MEDICAL CODING AND BILLING

Flashcards Fo R Medica
Created May 3, 2009
by kacosta21
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Side ASide B
WHAT IS THE PROGRAM MANDATED BY FEDERAL AND STATE GOVERNMENT THAT REQUIRES EMPLOYERS TO COVER...
WORKERS COMPENSATION
ACCORDING TO THE US CENSUS BUREAU DATA FROM 2005 WHAT % OF PEOPLE IN THE UNITED STATES ARE...
27%
WHICH ACT MANDATES REGULATIONS THAT GOVERN PRIVACY, SECURITY AND ELECTRONIC TRANSACTIONS STANDARDS...
HIPPA
THE FIRST BLUE SHIELD PLAN WAS FOUNDED IN? -MICHIGAN -CALIFORNIA -CONNECTICUT -OHIO
CALIFORNIA
A SUCCESSFUL HEALTH INSURANCE SPECIALIST SHOULD HAVE WHICH OF THE FOLLOWING CHARACTERISTICS? -WORK...
ALL OF THE ABOVE
REIMBURSEMENT FOR INCOME LOST AS A RESULT OF TEMPORARY/PERMANENT ILLNESS OR INJURY IS: -LIABILITY...
DISABILITY INSURANCE
WHAT DOES CPT STAND FOR? -CODES POSTED VIA TELEPHONE -CLINICAL PROCEDURE TESTS -CURRENT...
CURRENT PROCEDURAL TERMINOLOGY
DISABILITY INSURANCE PROVIDES THE DISABLED PERSON WTIH FINANCIAL ASSISTANCE BUT DOESNT GENERALLY...
BOTH MEDICAL SERVICES AND UNEMPLOYMENT INSURANCE BENEFITS
WHICH OF THE FOLLOWING IS NOT A PROFESSIONAL ASSOCIATION FOR HEALTH INSURANCE SPECIALIST -AMERICAN...
AMERICAN MEDICAL ASSOCIATION
ICD-9CM STANDS FOR  
INTERNATIONAL CLASSIFICATION OF DISEASES-9TH REVISION , CLINICAL MODIFICATION
IF THE INSURANCE PLAN HAS A HOLD HARMLESS CLAUSE; IT MEANS  
PATIENT IS NOT RESPONSIBLE FOR PAYING WHAT THE INSURANCE PLAN DENIES
HEALTH CARE COVERAGE AVAILABLE THROUGH EMPLOYERS AND OTHER ORGANIZTIONS IN WHICH EMPLOYERS...
GROUP HEALTH INSURANCE
THIS TYPE OF INSURANCE PROVIDES COVERAGE FOR CATASTROPHIC OR PROLONGED ILLNESS AND INJURIES -MAJOR...
MAJOR MEDICAL INSURANCE
ANOTHER NAME FOR HEALTH INSURANCE SPECIALIST IS -MEDICAL RECORDS CLERK -BILLER -REIMBURSEMENT...
REIMBURSEMENT SPECIALIST
WHO REQUIRES PHYSICIAN OFFICES TO SUBMIT ICD-9SM CODES ON CMS1500 CLAIM FORMS? -HEDIS -MEDICARE -NATIONAL...
MEDICARE
EACH NEW PROVIDER MANAGED CARE CONTRACT INCREASES THE -PRACTICE'S PATIENT DATA BASE - # OF...
ALL OF THE ABOVE
THE CPT MANUAL IS PUBLISHED BY THE: -AMERICAN BOARD OF PHYSICIANS -AMERICAN MEDICAL ASSOCIATION -AMERICAN...
AMERICAN MEDICAL ASSOCIATION
IF PREAUTHORIZATION FOR TREATMENT BY SPECIALISTS AND POST TREATMENT REPORTS WERE NOT FILED...
DENIED
TRICARE INCLUDES 3 PLAN OPTIONS WHICH OF THE FOLLOWING IS NOT ONE OF THOSE OPTIONS? -TRICARE...
TRICARE SELECT
LIABILITY INSURANCE CLAIMS ARE MADE TO: -COVER COST OF MEDICAL CARE FOR TRAUMATIC INJURY OR...
