Insurance Final
Which is a variable-length file format used to bill institutional, professional ,dental, and drug claims?
ANSI ASC X12N 837
Which program measures improper payments in the Medicaid program and the State Children's Health Insurance Program (SCHIP)?
PERM
Which restricts patient information access to those with proper authorization and maintains the security of patient information?
confidentiality
Which are assigned to the MAC jurisdictions (replacing Program Safeguard Contractors) to review billing trends and patterns, focusing on providers whose billings for Medicare services are higher than the majority of providers in the community?
Zone Program Integrity Contractors
Which of the following is an example of fraud?
falsifying certificates of medical necessity plans of treatment
HIPAA defines abuse as involving actions that are ____ with accepted, sound medical, business, or fiscal practices, which directly or indirectly result in unnecessary costs to the program through improper payments.
inconsistent
Court decisions establish standard use legal decisions that serve as authoritative rules or patterns in future similar cases. The legal term for standard is _____.
precedent
The Federal Employee's Compensation Act ( FECA )
program provides workers' compensation to all federal and postal workers throughout the world for employment-related injuries and occupational diseases, and includes medical and vocational rehabilitation, payment for medical care and wage replacement.
The Federal Employment Liability Act (FELA) and the Merchant Marine Act were designed to
provide employees with protection from employer negligence
Which is an abbreviation for the Latin phrase qui tam pro domino rege quam pro sic ipso in hoc parte sequitur, meaning "who as well for the king as for himself sues in this matter?
qui tam
permanent disability
refers to an illness or injured employee's diminished capacity to return to work
Which documents patient information sent to authorized requestors and can be kept in manual or software formats?
release of information log
Record retention is the _____ of documentation for an established period of time, usually mandated by federal and/or state law.
storage
First Report Of Injury
workers' compensation form completed when the patient first seeks treatment for a work-related illness or injury.
First Report of Injury
is completed when the patient initially seeks treatment for a work- related illness or injury
The medical term for black lung is
pneumoconiosis
Workers Compensation Board
responsible for administering workers' compensation laws
Which involves the safekeeping of patient information by controlling access to records, protecting patient information from alternation/destruction/tampering/loss, and providing employee training in HIPAA requirements, which includes the consequences of improper disclosure of patient information?
security
Federal and state ______ are laws passed by legislative bodies, such as federal Congress and state legislatures.
statutes
Which requires documents, such as a patient record, to be produced in court?
supeona duces tecum
The Federal Black Lung Program
was enacted in 1969 to provide medical treatment and other benefits for respiratory conditions related to persons formerly employed in the nation's coal mines.
Which unique identifier is assigned to third-party payers and has 10 numeric positions, including a check digit as the tenth position?
HPID
Which program measures, monitors, and reduces the incidence of Medicare fee-for-service payment errors for short-term acute care, inpatient PPS hospitals?
HPMP
Which program provides consumers with quality of care information so they can make more informed decisions about health care options?
Hospital Inpatient Quality Reporting (Hospital IQR)
Which amended Title IX of the Public Health Service Act to encourage voluntary and confidential reporting of events that adversely affect patients, creating organizations that collect, aggregate, and analyze confidential information reported by health care providers?
Patient Safety and Quality Improvement Act of 2005
Which increased resources available to CMS to combat abuse, fraud, and waste in the Medicaid program, creating the Medicare Improvement Program (MIP)
Deficit Reduction Act of 2005
Civil law deals with all areas of the law that are not classified as _____ law.
criminal
Which is testimony under oath taken outside of court, such as at the physician's office?
deposition
The proposed standard for an electronic signature is _____, which applies a mathematical function to the electronic document.
digital
Breach of confidentiality involves the unauthorized release of patient information to a third party, such as health care employees who _____.
discuss patient information outside an exam room where other patients are present
The HIPAA Security Rule adopts standards and safeguards to protect health information that is collected, maintained, used, or transmitted_____.
electronically
The HIPAA Privacy Rule created national standards to protect individuals' medical records and other personal health information, and is also provides patients with _____.
greater access to their own medical records
HIPAA defines fraud as an _____ deception or misrepresentation that someone makes, knowing it is false, that could result in an unauthorized payment.
intentional
Which is a legal document containing a list of questions that must be answered in writing?
interrogatory
Any information communicated by the _____ is considered privileged communication, and HIPAA provisions address the privacy and security of protected health information.
patient to a health care provider
Which is the right of individuals to keep their information from being disclosed to others?
privacy
Medicare administrative contractors are organizations that contract with the Centers for Medicare and Medicaid Services to process fee-for-service health care claims and perform_____ for both Medicare Part A and Part B.
program integrity tasks
Which specifically requires an individual's authorization prior to disclosure and for which HIPAA has established specific requirements for an authorization form?
protected health information
Criminal law is _____law (statute or ordinance) that defines crimes and their prosecution.
public
arbitration
dispute-resolution process in which a final determination is made by an impartial person who may not have judicial powers.
Workers compensation survivor benefits are calculated according to the
employee's earning capacity at the time of illness or injury
Federal Black Lung Program
enacted in 1969 as part of Black Lung Benefits Act; provides medical treatment and other benefits for respiratory conditions related to former employment in the nations coal mines.
Federal and state laws require employers to maintain workers' compensation coverage to meet minimum standards, covering a majority of employees for work-related illnesses and injuries
if the employee was not negligent in performing assigned duties
The American Recovery and Reinvestment Act of 2009 (ARRA) protects whistleblowers, who are individuals that _____covered by the Act..
make specified disclosures relating to funds
Merchant Marine Act ( Jones Act )
not a workers' compensation statue, but provides seaman with the same protection from employer negligence, as FELA provides railroad workers.
The First Report of Injury form is completed by the
provider
Laws that are implemented as guidelines written by administrative agencies, such as CMS, are called ________.
regulations
Which is an order of the court that requires a witness to appear at a particular time and place to testify?
supeona
Which program assesses and measures improper Medicare fee-for-service payments (based on reviewing selected claims and associated medical records documentation)?
CERT
Medicare defines medical necessity as
"the determination that a service or procedure rendered is reasonable and necessary for the diagnosis or treatment of an illness or injury."
Nancy White's employer provides individual and family group health plan coverage, and it pays 80% of her annual premium. Nancy selected family coverage for her group health plan, which means her employer pays $12,000 per year (of the $15,000 annual premium). Nancy is responsible for the remaining $3,000 of the annual premium, which means approximately ______ is deducted from each of her 26 biweekly paychecks.
$115
The patient underwent office surgery on October 10, and the third party payer determined the reasonable charge to be $1,000. The patient paid the 20% coinsurance at the time of the office surgery. The physician and patient each received a check for $500, and the patient signed the check over to the physician. The overpayment was _______and the ____must reimburse the insurance company. (Remember! Coinsurance is the percentage of costs a patient shares with the health plan.)
$200, physician
A patient received services on April 5, totaling $1,000. He paid $90 coinsurance at the time services were rendered. (The payer required the patient to pay a 20% coinsurance of the reasonable charge at the time services were provided). The physicians accepted assignment, and the insurance company established the reasonable charge as $450. On July 1, the provider received $360 from the insurance company. On August 1, the patient received a check from the insurance company in the amount of $450. The overpayment was ________, and the ______ must reimburse the insurance company. (Remember! Coinsurance is the percentage of costs a patient shares with the health plan.)
$450, patient
National Coverage Determination
Rules developed by CMS that specify under what clinical circumstances a service or procedure is covered (including clinical circumstances considered reasonable and necessary) and correctly coded; Medicare administrative contractors create edits for NCD rules, called local coverage determinations (LCDs).
Chapter 19
S00-T88; Injury, Poisoning, and Certain Other Consequences of External Causes
Which allows states to create or expand existing insurance programs to include a greater number of children who are currently uninsured
SCHIP
Which allows states to create or expand existing insurance programs to include a greater number of children who are currently uninsured?
SCHIP
Individuals age 65 or older who have group health insurance based on their own or their spouse's current employment can delay their Part B enrollment without having to pay higher premiums. These individuals can enroll any time during a(n):
SEP
What information is entered in Block 13 of the TRICARE CMS-1500 claim form?
SIGNATURE ON FILE
outline
SOAP notes are written in _______________ format
When SIGNATURE ON FILE is the appropriate entry for a CMS-1500 claim block, which is also acceptable as an entry?
SOF
Chapter 2
C00-D49; Neoplasms
Which code set is copyrighted by the American Dental Association?
CDT
Spouse or child of a veteran who has been rated permanently and totally disabled for a service- connected disability by a VA regional office is eligible for
CHAMPVA
HCPCS level II codes are developed and maintained by ______ and do not carry the copyright of a private organization, which means they are in the public domain and many publishers print annual coding manuals.
CMS
Which organization is responsible for developing and maintaining the HCPCS level II codes?
CMS
Form used to submit Medicare claims; previously called the HCFA-1500.
CMS-1500
Observation or Inpatient Care Services
CPT codes used to report observation or inpatient hospital care services provided to patients admitted and discharged on the same date of service.
What protects beneficiaries from devastating financial loss due to serious illness or longterm treatment
Catastrophic Cap Benefit (maximum out of pocket per year is $1000 for active duty. $3000 for retirees and their families)
Who was ICD-10-CM developed by?
Centers for Disease Control and Prevention for all U.S. health care treatment settings.
Which is a member of the HCPCS National Panel?
Centers for Medicare and Medicaid Services
CMS
Centers for Medicareand Medicaid Services
Care Plan Oversight Services
Cover the physician's time supervising a complex and multidisciplinary care treatment program for a specific patient who is under the care of a home health agency, hospice, or nursing facility.
Block 14 of the CMS-1500 claim requires entry of the date the patient first experienced signs or symptoms of an illness or injury (or the date of last menstrual period of obstetric visits). Upon completion of Jean Mandel's claim, you notice that there is no documentation of that date in the record. The provider does document that her pain began five days ago. Today is May 10, YYYY. What do you enter in Block 14?
05 05 YYYY
Block 24A of the CMS-1500 claim contains dates of service (FROM and TO). If a procedure was performed on May 10, YYYY, in the office, what is entered in the TO block?
05 10 YY
The patient was seen in the provider's office on 12/03/YYYY for an injury sustained four months earlier. What is entered in Block 14 of the CMS-1500 claim?
