Chap 12 & 13

a. Authorized services usually are covered.

Which of the following is not a disadvantage of managed care? a. Authorized services usually are covered. b. Physicians' choices in the treatment of patients can be limited. c. More paperwork may be necessary. d. Reimbursement is historically less than with traditional health insurance.

b. Access to specialized care and referrals is limited.

Which of the following is not an advantage of managed care? a. Healthcare costs are usually contained. b. Access to specialized care and referrals is limited. c. Most preventive medical treatment is covered. d. Out-of-pocket expenses tend to be less than traditional insurance.

d. Both A and B

Which of the following plans require healthcare providers to become participating providers? a. All government-sponsored health plans b. Most privately sponsored health plans c. Indemnity health insurance plans d. Both A and B e. All of the above

STAT referral

Which of the following referrals can be approved online when it is submitted through the provider's Web portal to the utilization review department?

Medicare Part D

Which part of Medicare covers prescription drug services?

Which of the following is the correct ICD-10-CM code for this diagnostic statement; examination for a routine pap test?

Z01.419

preprocedural examination?

Z01.810

encounter for positive pregnancy test?

Z32.01

Babies are considered newborn or perinatal for the first ______ days.

28

ICD-10-CM uses up to ___ characters to identify a disease or injury.

7

iron-deficiency anemia?

D50.9

TRICARE

Dependents of military personnel are covered by which of the following government-sponsored health insurance plans?

Which of the following is the correct ICD-10-CM code for this diagnostic statement: diabetes mellitus, type 2, without complications?

E11.9

The first statement is true; the second is false.

Employee-sponsored group policies usually provide greater benefits at lower premiums because of the large pool of people from whom premiums are collected. However, these employee-sponsored group health insurance plans offer limited benefits, and healthcare access is limited to healthcare providers that are contracted with them.

the branch of medical science that deals with the incidence, distribution, determinants/characteristics, and control of a disease in a population.

Epidemiology

The "code first' notation can usually be ignored.

FALSE

The coder should always refer to the Tabular Index first.

FALSE

TRICARE

Health insurance designed for military dependents and retired military personnel is called_________________.

False

Health insurance typically covers services and procedures considered medically necessary. Most insurance policies also cover "elective" procedures, such as certain cosmetic surgeries, that are not considered medically necessary.

a. Difference between major medical reimbursement and patient financial responsibilities

Medigap policies cover which of the following? a. Difference between major medical reimbursement and patient financial responsibilities b. Difference between Medicare reimbursement and patient financial responsibilities c. Any services not covered under Medicare d. Any services not covered under Major medical

moderate cervical dysplasia?

N87.1

The abbreviation that is the equivalent of "unspecified" is

NOS

True

Nearly all of the physician's income is derived from the insurance payments received for services rendered.

self-funded plans

Organizations that fund their own insurance programs offer their employees

shortness of breath?

R06.02

lower abdominal pain, right lower quadrant?

R10.31

The allowed amount for Medicare charges is determined using:

Resource Based Relative Value Scale

False

TRICARE is a form of government insurance for veterans of the U.S. armed forces. (True or False)

A neoplasm or new growth is coded by the site or location of the neoplasm and its behavior.

TRUE

Etiology refers to the underlying cause or ongin of a disease

TRUE

The code for HIV indicates which of the following?

The HIV virus is present

Premium

The amount of money paid to keep an insurance policy in force is the _____________________.

deductible

The amount of money the policyholder pays per claim or per accident toward the total amount of an insured loss before the company will pay on the claim is known as the

Medicaid

The federal- and state-sponsored health insurance program for the medically indigent is called

d. All of the above

The medical assistant should always verify which of the following prior to the patient's appointment? a. Eligibility b. Benefits and exclusions c. Effective date of insurance d. All of the above

An organization that processes claims and provides administrative services for another organization is:

Third Party Administrator

CHAMPVA

Veterans of the U.S. Armed Forces may be covered by

c. HMOs

Which of the following MCOs typically has/have the lowest monthly premiums with lower patient financial responsibility? a. Medicare/Medicaid b. PPOs c. HMOs d. BC/BS e. IPA

Is defined as the absence of invasion of surrounding tissues.

carcinoma in situ

a certain percentage of the allowed amount that the policyholder is responsible for is

co-insurance

A set dollar amount that the policyholder must pay for each office visit is

copayment

are indented under the main term and must be included in the diagnostic statement

essential modifiers

The cause of a disorder is its __________.

etiology

A document sent by the insurance company to the provider and the patient explaining the allowed charge, the amount reimbursed for services, and the patient's financial responsibilities is:

explanation of benefits

Nonessential modifers must be in the actual diagnostic statement for the code to be used,

false

In some managed care plans referrals to a specialist must be approved by

gatekeeper

The medical assistant should never code a patient as having ______ unless it is clearly documented as confirmed in the medical record

human immunodeficiency virus

Someone who is poor, needy, or impoverished is considered:

indigent

are notes included in the Tabular Index to provide additional guidance for sclected diagnosis codes.

instructional notation

Accepted healthcare services appropriate for the evaluation and treatment of a disease, condition, illness, or injury and consistent with the applicable standard of care describes which of the following terms?

medically necessary

Diagnostic coding was originally developed to study causes of:

mortality

Which par of Medicare covers inpalient hospital charges?

part a

provider who enters into a contract with an insurance company and agrees to certain rules and regulations is called a

participating

review of Individual cases by a committee to make sure that services are medically necessary is called

peer review committee evaluation

a written agreement between two parties, where one party agrees to pay another party if certain specified circumstances occur is a

policy

An approved list of physicians, hospitals, and other providers is a(n):

provider network

An order from a primary care provider for the patient to see a specialist is a(n)

referral

abnormal condition resulting from a previous disease describes which of the following terms?

sequela

Burns are coded by

site and degree and the body surface involved.

a formal request for payment from an insurance company for services provided is:

to claim

The health insurance model that offers the most flexibility for patients is

traditional health insurance

streptococcal pharyngitis?

J02.9

asthma, unspecified, uncomplicated?

J45.909

bronchitis?

J86.0

localized skin infection at surgical site?

L08.9

ingrowing toenail, right great toe?

L60.0

degenerative joint disease, right knee?

M17.11

Which of the following letters in the ICD-10-CM is reserved by the World Health Organization to assign new diseases with uncertain etiology?

U

Part B

Under which of the following Medicare plans for primary care and specialists' services is the patient required to pay a monthly premium?

( HMOs & PPOs ) D. Both A and B

Which of the following managed care plans require preauthorization for medical services such as surgery? A.HMOs B. PPOs C. EPOs D. Both A and B E. All of the above Correct

when performing diagnostic coding you should start by looking

alphabetic

A designated person who receives funds from an insurance policy is:

beneficiary

in the alphabetic index, terms appear

bold

The International Classification of Discases was established by

world health