Module 105 Final Study

Premiums for group plans are generally less expensive than those for an individual plan because the cost of the group plan is spread among all the members who enroll in the plan. This means that the risk and cost are distributed among a larger pool of people, reducing the financial burden on each individual. This is possible because large groups of people do not have a high percentage of those who become sick, which helps to keep the overall cost lower. Additionally, group plans typically offer a wide range of benefits, contrary to the statement in the question.

The correct answer is Centers for Medicare and Medicaid Services (CMS). HCPCS Level II codes are developed by CMS, which is responsible for administering the Medicare and Medicaid programs. These codes are used to report medical procedures, supplies, and services for reimbursement purposes. The National Uniform Billing Committee (NUBC) is responsible for developing the UB-04 billing form used by hospitals, while the Centers for Disease Control and Prevention (CDC) focuses on public health issues and disease prevention. Therefore, the correct answer is CMS.

The correct answer is "HCPCS Level I CPT, Level II Medicare National Codes, and ICD-9-CM Volume III Procedures". This answer is correct because it includes all three coding systems used for coding procedures, services, and items. ICD-9-CM Volume I and Volume II are not used for coding procedures, services, and items, so the first option is incorrect. HCPCS I and II and ICD-9-CM also do not include all three coding systems, so the third option is also incorrect. The second option includes all three coding systems, so it is the correct answer.

The correct answer is HCPCS Level II Medicare National Codes. HCPCS Level II codes were developed in the 1980s to provide a standardized system for reporting supplies, equipment, medication, and other items to Medicare carriers. These codes are used for billing Medicare and are specific to Medicare's needs and requirements. CPT (Current Procedural Terminology) codes are used for reporting medical procedures and services, while ICD-9-CM Volume III codes are used for reporting procedures in hospitals. None of the above options are correct because only HCPCS Level II codes are specifically designed for reporting items to Medicare carriers.

The combined classification of "mortality and morbidity" in ICD-6 refers to death and disease. This means that the classification system in ICD-6 includes categories and codes for both fatal outcomes (mortality) and non-fatal outcomes (morbidity) of diseases and conditions. It provides a comprehensive framework for categorizing and coding information related to both death and disease, allowing for accurate and standardized reporting and analysis of health data.

Volume III is used by hospitals and other facilities to code significant procedures. This means that Volume III is specifically designed to assign codes to important or major medical procedures that are performed in healthcare settings. It is not used for coding noninvasive outpatient procedures or laboratory procedures.

The correct answer is Health Care Common Procedure Coding System (HCPCS). This system was adopted by the Health Care Financing Administration (HCFA), now known as Centers for Medicare and Medicaid Services (CMS), in 1983. Other payers, such as Blue Cross/Blue Shield, also adopted this system. HCPCS is used for reporting medical procedures and services provided to Medicare and Medicaid patients. It is a standardized coding system that helps in the reimbursement process and ensures accurate and consistent reporting of healthcare services.

The correct answer is "It is the provider's responsibility to make every attempt to collect patient responsibility amounts." This means that providers are expected to try their best to collect the amounts owed by the patient. It does not state that providers are generally not required to collect these amounts or that they only have to collect them for inpatient services. The answer "None of the above" is incorrect because the statement does indicate a responsibility for providers.

Optical scanning technology has improved claim processing by eliminating the need for manual data entry from the claim form into a computer system. This means that instead of spending time and effort on inputting data manually, the information can be scanned and automatically transferred into the computer system. This not only saves time but also reduces the chances of human error in data entry. Therefore, the correct answer is "Optical scanning replaces the process of having to input data manually from the claim form into a computer system."

The principal procedure is performed for definitive treatment of the principal diagnosis. This means that the main procedure that is done is intended to treat the primary reason for the patient's condition. The principal diagnosis refers to the main reason for the patient's hospitalization or visit to the healthcare facility. Therefore, the principal procedure is the one that is done to address and treat this main diagnosis.

The correct answer is "The procedure performed for definitive treatment of the principal diagnosis or the one closest to it." This answer is correct because the principal procedure refers to the main surgical or medical intervention performed to treat the primary diagnosis or the one that is most closely related to it. It is the procedure that is considered the most important in addressing the patient's condition and providing a definitive treatment.

The Centers for Medicare and Medicaid Services (CMS) utilize diagnosis code data to ensure appropriate utilization of health care services and control health care costs. By analyzing diagnosis codes, CMS can identify patterns and trends in the types of services being provided, which can help them determine if there is overutilization or unnecessary utilization of certain services. This allows them to implement strategies to control costs and ensure that resources are being allocated efficiently.