08 03 YYYY
What are the four programs of the Office of Workers' Compensation Programs
1) Energy Employee's Occupational Illness Compensation Program 2) Federal Black Lung Program 3) Federal Employee's Compensation Act ( FECA) Program 4) Longshore and Harbor Workers' Compensation Program
First Report of Injury ( 4 copies go to )
1) State Workers' Compensation Board/Commission 2) Employer - designated compensation payer 3) Ill or injured party's employer 4) Patients' work related injury chart
ICD-10-CM far exceeds ICD-9-CM in the number of codes provided, having been expanded to?
1) include health-related conditions 2) provide much greater specificity at the sixth digit level 3) add a seventh digit extension (for some codes)
3 circumstances qualify an employee for workers compensation benefits?
1) injured while working within the scope of the job description, 2) injured while performing a service required by the employer, 3) succumbs to a disorder that can be directly linked to employment ( asbestosis or mercury poisoning ) * some states have protection for jobs considered extremely stressful; stress would be the qualifying reason.
Medicare enrollment handled in two ways
1. automatically or 2. they apply for coverage.
General medicare eligibility requires:
1. individuals or their spouses to have worked at least 10 years in medicare covered employment 2. individuals to be the minimum of 65 years old. 3. individuals to be citizens or permanent residents of the united states.
medicare limits hospice care to 4 benefit periods:
1. two periods of 90 days each 2. one 30 day period. 3. a final lifetime extension of unlimited duration.
Up to what percent of the plan's payment schedule are private fee-for-service (PFFS) plans authorized to charge enrollees?
115
One of the circumstances under which Medicare would award an assigned claim conditional primary payer status and process the claim is when there is no response from a liability payer within ________ days of filing the claim.
120
TRICARE nonparticipating providers are subject to a limiting charge of ____________above the TRICARE fee schedule for participating providers.
15 percent
Medicare patients in a psychiatric hospital are allowed how many lifetime reserve days?
190
TRICARE was created what year?
1966
If a HCPCS drug code description states "per 50 MG" and is administered in an 80 MG does, which quantity (e.g., units) is reported on the CMS 1500 claim form?
2
How much is a beneficiary with Medicare Part B expected to pay for durable medical equipment (DME)
20 percent of the Medicare-approved amount
How long must records of employee vaccinations and accidental exposure incidents be retained?
20 years
The most common amounts range from
20% to 25% deductibles
The Energy Employees Occupational Illness and Compensation Program began providing benefits to eligible employees and former employees of the Department of Energy in
2001
States that apt to include a medically needy eligibility group in their Medicaid programs are required to include certain children who are under the age of_____ and who are full-time students
21
eligibility group in their medicaid program are required to include certain children who are under the age of and are full time students
21 years of age
How many CPT modifiers are there?
35 CPT Modifiers
How many appendices are there?
5 appendices
How many CPT sections are there?
6 sections
Which is the total number of Medicare lifetime reserve days (defined as the number of days that can be used just once during a patient's lifetime)?
60
lifetime reserve days
60 days - may be used only once during a pt's lifetime and are usually reserved for use during the pt's final, terminal hospital stay.
What length of time is the Medicare initial enrollment period (IEP)
7 months
Patients may elect to use their Medicare lifetime reserve days after how many continuous days of hospitalization
90
Medicare Part ________ reimburses institutional providers for inpatient, hospice, and some home health services.
A
medical savings account (MSA)
A __ __ __ (__) allows individuals to withdraw tax-free funds for healthcare expenses that are not covered by a qualifying high-deductible health plan.
preferred provider organization (PPO)
A __ __ __ (__) is a managed care network of physicians and hospitals that have joined together to contract with insurance companies, employers, and other organizations to provide health care to subscribers for a discounted fee.
managed care organization (MCO)
A __ __ __ (__) is responsible for the health of a group of enrollees and can be a health plan, hospital, physician group, or health system.
primary care provider
A __ __ __ is responsible for supervising and coordinating healthcare services for enrollees.
triple option plan; cafeteria plan
A __ __ __, which is usually offered either by a single insurance plan or as a joint venture among two or more insurance payers, provides subscribers or employees with a choice of HMO, PPo, or traditional health insurance plans. It is also called a __ __.
medical foundation
A __ __ is a nonprofit organization that contracts with and acquires the clinical and business assets of physician practices; the foundation is assigned a provider number and manages the practice's business.
network provider
A __ __ is a physician or healthcare facility under contract to the managed care plan.
risk pool
A __ __ is created when a number of people are grouped for insurance purposes; the cost of healthcare coverage is determined by employees' health status, age, sex, and occupation.
GPWW
A ___ establishes a contract that allows physicians to maintain their own offices and share services.
HMO
A ___ is an alternative to traditional group health insurance coverage and provides comprehensive healthcare services to voluntarily enrolled members on a prepaid basis.
What is included in parentheses following the eponym?
A desciption of the disease, syndrome, or procedure
If TRICARE users use providers in a network they can recieve what?
A discount on services and reduced co-payments
paragraph
A narrative clinic note is written in______________format
medical foundation
A nonprofit organization that contracts with and acquires the clinical and business assets of physician practices in called a __ __.
PAR
A participationg provider (PAR) is a health care provider who enters into a contract with a BCBS corporation
Medical Managed
A particular diagnosis (e.g., hypertension) may not receive direct treatment during an office visit, but the provider has to consider that diagnosis when considering treatment for other conditions.
Appendix A
Detalied descriptions of each CPT Modifier
Item Letters A through L preprinted in Block 21 of the CMS-1500 claim.
Diagnosis Pointer Letter
medically managed
Diagnosis that may not receive treatment during encounter
2
Diagnostic test results are documented in how many locations?
Which type of insurance is defined as reimbursement for income lost as a result of a temporary or permanent illness or injury?
Disability
Counseling
Discussion with a patient and/or faimily concerning one or more of the following areas: diagnostic results, impressions, and/or recommended diagnostic studies; progonsis; risks and benefits of management (treatment) and/or follow-up; importance of compliance with a chosen management (treatment) options; risk factor reduction; and patient and family education.
Objective
Documentation of measurable or objective observations made during physical examination and diagnostic testing.
Beneficiaries who become eligible for Medicare Part A on the basis of age and who also purchase Medicare Part B coverage continue to be eligible for TRICARE which is secondary to Medicare.
Dual Medicare and TRICARE Eligibility
Individuals who are eligible for both Medicare and Medicaid coverage are called
Dual eligibles
State legislatures may change Medicaid eligibility requirements
During the year, sometimes more than once
Chapter 4
E00-E89; Endocrine, Nutritional, and Metabolic Disorders
When a patient is covered by a large employer group health plan (EGHP) and Medicare, which is primary?
EGHP
When a patient is covered by a large employer group health plan (EGHP), and the patient is also a Medicare beneficiary, ________ is primary.
EGHP
Which is a characteristic of Medicare enrollment?
Eligible individuals are automatically enrolled, or they apply for coverage
Flexible Spending Account (FSA)
Employees contribute funds to the ___ through a salary reduction agreement and withdraw funds to pay medical bills.
What special handling is required for TRICARE hospice claims?
Enter the words HOSPICES CLAIMS on the envelope.
COBRA
Established an employee's right to continue healthcare beyond the scheduled benefit termination date.
When should you submit a TRICARE Mental Health Treatment Report?
Every 30 days for inpatient cases and on or about the 48th outpatient visit and every 24th visit thereafter.
Consultation
Examination of a patient by a healthcare provider, usually a specialist, for the purpose of advising the referring or attending physician in the evaluation and/or management of a specific problem with known diagnosis.
Dr. Taylor has instructed you, as a health insurance specialist, to obtain an Advance Beneficiary Notice (ABN) on all surgical cases in the practice just in case Medicare denies the claim. How should you handle this situation
Explain to Dr. Taylor that the practice cannot do this, as Medicare considers this activity fraudulent
Chapter 5
F01-F99; Mental, Behavioral, and Neurodevelopment Disorder
Which is a hospital payment monitoring program data analysis too that provides administrative hospital and state-specific data for specific CMS target areas?
FATHOM
Which regulates fraud associated with military contractors selling supplies and equipment to the Union Army?
False Claims Act
Which is considered a mandatory Medical service that states must offer to receive federal matching funds?
Family planning services and supplies
BCBS/PPO
A subscriber driven program
Other federal programs include:
Federal Employment Liability Act (FELA) Merchant Marine Act ( Jones Act )
What requires employers to maintain workers' compensation coverage?
Federal and state laws
HCPCS level II national codes are five characters in length, and they begin with letters _______, followed by four numbers.
A-V
Chapter 1
A00-B99; Certain Infectious and Parasitic Diseases
A diabetic patient received a J-cell alkaline replacement battery for her home blood glucose monitor. Assign the HCPCS level II code.
A4235
patient record
A____________ serves as the business record for a patient encounter and is maintained in a paper or automated format.
Providers may receive reimbursement from medicaid on what basis?
Adjusted claims
Monderate (Conscious) Sedation
Administation of moderate sedation or analgesia, which results in a drug-induced depression of consciousness; CPT established a package concept for moderate (conscious) sedation, and the bull's eye symbol located next to the code number identifies moderate (conscious) sedation as an inherent part of providing specific procedures.
Medicaid is jointly founded by federal and state governments, and each state
Administers it's own Medicaid program
ABN
Advance Beneficiary Notice; acknowledges patient responsibility for payment if Medicare denies the claim.
Global Surgery
Also called package concept or surgical package; inclueds the procedure, local infiltration, metacarpal/digital block or tropical anesthesia when used, and normal, uncomplicated follow-up care.
Which professional organization maintains level 2 "D" codes?
American Dental Association
Face-to-Face Time
Amount of time the office or outpatient care provider spends with the patient and/or family.
Logan is the daughter of Amy (DOB 3/29/68) and Bill (BOD 11/15/70) and is covered by both parents' health insurance plans. According to the birthday rule, a medical claim for Logan will be submitted to
Amy's plan as primary payer and Bill's plan as secondary payer.
EPO
An ___ is a managed care plan that provides benefits to subscribers who are required to receive services from network providers.
IDS
An ___ is an organization of affiliated providers' sites that offer joint healthcare services to subscribers.
If a TRICARE Prime beneficiary seeks care from a facility outside of the tratment area without prior approval,the point-of-service option is activated. This will result in what cost(s) to the beneficiary?
An annual deductible plus 50% or more of visit or treatment fees.
which is subject to medicaid preauthorization guidelines
Any extension of inpatient acute care hospital days
discharge planning
Arranging appropriate healthcare services for discharged patients.
