NHA Certified Billing and Coding Specialist (CBCS) Study Guide, Exams of Nursing

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Specialist (CBCS) Study Guide Latest

NHA Certified Billing and Coding

Specialist (CBCS) Study Guide Latest

The symbol "O" in the Current Procedural Terminology reference is used to indicate what? - Ans Reinstated or recycled code In the anesthesia section of the CPT manual, what are considered qualifying circumstances? - Ans Add-on codes As of April 1, 2014 what is the maximum number of diagnoses that can be reported on the CMS-1500 claim form before a further claim is required? - Ans 12 What is considered proper supportive documentation for reporting CPT and ICD codes for surgical procedures? - Ans Operative report What action should be taken first when reviewing a delinquent claim? - Ans Verify the age of the account A claim can be denied or rejected for which of the following reasons? - Ans Block 24D contains the diagnosis code A coroner's autopsy is comprised of what examinations? - Ans Gross Examination Medigap coverage is offered to Medicare beneficiaries by whom? - Ans Private third-party payers What part of Medicare covers prescriptions? - Ans Part C What plane divides the body into left and right? - Ans Sagittal Where can unlisted codes be found in the CPT manual? - Ans Guidelines prior to each section

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Ambulatory surgery centers, home health care, and hospice organizations use which form to submit claims? - Ans UB-04 Claim Form What color format is acceptable on the CMS-1500 claim form? - Ans Red Who is responsible to pay the deductible? - Ans Patient A patient's health plan is referred to as the "payer of last resort." What is the name of that health plan? - Ans Medicaid Informed Consent - Ans Providers 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. Implied Consent - Ans A patient presents for treatment, such as extending an arm to allow a venipuncture to be performed. Clearinghouse - Ans Agency that converts claims into standardized electronic format, looks for errors, and formats them according to HIPAA and insurance standards. Individually Identifiable - Ans Documents that identify the person or provide enough information so that the person can be identified. De-identified Information - Ans Information that does not identify an individual because unique and personal characteristics have been removed. Consent - Ans A patient's permission evidenced by signature. Authorizations - Ans Permission granted by the patient or the patient's representative to release information for reasons other than treatment, payment, or health care operations. Reimbursement - Ans Payment for services rendered from a third-party payer. Auditing -

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Crossover Claim - Ans Claim submitted by people covered by a primary and secondary insurance plan. Assignment of Benefits - Ans Contract in which the provider directly bills the payer and accepts the allowable charge. Allowable Charge - Ans The amount an insurer will accept as full payment, minus applicable cost sharing. Clean Claim - Ans Claim that is accurate and complete. They have all the information needed for processing, which is done in a timely fashion. Dirty Claim - Ans Claim that is inaccurate, incomplete, or contains other errors. Medicare Administrative Contractor (MAC) - Ans Processes Medicare Parts A and B claims from hospitals, physicians, and other providers. Remittance Advice (RA) - Ans The report sent from the third-party payer to the provider that reflects any changes made to the original billing. Explanation of Benefits (EOB) - Ans Describes the services rendered, payment covered, and benefit limits and denials. National Provider Identifier (NPI) - Ans Unique 10-digit code fro providers required by HIPAA. Heath Maintenance Organization (HMO) - Ans Plan that allows patients to only go to physicians, other health care professionals, or hospitals on a list of approved providers, except in an emergency. Modifier - Ans Additional information about types of services, and part of valid CPT or HCPCS codes. By signing block 12 of CMS-1500 form, a patient is doing what? - Ans Authorizes the release of medical information. Claim -

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Ans Complete record of the services provided by the health care professional, along with appropriate insurance information. Where does the NPI number go on the CMS-1500 form? - Ans 17b What are two pieces of information that need to be collected from patients? - Ans Full name and date of birth. Deductible - Ans The amount of money a patient m just pay out of pocket before the insurance company will start to pay for covered benefits. Coinsurance - Ans the pre-established percentage of expenses paid by the insurance company after the deductible has been met. Copayment - Ans A fixed dollar amount that must be paid each time a patient visits a provider. Medicare Part A - Ans Provides hospitalization insurance to eligible individuals. Medicare Part B - Ans Voluntary 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 Advantage (MA) - Ans Combined 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 D - Ans A p.an run by private insurance companies and other vendors approved by Medicare. Medigap - Ans A private health insurance that pays for most of the charges not covered by Parts A and B. What are the three major kinds of government insurance plans? - Ans Medicare, Medicaid, and State Children's Health Insurance Program (SCHIP) Referral - Ans Written recommendation to a specialist.

