Medical Insurance Final Exam Review

________ are notes included in the Tabular Index to provide additional guidance for selected diagnosis codes

Instructional notations

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

MEDICAID

The federal government's health insurance program for people age 65 and older is...

MEDICARE

C50.0

Malignant neoplasm of nipple and areola

The signs and symptoms of a disease are its______

Manifestations.

Which of the following HCPCS codes range from A4000 to A8999?

Medical Supplies and Surgical Supplies

Code linkage is a review of which two items to ensure medical necessity and appropriate reimbursement?

Modifiers and add-on codes.

The abbreviation that is the equivalent of "unspecified" is ______.

NOS

Number assigned by the centers of Medicare Medical Services CMS that classifies the healthcare provider by license and medical specialties?

NPI

The______ table describes malignancies

Neoplasms

A(n) __________ patient is one who is having his or her first encounter with the physician

New

S01.0

Open wound of head

When searching the Alphabetic index, " humerus" is an example of which of the following?

Organ or anatomic site.

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

Part B

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

Participating

Qualitative and quantitative codes for drug testing are found in which of the following CPT sections?

Pathology

Physical status modifier P4 is assigned to which of the following?

Patient with severe systemic disease that is a constant threat to life

Which term applies to the period from the last month of pregnancy to 5 months after giving birth?

Peripartum

______ is a documented medical condition that is present in the patient before the insurance policy goes into effect.

Preexisting Condition

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

Premium

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

Premium

Z49.0

Preparatory care for renal dialysis.

Most of today's health insurance policies cover which of the following?

Preventive Care and Procedures deemed medically necessary.

_______ is a method of setting Medicare fees.

RBRVS

The process by which the medical office submits a claim to the insurance company, which then pays the provider for services rendered...

REIMBURSEMENT

Which of the sections uses the code range between 70000 and 79999?

Radiology

R21

Rash and other specific skin eruption.

Used when authorization has been obtained from patient in a previously signed document

SOF

Which type of referral is usually processed immediately?

STAT

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

STAT referral

When completing the CMS-1500 Form, which section contains information about the patient and the insured?

Section 2

Which ICD-10-CM sections includes guidelines for reporting additional diagnoses in non-outpatient settings?

Section III

Which of the following instructions in the Alphabetic Index indicates that another main term may reference additional useful index entries?

See Also.

Organizations that fund their own insurance programs offer their employees....

Self-funded plans

Under Medicare Part A, which of the following goods/services would be covered? a. Medications administered in the medical office b. Homemaker/health aide services c. Services in a hospital on an inpatient basis d. Canes and walkers purchased in a pharmacy

Services in a hospital on an inpatient basis.

The Federal Tax ID number (Box 25) for the provider filing the claim can be presented as

Social Security Number (SSN) and Employer Identification Number (EIN).

At times, the medical assistant must code a(n)________ if the physician is not yet sure of the diagnosis.

Symptoms

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

TRICARE

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

TRICARE

The TRICARE option that is similar to a preferred provider network is ...

TRICARE EXTRA

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

TRUE

Divided into 21 chapters. Each chapter is subdivided into categories In each chapter, all of the 3-character category codes begin with the alphabetic letter assigned to that chapter..

Tabular List

Which organization developed the system used for procedural coding?

The American Medical Association

The code HIV indicates...

The HIV virus is present.

All conditions that occur during or following medical care or surgery are classified as complications. There must be a cause-and-effect relationship between the care provided and the condition, and an indication in the documentation that it is a complication.

The first statement is false the second statement is true.

When wounds of more than one classification are repaired, list the less complicated repair as the primary procedure and the more complicated repair as the secondary procedure. When multiple wounds are repaired, add together the lengths of those in the same classification.

The first statement is false; the second is true.

Which of the following steps to medical billing should be performed prior to rendering medical services?

Verify the patient's eligibility for insurance coverage, Collect patient insurance information

Which is a method of closed treatment of fractures?