Physical Examination
Assessment of the patient's organ (e.g., extremities) and body systems (e.g., cardiovascular).
Although they may do so more frequently, how often are providers required to collect or verify Medicare as Secondary Payer (MSP) information
At the time of the initial beneficiary encounter only
Medicare+Choice
BBA established the _____ program which expanded Medicare coverage options by creating managed care plans.
Indemnity Coverage
BCBS indemnity coverage offers choice and flexibility to subscribers who want to receive a full range of benefits along with the freedom to use any licensed healthcare provider. Coverage includes hospital-only or comprehensive hospital and medical coverage. Subscribers share the cost of benefits through coinsurance options, do not have to select a primary care provider, and do not need a referral to see a provider
Flexible Spending Account (FSA)
By law, employees forfeit unspent funds remaining in the ___ at the end of the year.
which phrase is located on a Federal Employee Program plan ID card?
Government Wide Service Benefit Plan
preauthorization
Grants prior approval for reimbursement of a healthcare service.
two
Healthcare providers use_______________major formats for documenting clinic notes.
Home Services
Healthcare services provided in a private residence.
Which is associated with "last resort" health insurance for individuals who cannot obtain coverage due to a serious medical condition
High-risk
BCBS indemnity coverage is characterized by certain limitations, including
Hospital-only or comprehensive hospital and medical coverage
Which is considered a minimum benefit under BCBS basic coverage?
Hospitalizations
up to 4
How many diagnosis codes may be reported on each CMS-1500 claim?
Chapter 9
I00-I99; Diseases of Circulatory System
What special handling is required if a patient requests a copy of the remittance advice (RA) that contains information about multiple patients?
Identify information about all patients except the requesting patient is removed.
self-referral
If the enrollee sees a nonmanaged care panel specialist without a referral from the primary care physician, this is known as a ___.
Which established the CERT, FATHOM, HPMP, PEPPER, and PERM programs?
Improper Payments Information Act of 2002
The intent of mandating HIPAA's national standards for electronic transactions was to?
Improve efficiency and effectiveness of the healthcare systems
Health Savings Account (HSA)
In a __ __ __ (__) money deposited (and earnings) is tax-deferred, and money withdrawn to cover qualified medical expenses is tax-free, Money can be withdrawn for purposes other than healthcare expenses after payment of income tax plus a 15 percent penalty. Unused balances "roll over" from year to year; if an employee changes jobs, he or she can continue to use the FSA to pay for qualified healthcare expenses.
madates
Managed care plans that are "federally qualified" and those that must comply with state quality review ___ are required to established quality assurance programs.
enrollees
Managed health care was developed as a way to provide affordable, comprehensive, prepaid healthcare services to ___.
legislation; EQRO
Many states have enacted ___ requiring an ___ to review health care provided by managed care organizations.
Medicaid policies for eligibility are complex and very among states; thus, a person who is eligible for Medicaid in one state
May not be eligible is another state
Refer to Figure 4-20 in the chapter. Which payer's claim should be followed up first to obtain reimbursement?
Medicaid
TRICARE plans are primary to what other insurance?
Medicaid
19 of Social Security Act , establishe a federal mandated state administered program known as
Medicaid Programs
which allows providers to access the state's eligibility data electronically?
Medicaid eligibility verification systems MEVS
secondary diagnoses or coexisting diagnoses
Medically managed diagnoses are also known as_____________
CMS is responsible for administering the ________ program.
Medicare
Which was implemented to assist with CMS audit, oversight, anti-fraud, and anti-abuse efforts related to the Medicare Part D benefit?
Medicare Drug Integrity Contractors Program
Medicare hospital insurance is also known as:
Medicare Part A
The qualified disabled working individual (QDWI) helps individuals who received Social Security and Medicare because of disability, but who lost their Social Security benefits and free Medicare Part A because they returned to work and their earnings exceed the limit allowed, by requiring states to pay their:
Medicare Part A premiums
Medicare medical insurance is also known as:
Medicare Part B
Occupational therapy is covered by:
Medicare Part B
Medicare Advantage is also known as:
Medicare Part C
Which Medicare plan offers prescription drug coverage to beneficiaries to help lower prescription drug costs?
Medicare Part D
The original Medicare plan (or Medicare fee-for-service plan) includes:
Medicare Parts A and B
Medicare part D
Medicare Prescription Drug Plans offer prescription drug coverage to all medicare beneficiaries that mya help lower prescription drug costs and help protect against higher costs in the future.
Which is a type of Medigap insurance that requires enrollees to use a network of providers (doctors and hospitals) in order to receive full benefits
Medicare SELECT
Providers who do not accept assignment of Medicare benefits do not receive information included on the _____, which is sent to the patient.
Medicare Summary Notice
gag clauses
Medicare and many states prohibit managed care contracts from containing __ __, which prevent providers from discussing all treatment options with patients, whether or not the plan would provide reimbursement for services.
Which component of the Medicare Modernization Act of 2003 was created to provide tax-favored treatment for individuals covered by a high-deductible health plan
Medicare savings account
Which covers all Medicare Part A and Part B health care for individuals who can benefit the most from special care for chronic illnesses, care management of multiple diseases, and focused care management?
Medicare special needs plan
Which is considered a service reimbursed by BCBS major medical coverage?
Mental Health Visits
MHSS
Military Health Services System
The entire healthcare system of the U.S. uniform services is known as the...
Military Health Services System (MHSS)
What is the entity called that is the entire healthcare system of the US uniformed services, Military Treatment Facilities and various civilian healthcare programs called?
Military Health Services System (MHSS)
MTF
Military Treatment Facility
The Department of Labor also manages programs designed to prevent work-related injuries and illnesses, they include?
Mine and Safety Health Administration ( MSHA ) Occupational Safety and Health Administration (OSHA)
Comphrehensive Assessment
Must include an assessment of the patient's functional capacity, identification of potential problems, and a nursing plan to enhance, or at least maintain, the patient's physical and psychosocial functions.
Chapter 14
N00-N99; Diseases of the Genitourinary System
What is entered in Block 11 of the CMS-1500 claim when a reference lab provides services to a Medicare patient in the absence of a face-to-face encounter
NONE
Dr. Smith evaluates Marcia Brady during a three-month recheck of her diabetes mellitus. He performs venipunture and sends the patient's blood sample to an outside laboratory for testing of the blood glucose level. Dr. Smith's insurance specialist enters the outside laboratory's _______ in Block 24J because the blood glucose test is reported in Block 24D on the line.
NPI
Which unique identifier is assigned to health care providers as a 10-digit numeric identifier, including a check digit in the last position?
NPI
Block 33a of the CMS-1500 claim contains the provider's
NPI.
POS
Patients can use the managed care panel of providers (paying discounted healthcare costs) or self-refer to out-of-network providers (and pay higher healthcare costs).
When a patient has Medicaid coverage in addition to other, third-party coverage, Medicaid is always considered the
Payer of last resort
Nursing Facility Services
Performed at the following sites; skilled nursing facilities (SNFs), intermediated care facilities (ICFs), and long-term care facilities (LTCFs).
HCPCS level two codes are organized by type, depending on the purpose of the codes and the entity responsible for establishing and maintaining them. The four types include _________.
Permanent national, Miscellaneous, Temporary codes, and Modifers
ERISA
Permitted large employers to self-insure employee healthcare benefits.
Which type of automobile insurance reimburses medical expenses for covered individuals, regardless of fault, for treatment due to an automobile accident?
Personal injury protection
Coordination of Care
Physician makes arrangements with other providers or agencies for services to be provided to a patient.
Which device displays eligibility data about a medical patient when a provider swipes the patience medical Id card through an electronic reader
Point of services
second surgical opinion
Prior to scheduling elective surgery, managed care plans often require a __ __ __; that is, a second physician is asked to evaluate the necessity of surgery and recommend the most economical, appropriate facility in which to perform the surgery.
Category I Codes
Procedures/services identified by a five-digit CPT code and descriptor nomenclature; these codes are tranditionally associated with CPT and organized within six sections.
Case Management Services
Process by which an attending physician coordinates and supervises care provided to a patient by other providers.
what do TRICARE contractors do
Process regional claims
Surveillance of fraud and abuse activities worldwide involving purchased beneficiary care in the Military healthcare system
Program Integrity Office
The entity responsible for the prevention, detection,investigation,and control of TRICARE fraud,waste.and abuse is the...
Program Integrity Office
What does a beneficiary service representative do?
Provide TRICARE information and how to use it
EPO
Provides benefits to subscribers who are required to receive services from network providers.
HMO
Provides comprehensive healthcare services to voluntarily enrolled members on a prepaid basis.
Concurrent Care
Provision of similar services, such as hospital inpatient visits, to the same patient by more than one provider on the same day.
Which is considered a commercial health insurance company?
Prudential
Chapter 17
Q00-Q99; Congenital Malformations, Deformations, and Chromosomal Abnormalities
Chapter 18
R00-R99; Symptoms, Signs, and Abnormal Clinical and Laboratory Findings, Not Elsewhere Classified
Organ- or Disease-Oriented Panel
Series of blod chemistry studies routinely ordered by providers at the same time to investigate a specific organ (e.g., liver panel) or disease (e.g., thyroid panel).
Emergency Department Services
Services provided in an organized, hospital-based facility, which is open on a 24-hour basis, for the purpose of "providing unscheduled episodic services to patients requiring immediate medical attention.
Partial Hospitalization
Short term, intensive treatment program where individuals who are experiencing an acute episode of an illness (e.g., geriatric, psychiatric, ro reahbilitative) can receive medically supervised treatment during a significant number of daytime or nighttime hours; this type of program is an alternative to 24-hour inpatient hospitalization and allows the patient to maintain their everyday life without the disruption associated with an inpatient hospital stay.
What should be entered block 11A if policy gender if unknown?
Should be left blank
Preoperative Clearance
Situation that occurs when a surgeon asks that a specialist or another physician (e.g., general practice) examine a patient and certify whether that patient can withstand the expected risks of a surgery.
Outpatient Code Editor
Software that edits outpatient claims submitted by hospitals, community mental health centers, comphrehensive outpatient rehabilitation facilities, and home health agencies; the software reviews submissions for coding validity (e.g., missing fifth digits) and coverage (e.g., medical necessity); OCE edits result in one of the following dispositions: rejection, denial, return to provider (RTP), or suspension.
iCD-9-CM or ICD-10-CM Codes
Spaces are used on the CMS-1500 claim, which is entered between the third and fouth digits
local coverage determinations
Specifies under what clinical circumstances a service is covered, and lists covered and noncovered codes
Plan
Statement of the physician's future plans for the work-up and medical management of the case.
