

8. Greater standardization in clinical medical terminology: An advantage of electronic

medical records is greater standardization in clinical medical terminology.

9. Penalized through payment adjustments starting in 2015: Under the Medicare

incentive program for implementation of the electronic health record, eligible providers will be penalized through payment adjustments starting in 2015 if they have not demonstrated meaningful use.

10.The reasons for documentation are:: a) defense of a professional liability

claim, b) insurance carriers require accurate documentation. both answers are correct

11.Problem-focused: Levels of Evaluation & Management services are based on

types of physical examinations that may be problem-focused.

12.Co-morbidity: A co-morbidity is an underlying disease or condition present

at the time of the visit.

13.Critical Care: Your physician has been to the hospital providing constant

bed- side attention and treating a patient in respiratory failure. These services are con- sidered critical care.

14.Unspecified: In the ICD-10 Clinical Modification, a code with a 9 as the

fourth digit or a 10 as the fifth digit means that the information in the health record is unspecified.

15.ICD-10 code Z79.4: The ICD-10 code Z79.4 refers to a patient who

routinely takes insulin.

16.The Table of Drugs and Chemicals.: What table contains classifications of

substances for identifying poisoning states? The Table of Drugs and Chemicals.

17.CPT or Current Procedural Terminology: What book is used in a physician's

office for coding medical procedures? CPT

18.Every year: The CPT is updated and revised every year.

19.Unlisted Code: When a service rendered is not listed in the CPT, use

an "unlisted" code for your procedure.

20.What does "bundling" mean?: Bundling is the grouping together of codes

related to a specific procedure.

21.When a question is unanswerable: When completing a form, if any question is

unanswerable, leave the space blank.

22.National Provider Identifier (NPI): The NPI is a 10-digit identification number

that replaces all numbers assigned by health plans

23.Clearinghouse: A clearinghouse receives transmission of insurance

claims, separates claims and sends them electronically to the correct insurance payer.

24.Employers Identification Number (EIN): The IRS assigns the employers iden-

tification number.

25.All of the Above: The HIPAA security rule addresses security of electronic pa-

tient health information in which of the following areas: 1) Administrative safeguards,

2. Technical safeguards, 3) Physical safeguards, 4) All of the Above

26.Daily: How often should you post payments in the practice management

sys- tem?

27.Daily or Weekly: How often should you batch scrub, edit and transmit claims?

28.Daily: How often should you audit claims batched and transmitted with

confir- mation reports?

29.Weekly: How often should you make follow up calls to resolve reasons

for rejection?

30.Daily: How often should you correct rejections and resubmit claims?

31.Explanation of Benefits (EOB): The document, together with the payment

voucher, that is sent to a physician who has accepted assignment of benefits is called the explanation of benefits (EOB).

32.Tickler File: Pending or resubmitted insurance claims may be tracked

through a tickler file.

33.Redetermination: The first level of appeal in the Medicare program is

called redetermination.

34. 60 days: Tri-Care appeals are normally resolved within 60 days.

35.$300 or more: In a Tri-Care case, a request for an independent hearing may

be pursued if the amount in question is $300 or more.

36.1.5 to 2 times the charges for 1 month of services: The average amount of

accounts receivable should be 1.5 to 2 times the charges of 1 month of services.

37.before any services are provided: The patient is most likely to be cooperative in

furnishing details necessary to complete the registration process before any services are provided.

38.Professional courtesy: A professional courtesy means charging nothing, either

of a patient or an insurance company, for medical care.

39.Computer billing: What is the type of billing system in which

management software is used? Computer Billing

40.Outsourcing: Employment of billing services is called outsourcing.

41.Unsecured debt: In a bankruptcy case, most medical bills are

considered unsecured debt.

42.Chapter 13: Which type of bankruptcy is considered "wage earner's"

bankrupt- cy? Chapter 13

43.Ross-Loos Medical Group: America's oldest privately owned, prepaid medical

group is the Ross-Loos Medical Group.

44.Capitation: Capitation is when an HMO is paid a fixed amount for each

patient served without considering the actual number of services or nature

of services provided.

