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NHA CBCS A+ VAULT: DOMINATE
MEDICAL CODING, BILLING, ETHICS &
REIMBURSEMENT – 2026/
Sagittal - THE CORRECT ANSWER-Which of the following planes divides the body into left and right Claim adjudication:( The term used in the industry to refer to the process of paying claims submitted on denying them after comparing claims to the benefit or coverage requirements) - THE CORRECT ANSWER-3rd Party payer validates a claim which takes place next NCCI ( National Correct Coding Initiative) - THE CORRECT ANSWER- Developed to reduced Medicare Program expenditure by detecting in appropriate codes & eliminating improper coding 0% - THE CORRECT ANSWER-Beneficiary of Medicaid/ Medicare crossover claim is responsible for the percentage Internal monitoring and auditing - THE CORRECT ANSWER-Which of the following steps would be part of a physicians practice compliance program HIPPA - THE CORRECT ANSWER-Which of the following acts applies to the administrative simplification guidelines?
Accounts recievable - THE CORRECT ANSWER-Patient charges that have not been paid will appear in which of the following adjudication - THE CORRECT ANSWER-Which of the following is considered the final determination of the issues involving settlement of an insurance claim A billing worksheet from the patient account - THE CORRECT ANSWER-A prospective billing account audit prevents fraud by reviewing & comparing a completed claim for with which of the following documents Lymphatic system - THE CORRECT ANSWER-Which of the following parts of the body system regulates immunity Billing using 2- digit CPT Modifiers to indicate a procedure as preformed differs from its usual 5 digit code - THE CORRECT ANSWER-Which of the following is allowed when billing procedural codes Direct Data entry - THE CORRECT ANSWER-A biller will electronically submit a claim to the carrier via which of the following? A Providers office with fewer than 10 fulltime employees - THE CORRECT ANSWER-Medicare enforces mandatory submission of electronic claims for most providers. Which of the providers is allowed to submit paper claims to Medicare?
Left upper quadrant - THE CORRECT ANSWER-Location of the stomach, spleen, part of the pancreas and liver 18% - THE CORRECT ANSWER-Coding a front torso burn, what % should be used? An italicized code used as the 1st listed diagnosis - THE CORRECT ANSWER-Result of a claim being denied Charging excessive fees - THE CORRECT ANSWER-Example of Medicare abuse Codes must correspond to the diagnosis pointer in block 24E - THE CORRECT ANSWER-Diagnostic codes in Block 21 of the CMS form (S) Subjective - THE CORRECT ANSWER-Soap note to indicate patient level of pain to provider HIPPA Standard transaction - THE CORRECT ANSWER-Standardized format used in electronic filing of claims 3rd Party Payer - THE CORRECT ANSWER-Insurance Carrier is a Remittance Advice (RA)- A letter sent to a patient from insurance provider stating that their invoice is paid - THE CORRECT ANSWER-When send a claim to a 2nd payer you need to send a copy of
Contractual allowance- difference between what hospitals bill and what they receive in payment from 3rd Party Payers - THE CORRECT ANSWER-Remark code from a EOB document-(EOB)- statement sent by a health insurance company covered individual explaining what medical treatments and/ or services were paid for on their behalf Professional component- Provided by a physician, may include supervision, interpretation, and writer report - THE CORRECT ANSWER-CPT code used to indicate provider supervised and interpreted Informed consent - THE CORRECT ANSWER-Providers explain medical or diagnostic procedures, surgical interventions, and the benefits and risks involved, giving the patients opportunity to ask questions before medical intervention is provided. Signature is required Implied consent - THE CORRECT ANSWER-A patient presents for treatment, such as extending an arm to all venipuncture to be performed. Signature is NOT required Clearinghouse - THE CORRECT ANSWER-Agency, that converts claims into standardized electronic format, looks for errors, and formats them according to HIPPA and insurance standards De- identifiable information - THE CORRECT ANSWER-Information that does not identify and individual because unique and personal characteristics have been removed
What is the Difference between Fraud and abuse? - THE CORRECT ANSWER-Fraud is intentionally misrepresenting services rendered for the purpose if receiving a higher payment. Abuse refers to practices that are often done unknowingly as a result of poor business practices, directly or indirectly resulting in unnecessary costs to the program through improper payments. What is the main job of the office inspector general?(OIG) - THE CORRECT ANSWER-Protects Medicare and other HHS programs from fraud and abuse by conducting audits, investigations, and inspections Timely filing requirment - THE CORRECT ANSWER-Within 1 Calendar year of a claims date Electronic data interchange (EDI) - THE CORRECT ANSWER-The transfer of electronic information in a standard format Coordination of benefits rule - THE CORRECT ANSWER-Determines which insurance plan is primary and which is secondary insurance. Conditional Payment - THE CORRECT ANSWER-Medicare payment that is recovered after primary insurance pays. Crossover claim - THE CORRECT ANSWER-Claim submitted by people covered by primary and secondary insurance plan