Without manipulation and/or traction, with manipulation and/or traction.

A type of insurance that protects workers from loss of wages after an industrial accident that happened on the job is called...

Workers compensation.

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

a. Difference between major medical reimbursement and patient financial responsibilities

Medical assistants have the trust of the physician and practice that employs them. A medical assistant must...

adhere to ethical standards concerning assigning and reporting codes clearly. be responsible and knowledgeable to ensure that no fraud takes place in coding. be responsible and knowledgeable to ensure that no fraud takes place in claim submission.

Burns are coded to the site by _________

degree

Patients who are injured at work and covered under workers' compensation should

have all their medical records sent to the employer's insurance company

With an HMO, the patient..

must use HMO physicians

The insured's address in block 7 refers to the ______ address.

policyholder's

Burns are coded ...

the body surface involved, site and degree.

Electronic data interchange is

transferring data back and forth between two or more entities.

The yearly deductible for medicare patients is...

$166

If Mr. Jones's insurance has a $500 deductible and a $50 surgery co-pay, how much will his insurance pay on his bill of $4,359?

$3,809

If Mr. Jones's insurance has a $500 deductible and a $50 surgery co-pay and then pays 80% of the charges, how much will his policy pay on his bill of $4,359?

$3047.20

Which modifiers indicates a professional component and is used when a separate technician performs the service but the provider reviews the report and makes an accurate diagnosis?

-26

Anesthesiology

00100 to 01999 and 99100 to 99140

Surgery

10040 to 69990

The physician's office place-of-service code is?

11

A secondary health plan is noted in which block?

11D

The assignment of benefits is located in block

13

One time unit in anesthesia coding typically equals ?

15 minutes

The patient's name is found in block?

2

Which of the following codes is assigned to an urgent care facility as the place of service?

20

What percentage of the bill will Susan Holms be responsible for after the allowed Medicare payment?

20% of the allowable amount

Procedures performed on the patient are found in what block?

24D

Babies are considered newborn or perinatal for the first _______ days

28.

The physician's signature is located in block?

31

The insured's name is found in block?

4

How many procedures can be billed on the CMS-1500

6

The CPT tabular list is divided into _____ sections

6

The patient must be ____ years of age to qualify for _______, unless the person is disabled.

65, Medicare

Which of the following codes has been assigned for the following procedure: Suture of a recent wound on the eyelid

67930

Radiology (including Nuclear Medicine and Diagnostic US)

70010 to 79999

Which of the following codes has been assigned for the following procedure : Chest x-ray examination, single view, frontal

71010

Susan Holms, a patient on Medicare, has met her deductible for the year. What percentage of her bill will be covered by Medicare?

80%

Pathology and Laboratory

80048 to 89356

Medicine

90281 to 99199 and 99500 to 99602

Evaluation and Management (E/M)

99201 to 99499

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.

A. Authorized services usually are covered.

Under Medicare Part B, which of the following goods/services would be covered? a. Durable medical equipment such as a wheelchair b. Surgery in a hospital c. Over-the-counter drugs d. Cosmetic surgery

A. Durable medical equipment such as a wheelchair.

Having a sudden onset, sharp rise, and short course; providing or requiring short-term medical care.

ACUTE

A(n) __________ code indicates that additional or supplemental procedures carried out in addition to the primary procedure are needed

Add-on

Which of the following options would code J30.9 belong to?

Allergic Rhinitis.

The maximum amount of money third-party payers will pay for a specific procedure or service is called the

Allowable Amount

The maximum amount of money third-party payers will pay for a specific procedure or service is called the...

Allowable Amount

An eponym will be used in which of the following CPT divisions?

Alphabetic Index

Patients signs a (n) __________ form so that the physician will receive payment for services directly

Assignment of Benefits.

To examine claims for accuracy and completeness before they are submitted is to _________ the claims.

Audit

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.

