Understanding Medical Coding and Billing Practices, Exams of Advanced Education

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CBCS PRACTICE FOR NHA 2023 - 2024

The symbol "O" in the Current Procedural Terminology reference is used to indicate what? - Reinstated or recycled code In the anesthesia section of the CPT manual, what are considered qualifying circumstances? - Add-on codes What is considered proper supportive documentation for reporting CPT and ICD codes for surgical procedures? - Operative Report Where can unlisted codes be found in the CPT manual. - Guidelines prior to each section Where does the NPI number go on the CMS-1500 form? - 17b The transfer of electronic information in a standard form. - Electronic Data Interchange Describes the services rendered, payment covered, and benefit limits and denials. - Explanation of Benefits (EOB) Claim submitted by people covered by a primary and secondary insurance plan. - Crossover Claim By signing block 12 of CMS-1500 form, a patient is doing what? - Authorizes the release of medical information. Provides hospitalization insurance to eligible individuals. - Medicare Part A 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 Part B 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 Advantage (MA) prescription drug coverage by Medicare - Medicare Part D A private health insurance that pays for most of the charges not covered by Medicare Parts A and B. - Medigap Approval from the health plan for an inpatient hospital stay or surgery. - PreAUTHORIZATION

A review that looks at whether the procedure could be performed safely but less expensively in an outpatient setting. - PreCERTIFICATION A written request for a verification of benefits. - PreDETERMINATION The primary physician. - Who is usually the Gatekeeper? A list of prescription drugs covered by an insurance plan. - Formulary Providers and facilities in a PPO's network. - Tier 1 Providers and facilities within a broader, contracted network of the insurance company. - Tier 2 Providers and facilities out of the network. - Tier 3 Providers and facilities not on the formulary. - Tier 4 Tier 2 provider - Preferred Provider Information about health care services that patients have received and financial transactions that have taken place. - Charge Description Master (CDM) Billing patients for charges in excess of the Medicare fee schedule. - Balance Billing A group of submitted claims. - Batch Codes used to classify visits when circumstances other than disease or injury are the reason for the appointment. - V Codes Codes used to classify environmental events, circumstances, and conditions, such as the cause of injury, poisoning, and other adverse events. - E Codes Code that covers physicians' services and hospital outpatient coding. - Category 1 CPT Code Code designed to serve as supplemental tracking codes that can be used for performance measurement. - Category 2 CPT Code Code 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. - Category 3 CPT Code The extraction of specific data from a medical record, often for use in an external database, such as a cancer registry. - Abstracting

This program was developed by CMS to promote national correct coding methods and to control inappropriate payment of Part B claims and hospital outpatient claims. - NCCI When an insurance company transfers data to allow coordination of benefits of a claim. - Crossover The third-party payer reimburses the patient and the patient is responsible for reimbursing the provider. - What happens if Block 13 is left blank? The electronic transmission and code set standards require every provider to use the healthcare transactions, code sets, and identifiers. - HIPPA compliance guidelines for electronic health records. Indicates a revised code. - Triangle Symbol A coding book that contains codes for medical products and supplies. - HCPS form required when a TRICARE member seeks medical services outside an military treatment facility. - Non-Availability Statement (NAS) Individuals with similar diagnosis and determining needs. - DRGs (diagnosis-related groups) History of present illness, present illness. - HPI, PI Responsible for updating HCPCS and CPT changes. - AMA (American Medical Association) Releasing, giving access to, or transferring PHI to an outside person or organization. - Disclosure An examination of a knee joint via small incision and optical device. - Arthroscopy Surgical fixation of the stomach to the abdominal wall for correction of displacement. - Gastropexy Protects the confidentiality, integrity, and availability of electronic health information. - HIPAA Security Rule Some senior HMOs provide services not covered by Medicare such as... - Eyeglasses and Prescription Drugs a service company that receives electronic or paper claims from the provider, checks and prepares them for processing, and transmits them in HIPAA-complaint format to the correct carriers. - Clearinghouse Used for billing hospital services. - UB-04 form

