NHA - Certified Billing and Coding Specialist (CBCS) Study Guide 2024-2025. Q & A.Grade A+, Exams of Programming Languages

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NHA - Certified Billing and Coding Specialist (CBCS)

Study Guide 2024-2025. Questions and Correct,

Verified Answers. Graded A+

A billing and coding specialist can ensure appropriate insurance coverage for an outpatient procedure by obtaining what? - ANSPrecertification A claim can be denied or rejected for which of the following reasons? - ANSBlock 24D contains the diagnosis code A coroner's autopsy is comprised of what examinations? - ANSGross Examination A patient's health plan is referred to as the "payer of last resort." What is the name of that health plan? - ANSMedicaid Abstracting - ANSThe extraction of specific data from a medical record, often for use in an external database, such as a cancer registry. Abuse - ANSPractices that directly or indirectly result in unnecessary costs to the Medicare program. Account Number - ANSNumber that identifies specific episode of care, date of service, or patient. Accounts Receivable Department - ANSDepartment that keeps track of what third-party payers the provider is waiting to hear from and what patients are due to make a payment. Advance Beneficiary Notice of Noncoverage - ANSForm provided if a provider believes that a service may be declined because Medicare might consider it unnecessary. Aging Report - ANSMeasures the outstanding balances in each account. Allowable Charge - ANSThe amount an insurer will accept as full payment, minus applicable cost sharing.

Ambulatory surgery centers, home health care, and hospice organizations use which form to submit claims? - ANSUB-04 Claim Form APC Grouper - ANSHelps coders determine the appropriate ambulatory payment classification (APC) for an outpatient encounter. As of April 1, 2014 what is the maximum number of diagnoses that can be reported on the CMS- claim form before a further claim is required? - ANS Assignment of Benefits - ANSContract in which the provider directly bills the payer and accepts the allowable charge. At what percentage should a front torso burn be coded? - ANS18% Auditing - ANSReview of claims for accuracy and completeness. Authorizations - ANSPermission granted by the patient or the patient's representative to release information for reasons other than treatment, payment, or health care operations. Balance Billing - ANSBilling patients for charges in excess of the Medicare fee schedule. Batch - ANSA group of submitted claims. Block 17b on the CMS-1500 claim form should list what information? - ANSReferring physician's national provider identifier number. Business Associate (BA) - ANSIndividuals, groups, or organizations who are not members of a covered entity's workforce that perform functions or activities on behalf of or for a covered entity. By signing block 12 of CMS-1500 form, a patient is doing what? - ANSAuthorizes the release of medical information.

Category I CPT Code - ANSCode that covers physicians' services and hospital outpatient coding. Category II CPT Code - ANSCode designed to serve as supplemental tracking codes that can be used for performance measurement. Category III CPT Code - ANSCode used for temporary coding for new technology and services that have not met the requirements needed to be added to the main section of the CPT book. Charge description Master (CDM) - ANSInformation about health care services that patients have received and financial transactions that have taken place. Claim - ANSComplete record of the services provided by the health care professional, along with appropriate insurance information. Clean Claim - ANSClaim that is accurate and complete. They have all the information needed for processing, which is done in a timely fashion. Clearinghouse - ANSAgency that converts claims into standardized electronic format, looks for errors, and formats them according to HIPAA and insurance standards. Coinsurance - ANSthe pre-established percentage of expenses paid by the insurance company after the deductible has been met. Computer-assisted Coding (CAC) - ANSSoftware that scans the entire patient's electronic record and codes the encounter based on the documentation in the record. Conditional Payment - ANSMedicare payment that is recovered after primary insurance pays. Consent - ANSA patient's permission evidenced by signature. Coordination of Benefits Rules - ANSDetermines which insurance plan is primary and which is secondary.

Copayment - ANSA fixed dollar amount that must be paid each time a patient visits a provider. Cost Sharing - ANSThe balance the policyholder must pay the provider. CPT codes are used to describe what? - ANSServices rendered by the provider. Crossover Claim - ANSClaim submitted by people covered by a primary and secondary insurance plan. De-identified Information - ANSInformation that does not identify an individual because unique and personal characteristics have been removed. Deductible - ANSThe amount of money a patient m just pay out of pocket before the insurance company will start to pay for covered benefits. Dirty Claim - ANSClaim that is inaccurate, incomplete, or contains other errors. E Codes - ANSCodes used to classify environmental events, circumstances, and conditions, such as the cause of injury, poisoning, and other adverse events. Electronic Data Interchange (EDI) - ANSThe transfer of electronic information in a standard form. Encoder - ANSSoftware that suggests codes based on documentation or other input. Encounter - ANSA direct, professional meeting between a patient and a health care professional who is licensed to provide medical services. Encounter Form - ANSForm that includes information about past history, current history, inpatient record, discharge information and insurance information.