B. Access to specialized care and referrals is limited.

Which of the following options would not be used to extract the diagnostic statements? Select one: a. Superbill b. Chief complaint c. Treatment notes d. Pathology report

B. Chief Complaint

Which of the following HMO models hires physicians and pays them a salary rather than contracting the physicians to create a network? a. IPA b. Staff model c. Group model d. PPO

B. Staff Model

The amount payable by an insurance company for a monetary loss to an individual insured by that company, under each coverage is called the....

Benefits.

M16.0

Bilateral primary osteoarthritis of hip

Which of the following plans require healthcare providers to become participating providers? Select one: 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

Both A and B

Preauthorization specifically determines the dollar amount approved for the medical procedure, while precertification gives the provider approval to render the medical service.

Both statements are false.

Codes that are grouped together and paid as one service or procedure are known as __________

Bundled

Which of the following individuals would not normally be eligible for Medicare? Select one: a. A 66-year-old retired woman Incorrect b. A blind teenager c. A 23-year-old recipient of AFDC d. A person on dialysis

C. A 23 year old recipient of AFDC

Which of the following expenses would be paid by Medicare Part B?

C. Physicians Office Visits.

Statement in the patient's own words that describes the reason for the office visit; should be documented in the patient's own words; reason why the patient wants to see the physician..

CC

Joe Smith is a disabled serviceman who was honorably discharged from the military service. His wife and minor children are covered under an insurance program called...

CHAMPVA

Veterans of the U.S. armed forces may be covered by....

CHAMPVA

________ is a form of government insurance for veterans of the U.S. armed forces.

CHAMPVA

A term describing a disease that manifests over a long period because medical treatment has not been able to resolve it...

CHRONIC

When the insurance company pays 80% of the charge and the patient pays the remaining 20%, this is called...

CO-INSURANCE

Which of the following is a fixed amount per visit and is typically paid at the time of medical services?

CO-PAYMENT

_____is a fixed fee that is paid by the patient at each visit.

CO-PAYMENT

Which of the following terms is synonymous with HCPCS Level 1?

CPT codes.

Which coding system would be used to code for a bilateral salpingo-oophrectomy?

CPT coding.

A payment method in which providers are paid for each individual enrolled in a plan, regardless of whether the person sees the provider that month, is called a ______ plan.

Capitation plan

Codes with a plus sign are additional codes that must be used with which of the following?

Category 1 Codes

Which codes can be used to help measure performance and outcomes?

Category II codes.

G03.1

Chronic Meningitis

B18.2

Chronic viral hepatitis C

A(n) __________ claim has been completed accurately and completely

Clean

Claims submitted to a(n) __________ are forwarded to individual insurance carriers

Clearinghouse

Condition that occurs at same time as primary diagnosis and affects patient's treatment or recovery from the primary condition

Concurrent Condition

Q30.3

Congenital perforated nasal septum

Something that is partly responsible for a development of an illness

Contributory Factors

Special symbols used to provide additional information about certain codes are called __________; seven are used in CPT-4 coding

Conventions

The dollar value of each basic unit value used in anesthesia coding is called the __________.

Conversion Factor

Mary and Jim Smith both work and both participate in the health insurance plan offered by their separate employers. When Mary and Jim use their insurance, they are regulated by a term known as

Coordination of Benefits.

Procedure code modifiers are found in column __________ of block 24

D

Which part of Medicare covers prescription drug services?

D.

Which statement is NOT true about Medicaid. a. Medicaid is for low income patients b. Physicians can choose whether to accept Medicaid patients c. Patients with Medicaid cannot be billed for services rendered at the office. d. Only patients over 65 qualify for Medicaid

D.

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

D. All of the Above

Which of the following are not reviewed by a utilization review committee? a. Physician referrals b. Cases of emergency department visits and urgent care c. Individual cases to ensure medical care services are medically necessary d. Fees for services provided

D. Fees for services provided.

Claims that have errors or omissions that must be corrected and resubmitted to receive reimbursement are called _____________ claims.