The correct answer is "Treatment authorization code." A payer provides a treatment authorization code, which is reported on the claim when services are authorized. This code is recorded on the CMS-1450 form and serves as a reference for the approved treatment. It ensures that the services being claimed are authorized by the payer and helps facilitate the reimbursement process.

A significant procedure is a term used to describe a medical procedure that is surgical and carries a high risk, either in terms of the procedure itself or the anesthesia involved. It may also refer to procedures that require specialized training or expertise. This term is used to distinguish these procedures from less complex or risky ones.

Source documents used by coders include encounter forms, a requisition, and Emergency Department records. These documents provide essential information about the patient's medical and financial details, which are necessary for accurate coding. In addition, coders also refer to coding references and dictionaries to ensure correct coding procedures. Therefore, all of the above options are correct as they represent the various source documents used by coders in their coding process.

A liver biopsy is considered a significant procedure because it involves the removal of a small piece of liver tissue for further examination. This procedure is typically performed to diagnose and monitor various liver diseases such as hepatitis, cirrhosis, and liver cancer. It provides valuable information about the structure and function of the liver, helping doctors make accurate diagnoses and determine appropriate treatment plans. Both the pregnancy test and MRI are important procedures, but they do not involve the same level of invasiveness or diagnostic significance as a liver biopsy.

The correct answer is 21 and 24D. Diagnosis codes are recorded in block 21 of the CMS-1500 form, while procedure codes are recorded in block 24D. These codes are essential for accurately documenting and billing for medical services provided.

Services are grouped by revenue code category on the UB-04 in Section 2. This section is specifically designated for listing revenue codes and their corresponding charges. It allows for a clear and organized breakdown of the services provided and their associated costs, making it easier for insurance companies and other payers to process and reimburse claims accurately.

Payer edits are used to review claim data and identify any problems related to the services billed. This can include services that are not medically necessary, meaning they may not be required for the patient's condition or are not supported by medical evidence. By identifying these unnecessary services, payers can ensure that they are not paying for treatments that are not beneficial to the patient's health.

The electronic claims process can be accomplished through direct transmission, where the claims are sent directly from the healthcare provider to the payer electronically. This eliminates the need for any intermediaries. Another way is through a clearinghouse, which acts as an intermediary between the healthcare provider and the payer. The clearinghouse receives the claims from the provider, checks for errors, and then forwards them to the appropriate payer. Both methods are commonly used in electronic claims processing to streamline the reimbursement process and improve efficiency.

The term "conventions" refers to special terms, punctuation marks, abbreviations, or symbols used as shorthand in a coding system to communicate special instructions efficiently to the coder. It encompasses all the options provided in the question, including guidelines and instructions. Conventions are established practices or standards that help ensure consistency and understanding in a coding system.

The principal diagnosis refers to the condition that is primarily responsible for the patient's admission to the hospital. It is the main reason for the patient seeking medical care and is determined after a thorough study of the patient's symptoms, medical history, and diagnostic tests. The principal diagnosis helps healthcare providers in planning and providing appropriate treatment for the patient. Therefore, the principal diagnosis is the correct answer in this case as it accurately represents the condition determined after study.

The correct answer is "Appeals process". The appeals process is a formal way for healthcare providers to request a reconsideration of a claim determination made by a payer. It allows providers to challenge the decision and provide additional information or evidence to support their case. This process is important for resolving disputes and ensuring that claims are accurately adjudicated. The billing process and claims process are related to the overall healthcare reimbursement process but do not specifically address the formal request for reconsideration of a claim determination.

The correct answer is HCPCS Level I and/or HCPCS Level II, and some payers may require ICD-9-CM Volume III. HCPCS Level I and II are procedure coding systems that are commonly used to report procedures, services, and items for hospital ambulatory surgery. Some payers may also require the use of ICD-9-CM Volume III for certain procedures. ICD-9-CM Volume I and II are not specifically used for reporting procedures in hospital ambulatory surgery.

The correct answer is Outpatient and inpatient. ICD-9-CM diagnosis coding guidelines vary for services performed in outpatient and inpatient settings. These guidelines provide specific instructions on how to assign codes for different types of encounters, such as outpatient visits, emergency room visits, and inpatient admissions. The coding guidelines for outpatient services may differ from those for inpatient services due to the nature of the care provided and the documentation requirements. It is important for medical coders to be familiar with these guidelines to ensure accurate and consistent coding.