Which refers to the contractual right of a third-party payer to recover health care expenses from a liable party?
Subrogstion
The plan ID card for a subscriber who opts for BCBS's Healthcare Anywhere PPO coverage uniquely contains the logo
Suitcase
A licensed physician in good standing who, according to state regulations, engages in the direct supervision of nurse practitioners and/or physician assistants whose duties are encompassed by the supervising physician's scope of practice.
Supervising Physician
Covers the deductible and copay or coinsurance of a primary health insurance policy.
Supplemental Plan
Which requirements are used to determine Medical eligibility for mandatory categorically needy eligibility groups?
TANF
Which requirements are used to determined medicaid eligibility for mandatory categorically needed eligibility
TANF Temporay assistance needy families
risk contract
TEFRA defined __ __ as an arrangement among providers to provide capitated healthcare services to Medicare beneficiaries.
Preferred provider organization option
TRICARE Extra
The organization responsible for coordinating and administering the TRICARE program is the....
TRICARE Management Activity
What office is responsible for coordination and administration of TRICARE
TRICARE Management Activity
In which TRICARE option are active military personnal required to enroll?
TRICARE Prime
Military Treatment facilities are the principal source of health care under this option.
TRICARE Prime
The managed care option that is similar to a civilian HMO is called
TRICARE Prime
Which program can save the beneficiaries money if using an in-network provider and how much?
TRICARE Prime
Fee-for-service option
TRICARE Standard
The new name for CHAMPUS is...
TRICARE Standard
What are business offices staffed with representatives and healthcare finders that assist TRICARE sponsors with healthcare needs and answer program questions
TRICARE business center (TBC)
When a civilian has medical insurance and TRICARE; which is the primary
TRICARE is secondary to all insurance except Medicaid
which TRICARE is similar to an HMO
TRICARE prime
Which TRICARE option has the highest out-of-pocket costs of all the TRICARE plans?
TRICARE standard
Which TRICARE option is a fee-for-service plan?
TRICARE standard
Which created the Physician Quality Reporting System that established a financial incentive for eligible professionals who participate in a voluntary quality reporting program?
Tax Relief and Health Care Act of 2006
Category III Codes
Temporary codes for data collection purposes that are assigned an alphanumeric identifier with a letter in the last field (e.g., 0001T); these codes are located after the Medicine section, and will be archived after five years unless accepted for placement with Category I sections of CPT.
Abbrviations
The index and tabular list contains abbreviations to save space.
replace fee-for-service plans with affordable, quality care to healthcare consumers.
The intent of managed health care was to ________________________.
fee-for-service
The intent of managed health care was to replace conventional ___ plans with more affordable quality care to healthcare consumers and providers who agreed to certain restrictions.
which is considered a valid entry in Block 24H of a Medicaid claim
The letter B, If the service was for both EPSDT and family planning
Scope
The most appropriate level of service is provided, taking into consideration potential benefit and harm to the patient.
Which is an interpretation of the birthday rule regarding two group health insurance policies when the parents of a child covered on both policies are married to each other and live in the same household?
The parent whose birth month and day occurs earlier in the calendar year is the primary policyholder.
Place of Service (POS)
The physical location where health care is provided to patients (e.g., office or other outpatient settings, hospitals, nursing facilities, home health care, or emergency departments); the two-digit location code is required by Medicare.
Which TRICARE option is activated when the beneficiary seeks medical care without prior approval
The point-of-service option (requires annual deductible plus 50 percent or more of visit and treatment fees)
continuity of care
The primary purpose of the patient record is to provide____________
diagnosis/condition
The procedure or service is linked with the ___________ that provided medical necessity for performing the procedure or service
Purpose
The procedure or service is performed to treat a medical condition.
standards
The term that describes requirements created by accreditation organizations is ___.
Evidence
The treatment is cost-effective for this condition when compared to alternative treatments, including no treatment.
subjective
The_______________part of the SOAP note contains the chief complaint and the patient's description of the presenting problem.
assessment
The_______________part of the SOAP note contains the diagnostic statement and may include the physician's rationale for the diagnosis.
plan
The______________part of the SOAP note is the statement of the physician's intended medical management of the case.
objective
The_____________part of the SOAP note contains documentation of measurable or objective observations made during the physical examination and diagnostic testing.
Why not obtain a signature from First Report of Injury or CMS-1500 claim form?
There is no patient signature line on this form and the law states when a patient requests treatment for a work related injury or disorder, the patient has given consent for the filing of compensation claims and reports.
What are the TRICARE Regions?
Three in the United States (North,West, South) TRICARE Overseas
Which requires providers to make certain written disclosures concerning all finance charges and related aspects of credit transactions?
Truth in Lending Act
Multiple Surgical Procedures
Two or more surgeries performed during the same operative session.
point-of-service plan (POS)
Under a __ __ (__) patients have freedom to use the managed care panel of providers or to self-refer to out-of-network providers.
How many diagnoses can be reported on the CMS-1500 form in block 21?
Up to 4 diagnoses
four
Up to_________diagnoses may be reported on the CMS-1500 claim form.
Medicare Coverage Database
Used by Medicare administrative contractors, providers, and other healthcare industry professionals to determine whether a procedure or service is reasonable and necessary for the diagnosis or treatment of an illness or injury; contains national coverage determinations (NCDs), including draft policies and proposed decisions; local coverage determinations (LCDs), including policy articles; and national coverage analyses (NCAs), coding analyses for labs (CALs), Medicare Evidence Development & Coverage Advisory Committee (MedCAC) proceedings, and Medicare coverage guidance documents.
Narrative Clinic Note
Using paragraph format to document health care.
Chapter 20
V00-Y99; External Causes of Morbidity
Assertive listening telecommunication device for the deaf (TDD). Assign the HCPCS level II code.
V5272
Which type of claim should not have been orginally paid by Medicaid?
VOIDED- a claim that Medicaid should not have orginally paid and results in a deduction from the lump-sum payment made to the provider
Time limit for filing First Report of Injury form?
Varies from 24 hours to 14 calendar days; depending on state requirements. It is best to complete immediately as not to forget and miss the qualifying time limits.
Operative Report
Varies from a short narrative description of a minor procedure that is performed in the physician's office to a more formal report dictated by the surgeon in a format required by the hospitals and ambulatory surgical centers (ASCs).
Which is the best way to prevent delinquent claims?
Verify health plan identification information on all patients
VistA
Veteran's Health Information System and Technology Architecture. VistA electronic health record was developed by the U.S. Department of Veterans Affairs.
enrollees
What term best describes those who receive managed healthcare plan services?
health status code
When a provider documents justification for a patient seeking health care services but no disorder is documented, the health insurance specialist usually assigns what type of code?
block 21
Where is the first-listed diagnosis reported on the CMS-1500 claim?
Which is responsible for administering workers' compensation laws?
Workers' Compensation Board
Does tricare standard give freedom in selecting civilian providers
Yes (but out of pocket costs are higher)
Is it recommended that an authentication legend be generated?
Yes, it is recommended that an authentication legend be generated when the procedure is completed.
Is CPT inconsistent?
Yes, its use of subsection, category, and subcategory terminology.
Chapter 21
Z00-Z99; Factors Influencing Health Status and Contact with Health Services
Consumer-directed health plans (CDHPs)
__ __ __ (__) include many choices that provide individuals with an incentive to control the costs of health benefits and health care. Individuals have greater freedom in spending healthcare dollars, up to a designated amount, and receive full coverage for in-network preventive care.
managed health care
__ __ __ combines healthcare delivery with the financing of services provided.
physician incentives
__ __ include payments made directly or indirectly to healthcare providers to encourage them to reduce or limit services.
case management
__ __ involves the development of patient care plans for the coordination and provison of care for complicated cases in a cost-effective manner.
utilization management
__ __ is a method of controlling healthcare costs and quality of care by reviewing the appropriateness and necessity of care provided to patients prior to the administration of care.
HIPAA
___ created federal standards for insurers, HMOs, and employer plans, including those who self-insure.
TEFRA
___ created medicare risk programs, which allowed federally qualified HMOs and competitive medical plans that met specified Medicare requirements to provide Medicare-covered services under a risk contract.
accreditation; survey
___ organizations develop standards (requirements) that are reviewed during a ___.
fee-for-service
___ plans reimburse providers for individual healthcare services rendered.
Texas
___ was the first state to enact legislation allowing consumers to sue an HMO for medical malpractice.
accreditation
____ is a voluntary process that a healthcare facility or organization undergoes to demonstrate that it has met standards beyond those required by law.
The National Committee for Quality Assurance (NCQA)
____________ (____) evaluates managed care organizations.
local coverage determinations(LCDs)
_________________specify under what clinical circumstances a service is covered.
chargemasters
_______________are used to select procedures, services, and supplies provided to hospital emergency department patients and outpatients.
auditing processes
______________involve reviewing patient records and CMS-1500 or UB-04 claims to process coding accuracy and completeness of documentation.
operative reports
_____________may vary from short narrative descriptions to formal dictated reports.
advance beneficiary notice
____________is a waiver form required by Medicare for all outpatient and physician office procedures/services that are not covered by the Medicare program
Applying for Medicare
a 7 month initial enrollment period (IEP) (before they turn 65), begins that provides the an opportunity for the individual to enroll in Medicare part A and/or Part B.
Third party Adminstrator
a company that provides administrative services to health care plans
What is found exempt in Appendix E?
a complete list of codes that are exempt from modifier -51.
Which is considered a mandatory Medicaid services that states must offer to recieve federal matching funds?
a family planning services and supplies
Providers receives
a medicaid remittance advice which explains claims reimbursement, medicaid used this notice to communication about claims processing & remimbursment provider
one way federal government verifies reciept of Medicaid services by a patient is by use of
a monthly survey sent to a sample of medicaid recipients requesting verification
What has the Joint Commission implemented?
a patient safety goal to help reduce the numbers of medical errors related to incorrect use of terminology. to facilitate compliance with the goal, the Joint Commission issued a list of abbreviations, acronyms, and symbols that should no longer be used by providers.