COVER THE COST OF MEDICAL CARE FOR TRAUMATIC INJURIES OR LOST WAGES
WHAT INVOLVES LINKING EVERY PROCEDURE OR SERVICE CODE REPORTED ON THE CLAIM TO A CONDITION...
DIAGNOSIS CODING AND MEDICAL NECESSITY
US CENSUS BUREAU DATA FROM 2005 ESTIMATES THAT WHAT % OF PEOPLE IN THE US ARE COVERED BY SOME...
84%
PREVENTATIVE SERVICES: -MAY RESULT IN EARLY DETECTION OF HEALTH PROBLEMS -REQUIRED BY MOST...
THE FRST AND 3RD CHOICE
THE PROCESS OF REPORTING DIAGNOSES, PROCEDURES AND SERVICES AS NUMBERIC AND ALPHANUMERIC CHARACTERS...
CODING  
t or f? to reduce coding & billing errors health insurance specialists need to ecplain...
true
t or f? insurance specialists who are employed by insurance companies review claims for completeness...
true
t or f? liability insurance is a policy that covers losses to a 3rd party caused by the insured?
true
t or f? OSHA was designed to protect all employers against injuries from occupational hazards...
false
t or f? medical malpractice insurance is a type of liability insurance that covers physicians...
true
t or f? the mutual exchange of data between the provider and insurance company is called electronic...
false
t or f? the AAPC, AHMA and AMBA offer exams leading to professional credentials?
true
t or f? disablility insurance always pays for health care services and provides the disabled...
false
t or f? health insurance specialists review health related claims to determine the medical...
true
t or? medical care includes the identification of disease and te provision of care and treatment...
true
t or f? the patient receives a remittance advice which is a report that details the reults...
false
t or f? a health care facility that employs health insurance specialists is legally responsible...
true
t or f? group health insurance is coverage available through employers and other organizations...
true
t or f? title XVIII of the social security act provides health care services to americans over...
true
t or f? third party administrators (TPAs) administer health care plans and process claims thus...
true
t or f? in patient is person admitted to a hospital for treatment with expecation patient will...
true
t or f? the first listed diagnoses and the primary disagnosis are the same thing?
false
t or f? codes that desribe signs and symptoms as opposed to definitive diagnoses are never...
false
t or f? v codes are located in the index and are assigned for patient encounters when a circumstance...
false
t or f? e codes are located in the tabular list of diseases and describe external causes of...
true
t or f? nonessential modifiers are qualifying words that dont have to be inclded in the diagnostic...
true
t or f? coding conventions are rules that apply to the assignment of icd9-cm codes and are...
false
t or f? a lesion is a neoplasm defined as any discontinuity of tissue that is not malignant?
false
t or f? an adverse effect or reaction is the appearance of a pathologic condition cause by...
true
t or f? a late effect is a residual effect or sequelae of a previous acute illness injury...
true
t or f? the health insurance specialist employed in a physicians office assigns icd9-cm codes...
false
t or f? the icd9-cm is organized into 3 volumes?
true
the health insurance specialist employed in a physician's office assigns icd9-sm codes to: -diagnoses...
by provider
what volume of the icd9sm contains the index to disease? -voolume 3 -volume 2 -volume 1  
volume 2
the medicare catastrophic coverage act mandated the reporting of icd9 diagnosis codes on what...
all medicare claims
an outpatient is a person treated in which of the following settings? -hospital observation...
all above
codes that describe signs and symtoms as opposed to deginitive diagnosis are acceptable to...
the dr hasnt documented a confirmed diagnosis
__codes are located in the tabular list of diseases and are assigned for patient encounters...
v code
removal of a cast applied by another physician personal history of breast cancer and exposure...
v code
what type of code describes external causes of injury poisining or other adverse reactions...
e codes
the classification of industrial accidents accoding to agency is found in what appendix of...
D
the list of 3 digit categories is found in what appendix of the icd9cm? Appendix E D C or...