The correct answer is "List the principal procedure in FL 67." On the CMS-1450 form, FL 67 refers to the field where the primary procedure is listed. The term "principal procedure" is commonly used in medical billing and coding to refer to the most significant or major procedure performed during a hospital stay. Therefore, listing the principal procedure in FL 67 is the first step when sequencing procedures on the CMS-1450 form.

HCPCS Level I and/or HCPCS Level II is the correct answer because these coding systems are specifically designed to report procedures, services, and items for hospital outpatient services. ICD-9-CM Volume I, II is used for diagnosis coding, while ICD-9-CM Volume III is used for procedure coding in inpatient hospital settings. Therefore, the correct coding system for reporting procedures, services, and items in hospital outpatient services is HCPCS Level I and/or HCPCS Level II.

The correct answer is 21, 24D. Diagnosis and procedure codes are reported in block 21 and block 24D on the CMS-1500 claim form. Block 21 is used to report the diagnosis codes, which indicate the patient's condition or reason for the visit. Block 24D is used to report the procedure codes, which describe the specific services or treatments provided to the patient. Therefore, both block 21 and block 24D are used to accurately report the diagnosis and procedure codes on the claim form.

During a patient visit, charge capture data is collected and used for various purposes. One of these purposes is to print a detailed itemized statement for the patient. Additionally, the charge capture data is also utilized to complete specific form locators on the claim form. In this case, the correct form locators for completing the claim form are FL 42-49.

E codes are used to describe the external cause of an injury or illness. They provide information about how the injury or illness occurred, such as the place, activity, and cause. E codes are used in medical coding to provide additional details about the circumstances surrounding the injury or illness, and they are particularly important for tracking and analyzing data related to injuries and their causes.

Significant procedures are defined as those that are surgical in nature, carry high procedural or anesthetic risk, and require specialized training. This means that any procedure that meets any of these criteria can be considered significant. Surgical procedures involve invasive techniques, while high procedural or anesthetic risk indicates that the procedure may have potential complications or adverse effects. Additionally, specialized training is necessary to perform these procedures, highlighting their complexity and the need for expertise. Therefore, the correct answer is "All of the above" as all three options are true for significant procedures.

Coding systems are used in the billing process to facilitate the submission of claims. By using codes, healthcare providers can accurately describe the services they provided and the patient conditions that were treated. This allows for efficient processing of claims by insurance companies and ensures that healthcare providers are properly reimbursed for their services. Using coding systems also helps in maintaining standardized and consistent documentation, which is essential for accurate billing and reimbursement.

The OCE (Outpatient Code Editor) is a tool used to identify claim issues in outpatient coding. It has over 60 edits that are used to identify various types of claim issues. The edits include identifying problems related to coding and coverage, incorrect completion of claims, and issues with the coding system. Therefore, the correct answer is "Coding and coverage" as these are among the claim issues that the OCE identifies.

According to the ICD-9-CM guidelines, an uncertain diagnosis can be coded as if the condition existed or was established for inpatient services. This means that even if the diagnosis is uncertain, it can still be coded as if the condition is present for inpatient services. This allows healthcare providers to accurately document and code the patient's condition, even if there is uncertainty surrounding the diagnosis.

The correct answer is "Value codes." Two-digit alphanumeric codes recorded in FL 39-41 on the CMS-1450 are referred to as value codes. These codes are used to identify specific values, such as amounts or quantities, related to the services provided on the claim. They provide additional information for billing and reimbursement purposes.

The principal procedure refers to the main procedure performed for the definitive treatment of the principal diagnosis. It is the procedure that is most closely related to the primary reason for the patient's hospitalization or medical care. This procedure is considered the most important and significant in terms of addressing the patient's condition or illness. Therefore, the correct answer is Principal procedure.

ICD-9-CM Volume III is used for reporting significant procedures and services in FL 80-81 on the CMS-1450. This coding system specifically focuses on procedures and services, making it the appropriate choice for reporting them on the form. HCPCS Level I and II are used for reporting healthcare procedures and services in other contexts, but they are not specifically designed for reporting on the CMS-1450 form. Similarly, while HCPCS and National Drug Codes are relevant for reporting certain types of information, they are not the appropriate coding systems for reporting significant procedures and services in FL 80-81 on the CMS-1450.