Which of the following can be a designated state workers' compensation fiscal agent?
a private, commercial insurance company
Special Report
a report that accompanies the claim to help determine the appropriateness and medical necessity of the services or procedures. It is required by many third party payers when a rarely used, unusual, variable, or new service or procedure is preformed
Unlisted Procedure
a service that is not listed in CPT, reported with an unlisted procedure code and requires a special report when used found at the beginning of each section
Workers Compensation Board or Commission is:
a state agency responsible for administering workers' compensation laws and handling appeals for denied claims or cases in which a worker feels compensation was too low
What is require by Medicare?
a waiver is require for all outpatient and physician office procedures not covered by Medicare (ABN).
Attestation that the services were billed properly is indicated by the provider signature in Block: a. 31 b. 17 c. 33 d. 21
a. 31
If a service provided can be categorized as both EPSDT and family planning what is entered in Block 24H on the CMS 1500 claim form? a. B b. E c. E, F d. F
a. B
A disproportionate share hospital is one that treats a disproportionate number of what type of patient? a. Medicaid b. Medicare c. self-pay d. veterans
a. Medicaid
A Medicaid claim that has been corrected, resulting in additional payment(s)d to the provider is a _____ claim a. adjusted b. rejected c. suspended d. voided
a. adjusted
Medicaid is jointly funded by federal and state governments, and each state: a. administers its own Medicaid program b. adopts the federal scope of services c. establishes uniform eligibility standards d. implements managed care for payment
a. administers its own Medicaid program
Which of the following practices is prohibited by law? a. balance billing of Medicaid patients b. billing a Medicaid patient for a service that is not a covered benefit c. billing the patient directly for a service provided when the individual's Medicaid eligibility has changed d. charging the Medicaid patient a copayment for a service
a. balance billing of Medicaid patients
Medicaid-covered services are paid only when the service is determined by the provider to be medically necessary, which means the services are? a. consistent with the patient's symptoms, diagnosis, condition, or injury b. furnished primarily for the convenience of the recipient or the provider c. provided when other equally effective treatment are available or suitable d. recognized as being inconsistent with generally accepted standards
a. consistent with the patient's symptoms, diagnosis, condition, or injury
An individual who is covered by both Medicare and Medicaid is called a(n)? a. dual eligible b. mandatory enrollee c. optional enrollee d. payer of last resort
a. dual eligible
Individuals who are eligible for both Medicare and Medicaid coverage are called? a. dual eligible b. Medicaid allowables c. PACE participants d. participating providers
a. dual eligibles
Which is considered a mandatory Medicaid service that states must offer to receive federal matching funds? a. family planning services and supplies b. nursing facility services or those under age 21 c. rehabilitation and physician therapy services d. transportation services
a. family planning services and supplies
The billing entity, as reported in Block 33 of the CMS-1500 claim, includes the legal business name of the a. medical practice. b. patient (or spouse). c. insurance company. d. acute care hospital.
a. medical practice.
Outpatient surgery and surgeon charges for inpatient surgery are billed according to a global fee, which means that the presurgical evaluation and management, initial and subsequent hospital visits, surgical procedure, discharge visit, and uncomplicated postoperative follow-up care in the surgeon's office are billed as a. one charge. b. multiple charges. c. DRG payments. d. separate charges.
a. one charge.
Medigap plans are supplemental plans that are: a. sold by private commercial insurance companies b. designed by private commercial insurance companies c. sold by the federal government to cover gaps in Medicare d. sold by the federal government to cover gaps in Medicaid
a. sold by private commercial insurance companies
The optical character reader (OCR) is a device that is used to a. view CMS-1500 text. b. enter CMS-1500 claims. c. scan CMS-1500 claims. d. convert CMS-1500 claims.
a. view CMS-1500 text.
What are commonly used by providers?
abbreviations are commonly used by providers when documenting patient care.
taking advantage of a situation
abuse
The term sponsor is used to describe....
active duty, retired or deceased military personnel
Medicare Prescription Drug plans (Part D)
add prescription drug coverage to the Original medicare plan, some medicare cost plans, some medicare private fee for service plans and medical savings account plans.
In the tabular list....
additional terms are indented below the term to which they are linked.
Comparing the claim to payer edits and the patient's health plan benefits is part of claims ______.
adjudication
When an appeals board renders a final determination on a claim, this is known as
adjudication
Medicaid makes payments directly to providers
adjusted payment claims, resulting in additional payments to the provider
Which is a document that acknowledges patient responsibility for payment if Medicare denies the claim
advance beneficiary notice
Which is a written document provided to a Medicare beneficiary by a provider prior to rendering service that is unlikely to be reimbursed by Medicare
advance beneficiary notice of noncoverage
The time period between the point at which a claim is submitted and when the claim is paid is called ________period?
aging
The Medicare Prescription Drug, Improvement, and Modernization Act (MMA) requires?
all code sets to be valid at the time services are provided.
When a pt chooses Medicare hospice benefits:
all other medicare benefits stop, with the exception of physician services or treatment for conditions not related to the pt's terminal diagnosis.
hospice care
all terminally ill pts' qualify for this.
Medicaid eligibility verification system
allows a provider to electronically access a state medicaid eligibility files
physician fee schedule
also called the resource based relative value scale, (RBRVS)
Medicare Part C
also known as Medicare Advantage Plans, are health plan options that are approved by Medicare but managed by private companies.
If the patient has paid a copayment on the claim being submitted, this is indicated on the CMS-1500 claim by entering the
amount paid in Block 29.
When the CMS-1500 claim require a response to YES or NO entries, enter
an X
Table of Neoplasms
an alphabetic index of anatomic sites for which there are six possible code numbers according to whether the neoplasm in question is malignant primary, malignant secondary, malignant in situ, benign, of uncertain behavior, or of unspecified nature.
Table of Drugs
an alphabetic index of medicinal, chemical, and biological substances that result in poisonings and adverse effects.
What is ICD-10-PCS?
an entirely new procedure classification system that was developed by CMS for use in hospitals only.
CMS is responsible for?
annually revising and updating the ICD-10-PCS procedure classification
persons confined to a psychiatric hospital
are allowed 190 lifetime reserve days instead of the 60 days allotted for a stay in an acute care hospital.
medicaid beneficiaries
are also enrolled in PCCM plans Balanced Budget Act
Medical Managed Diagnoses
are also known as secondary diagnosis or coexisting diagnosis. may or may not receive treatment during an encounter.
Eponyms
are diseases or syndromes that are named for people.
Medicare Claims
are filed on CMS-1500 claims
ICD-10-CM coding conventions
are general rules use in the classification, and they are independent of coding guidelines.
Parentheses
are used in the index and tabular list to enclose nonessential modifiers, which are supplementary words that may be present in or absentfrom the physician's statement of a disease or procedure without affecting the code number to which it is assigned.
Brackets
are used in the index to identify manifestation codes and in the index and tabular list to enclose abbreviations, synonyms, alternative wording, or explanatory phrases.
Chargemasters
are used to select procedures, services, and supplies provided to hospital emergency department patients and outpatients.
How is ICD-10-PCS published?
as a separate single-volume coding manual, with the Index to Procedures located in front of the Tables.
How is ICD-10-CM published?
as a single-volume coding manual, with the Index to Diseases and Injuries, Neoplasm, Table of Drugs and Chemicals, and Index to external Causes located in front of the Tabular List of Diseases and Injuries.
Prolonged Services
assigned in addition to other E/M services when treatment exceeds by 30 minutes
Which means that the patient and/ or insured has authorized the payer to reimburse the provider directly?
assignment of benefits
What does a health insurance specialist employed in a provider's office do?
assigns ICD-10-CM codes to diagnoses, conditions, signs, and symptoms documented by the health care provider.
Which component is included in the surgical package?
assistant surgeon services
Which is offered to members and marketed to small business owners as a way to provide coverage to employees?
association health insurance
Updates to ICD-10-CM and ICD-10-PCS are available?
at the official CMS (www.cms.gov) and NCHS (www.cdc.gov/nchs) websites.
Encoders
automate the coding process. This means that computerized or web-based software is used instead of coding manuals.
Which type of insurance is a contract between an individual and an insurance company whereby the individual pays a premium and, in exchange, the insurance company agrees to pay for specific vehicle-related financial losses during the term of the policy?
automobile
Eligibility informations is....
available over the telephone, subject to conditions intended to ensure the protection of the beneficiarys privacy rights.
Which Block requires entry of either the Social Security number (SSN) or the employer tax identification number (EIN)? a. 21 b. 25 c. 24B d. 17
b. 25
The name, address, and telephone number of the billing entity are entered in Block: a. 25 b. 33 c. 21 d. 17
b. 33
Unless the Medicare administrative contractor grants an exception, Medicare coverage for observation services is limited to not more than how many hours? a. 36 b. 48 c. 72 d. 24
b. 48
Which was developed by CMS to assign the unique health care provider and health plan identifiers and to serve as a database from which to extract data? a. PEPPER b. NPPES c. NPI d. PATH
b. NPPES
Which allows states to create or expand existing insurance programs to include a greater number of children who are currently uninsured? a. FMAP b. SCHIP c. SSDI d. TWWIA
b. SCHIP
Medicaid remittance advice documents should be maintained for how long? a. according to the federal statute of limitations b. according to the statute of limitations of the state in which the provider practices c. indefinitely d. until the patient no longer qualifies for Medicaid coverage
b. according to the statute of limitations of the state in which the provider practices...