Two causes of a claim transmission errors - THE CORRECT ANSWER- Missing or invalid patient identification number and lack of authorization or referral number Assignment of Benefits - THE CORRECT ANSWER-Contract in which the provider directly bills the payer and accepts the allowable charge. Clean claim - THE CORRECT ANSWER-Claim that is accurate and complete Dirty claim - THE CORRECT ANSWER-Claim that inaccurate, incomplete, or contains other errors Medicare administrative Contractor (MAC) - THE CORRECT ANSWER- Processes Medicare Parts A & B claims from hospitals, physicians, and other providers Remittance Advice (RA) - THE CORRECT ANSWER-The report sent from the third-party payer to the provider that reflects any changes made to the original billing. 2 Pieces of Information that need to be collected from patients - THE CORRECT ANSWER-Patients name and date of birth Deductible - THE CORRECT ANSWER-Amount you must pay out of pocket before you begin receiving any benefits from your insurance company
Medicare Advantage - THE CORRECT ANSWER-Combined package of benefits under Medicare Parts A & B that may offer extra coverage for services such a, vision, hearing, dental, health and wellness, or prescription coverage. Medigap - THE CORRECT ANSWER-Private health insurance that pays for most of the charges not covered parts A& B Referral - THE CORRECT ANSWER-Written recommendation to a specialist Precertification - THE CORRECT ANSWER-A review that looks at whether the procedure could be performed safely but less expensively in an outpatient setting. predetermination - THE CORRECT ANSWER-A written request for a verification of benefits. Who is the gatekeeper - THE CORRECT ANSWER-primary care physician Preauthorization - THE CORRECT ANSWER-Approval for the health plan for an inpatient hospital stay or surgery Tier 1 - THE CORRECT ANSWER-Providers and facilities in a PPO network
Tier 2 - THE CORRECT ANSWER-Providers and facilities within the broader, contracted network Tier 3 - THE CORRECT ANSWER-Providers and facilities out of the network Tier 4 - THE CORRECT ANSWER-Providers and facilities not on the formulary Formulary - THE CORRECT ANSWER-a list of prescription drugs covered by a specific health care plan Charge Description Master (CDM) - THE CORRECT ANSWER- Information about health care services that patients have received and financial transactions that have taken place. Medicare Summary Notice (MSN) - THE CORRECT ANSWER- Document that outlines the amounts billed by the provider and what the patient must pay the provider. Cost sharing - THE CORRECT ANSWER-The balance the policyholder must pay to the provider. Medical Necessity - THE CORRECT ANSWER-The documented need for a particular medical intervention. 2 reasons a claim may be denied - THE CORRECT ANSWER-Invalid subscriber name was given or coding error was made
Encounter forms - THE CORRECT ANSWER-Form that contains of DOS, CPT, ICD codes, fees and copay information is called Add on Codes - THE CORRECT ANSWER-Anesthesia section of CPT manual which are considered qualifying circumstances Title 11 - THE CORRECT ANSWER-Patient presents with chest pain & shortness of breath with abnormal ECG provider call a cardiologist. What portion of the HIPPA allows this Code set standards pertain to all providers - THE CORRECT ANSWER- HIPPA compliance guideline affecting EHR Red - THE CORRECT ANSWER-Color formats on CMS 1500 form acceptable Patient Ledger account - THE CORRECT ANSWER-Financial record generated by a provider office Coding Compliance Plan - THE CORRECT ANSWER-Which of the following includes procedures and best practices for correct coding CPT Category II Codes - THE CORRECT ANSWER-Designed to serve as supplemental tracking codes that can be used for performance measurement. Modifiers are used CPT Category III - THE CORRECT ANSWER-Temporary coding for new technology and services that have not met the requirements needed
HCPS Level II - THE CORRECT ANSWER-National Codes, Uses modifiers HCPS Level 3 Codes - THE CORRECT ANSWER-Temporary Codes How many CPT code category sections are listed in the CPT manual? - THE CORRECT ANSWER- 6 MS-DRG grouper - THE CORRECT ANSWER-Software that helps coders assign the appropriate Medicare severity diagnosis- related group based on the level of services provided, severity of the illness or injury, and other factors. APC Grouper - THE CORRECT ANSWER-Determine the appropriate ambulatory payment classification for outpatient encounter NON PAR - THE CORRECT ANSWER-15% over fee schedule amount Non medical Code - THE CORRECT ANSWER-Why a payment was not paid or adjusted A bilateral procedure - THE CORRECT ANSWER-A billing and coding specialists should add modifier - 50 when reporting which procedure
Patients demographics - THE CORRECT ANSWER-On the CMS 1500 Form blocks 1-13 are A patients signature authorizing the release of any medical information necessary to process the claim. - THE CORRECT ANSWER- Block 12 Other insured policy or group number - THE CORRECT ANSWER-Block 9a contains Date of current injury, illness, or LMP - THE CORRECT ANSWER-Block 14 Name of referring provider - THE CORRECT ANSWER-Block 17 Referring provider NPI number - THE CORRECT ANSWER-17b What block does the diagnosis codes go on CMS 1500 form? - THE CORRECT ANSWER-Block 21 Dates of services on the CMS 1500 for are to be placed on what block? - THE CORRECT ANSWER-Block 24A Diagnosis pointer is in what field on the CMS 1500 - THE CORRECT ANSWER-Block 24E Signature of physcican or supplier is provided in what field - THE CORRECT ANSWER-Block 31
Billing provider NPI number is on what block on the CMS 1500 form? - THE CORRECT ANSWER-Block 33a