E
____identifies codes to be assigned when info needed to assign a more specific code cnt be...
NEC
A ___is a procedure performed for definitive treatment rather than diagnostic purposes -principal...
principle procedure
it is always necessary that these codes be coded directly from the pathology report -codes...
codes for neoplasms
requiring diagnosis codes to be reported on submitted claims? -e codes -v codes -medical...
medical necessity  
acknowledges patient responsbility for payment if medicare denies the claim? -complication -advanced...
advanced benfit notice
automates the coding process using computerized or web based software? -encoder -codes -cpt
encoder
condition that develops after outpatient care? -volume 3 -complications -burns
complications
working diagnosis that isnt yet proven or established? -qualified diagnoses -primary diagnosis -secondary...
qualified diagnosis
tabular list of diseases? -volume 2 -volume 1 -volume 3
volume 1
index to disease? -volume 3 -volume 2 volume 1
volume 2
late effects of an injury or illness? -iatrogenic -burns -seqauelae
seqauelae
result of medical intervention? -iatrogenic -seqeuelae -complcation
iatrogenic
what constitutes as a qualified diagnoses?
wokring diagnosis that hasnt been proven or established.
errors and omissions insurance? -professional liability insurance -hold harmless clause -medical...
professional liability insurance
certified professional coder? -cpt -aapc -eob
aapc
national codes -hcpcs level 1 codes -"         "...
level 2
exchange of data between provider and insurance company -remittance advice -coding -electronic...
electronic data interchange
diagnostic codes? -j codes -icd 9cm -cpt codes
icd9cm
patient not responsible for paying what the plan denies -eob -remittance adivce -hold harmless...
hold harmless clause
results of processing a claim sent to patient -eob -mmp -cpt
eob
hcpcs level 1 codes -national -icd 9 -cpt
cpt
which of the following is not an example of a managed care plan? -integrated delivery system -concumer...
consumer directed health plan
method of utlilizing health costs and quality of care by reviewing the appropriatness and necessity...
utilization managment
managed care plan enrollees received most of their care from: -any nonparticipating provider -their...
the primary care provider
network of physicians and hospitals that have joined together to contract with insurance companies...
preferred provider organization
what organization is owed by hospitals and phsyician groups that obatin managed care plan contracts? -intergarated...
physician hospital organziation
this is created when a number of people are grouped for insurance purposes and the cost of...
risk pool
plan offered by single insurance plan or as joint venture by 2 or more insurance carriers and...
triple option plan
prior to scheduling elective surgery managed care plans often require -preauthorization -second...
secon surgical opinion
the health care plan that reimburses providers for individual health care services provided...
fee for service plan
what organization is responsible for the health of a group of enrollee and can be a health...
managed care organization
which of the following would be considered an example of a managed care plan? -exclusive povider...
all the above
nonprofit organzation that contracts with and acquires the clinical and business assets of...
medical foundation
primary care provider -gatekeeper -enrolles -capitation
gatekeeper
heatlh care accreditation organization -joint comision -case managment -gate keeper
joint comission
physicians and hospitals joined together to contract with insurance companies for a discounted...
ppo
provides health care to enrolled members on a prepaid basis -hmo -ppo -mso
hmo
provides practice management services to individual physician practices -mso -hmo -ppo
mso
development of patient care plans -enrollees -case managment -joint comission
case management
patients may use hhmo providers or self refer to non hmo providers -network provider -point...
point pf service plan
t or f? hmos dont provide preventative care services to promote wellness or good health
false
t or f? a health maitenance organization(hmo) is an alternative to traditional group health...
false
t or f? case managment involves the development of patient care plans for the coordination...
true
t or f? the inspector general established the quality improvment system for managed care to...
false
t or f? accredtation is a voluntary process that a health care facility or organization undergoes...
true
t or f? in managed health care plan enrollees receive care frm a primary care prvider who...
true
t or f?a netwrk provider is a physician or health care facility under contract to the managed...
true
t or f?a risk pool is created when a number of people are grouped for insurance purposes
true
t or f? the national committee for quality assurance is a private for profit organization that...
false
t or f? a preferred provider organization is a network of physicians and hospitals that have...