What type of statement does the patient sign to authorize the payer to directly reimburse the provider? a. accept assignment b. assignment of benefits c. coordination of benefits d. authorization to release information
b. assignment of benefits
Relatives or legal guardians who take care of children under age 18, or age 19 if still in high school, are called _____ by the Medicaid program? a. administrators b. caretakers c. gatekeepers d. providers
b. caretakers
When unlisted codes are reported on a CMS-1500 claim, what is submitted to the payer with the claim to clarify the services rendered? a. remittance advice b. claim attachment c. explanation of benefits d. source document
b. claim attachment
State legislatures may change Medicaid eligibility requirements? a. as directed by the federal government b. during the year, sometimes more than once c. no more than once during each year d. to clarify services and payments only
b. during the year, sometimes more than once
Preauthorization guidelines for Medicaid recipients are required for which of the following? a. admission for preoperative testing and prenatal care b. elective admissions and extension of inpatient days c. outpatient procedures and prescription medications d. routine physician office visits and emergency outpatient treatment
b. elective admissions and extension of inpatient days
Annual income guidelines for the poverty level that impact Medicaid eligibility are established by the ____ government. a. county b. federal c. municipality d. state
b. federal
Up to how many modifiers can be entered to the right of each CPT or HCPCS level II code on the CMS-1500 claim? a. six b. four c. three d. five
b. four
The ultimate purpose of the Programs of All Inclusive Care for the Elderly is to? a. decrease the burden of home healthcare agencies b. help the person maintain independence, dignity, and quality of life c. prevent a patient from being admitted to a nursing facility c. replace the services of home health care and day health centers
b. help the person maintain independence, dignity, and quality of life
The spousal impoverishment protection legislation exempts which items from the couple's combined countable resources? a. boat, hunting camp, savings account, and investment dividends b. primary home, household goods, automobile, and burial funds c. rental property, retirement income, certificates of deposit, and employment income d. summer home, stocks, bonds, and SSI income
b. primary home, household goods, automobile, and burial funds
Certain individuals who have resources at or below twice the standard allowed under SSI program and income at or below 100 percent of the FPL do not have to pay their monthly Medicare premiums, deductibles, and coinsurance; they are categorized as? a. qualified disabled and working individuals b. qualified Medicare beneficiaries c. qualifying individuals d. specified low-income Medicare beneficiaries
b. qualified Medicare beneficiaries
When entering patient claims data onto the CMS-1500 claim, enter alpha characters using a. sentence case. b. upper case. c. title case. d. lower case.
b. upper case.
Billing the patient for non covered service is called
balance billing
benefit period
begins with the first day of hospitalization and ends when the patient has been out of the hospital for 60 consecutive days.
The Medicare "spell of illness" is also known as the
benefit period
What begins with a Medicare subscriber's first day of hospitalization and ends when the patient has been out of the hospital for 60 consecutive days?
benefit period
Providers and DMEPOS dealers obtain annual lists of valid HCPCS level II codes, which include ____ for services.
billing instructions
Which is an example of durable medical equipment (DME)?
blood glucose monitor
Dual Eligibles
both programs clients or patients is eligible for Medicare and Medicaid programs
How do workers compensation laws protect the employer?
by limiting the award an injured employee can recover from an employer and by limiting the liability of coworkers in most incidents.
When reporting code 73110 (radiologic examination of the wrist; complete, minimum of three views) on the CMS-1500 claim, report units as: a. 3 b. 1 with modifier -51 c. 1 d. 3 with modifier -51
c. 1
States that opt to include a medically needy eligibility group in the Medicaid program are required to include certain children who are under the age of ___ and who are full-time students. a. 18 b. 19. c. 21 d. 25
c. 21
Which situation requires the provider to write a letter explaining special circumstances? a. Surgery defined as an inpatient procedure was performed while the patient was in the hospital. b. Surgery typically categorized as an ASC procedure was performed in a hospital outpatient setting. c. A patient's inpatient stay was prolonged because of medical or psychological complications. d. Charges submitted to the payer are lower than the provider's normal fee (e.g., -22 added to code).
c. A patient's inpatient stay was prolonged because of medical or psychological complications.
Which was designed to accommodate optical scanning of paper claims? a. UB-04 b. HCFA-1500 c. CMS-1500 d. ANSI ASC X12
c. CMS-1500
Physician services for inpatient care are billed on a fee-for-service basis, and physicians submit _____ service/procedure codes to payers. a. HCPCS level III b. ICD-10-CM c. CPT/HCPCS level II d. DSM-5
c. CPT/HCPCS level II
Select the correct entry for the name of a provider on the CMS-1500 claim. a. MARY SMITH, MD b. DR. MARY SMITH c. MARY SMITH MD d. SMITH, MARY, MD
c. MARY SMITH MD
The spousal impoverishment protection legislation was originally part of the? a. Balanced Budget Act of 1997 b. Health Insurance Portability and Accountability Act c. Medicare Catastrophic Coverage Act d. Tax Equity and Fiscal Responsibility Act
c. Medicare Catastrophic Coverage Act
An optical scanner converts printed or handwritten characters into text that can be viewed by an: a. POS b. OAC c. OCR d. MAC
c. OCR
The unit in charge of safeguarding the state's Medicaid program against unnecessary or inappropriate use of services is the? a. Office of Inspector General b. state insurance commissioner c. Surveillance and Utilization Review System d. U.S. Attorney General
c. Surveillance and Utilization Review System
The Medicaid program that makes cash assistance available on a time-limited basis for children deprived of support because of a parent's death, incapacity, absence, or unemployment is the? a. Early and Periodic Screening, Diagnostic, and Treatment Program b. State Children's Health Insurance Program c. Temporary Assistance to Needy Families d. Ticket to Work and Work Incentives Improvement Act of 1999
c. Temporary Assistance to Needy Families
Which is considered a voided claim? a. a claim that has a negative balance for which the provider receives no payment until amounts exceed the negative balance amount b. a claim that has a payment correction submitted on it, which results in additional reimbursement being made to the provider c. a claim that Medicaid should not have originally paid and results in a deduction from the lump-sum payment made to the provider d. a claim that underwent review to safeguard against unnecessary or inappropriate use of Medicaid services or excess payment
c. a claim that Medicaid should not have originally paid and results in a deduction from the lump-sum payment made to the provider
Entering an X in any of the YES boxes in Block 10 of the CMS-1500 alerts the commercial payer that: a. emergency treatment was provided b. it is solely responsible for payment of the claim c. another insurance company might be liable for payment d. the provider agrees to accept assignment
c. another insurance company might be liable for payment
A patient develops surgical complications and returns to the operating room to undergo surgery related to the original procedure. The return surgery is a. coded for office data capture purposes only. b. not reported on the CMS-1500 or UB-04. c. billed as an additional surgical procedure. d. included as part of the original procedure.
c. billed as an additional surgical procedure.
Medicare beneficiaries with low income and limited resources may be eligible for Medicaid benefits: as a result, beneficiaries will receive additional services (not covered by Medicare), such as? a. ambulatory surgery services, emergency department services, and outpatient care b. inpatient hospitalizations, home health care, and hospice care services c. nursing facility care beyond 100 days, prescription drugs, eyeglasses, and hearing aids d. physician office services, urgent care, and durable medical equipment
c. nursing facility care beyond 100 days, prescription drugs, eyeglasses, and hearing aids
When a patient has Medicaid coverage in addition to other, third-party payer coverage, Medicaid is always considered the? a. adjusted claim b. medically necessary service c. payer of last resort d. remittance advice
c. payer of last resort
Block 23 of CMS-1500 claim contains the Medicaid ____ number, if applicable? a. identification b. national provider identification c. preauthorization d. resubmission code
c. preauthorization
What coverage does a Medicaid "Baby Your Baby" program provide? a. delivery and nursery car services for the newborn b. Medicaid coverage through the first year of the infant's life c. prenatal care only for the pregnant mother d. specialized care for a high-needs newborn, such as neonatal intensive care unit services
c. prenatal care only for the pregnant mother
Which information is entered in Blocks 9-9d on the primary insurance claim? a. employer tax identification number b. primary insurance c. supplemental plan d. billing entity
c. supplemental plan
Court decisions that establish a standard create _____law.
case
The temporary assistanc to needy families(TANF) program provides
cash assistance on a limited time basis for children deprived of support
For certain items or services reported on a claim submitted to the DME MAC, the DMEPOS dealer must received a signed _________.
certificate of medical necessity (CMN)
Which is the financial record source document usually generated by a hospital?
chargemaster
Material Safety Data Sheets (MSDS) contain data regarding
chemical and hazardous substances used at a worksite
Which supporting documentation is associated with submission of an insurance claim?
claims attachment
CPT Modifiers
clarify services and procedures performed by providers. they are reported as 2 digit numeric codes added to the 5 digit CPT code.
Which facilitates processing of nonstandard claims data elements into standard data elements?
clearinghouse
The Federal Black Lung Program covers
coal miners who are totally disabled due to pneumoconiosis.
GEMs published by NCHS and CMS do not contain?
code descriptions, however, other publishers include code descriptions to facilitate code translation.
HCPCS level II is considered a _______ system.
coding
Which type of automobile insurance pays for damage to a covered vehicle caused by hitting an object or being hit during an automobile accident?
collision
Programs of all inclusive care for the Elderly (PACE)
combine
When entering the patient's name in Block 2 of the CMS-1500 claim, separate the last name, first name, middle initial (if known) with
commas.
Medigap coverage is offered to Medicare beneficiaries by
commercial payers
example of employer fraud
committed by an employer who misrepresents payroll amounts or employed classifications
provider fraud
committed by healthcare providers and attorneys who inflate their bills for services or bill for treatment of non-work related illnesses and injuries
example of employee fraud
committed when an employee lies or provides false information or a false statement, intentionally fails to report income from work, or willfully misrepresents a physical condition to obtain benefits from the state compensation fund
ICD-10-CM/PCS Coordination and Maintenance Committee
committee is responsible for overseeing all changes and modifications to ICD-10-CM (diagnosis) and ICD-10-PCS (procedure) codes. And also discusses issues such as the creation and update of general equivalence mappings (GEMs).
To determine if a patient is receiving concurrent care for the same condition by more than one provider, the payer will check the claim against the
common data file
Which is an abstract of all recent claims filed on each patient, used by the payer to determine whether the patient is receiving concurrent care for the same condition by more than one provider?
common data file
Reimbursement for loss of or damage to a vehicle (e.g. caused by fire, flood, hail, theft, vandalism, or wind) is covered by _______ (automobile) insurance.
comprehensive
Automating the medical coding process is the goal of?
computer-assisted coding (CAC)
CAC
computer-assisted coding; uses a natural language processing engine to "read" patient records and generate ICD-10-CMand HCPCS/CPT codes.
Medicaid-covered services are paid only when the service is determined by the provider to be medically necessary, which means the services are
consistent with the patient's symptoms, diagnosis,condition, or injury
What do you do if an injured worker presents for the first visit without a written or personal referral from the employer
contact the employer immediately
what if treatment is sought in another state than where the injury occurred
contact the workers' compensation board/commission of the state where the work related injury occurred
Appendix III
contains an E/M CodeBuilder that can be used to audit patient record documenation to ensure that codes submitted to payers are arrcurate.
When an insurance company uses the patient's SSN as the patient's insurance identification number, Block 1a of the CMS-1500
contains the identification number without hyphens or spaces.