Access is based on the role a person plays in an organization. - Role-Based Access An insurance claim that is submitted with errors. - Dirty Claim down coding occurs. - Payments will be less if... Total number of modifiers that can be indicated on the CMS-1500 form. - 4 Modifiers An electronic document that lists patients, dates of service, charges, and the amount paid or denied by the insurance carrier. - ERA (electronic remittance advice) Abnormal growths of new tissue that are classified as benign or malignant. - Neoplasms The on-going availability of cash for operations in a medical practice. - Cash Flow Federal agency in the Department of Health and Human Services that runs Medicare, Medicaid, clinical laboratories, and other government health programs; responsible for enforcing all HIPAA standards other than the privacy and security standards. - CMS (Centers for Medicare and Medicaid Services) Refers to the muscular wall of the heart. - Myocardium Pay the physician within 2 to 3 weeks and honor the assignment, even before the company recovers their money from the patient. - If an insurance company admits that a patient signed an assignment of benefits document and that it inadvertently paid the patient instead of the physician, the insurance company should... Damage from wear-and-tear, power failure, and destruction by fire or flood. - Daily back-ups of the system, and storage at an offsite location, allow for restoration of information and eliminate the risk for loss of data due to... Processes Medicare Parts A and B claims from hospitals, physicians, and other providers. - Medicare Administrative Contractor (MAC) The main reason for the patient's visit. - Chief Complaint (CC) System of payment used by managed care plans in which physicians and hospitals are paid a fixed, per capita amount for each patient enrolled over a stated period regardless of the type and number of services provided; reimbursement to the hospital on a per-member/per-month basis to cover costs for the members of the plan. - Capitation CPT codes are published annually. These codes are added, revised, and deleted each year. This month is when you would start using these codes. - January

An age-appropriate review of a patient's past and current activities. - Social History (SH) exceptions to the right of the privacy rule. - Gunshot wound cases are... Urine moves through the kidneys to the bladder through these. - Ureters Surgical removal of the tonsils. - tonsillectomy Consideration for others. - Medical etiquette refers to subjective, objective, assessment, plan - A common format for medical record documentation. - soap Most physician/patient contracts are. - Implied Organization that publishes diagnostic and procedure coding competencies for outpatient services and diagnostic coding and reporting requirements for physician billing. - American Health Information Management Association (AHIMA) A systematic approach for collecting the patient's self-reported data on all body systems. - Review of Systems (ROS) When coding a front torso burn, which of the following percentages should be coded? - 18% CPT/HCPCS codes (procedures, services, supplies) - Block 24d electrocardiogram - Common abbreviation for the test that assesses the electrical activity of the heart. - ECG Confidential information about patients should never be discussed with. - Family, Coworkers, Friends "Let the master answer" an employer is vicariously liable for the behavior of an employee working within his or her scope of employment. - Respondeat Superior Condition established after study to be chiefly responsible for admission to hospital. - Principal Diagnosis (PDX) Who is responsible for entering proper medical documentation to support reimbursement of procedures and services? - Clinician Document given to medicare beneficiaries indicating the services medicare is unlikely to pay for. - Advanced Beneficiary Notice (ABN)