45.Foundation for Medical Care: What does one call an organization of physicians

sponsored by a state or local medical association concerned with the development and delivery of medical services and the cost of health care? Foundation for Medical Care

46.Independent Practice Association (IPA): In an independent practice associa- tion

(IPA), physicians are not employees and are not paid salaries.

47.Point-of-Service Plan: A program that combines an HMO-style cost manage-

ment with a PPO-style freedom of choice is called a Point-of-Service plan.

48.Medicare: Medicare is a Federal Health Insurance plan.

49.PAP Smears: PAP Smears for a Medicare patient with low risk may be

billed once every 24 months.

50.Eyeglasses and prescription drugs: Some senior HMOs may provide services not

covered by Medi-Care, such as eyeglasses and prescription drugs.

51.Clinical laboratory tests: There is a mandatory assignment in Medi-Care for

clinical laboratory tests.

52.HCPCS Modifier GA: When a Medicare patient signs an advanced beneficiary

notice of non coverage, the procedure code for services provided must include the HCPCS modifier GA.

53.Diagnostic Related Groups (DRGs): Payments to hospitals for MediCare ser-

vices are classified according to Diagnostic Related Groups (DRGs).

54.Claims Assistance Professional (CAP): A claims assistance professional

(CAP) may act as a client representative on behalf of a MediCare beneficiary.

55.Medicare overpayment: If an obvious overpayment by check is received from

Medicare, the insurance billing specialist should deposit the check, then write Medicare to acknowledge the overpayment.

56.Medicaid vendor payments: In the Medicaid program, Congress has autho-

rized vendor payments, which are payments from the welfare agency directly to the physician.

57.Medically needy: Medically needy individuals, including the blind, the

disabled, the elderly and the poor, require help in meeting costs of medical care.

58.Medicaid: Medicaid (Medi-Cal in California) is administered by the state

govern- ment with partial federal funding.

59.Medically Needy: Medi-Caid (Medical) is available to low income folks and

the Medically needy, including the blind, the disabled and the elderly.

60.Month and type of service: Medicaid eligibility must always be checked for the

month and type of service.

61.Managed care organization: Medicaid managed care patient claims should be

sent to the managed care organization and not to the Medicaid fiscal agent.

62.Primary Care Manager (PCM): The physician responsible for managing

Tri-Care Prime patients is referred to as the Primary Care Manager (PCM).

63.TriCare outpatient claims: TriCare outpatient claims must be filed within one

year of service.

64.TriCare Prime and TriCare Extra: TriCare Prime and TriCare Extra claims are

filed by the provider to the TriCare subcontractor.

65.Compulsory laws: State compensation laws that require an employer to

accept certain provisions and specified benefits are called compulsory laws.

66.Worker's Comp Law exemptions: In many states, Worker's Comp laws exempt

certain occupations such as Domestic Employees, Gardeners and Babysitters

67.Temporary disability claim: If a worker has a work related injury and is unable

to perform their job for two months, then returns to modified work for one month before returning to full work, the claim is referred to as temporary disability claim.

68.Deposition: A procedure in which an attorney asked a sworn witness a

series of questions regarding a legal case in a setting other than a courtroom.

69.Separate financial and health records: What is the correct procedure for

maintaining an industrial patient's financial and health records when the same physician is seeing a patient as a private patient? Separate financial and health records.

70.Supplemental reports: Supplemental reports for patients on temporary

disabil- ity should be sent to the insurance carrier after every visit.

71.Worker's Comp responsibility: In a Worker's Comp case, a contract and

financial relationship exists between the physician and the insurance company, not the patient.

72.Guaranteed Renewable: "Guaranteed Renewable" means a policy must be

renewed so long as the premiums are paid on time; premiums may be increased.

73.State Disability Insurance (SDI): State Disability Insurance is also known as:

A) Unemployment Compensation Insurance (UCD),

B) Temporary Disability Insurance

(TDI), Both A & B are correct

74.State Disability Insurance benefits: State Disability Insurance benefits begin

after the seventh consecutive day of disability.