Medicare categorizes HMOs and PPOs as
coordinated care plans
The provision in group health insurance policies that specifies in what sequence coverage will be provided when more than one policy covers the claim is
coordination of benefits
Which is a group health insurance policy provision that prevents multiple payers from reimbursing benefits covered by other policies?
coordination of benefits
Which is the fixed amount patients pay each time they receive health care services?
copayment
Medicare special needs plans
cover all Medicare part A & B health care for individuals who can benefit the most from special care for chronic illnesses, care management of multiple diseases, and focused care management.
major medical
coverage beyond BCBS basic coverage
Group health insurance is available through employers and other organizations, and all or part of the premium costs are paid by employers. Employer-based group health insurance __________.
covers all employees, regardless of health status, and cannot be canceled if an employee becomes ill
Initial Hospital Care
covers the first inpatient encounter the admitting/attending physician has with the patient for each admission.
The sequence of activities that can normally be expected to result in the most cost-effective clinical course of treatment is called the
critical pathway
Which is the correct entry of a patient's or policyholder's name in Block 2 or 4 on the CMS-1500? a. DOE, JOHN S. b. JOHN S. DOE c. JOHN S DOE d. DOE, JOHN, S
d. DOE, JOHN, S
Which act prohibits a payer from notifying the provider about payment or rejection of unassigned claims or payments sent directly to the patient? a. Federal Claims Collection Act b. Tax Relief and Health Care Act of 2006 c. Improper Payments Information Act of 2002 d. Federal Privacy Act of 1974
d. Federal Privacy Act of 1974
Which requirements are used to determine Medicaid eligibility for mandatory categorically needy eligibility groups? a. AFDC b. EPSDT c. PACE d. TANF
d. TANF
Each state's annual federal medical assistance percentage is determined by using a formulas that? a. calculates an appropriate dollar amount based on each state's population b. calculates the amount to be awarded based on the number of uninsured and unemployed individuals in each state c. compares each state's annual Medicaid expenditures and calculates the percentage each will receive d. compare the state's average per capita income level with the national average
d. compare the state's average per capita income level with the national average
Which are preprinted in Block 21 of the CMS-1500 claim? a. days or units b. modifiers c. charges d. diagnosis pointers
d. diagnosis pointers
Unless state law specifies a longer period, according to Medicare Conditions of Participation (CoP), how many years are providers required to keep copies of any government insurance claims and copies of all attachments filed? a. seven b. six c. three d. five
d. five
When one charge covers presurgical evaluation and management, initial and subsequent hospital visits, surgical procedure, the discharge visit, and uncomplicated postoperative follow-up care in the surgeon's office, this is called a(n) a. fee-for-service charge. b. combined medical/surgical case. c. itemized list of separate charges. d. global fee.
d. global fee.
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. managed care b. life c. disability d. homeowner's
d. homeowner's
Medicaid provides medical and health-related services for individuals and families with low incomes and limited resources, who are collectively known as? a. categorically needy b. dual eligible c. medically disabled d. medically indigent
d. medically indigent
States rarely require Medicaid recipients to pay a? a. coinsurance b. copayment c. deductible d. premium
d. premium
The Medicare Catastrophe Coverage Act of 1988 (MCCA) implemented Spousal Impoverishment Protection Legislation in 1989 to prevent married couples from being required to ___ income and other liquid assets (cash and property) before one of the partners could be declared eligible for Medicaid coverage for nursing facility care a. augment b. increase c. procedure d. spend down
d. spend down
Which statement is an accurate interpretation of the phrase "assignment of benefits"? If signed by the patient on the CMS-1500 claim a. the provider accepts as payment what the payer reimburses. b. the payer sends reimbursement for services to the patient. c. the provider cannot collect copayments from the patient. d. the payer is instructed to reimburse the provider directly.
d. the payer is instructed to reimburse the provider directly.
Medicaid will conditionally subrogate claims? a. because Medicaid eligibility is determined by income b. on Medicare/Medicaid crossover cases c. until preauthorization is obtained for nonemergency admissions d. when there is liability insurance to cover a person's injuries
d. when there is liability insurance to cover a person's injuries
How frequently should a patient's Medicaid eligibility be verified? a. at the time of the patient's annual wellness checkup b. on a monthly basis c. when the patient notifies you of any changes in Medicaid coverage d. with each visit to the provider
d. with each visit to the provider
Which information must be obtained about the beneficiary to confirm Medicare eligibility over the phone
date of birth
A chronological summary of all transactions posted to individual patient accounts on a specific day is recorded on a
day sheet
Skilled nursing facility (SNF) inpatients who meet Medicare's qualified diagnosis and comprehensive treatment plan requirements when they are admitted after a three-day-minimum acute hospital stay are required to pay the Medicare rate of $148 per day for SNF inpatient care during which period?
days 21-100
Supplements insurance covers , not health care expenses
deductible, copayments, coinsurances
If a patient fails to alert the provider that an injury was work-related, then changes his mind later and tries to receive workers' compensation benefits, the claim will most likely be
denied by the workers' compensation payer, and the patient will have to appeal
Workers' compensation insurance also provides payments to qualified
dependents of workers who die from a compensable illness or injury.
The Medicare Part D coverage gap (or Medicare Part D "donut hole") for the Medicare Part D prescription drug program is best described as the:
difference between the initial coverage limit and the catastrophic coverage threshold.
HCPCS level II was introduced in 1983 after Medicare found that its payer used more than 100 different coding systems, making it ____________________________.
difficult to analyze claims data.
Reimbursement for income lost as a result of a temporary or permanent illness or injury is covered by ________ insurance.
disability
Because HCPCS level II is not a reimbursement methodology or system, its procedure, product, and service codes ________ coverage (e.g., payment).
do not guarantee
Medicare Part B will cover some home health care services if the patient
does not have Medicare Part A
States's legislatures may change medicaid eligibility requirements
during the year, sometimes more than once
Medicaid
eligibilty standards are determined by individual states
Claims for treatment provided to injured employees on worker's compensation cases should be sent to the
employer-designated compensation payer
When completing a CMS-1500 claim for Medicare-Medicaid (Medi-Medi) crossover claims
enter an X in both the Medicare and Medicaid boxes of Block 1
Medicaid reimbursement is expidited when the provider
enters an X in the Yes box in Block 27 to accept assignment
which services are exempt from medicaid copayments
family planning services
One of the benefits of becoming a Medicare participating provider (PAR) is
faster processing and payment of assigned claims
The medicaid program is funded by
federally mandated and state administered
The original Medicare plan is also called Medicare
fee-for-service
After the claim has been acknowledged, the information that must be included on all correspondence to the employer, payer, and the Commission Board is the
file/case number assigned to the claim
Qualifying Circumstances
five-digit CPT codes that describe situations or conditions that affect the administration of anesthesia
A series of fixed-length records submitted to payers to bill for health care services is an electronic _______.
flat file format
If a particular service has both a CPT code and a HCPCS level II code, the provider will?
follow instructions provided by the payer
Medicare literature - "spell of illness"
formerly called "spell of sickness", in place of benefit period.
How many regional MACs are assigned by CMS to process DME claims?
four
purposeful intent
fraud
CMS decided to have all DME claims processed by only four DME MACs to reduce _______ claims.
fraudulent
Updateable coding manuals are available....
from publishers as a subscription service, and they are usually stored in a three ring binder so outdated pages can be removed and new pages can be added.
Drugs are listed in the HCPCS table of drugs according to?
generic name
Which health plan is required to accept employees and their family members?
group
For a beneficiary to qualify for Medicare's skilled nursing benefit the individual must have
had a least three inpatient days of an acute hospital stay
physician fee schedule
has reimbursed provider services according to this schedule and the "physician billing schedule" and also has limits amounts nonparticipating providers can charge beneficiaries.
Nonparticipationg providers (nonPars)
have not signed participating provider contracts, and they expect to be paid the full fee charged for services rendered. the patience may be asked to pay the provider in full and then be reimbursed by CBS for the allowed fee for each service, minus the patient's deductible and copayment obligations. Even when the provider agrees to file the claim for the patient, the insurance company sends the payment directly to the patient and not to the provider.
Disability insurance does not reimburse for
health care expense
The life cycle of an insurance claim is initiated when the
health insurance specialist completes the CMS-1500 claim.
General Enrollement period
held every Jan. 1st through March 31 of each year. is for those individuals that wait until they reach age 65 causing a delay in the start of part B of the coverage.
Medicare Part B
helps cover physician services, outpatient hospital care, and other services not covered by part A including physical and occupational therapy and some health care for pts who do not have medicare part A.
All terminally ill Medicare patients qualify for _______ care
hospice
Why is the patient record important?
important to the health care facility because it contains documenation of all health care services provided to the patient and supports the following: diagnosis, justifies treatment, and records treatment results.
medicaid is usually discontinued at end of the month
in which a person no longer meets the criteria of any medicaid eligibility group
Preventive Medicine Services
include routine examinations or risk management counseling for children and adults who exhibit no overt signs or symptoms of a disorder while presenting to the medical office for a preventive medical physical.
Global Surgery Period
includes the preoperative assessment, surgery, and postoperative care.
global surgery
includes the preoperative assessment, the procedure, anesthesia(when used), and normal, uncomplicated follow-up care.
Medicare Enrollment
individuals age 65 and over do not pay a monthly premium for medicare part A, IF they or a spouse paid Medicare taxes while they were working. Those who didn't pay medicare taxes "buy in" to medicare part A by paying monthly premiums.
Early and Periodic Screening, Diagnosic, and Treatment(EPSDT) services are offered for which Medicaid enrolled population
individuals under age 21
Medicare part D
individuals who join a medicare drug plan pay a monthly premium
What information is needed by hospitals and ambulatory surgical centers?
information is date of surgery, patient i.d., pre and post-op diagnosis, list of procedures performed, and names of primary and secondary surgeons.
Medicare Part A reimburses providers for:
inpatient hospital charges
To recieve matching funds through Medicaid, states must offer what coverage
inpatient hospital services
Guidelines
instructions provided at the beginning of each section, which difine terms particular so that section and provide explanation for codes and services that apply to the section.
Manifestation
is a condition that occurs as the result of another condition, and manifestation codes are always reported as secondary codes.
Encounter
is a face-to-face contact between a patient and a health care provider who assesses and treats the patient's condition.
