Lucky Luciano's Insurance: Chapter 11 Cms-1500

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Questions and Answers
  • 1. 

    Physicians services for inpatient care are billed on a fee-for-service basis, and physicians submit _______ service/procedure codes to payers.

    • A.

      CPT/HCPCS level II

    • B.

      DSM-IV-TR

    • C.

      HCPCS level III

    • D.

      ICD-9-CM ( or ICD-10-CM)

    Correct Answer
    A. CPT/HCPCS level II
    Explanation
    Physicians services for inpatient care are billed on a fee-for-service basis, meaning that physicians are paid for each specific service or procedure they provide. To ensure accurate payment, physicians submit CPT/HCPCS level II codes to payers. These codes provide a standardized way to describe the services and procedures performed, allowing payers to determine the appropriate reimbursement amount. The CPT/HCPCS level II coding system is widely used in the United States healthcare system for billing and reimbursement purposes.

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  • 2. 

    A patient develops surgical complications and returns to the operating room to undergo surgery related to the original procedure. The return surgery is

    • A.

      Billed as an additional surgical procedure

    • B.

      Coded for office data capture purposes only

    • C.

      Included as part of the original procedure

    • D.

      Not reported on the CMS-1500 or UB-04

    Correct Answer
    A. Billed as an additional surgical procedure
    Explanation
    The patient's return surgery is billed as an additional surgical procedure because it is a separate procedure performed to address complications that arose from the original procedure. This means that the surgeon will bill for the additional surgery in addition to the original procedure.

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  • 3. 

    Outpatient surgery and surgeon charges for inpatient surgery are billed according to a global fee, which means that the pre surgical evaluation and management, initial and subsequent hospital visits, surgical procedure, discharge visit, and uncomplicated postoperative follow- up care in the surgeons office are billed as

    • A.

      DRG payments

    • B.

      Multiple charges

    • C.

      One charge

    • D.

      Separate charges

    Correct Answer
    C. One charge
    Explanation
    Outpatient surgery and surgeon charges for inpatient surgery are billed as one charge. This means that all the components of the surgical process, including pre-surgical evaluation, hospital visits, surgical procedure, postoperative care, and follow-up visits, are combined into a single fee. This simplifies the billing process for the patient and ensures that all necessary services are covered under a single charge.

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  • 4. 

    When one charge covers pre surgical evaluation and management, initial and subsequent hospital, surgical procedure, the discharge visit, and uncomplicated postoperative follow up care in the surgeons office, this is called a 

    • A.

      Combined medical/surgical case

    • B.

      Fee-for service charge

    • C.

      Global fee

    • D.

      Itemized list of separate charges

    Correct Answer
    C. Global fee
    Explanation
    A global fee refers to a single charge that covers all aspects of a medical/surgical case, including pre-surgical evaluation, hospitalization, surgical procedure, discharge visit, and postoperative follow-up care. This means that the patient pays one fee for the entire package of services provided, rather than separate charges for each individual component.

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  • 5. 

    Which situation requires the provider to write a letter explaining special circumstances?

    • A.

      A patients inpatient stay was prolonged due to medical or psychological complications.

    • B.

      Charges submitted to the payer are lower than the providers normal fee( -22 added to code)

    • C.

      Surgery defined as an inpatient procedure was performed while the patient was in the hospital

    • D.

      Surgery typically categorized as an office procedure was performed in a hospital outpatient setting

    Correct Answer
    A. A patients inpatient stay was prolonged due to medical or psychological complications.
    Explanation
    The provider would need to write a letter explaining special circumstances when a patient's inpatient stay was prolonged due to medical or psychological complications. This is because the extended stay may require additional documentation and justification to the payer for the need of continued hospitalization.

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  • 6. 

    An optical character reader (OCR) is a device that is used to

    • A.

      Convert CMS-1500 claims

    • B.

      Enter CMS-1500 claims

    • C.

      Scan CMS-1500 claims

    • D.

      View CMS-1500 claims

    Correct Answer
    D. View CMS-1500 claims
    Explanation
    An optical character reader (OCR) is a device that is used to view CMS-1500 claims. OCR technology allows the device to scan and interpret the text on the claims, making it possible to view the information electronically. This can be helpful for quickly accessing and reviewing the content of CMS-1500 claims without the need for manual data entry or physical paperwork.

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  • 7. 

    When entering patient claims data  onto the CMS-1500 claim, enter alpha characters using 

    • A.

      Lower case

    • B.

      Sentence case

    • C.

      Title case

    • D.

      Upper case

    Correct Answer
    D. Upper case
    Explanation
    When entering patient claims data onto the CMS-1500 claim, it is recommended to enter alpha characters in upper case. This is because upper case letters are easier to read and less prone to errors or misinterpretation. Using upper case ensures clarity and consistency in the data entry process, reducing the chances of mistakes that could lead to claim denials or delays in processing.

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  • 8. 

    Which statement is an accurate interpretation of the phrase "assignment of benefits"? If signed by the patient on the CMS-1500 claim 

    • A.

      The payer is instructed to reimburse the provider directly

    • B.

      The payer sends reimbursement for services to the patient

    • C.

      The provider accepts as payment what the payer reimburses

    • D.

      The provider cannot collect copayments from the patient

    Correct Answer
    A. The payer is instructed to reimburse the provider directly
    Explanation
    The phrase "assignment of benefits" refers to the patient authorizing the payer to reimburse the healthcare provider directly. This means that the provider will receive payment from the payer instead of the payment being sent to the patient. The provider accepts this payment as full payment for the services rendered, and they may not collect additional copayments from the patient.

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  • 9. 

    The billing entity as reported on block 33 of the CMS-1500 claim, includes the legal business name of the

    • A.

      Acute care hospital

    • B.

      Insurance company

    • C.

      Medical practice

    • D.

      Patient or (spouse)

    Correct Answer
    C. Medical practice
    Explanation
    The correct answer is medical practice because the billing entity refers to the entity that is responsible for submitting the claim for reimbursement. In this case, it would be the medical practice that provided the medical services and is seeking payment for those services. The acute care hospital, insurance company, and patient or spouse are not typically responsible for submitting the claim and therefore would not be considered the billing entity.

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  • 10. 

    When an x is entered in one or more of the YES boxes in Block 10 of the CMS-1500 claim, payment might be the responsibility of a _______ insurance company

    • A.

      Disability

    • B.

      Homeowners

    • C.

      Life

    • D.

      Managed care

    Correct Answer
    B. Homeowners
    Explanation
    When an "x" is entered in one or more of the YES boxes in Block 10 of the CMS-1500 claim, payment might be the responsibility of a homeowners insurance company. This suggests that the claim is related to a situation that involves damage or loss to the insured person's home, such as a fire, theft, or other covered event. In such cases, the homeowners insurance policy would typically provide coverage for the expenses or damages incurred, including any medical expenses related to injuries sustained on the property.

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