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Ans 80% for the insurance carrier and 20% for the patient. Accounts Receivable Department - Ans Department that keeps track of what third-party payers the provider is waiting to hear from and what patients are due to make a payment. Aging Report - Ans Measures the outstanding balances in each account. Charge description Master (CDM) - Ans Information about health care services that patients have received and financial transactions that have taken place. Account Number - Ans Number that identifies specific episode of care, date of service, or patient. Health Record Number - Ans Number the provider uses to identify an individual patient's record. Medicare Summary Notice (MSN) - Ans Document that outlines the amounts billed by the provider and what the patient must pay the provider. Subscriber - Ans Purchaser of the insurance or the member of group for which an employer or association as purchased insurance. Subscriber Number - Ans Unique code used to identify a subscriber's policy. Cost Sharing - Ans The balance the policyholder must pay the provider. Batch - Ans A group of submitted claims. Balance Billing - Ans Billing patients for charges in excess of the Medicare fee schedule. Notice of Exclusions from Medicare Benefits - Ans Notification by the physician to a patient that a service will not be paid. Advance Beneficiary Notice of Noncoverage - Ans Form provided if a provider believes that a service may be declined because Medicare might consider it unnecessary.

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What does the term reconciliation mean? - Ans Refers 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. Write-off - Ans The difference between the provider's actual charge and the allowable charge. Medical Necessity - Ans The documented need for a particular medical intervention. What are two reasons why a claim may be denied? - Ans An invalid subscriber name was given or a coding error was made. What is the role of the accounts receivable department? - Ans Manages follow-up to the billing process for a provider's office. What are two kinds of information the CDM stores? - Ans Description of services and revenue code. What are the four types of nonmusical codes used by Medicare to explain claims? - Ans Group codes, claims adjustment reason codes (CARCs), remittance advice remark codes (RARCs) and provider-level adjustment reason codes. Who benefits from the new appeals process, and why? - Ans The patient; the new process lays out steps the insurance company must follow and makes sure that tasks get done in a timely fashion. When can a patient request an external independent review? - Ans After an internal appeal has been denied. V Codes - Ans Codes used to classify visits when circumstances other than disease or injury are the reason for the appointment. E Codes - Ans Codes used to classify environmental events, circumstances, and conditions, such as the cause of injury, poisoning, and other adverse events. Encounter - Ans A direct, professional meeting between a patient and a health care professional who is licensed to provide medical services. Mortality - Ans The incidence of death in a specific population.

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Ans Classifying morbidity and mortality, indexing hospital records by disease and operations and reporting diagnoses by physicians. How does ICD-10-CM improve upon ICD-9-CM? - Ans ICD-10-CM provides more detailed clinical information, updated medical terminology and classification of diseases. What are the goals of ICD-10-PCS? - Ans 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? - Ans Character 4 CPT codes are used to describe what? - Ans Services rendered by the provider. What doe modifiers provide? - Ans 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? - Ans They were established to report services, supplies, and procedures not represented in CPT. What part of the medical record is used to determine the correct E/M code used for billing & coding? - Ans History and physical Which block on the CMS-1500 claim form is used to bill ICD codes? - Ans 21 Which block should the billing and coding specialist fill out on the CMS-1500 claim form when billing a secondary insurance company? - Ans 9a What happens after a third-party payer validates a claim? - Ans Claim adjudication What is the purpose of running an aging report each month? - Ans It indicates which claims are outstanding. What are Z codes used to identify? - Ans Immunizations

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What type of insurance is considered the payer of last resort? - Ans Medicaid What modifier should be used to indicate a professional service has been discontinued prior to completion? - Ans - What form is used as a financial report of all services provided to patients? - Ans Patient account record What block on the CMS-1500 form should you enter the prior authorization number?

• Ans 23 Block 17b on the CMS-1500 claim form should list what information? - Ans Referring physician's national provider identifier number. What is modifier -50 used for? - Ans A bilateral procedure What information is recorded in Block 33a of the CMS-1500 form? - Ans National Provider Identification Number What block on the CMS-1500 claim form is required to indicate a workers' compensation claim? - Ans 10a When submitting claims, what is the outcome if block 13 is left blank? - Ans The third-party payer reimburses the patient and the patient is responsible for reimbursing the provider. What was developed to reduce Medicare program expenditures by detecting inappropriate codes and eliminating improper coding practices? - Ans NCCI What policy determines if a particular item or service is covered by Medicare? - Ans National Coverage Determination (NCD) What is an example of Medicare abuse? - Ans Charging excessive fees. What notice explains why Medicare will deny a particular service or procedure? - Ans Advance Beneficiary Notice (ABN) In the anesthesia section of the CPT manual what is considered qualifying circumstances? -

Specialist (CBCS) Study Guide Latest

Ans Billing provider