Explanation of Benefits (EOB) - ANSDescribes the services rendered, payment covered, and benefit limits and denials. Formulary - ANSA list of prescription drugs covered by an insurance plan. Fraud - ANSMaking false statements of representations of material facts to obtain some benefit or payment for which no entitlement would otherwise exist. Health Record Number - ANSNumber the provider uses to identify an individual patient's record. Heath Maintenance Organization (HMO) - ANSPlan that allows patients to only go to physicians, other health care professionals, or hospitals on a list of approved providers, except in an emergency. How does ICD-10-CM improve upon ICD-9-CM? - ANSICD-10-CM provides more detailed clinical information, updated medical terminology and classification of diseases. How many CPT code category sections are listed in the CPT manual? - ANSSix Implied Consent - ANSA patient presents for treatment, such as extending an arm to allow a venipuncture to be performed. In the anesthesia section of the CPT manual what is considered qualifying circumstances? - ANSAdd-on codes In the anesthesia section of the CPT manual, what are considered qualifying circumstances? - ANSAdd- on codes Individually Identifiable - ANSDocuments that identify the person or provide enough information so that the person can be identified.

Informed Consent - ANSProviders explain medical or diagnostic procedures, surgical interventions, and the benefits and risks involved, giving patients an opportunity to ask questions before medical intervention is provided. Medicaid - ANSA government-based health insurance option that pays for medical assistance for individuals who have low incomes and limited financial resources. Medical Necessity - ANSThe documented need for a particular medical intervention. Medicare - ANSFederally funded health insurance provided to people age 65 or older, and people 65 and younger with certain disabilities. Medicare Administrative Contractor (MAC) - ANSProcesses Medicare Parts A and B claims from hospitals, physicians, and other providers. Medicare Advantage (MA) - ANSCombined package of benefits under Medicare Parts A and B that may offer extra coverage for services such as vision, hearing, dental, health and wellness, or prescription drug coverage. Medicare Part A - ANSProvides hospitalization insurance to eligible individuals. Medicare Part B - ANSVoluntary supplemental medical insurance to help pay for physicians' and other medical professionals' services, medical services, and medical-surgical supplies not covered by Medicare Part A. Medicare Part D - ANSA p.an run by private insurance companies and other vendors approved by Medicare. Medicare Summary Notice (MSN) - ANSDocument that outlines the amounts billed by the provider and what the patient must pay the provider. Medigap - ANSA private health insurance that pays for most of the charges not covered by Parts A and B.

Medigap coverage is offered to Medicare beneficiaries by whom? - ANSPrivate third-party payers Modifier - ANSAdditional information about types of services, and part of valid CPT or HCPCS codes. Morbidity - ANSThe number of cases of disease in a specific population. Mortality - ANSThe incidence of death in a specific population. MS-DRG Grouper - ANSSoftware 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. National Provider Identifier (NPI) - ANSUnique 10-digit code fro providers required by HIPAA. Notice of Exclusions from Medicare Benefits - ANSNotification by the physician to a patient that a service will not be paid. Preauthorization - ANSApproval from the health plan for an inpatient hospital stay or surgery. Precertification - ANSA review that looks at whether the procedure could be performed safely but less expensively in an out patient setting. Predetermination - ANSA written request for a verification of benefits. Preferred Provider - ANSTier 2 provider Referral - ANSWritten recommendation to a specialist. Reimbursement - ANSPayment for services rendered from a third-party payer.

Remittance Advice (RA) - ANSThe report sent from the third-party payer to the provider that reflects any changes made to the original billing. Stark Law - ANSProhibits a provider from referring Medicare patients to a clinical laboratory service in which the provider has a financial interest. Subscriber - ANSPurchaser of the insurance or the member of group for which an employer or association as purchased insurance. Subscriber Number - ANSUnique code used to identify a subscriber's policy. The billing and coding specialist should follow the guidelines in the CPT manual for which of the following reasons? - ANSThe guidelines define items that are necessary to accurately code. The symbol "O" in the Current Procedural Terminology reference is used to indicate what? - ANSReinstated or recycled code Tier 1 - ANSProviders and facilities in a PPO's network. Tier 2 - ANSProviders and facilities within a broader, contracted network of the insurance company. Tier 3 - ANSProviders and facilities out of the network. Tier 4 - ANSProviders and facilities not on the formulary Timely Filing Requirements - ANSWithin 1 calendar year of a claim's date of service. Unbundling - ANSUsing multiple codes that describe different components of a treatment instead of using a single code that describes all steps of the procedure.

Upcoding - ANSAssigning a diagnosis or procedure code at a higher level than the documentation supports, such as coding bronchitis as pneumonia. V Codes - ANSCodes used to classify visits when circumstances other than disease or injury are the reason for the appointment. What action should be taken first when reviewing a delinquent claim? - ANSVerify the age of the account What are HCPCS Level II codes used for? - ANSThey were established to report services, supplies, and procedures not represented in CPT. What are the four types of nonmusical codes used by Medicare to explain claims? - ANSGroup codes, claims adjustment reason codes (CARCs), remittance advice remark codes (RARCs) and provider-level adjustment reason codes. What are the goals of ICD-10-PCS? - ANSImprove accuracy and efficiency of coding, reduce training effort, and improve communication with physicians. What are the three major kinds of government insurance plans? - ANSMedicare, Medicaid, and State Children's Health Insurance Program (SCHIP) What are three purposes of ICD-9-CM? - ANSClassifying morbidity and mortality, indexing hospital records by disease and operations and reporting diagnoses by physicians. What are two kinds of information the CDM stores? - ANSDescription of services and revenue code. What are two pieces of information that need to be collected from patients? - ANSFull name and date of birth. What are two reasons why a claim may be denied? - ANSAn invalid subscriber name was given or a coding error was made.