false
t or f? the intent of managed health care was to replace conventional fee for service plans...
true
t or f? when a second physician is asked to evaluate the necessity of surgery and recommend...
false
areas of the law that are not classified as criminal -civil law -criminal law -case law
civil law
information communicated by a patient to a health care provider -privacy -privelaged communication -fraud
privealged communication
intentional deception or misrepresentation -abuse -fraud -case law
fraud
the practice of reporting multiple codes for a service when a single code should be assigned
unbundling
actions inconsistent with accepted practices -fraud -abuse -miscommunication
abuse
document containing list of question that must be answered in writing  
interrogatory
law based on court decisions that establish a precedent -civil law -criminal law -case law
case law
public law that defines crimes and their prosecution -criminal law -civil law -case law
criminal law
explain the difference between assignemtne of benefits and accept assignment
assisngment of benefits: regarding benefits accept assignemnt: provider accepts the assignment
t or f? protected health information is information that is identifiable to an individual sch...
true
t or f?the HIPPA security rule adopts standards and safe gaurds to protect health information...
true
t or f?a dated signed special release form is generally considered valid for as long as the...
false
t or f? the patient account record is a permanent record of all financial transactions between...
true
t or f?workers compensation insurance is always considered to be the primary insurance plan
true
t or f? the encounter form is the financial record source document used by health care providers...
true
t or f? a claims attachment is a set of supporting documentation or information that is associated...
true
t or f? the privacy rule establishes standards for how PHI should be controlled by indicating...
true
t or f?an appeal is documented as a letter signed by the provider explaining why a claim should...
true
t or f? an insurance company that is prohibited from reviewing patient records will probably...
true
t or f? the national correct coding initiative was developed to reduce medicare program expenditures...
true
t or f? record retention is the storage of documentation for an established period of time...
true
t or f? the birthday rule state that the parent whose birth year is the the earliest holds...
false
t or f? a clean claim is one that contains all required data elements needed to process and...
true
t or f? when submitting claims "signature on file" can be submitted for the patients signature...
true
t or f? it is not necessary to submit a claims attachemnt when using an unlisted cpt code
false
t or f? hippa requires all health plans health care clearing houses and health care providers...
true
t or f? a voluntary compliance program can help physicians avoid generating erroneous and fraudulent...
true
t or f? third party payers use medical necessity measurements to make a decidion about whether...
true
the___mandates the retention of patient records and health insurance claims for a minimum of...
hippa
the most common form of medicare fraud is: -soliciting offering or receiving kickbacks -misrepresenting...
all
participants maintain at their own expense and at the same rate health care plan coverage tat...
consolidation omnibus budget reconciliation act
medical necessity is the measure of whether a health care procedure or service is appropriate...
diagnosis and treatment of condition
the cms 1500 claim form is used to report -professional services -inpatient expenses -technical...
professional services and technical services
__is the storage of documentation for an established period of time usually mandated by federal...
record retention
which of the following is not an  example of abuse -falsifyin certificates of medical...
frst one
before scheduling an appointment w/a specialist a manage care patent must obtain a: -referral...
the frst 2
the patient ledger is also known as the -patient account record -superbill -encounter form
patient account record
the chick in process for a patient who is__is more extensive than for a____patient -established/new -new/returning -referred/new
new/returning
which of the following is NOT a criteria used to determin medical necessity? -reimbursement -value -scope -purpose
reimbursment
the cms1500 claim form requires responses to standard questions pertaining to whether the patients...
all
the__are the financial record source documents used by health care providers to record serices...
super bill and encounter form
in 1996 congress passed the ___because of concerns about fraud and abuse -health insurance...
health insurance portability and accountability act
a ___contracts with a 3rd party payer and accepts whatever the plan pays for procedures or...
network provider and participating provider
the health care industry is heavily regulated by___and_____legislation -state/city -city/local -federal/state
federal and state
the___is the person responsible for paying the charges -gaurantor -patient -beneficiary
garuantor
the development of an_____begins when the patient contacts a health care providers office and...
insurance claim


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