Insurance and Medical Coding Test Prep

Medical billing fraud is defined as the act of billing for services that were not actually performed. This means that healthcare providers or billing companies are falsely claiming payment for services that were never provided to patients. This type of fraud can involve submitting claims for procedures, tests, or treatments that never took place, leading to illegal financial gain for the fraudulent party. It is a serious offense and can result in legal consequences for those involved.

HIPAA, or the Health Insurance Portability and Accountability Act, was created to achieve multiple objectives. Firstly, it aimed to establish standards for electronic transactions in healthcare, ensuring efficient and secure exchange of health information. Secondly, it aimed to protect patient privacy by setting guidelines for the confidentiality and security of personal health information. Lastly, it aimed to combat fraud and abuse within the healthcare system by implementing measures to detect and prevent fraudulent activities. Therefore, the correct answer is "All of the above".

Tricare Prime patients should see physicians at their military treatment facility. This is because Tricare Prime is a managed care option offered to active duty service members and their families, and it requires patients to receive most of their care from military treatment facilities. These facilities are specifically designed to cater to the healthcare needs of military personnel and their dependents, ensuring that they receive appropriate and specialized care. Therefore, it is recommended for Tricare Prime patients to seek medical attention at their military treatment facility.

Internal audit is conducted within an organization to ensure that the claims made by the coders and billers are accurate and billed correctly. It helps in identifying any errors or discrepancies in the billing process and ensures compliance with coding and billing regulations. The purpose of an internal audit is not related to patients checking their co-pays, Medicare reviewing charges, or an outside agency verifying billing accuracy.

Colonography refers to a radiographic image of the interior of a colon. This procedure is used to detect abnormalities, such as polyps or tumors, in the colon. It involves the use of a contrast agent and specialized imaging techniques to create detailed images of the colon. Colonography is often used as a less invasive alternative to colonoscopy for screening and diagnosing colon-related conditions. Cholangiography is a procedure used to visualize the bile ducts, while duodenoscopy is used to examine the duodenum.

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The GPCI (Geographic Practice Cost Index) takes into account the geographic location of a practice or provider when it involves the RBRVS (Resource-Based Relative Value Scale) calculation. This means that the cost of practicing medicine can vary depending on the location, as certain areas may have higher overhead costs or different malpractice risk levels. Therefore, the GPCI considers the geographic location as an important factor in determining the reimbursement rates for medical services.

ICD-9 codes are necessary to include on a claim because they indicate the medical necessity of the service. These codes provide specific information about the diagnosis or condition for which the service was provided. By including the ICD-9 codes, it helps to justify why the service was necessary and supports the claim for reimbursement. It also helps in ensuring accurate and appropriate coding and billing practices.

The correct answer is the age of the patient and whether or not the hernia is acute or chronic. This is because the repair codes for diaphragmatic hernia are divided based on the age of the patient and the acuteness or chronicity of the hernia. This classification helps in determining the appropriate treatment approach and surgical procedure for the patient.

The correct code for the procedure described is 23470. This code specifically refers to the excision of the head of the humeral bone and the replacement with the necessary or appropriate implant. The other codes listed, 23195 and 23472, do not specifically mention the excision and replacement of the head of the humeral bone, making them incorrect choices. The combination of codes 23195 and 23470 is also not necessary, as 23470 alone covers the entire procedure.