What are Z codes used to identify? - ANSImmunizations What block on the CMS-1500 claim form is required to indicate a workers' compensation claim? - ANS10a What block on the CMS-1500 claim form is used to accept assignment of benefit? - ANS What block on the CMS-1500 claim form should be completed for procedures, services and supplies? - ANS24D What block on the CMS-1500 form should you enter the prior authorization number? - ANS What character of ICD-10-PCS for medical or surgical procedure would identify the body part? - ANSCharacter 4 What color format is acceptable on the CMS-1500 claim form? - ANSRed What describes the term "crossover" as it relates to Medicare? - ANSWhen an insurance company transfers data to allow coordination of benefits of a claim. What doe modifiers provide? - ANSThe 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 does the term reconciliation mean? - ANSRefers to the process the billing office goes through to determine what payments have come in from the third-party payer and what the patient owes the provider. What form is used as a financial report of all services provided to patients? - ANSPatient account record What formats are used to submit electronic claims to a third-party payer? - ANS

What happens after a third-party payer validates a claim? - ANSClaim adjudication What information is recorded in Block 33a of the CMS-1500 form? - ANSNational Provider Identification Number What is a common coinsurance percentage split? - ANS80% for the insurance carrier and 20% for the patient. What is a HIPAA compliance guideline affecting electronic health records? - ANSThe electronic transmission and code set standards require every provider to use the healthcare transactions, code sets, and identifiers. What is abstracting? - ANSIt involves reviewing the health record and/or encounter form and translating the medical documentation into the specific code sets. What is an example of a remark code from an explanation of benefits document? - ANSContractual allowance What is an example of Medicare abuse? - ANSCharging excessive fees. What is considered proper supportive documentation for reporting CPT and ICD codes for surgical procedures? - ANSOperative report What is modifier -50 used for? - ANSA bilateral procedure What is the advantage of employer-based self-insured health plans? - ANSDue to economies of scale, employer-based self-insured health plans are more reasonably priced than private insurance. What is the coinsurance percentage? - ANSAmount the provider is allowed for the service and the amount he was paid. The patient has coinsurance responsibility to what provider was allowed.

What is the main job of the Office of the Inspector General (OIG)? - ANSThe OIG protects Medicare and other HHS programs from fraud and abuse by conducting audits, investigations , and inspections. What is the purpose of running an aging report each month? - ANSIt indicates which claims are outstanding. What is the role of the accounts receivable department? - ANSManages follow-up to the billing process for a provider's office. What modifier should be used to indicate a professional service has been discontinued prior to completion? - ANS- What national provider identifiers (NPIs) is required in Block 33a of a CMS-1500 claim form? - ANSBilling provider What notice explains why Medicare will deny a particular service or procedure? - ANSAdvance Beneficiary Notice (ABN) What part of Medicare covers prescriptions? - ANSPart C What part of the medical record is used to determine the correct E/M code used for billing & coding? - ANSHistory and physical What plane divides the body into left and right? - ANSSagittal What policy determines if a particular item or service is covered by Medicare? - ANSNational Coverage Determination (NCD) What standardized formats are used in the electronic filing of claims? - ANSHIPAA standard transactions What symbol indicates a revised code? - ANSTriangle

What type of insurance is considered the payer of last resort? - ANSMedicaid What was developed to reduce Medicare program expenditures by detecting inappropriate codes and eliminating improper coding practices? - ANSNCCI What's the difference between a copayment and coinsurance? - ANSCopayment is a flat fee that a patient pays; Coinsurance is a percentage of the covered benefits paid by both the insurance company and the patient. When can a patient request an external independent review? - ANSAfter an internal appeal has been denied. When submitting claims, what is the outcome if block 13 is left blank? - ANSThe third-party payer reimburses the patient and the patient is responsible for reimbursing the provider. Where can unlisted codes be found in the CPT manual? - ANSGuidelines prior to each section Where does the NPI number go on the CMS-1500 form? - ANS17b Which block on the CMS-1500 claim form is used to bill ICD codes? - ANS Which block should the billing and coding specialist fill out on the CMS-1500 claim form when billing a secondary insurance company? - ANS9a Who benefits from the new appeals process, and why? - ANSThe patient; the new process lays out steps the insurance company must follow and makes sure that tasks get done in a timely fashion. Who is responsible to pay the deductible? - ANSPatient Who is usually the gatekeeper? - ANSPrimary care physician

Write-off - ANSThe difference between the provider's actual charge and the allowable charge.