Chapter 6

10 steps of the revenue cycle

1. Preregister patient 2. Establish financial responsibility 3. Check in patients 4. Review coding compliance 5. Review billing compliance 6. Check out patient 7. Prepare and transmit claims 8. Monitor payer adjudication 9. Generate patient statements 10.Follow up on payments and collections

What is the minimum number of personal identifiers that patients should be asked for?

2

Accountable Care Organization (ACO)

A pay-for-performance model of healthcare reimbursement

What are groups of doctors, hospitals, and other healthcare providers who form a voluntary partnership that result in coordinated, high-quality care to their Medicare patients?

Accountable Care Organizations

Select the ways that practice management software greatly improves the efficiency of a claims process.

Allows for more accurate capturing of charges Submits automatic reminders Offers a variety of reporting options

Accounts that are "written off" refer to which of the following?

Bills the patient fails to pay

Which of the following are ways an insurance company submits payments to care providers and hospitals?

By check Auto deposit Electronically

What coding system is used by outpatient facilities such as physician's offices, surgery departments in hospitals and diagnostic laboratories?

CPT

What of the following are included on a Superbill?

CPT and/or ICD-10-CM codes Name and address of medical practice Patient's name Provider's NPI number

Evaluation and Management

CPT code that captures face-to-face time between a patient and the care provider

Which of the following terms describe a fixed amount that is the portion that the patient is responsible for and is collected at the time of service?

Co-pay Co-payment

What are some common libraries that built in the practice management software to perform functions within various applications?

Code tables Reports Alerts Fee schedule Insurance company

Healthcare Common Procedure Coding System

Coding system used to document services and procedures, equipment, supplies, and transport

Which of the following claims processes should have written polices?

Collections procedures Follow-up on unpaid claims Timing of filing claims Fee schedule

Using practice management (PM) software accomplishes which of the following?

Filing of claims Great billing accuracy Follow-up of claims electronic payment of claims

Compliance plan

Formal, written document that describes how rules, regulations, and standards are being adhered to Formal, written document that describes how rules, regulations, and standards are being adhered to

Which of the following is included in the documentation for a patient visit?

History of Present Illness Medication Review Chief Complaint

What is the medical coding classification for diagnoses currently in use in the United States?

IDC-10-CM

What does ICD stand for?

International Classification of Diseases

Which of the following are types of Accountable Care Organizations?

Investment Model Comprehensive ESRD Shared Savings

Which of the following claim actions are determined in the adjudication process?

Paid Partially paid Denied

Which of the following is true of the Pioneer ACO model?

Providers share in a greater percentage of savings, but they also share in a greater percentage of financial losses.

What is the document that accompanies the payment from the insurance company to the provider?

Remittance advice (RA)

Which of the following terms describe documents often used in medical offices to capture diagnoses and services or procedures performed for billing purposes?

Routing slips Encounter forms Superbills

An encounter form is also known as which of the following?

Superbill Routing slip

Fee schedule

The amount charged for services rendered, allocated by CPT

subcriber

The primary person covered by an insurance plan The primary person covered by an insurance plan

Adjudication

The process of determining if claims should be paid, denied, or partially paid

Affordable Care Act

Ties reimbursement to quality, patient satisfaction, and coordination of care

Which of the following are reasons why there needs to be an accounting of all patient visits and the charges that were incurred for each visit?

To show all procedures carried out To show accurate number of patients seen

Medical necessity

Using diagnostic codes to support services and procedures

To check if a claim has been paid, which menu will the healthcare professional look at?

accounts receivable

fraud

act of deception which takes advantage of another person or entity

transaction

actions, such as posting payments or processing claims, done in a practice management system to update patient accounts

After receipt of claims by the insurance carrier, the claim undergoes a process called ___________.

adjudication

Procedures and diagnoses are converted to a(n) _________ form in order to file claims to insurance companies.

alphanumeric

When is insurance verification usually completed by the office staff?

before each visit

Who is the only person authorized to make a diagnosis?

care provider

The information contained in the encounter form is eventually transferred to the ________ for submission.

claim form

What does the "CM" stand for in ICD coding?

clinical modification

Showing the relationship between a procedure that was performed and the diagnosis to support medical necessity is known as ____________.

code linkage

The relationship between the procedure code and the diagnosis that shows medical necessity is called which of the following?

code linkage

Evaluation and Management codes

codes representing the face-to-face time spent with a provider

What type of plan should be in place in every medical office and hospital in order to defend the practice in the event of a visit from the OIG?

compliance

In the medical field, care providers _________ patients using medical terms.

diagnose

What is the term for when a patient checks out of the hospital?

discharge

The ____________ in the record must support the need for any and all services and procedures

documentation

The _________ well-being of a medical office is of great importance if the practice is to stay in business.

financial

A co-pay is a ________.

fixed amount due at the time of service

To avoid negative consequences, a compliance plan should be ____ in every hospital and medical office.

followed

If a care provider is sanctioned from Medicare, that means the provider is __________ to accept Medicare patients into his or her practice.

forbidden

managed care plan

form of insurance that monitors patients, care, and performance to ensure quality

compliance plan

formal, written guidelines that describe how a healthcare office intends to follow established rules and regulations

The amount of a patient's co-pay may vary by

insurance plan

Charges begin to accrue when the patient _______.

is seen by the healthcare professional

fee schedule

list of how much as charged per service by CPT code

Expected methods of payment are discussed when a patient

makes an appointment.

Which of the following promotes quality, cost-effective healthcare through the monitoring of patients, preventive care, and performance measures of providers?

managed care plans

On the Superbill, each CPT code must ________ to a diagnosis code, because the diagnosis code shows medical necessity.

map

Charges begin to accrue once the ______

medical assistant or care provider interacts with the patient.

Services rendered to a patient cannot be billed to insurance unless they are proven to be _______ necessary.

medically

accounts receivable

monies coming into a medical practice

Only services deemed medically ________ can be billed to insurance.

necessary

The ________ is usually the person to set up information libraries within practice management software programs.

office manager

When should a patient be entered in the practice's database?

only once upon first visit

Monies being paid from the medical practice for supplies, rent, utilities are known as accounts _____.

payable

Due to the differences in insurance plan rules, what is important that the computer system efficiently applies to the correct patients when filing claims?

policies

co-payment

portion of a bill that is usually that responsibility of the patient; typically collected upon check-in

Therapeutic __________ are done to alleviate symptoms or correct a patient's conditions.

procedures

A remittance advice is typically given to a/an ________ , whereas an explanation of benefits is typically given to a/an ________ .

provider; patient

Accounts __________ refers to monies coming into a medical practice.

receivable

When filing claims the _____ may differ from insurance companies.

rules

Information on the ________ will be transferred to a form known as the CMS-1500 claim form and used to bill an outpatient encounter. Multiple choice question. diagnostic report

superbill

subscriber

the primary individual covered under an insurance plan

When submitting claims to insurance carriers, providers show medical necessity by

using code linkage

Depending on the terms of a patient's insurance coverage, the balance remaining after insurance has paid may be

written off as paid in full or sent to collections.