HCPCS Level II codes are five digit alphanumeric codes; the first letter is alphabetic. This means that the codes are a combination of letters and numbers, with the first character always being a letter. This format allows for a greater number of codes to be created and provides more specificity in describing medical procedures, supplies, and services. The alphanumeric nature of the codes also helps to differentiate them from other code sets, such as CPT codes, which are primarily numeric.

The content of ICD-9-CM Volume III includes an alphabetic index and tabular listing of procedures and services. This means that it provides a comprehensive list of procedures and services in alphabetical order, making it easy to locate specific information. The tabular listing further organizes the procedures and services in a structured format, allowing for quick reference and understanding. This combination of alphabetic index and tabular listing ensures that healthcare professionals can easily find the necessary information they need for coding and billing purposes.

The correct answer is CMS-1450. The CMS-1450 form, also known as the UB-04 form, is used to submit hospital inpatient services. It is used by hospitals and other healthcare facilities to bill for services provided to patients during their stay. The form includes information such as the patient's demographic details, diagnosis codes, and the services provided.

Payers will only pay for services that are covered and considered to be medically necessary. This means that the services must be deemed essential for the patient's condition and must meet the payer's criteria for medical necessity. If a service is not covered or is not considered medically necessary, the payer will not provide payment for it.

The number assigned by the insurance company or government program to identify the individual who is covered under the plan and reported in FL 60 on the CMS-1450 is referred to as the certificate, insured, or health insurance claim number. This number is used to track and process claims for the individual's health insurance coverage.

The correct answer is CMS-1500. The CMS-1500 claim form is used to submit hospital outpatient professional services. It is a standard form used by healthcare providers to bill Medicare and Medicaid, as well as other insurance companies. This form includes information about the patient, the services provided, and the charges associated with those services. It is important for healthcare providers to accurately complete and submit the CMS-1500 form in order to receive reimbursement for their services.

The correct answer is "Code also synchronous". This convention is found only in Volume III of ICD-9-CM and it instructs the coder to report other procedures as individual components in addition to the main procedure being coded. This means that if there are multiple procedures performed simultaneously, they should all be coded separately.

The hypertension table is used to identify a code describing malignant or benign hypertension. This means that the table provides specific codes that can be used to classify and document cases of hypertension that are either malignant (severe and rapidly progressing) or benign (mild or moderate). By using this table, healthcare professionals can accurately categorize and track different types of hypertension, leading to better diagnosis and treatment decisions.

HCPCS Level I and II codes describing hospital outpatient services are reported on the UB-04 in Section 2. This section of the UB-04 form is specifically designated for reporting the Healthcare Common Procedure Coding System (HCPCS) codes. HCPCS codes are used to identify specific medical procedures, services, and supplies provided in a hospital outpatient setting. By reporting these codes in Section 2, healthcare providers can accurately document and bill for the services rendered to patients in a hospital outpatient setting.

The correct answer is Medicare Secondary Payer laws. These laws outline the circumstances in which Medicare is not the primary payer for healthcare services. This means that Medicare will only pay for healthcare costs after other insurance plans, such as employer-sponsored plans or private insurance, have paid their share. The purpose of these laws is to ensure that Medicare is not paying for services that should be covered by other insurance plans, thus preventing unnecessary costs and preserving Medicare funds.

The CMS-1450 form, also known as the UB-04 form, is used for submitting medical claims for reimbursement. Form locators 67-76 are the specific fields on the form where diagnosis codes are listed. These codes provide information about the patient's medical condition or reason for the medical services provided. Therefore, the correct answer is form locators 67-76.

Electronic claim submission offers several advantages, including tracking the progress of the claim, providing proof of receipt, and reducing processing time. By submitting claims electronically, healthcare providers can easily monitor the status of their claims and ensure they are being processed in a timely manner. Additionally, electronic submission provides proof that the claim has been received by the payer, eliminating any disputes regarding claim submission. Moreover, the use of electronic systems streamlines the claims processing workflow, leading to faster turnaround times and quicker reimbursement for healthcare providers. Therefore, all of the mentioned advantages are applicable to electronic claim submission.

A Health Maintenance Organization (HMO) is a type of managed care plan that provides comprehensive healthcare services to members for a fixed fee. It emphasizes preventive care and requires members to choose a primary care physician who coordinates their healthcare. HMOs typically have a network of healthcare providers that members must use in order to receive coverage, and they often require pre-authorization for specialist visits or procedures. This distinguishes it from fee-for-service, which is a traditional healthcare payment model where providers are paid for each service rendered, and Worker's Compensation, which is a type of insurance that covers medical expenses and lost wages for employees injured on the job.