Grouping codes that are related to a procedure. - What does bundling mean? A summary sent to the patient from Medicare that summarizes all services provided over a period of time with an explanation of benefits provided. - Medicare Summary Notice (MSN) Refers to the insurance policy number. - Subscriber number Provision of a healthcare insurance policy that requires policyholders to pay for a portion of their healthcare services; a cost-control mechanism. - cost sharing Part of HIPAA policy, mandates that healthcare claims be submitted electronically. - Administration Simplification Compliance Act (ASCA) The transfer of electronic information, such as health claims, in a standard format. - Electronic Data Interchange (EDI) Medicare payment that is recovered after primary insurance pays. - Conditional Payment Claims with minor errors or omissions can be resubmitted according to payer guidelines. - Resubmission Process of Claim What plane divides the body into left and right? - Sagittal Plane divides body into front and back - coronal plane A federal and state assistance program that pays for health care services for people who cannot afford them. - Medicaid chronicles the details of a surgical procedure performed in a hospital, outpatient surgical center, or clinic. - Operative report (OR) Identifies add-on codes (Appendix D of CPT) for procedures that are commonly, but not always, performed at the same time and by the same surgeon as the primary procedure. - Plus Symbol the standard form used by health-care providers to bill for services, including disease state management services. - CMS-1500 form Basic information about patient or demographics. - Fields 1- 13 What type of insurance. - Block 1 Leave blank. - Block 8 Other Insured's Name - Block 9

The "accept assignment" indicates that the provider agrees to accept assignment under the terms of the Medicare program and some other insurance payers. Check this block if the provider participates in the insurance payer's program; that is the provider is a participating physician and agrees to abide by the terms of the agreement to accept assignment and writer off the difference between the original charge and the allowable amount set by the insurance carrier. - Block 27: Accept Assignment The total charge is the amount billed on this claim form for all services rendered. Add the charges reported in block 24F for all the lines of services on the claim form. - Block 28: Total Charge The amount paid is the payment received from the patient or other payers. - Block 29: Amount Paid The amount left after the patient has paid a co-pay or co-insurance is entered in this block. - Block 30: Balance Due The non-NPI number of the billing provider refers to the payer-assigned unique identifier of the professional. The 2 character qualifier of the non-NPI number is also entered in this block. - Block 32b: Other ID number Enter the NPI number of the service facility. - Block 32a: NIP Number It was used previously for a personal identification number (PIN), which became obsolete in

2008. • Block 17a: Other ID HIPAA established the National Provider Identification (NPI). In the past, each insurance carrier, including government programs, assigned an identifier to each provider service. All allied healthcare providers of serivce now are assigned an NPI, which the provider can use regardless of the insurance carrier being billed. The NPI replaces Medicare's Unique Provider Identification Number (UPIN) and almost all other federal, state, and private insurance carriers' Provider Identification Numbers (PINs). The NPI does not replace the Social Security number (SSN), employer identification number (EIN), or federal tax identification number (TIN) used by a provider of service. The SSN, EIN, and TIN are used for income and tax purposes and for reporting to the Internal Revenue Service. - Block 17b: NPI Number Date of current illness injury or pregnancy. - Block 14 The other insured's name indicates that another insurance exists that may cover the patient. This block is completed only if there is a secondary insurance policy and that policy is to be billed. - Block 9: Other Insured's Name The signature is the provider's verification that the claim is correct. - Block 31: Signature of Physician or Supplier

Referring Provider - DN qualifier Ordering Provider - DK qualifier Supervising Provider - DQ qualifier seven - ICD- 10 - PCS codes contain _______ characters. 21 chapters For some chapters, the body or organ system is the axis Other chapters group together conditions by etiology or nature of the disease process ICD- 10 - CM contains chapters for External Causes of Morbidity Previously known as E codes in ICD- 9 - CM Factors Influencing Health Status and Contact with Health Services Previously known as V codes in ICD- 9 - CM - ICD- 10 - CM Tabular List Where the code is indexed. - ICD- 10 - PCS Section 1 The body system - ICD- 10 - PCS Section 2 Root operation such as excision or incision. - ICD- 10 - PCS Section 3 Specific body part. - ICD- 10 - PCS Section 4 Approach used. - ICD- 10 - PCS Section 5 Device used to perform the procedure. - ICD- 10 - PCS Section 6 Qualifier to provide additional information about the procedure (diagnostic vs therapeutic). - ICD- 10 - PCS Section 7 Provides financial information about claims decisions. - claims adjustment reason code (CARC)a