DIRTY

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..

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...

Deductible

Medigap insurance is

Designed to fill "gaps" in coverage left by Medicare.

Which of the following is not documented in the estimation of benefits (EOB)?

Diagnosis

Extracted from the medical documentation, such as the history and physical findings, operative reports, and encounter form to translate into an ICD 10 code..

Diagnostic Statement

This is a type of convention that allows for future expansion of the code set without interruptions of the 6th character structure. Not needed for codes with less than 7th characters..

Dummy Placeholder

________ codes are used for physician's office visits

E/M

Every meeting between a patient and a healthcare provider. The patient's history and chief complaint, in addition to the medical services provided, are documented in the patient's health record

ENCOUNTER

Medical records used for procedural coding can include which of the following?

Encounter form Progress notes Pathology report Radiology report

The name of a specific person(s), place, or thing for whom or for which something (disease, procedure, instrument) is named..

Eponym

__________ are procedures or treatments named after a person

Eponym

A(n) __________ patient has seen the physician within the past 3 years

Established

The cause of a disorder is its..

Etiology

Which of the following levels of history includes a review of the systems that relate to the chief complaint?

Expanded problem focused-history.

The charges for procedures are listed in column __________ of block 24

F

Claims that are done by direct billing first go to the clearinghouse

FALSE

Dirty claims cannot be resubmitted.

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.

False.

CPT-4 codes have __________ digits

Five

Purpose is to assist with the changeover from ICD 9 - ICD 10 based on the description and meaning of a code. Create a useful, practical, code-to-code translation reference dictionary for both code sets..

GEMs

A policy that covers a number of people under a single master contract issued to the employer or to an association with which they are affiliated and that is not self-funded is usually called...

Group Policy

Durable medical equipment (DME) is coded using..

HCPCS Level II codes.

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

HIV

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

HMO's

Which of the following managed care plans require preauthorization for medical services such as surgery?

HMO's and PPO's

K72.0

Hepatic Failure, not elsewhere classified

Which of the following pays the hospital surgical room fee?

Hospital.

Which of the following codes will be used for a patient with a history of myocardial infarction with no symptoms but diagnosed by means of an electrocardiogram?

I25.2

A new or experimental procedure or service code is a category __________ code

III

Carcinoma_________ is defined as the absence of invasion of surrounding tissues.

IN SITU

Which of the following terms defines a malignant neoplasm site as the absence of invasion of surrounding tissues?

In situ

The insurance plan that reimburses all or part of the costs of services, provided that the charge is usual, customary, and reasonable for that particular service in that part of the country, is known as

Indemnity (fee-for-service)

Health Insurance benefits are determined by...

Indemnity Schedules. Service Benefit Plans. Relative Value Studies

How are subterms treated in the alphabetic index to diseases and injury?

Indented two spaces.

Which type of HMO model consists of physicians with separately owned practices who formally organize into a group but continue to practice in their own offices?

Independent Practice Association

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 first statement is true; the second is false.

Assignment of benefits means..

The insurance payment will go directly to the physician.

Entities that make payment on an obligation or debt but are not parties of the contract that created the debt are called...

Third-party payers.

When a Code First Note is present and the patient has an underlying condition, the underlying condition should be sequenced first. Wherever such a combination exists, a Use Additional Code Note is found with the etiology code, and a Code First Note is found with the manifestation code.

True

E10.0

Type 1 Diabetes Mellitus

Block 1 of the CMS-1500 contains what information?

Type of insurance coverage

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.

__________ codes are separated and reported individually

Unbundled

When coding for drug toxicity, which of the following refers to a condition when a patient takes less of a medication than is prescribed by his or her provider or by the manufacturer's instructions?

Underdosing

The deliberate increase in a CPT code despite a lack of documentation to receive higher reimbursement is known as..

Upcoding

A review of individual cases by a committee to make sure that services are medically necessary and to study how providers use medical care resources is called a(n)

Utilization Review