Advance Beneficiary Notice
is a form that a patient signs and is responsible for paying the bill if the Medicare denies the claim. Medicare patients need to sign this when it is felt Medicare may not pay for the service and the patient would be responsible for the bill.
a co-payment
is a minimal amount that the medicaid recipent pays at the time of each visit
Minor
is a patient seen by the provider for presenting problem that runs a definite and presrcibed course, is transient in nature, and is not likely to alter the patients permanent health status.
Demonstration/Pilot program
is a special project that tests improvements in medicare coverage, payment and quality of care.
medicap
is a supplemental insurance that assists with hospice, hospital, home health care services
Medicare cost plan
is a type of HMO that works in much the same way and has some of the same rules as a Medicare Advantage Plan. in this type of plan if an individual receives health care from a non-network provider, the original Medicare Plan covers the services.
Encoder software
is also available as a subscription service. It automates the coding process using computerized or web-based software; instead of manually looking up conditions (or procedures) in the coding manual index, the coder uses the software's searchfeature to locate and verify diagnosis and procedure codes.
hospice
is an autonomous centrally adminstered program of coordinated inpatient and outpatient palliative services (relieve of symptoms) for terminally ill pts' and their families.
Program all Inclusive
is an optional program for state medical plans
Reimbursement under the fee scheduled...
is based on relative value units (RVU's) that consider resources used in providing a service, such as (physician work, practice expense and malpractice expense).
Part B
is for outpatient only
The money deposited annually by Medicare into an MSA
is managed by a Medicare approved insurance company or qualified company. it is not taxed if the enrollee uses it to pay qualified healthcare expenses.
What is the primary purpose?
is of the patient record is to provide continuity of care.
respite care
is the temporary hospitalization of a terminally ill, dependent hospice pt for the purpose of providing relief for the nonpaid person who has the major day to day responsibility for care of that pt.
Colon
is used after an incomplete term or phrase in the index and tabular list when one or more modifiers (additional terms) is needed to assign a code.
Medicare Medical Savings Account (MSA)
is used by an enrollee to pay healthcare bills, while Medicare pays the cost of a special healthcare policy that has a high deductible (not to exceed $6000)
Italicized type
is used for all tabular list exclusion notes and to identify manifestation codes, which are never reported as the first-listed diagnoses.
Boldface type
is used for main term entries in the alphabetic index and all codes and descriptions of codes in the tabular list.
What is the difference with ICD-10-CM?
it includes many more codes and applies to more users than ICD-9-CM because it is designed to collect data on ebery type of health care encounter (e.g., inpatient, outpatient, hospice, home healthncare, and long-term care) Also enhances accurate payment for services rendered and facilities evaluation of medical processes and outcomes.
What type of form is a CMS-1500?
it is a outpatient claim form.
What does a health specialist review?
it reviews the patient record when assigning codes to diagnoses, procedures, and services.
Medicare
its a federal program authorized by Congress and administered by the centers for Medicare and medicaid Services.
adjudication
judicial dispute resolution process in which an appeal board makes a final determination
Another name for the patient account record is the patient _____.
ledger
Which HCPCS codes were discontinued in December 2003?
level III
Which claims are submitted to cover the cost of medicare for traumatic injures, lost wages, pain, and suffering?
liability
The supplier or provider should generate an ABN if he or she believes that a claim for the services is likely to receive a
medical necessity denial
5 classifications of workers' compensation cases?
medical treatment, temporary disability, permanent disability, vocational rehabilitation, and survivor benefits.
The Office of Workers' Compensation Programs administers provide
medical treatment, vocational rehabilitation, wage replacement benefits
The four type of HCPCS level II codes are _________.
miscellaneous, modifier, permanent, and temporary codes
when a patient is covered by primary and secondary or supplements insurance BC/BS health insurance plans modification area make to the CMS-1500 claim
modification can be made to area on the CMS-1500 claim form
What must patient record documentation justify?
must justify and support the medical necessity of procedures and services reported to payers.
What is required in Block 32 if an X is entered in the Yes box of Block 20
name and address of the outside laboratory
What is entered in Block 24J if the provider is a member of a group practice?
national provider identifier (NPI)
What is entered in Block17b of the CMS-1500 claim?
national provider identifier (NPI)
What does a bullet to the left of a code number identify?
new procedures and services.
What does the MMA require?
new, revised, and deleted ICD-9-CM codes be implemented each October 1 and updated each April, and changes to CPT ahd HCPCS level II national codes be implemented each January 1.
Another term that can be used to indicate a fee-of-service plan is a ______ plan.
noncapitated
Which describes any procedure or service reported on a claim that is not included on the payer's master benefit list?
noncovered benefit
Patients can be billed for
noncovered procedures
Programs of All-Inclusive Care for the elderly(PACE) work to limit out of pocket costs to benificiaries by
not applying deductibles, copayments, or other cost-sharing
a primary care provider in a medicaid care case management(PCCM) plan differs from an HMO primary care provider in that th Medicaid primary care provider is
not at risk for the cost of the care provided
NEC
not elsewhere classifiable; means "other" or "other specified" and identifies codes that are assigned when information needed to assign a more specific code cannot be located.
NOS
not otherwise specified; which is the equivalent of "unspecified." It identifies codes that are to be assigned when information needed to assign a more specific code cannot be obtained from the provider.
If the claim was denied because the service is not covered by the payer, the claim is
not paid by the third-party payer
What is entered in Block 17a of the workers compensation CMS-1500 claim?
nothing ; the block is left blank
One of the expectations that a nonparticipating provider has is to for services rendered
obtain payment for the full fee charged
The State Insurance Fund must offer
offer workers' compensation insurance to any employer requesting it.
The treating physicians personal signature is required
on all original reports and photocopies
When the same commercial payer issues the primary and secondary or supplemental policies, it is generally acceptable to submit ______ claim(s).
one
When the same payer issues the primary, secondary, or supplemental policies, the correct procedure for submitting the claim would be to submit __________.
one claim for all policies
Progress reports copies go to
one copy to compensation payer one copy to the patient file
An electronic claim that is rejected because of an error or omission is considered a(n):
open claim
Which is an example of supporting documentation?
operative report
Prospective authorization or precertification is a requirement of the BCBS managed care plan
outpatient pretreatment authorization
What is a series of very specific blood chemistry studies ordered at one time?
panel
Which must accept whatever a payer reimburses for procedures or services performed?
participating provider
Progress reports include:
patients name & compensation file/case number treatment and progress report work status at the present time statement of further treatment needed estimate of the future status with regard to work or permanent loss or disability copies of substantiating x-ray, laboratory, or consultation reports
When a patient has Medicaid coverage is addition to other, third-party payer coverage, Medicaid is always considered the
payer of last resort
Medicare Supplementary Insurance (MSI) is designed to supplement Medicare benefits by:
paying for services that Medicare does not cover
Medicare hospital insurance (Part B)
pays for doctors services; outpatient hospital care, durable medical equipment and some medical service that are not covered by Part A.
Medicare hospital insurance (Part A)
pays for inpatient hospitla critical care access; skilled nursing facility stays; hospice care; and some home health care.
Which claim status is assigned by the payer to allow the provider to correct errors or omissions on the claim and resubmit for payment consideration?
pending
Which practitioner who claims for services must accept assignments
physician assistant
When the patient is the domestic partner of the primary policyholder, this is indicated on the CMS-1500 claim by
placing an X in the OTHER box of Block 6.
When the patient is the domestic partner of the primary policyholder, this is indicated on the CMS-1500 claim form by......
placing an X in the OTHER box of block 6
black lung disease
pneumoconiosis
allow subscribers to choose between a network providers or out of network
point of service plan BC/BS
The person in whose name the insurance policy is issued is the?
policyholder
non-emergency hospitalization must be
pre-authorized
which is a program that requires providers to adhere to managed care provisions?
preferred provider network
If a provider is not registered with a regional MAC, a patient will receive medical equipment when the?
prescription is taken to a local DMEPOS dealer
When a physician treats a Medicare patient for a fractured femur and supplies the patient with crutches, two claims are generated. The physician's claim for the fracture care is sent to the _____, and the claim for the crutches is sent to the ______.
primary MAC, DME MAC
When an enrollee has a primary care provider who authorizes access to specialty care but is not at risk for the cost of the care provided, the beneficiary is enrolled in a(n)? a. Medicaid health maintenance organization b. Medicare/Medicaid crossover plan c. optional categorically needy group d. primary care case management plan
primary care case management plan
Which is considered a covered entity?
private-sector payers that process electronic claims
The sorting of claims by clearinghouses and payers is called claims:
processing
The sorting of claims upon submission to collect and verify information about the patient and provider is called claims ____.
processing
The Privacy Act of 1974
prohibits release of information unless all the listed required information is accurately provided.
Medicare Advantage plans
provide all medicare Part A (hospital) and Medical part B (medical) coverage and must cover medically necessary services.
What would happen if outdated codes are submitted on a claim?
providers and health care facilities will incur administrative costs associated with resubmitting corrected claims and delayed reimbursement for services provided.
Bluecross services was 1938 Blueshield
providers services Hospitals services
Which program helps individuals whose assets are not low enough to qualify them for Medicaid by requiring states to pay their Medicare Part A and B premiums, deductibles, and coinsurance amounts?
qualified Medicare beneficiary
An individual whose income is at or below 100 percent of the federal poverty level(FPL) and has recources at or below twice the standard allowed amount under the SSI program may recieve assistance from medicaid to pay for medicare premiums, deductibles, and coinsurance amounts as a
qualified medicare benificiary(QMB)
Which program helps low-income individuals by requiring states to pay their Medicare Part B premiums?
qualifying individual
when a patient has become retroactively eligible for Medicaid benifits, any payment made by the patient during the retroactive period must be
refunded to the patient by the practice
The purpose of respite care is to provide:
relief for a nonpaid caregiver who is responsible for a terminally ill or dependent patient
The conversion of CHAMPUS to TRICARE was the result of
reorganization of each branch of the United States uniformed services.
What does the CMS-1500 claim require?
requires entry of two-digit or two character modifiers.
Temporary hospitalization of a patient for the purpose of providing relief from duty for the nonpaid primary caregiver of a patient is called _________ care
respite
CMS
responsible for the operation of the Medicare program and for selecting medicare administrative contractors (MAC's) to process Medicare fee for service, Part A, Part B and durable medicine equipment, DME claims.
The first alphabetic character HCPCS code identifies the code?
section of HCPCS level II
Third-party recovery standards for investigation of liability coverage and the process for filing a lien in a potential liability case vary on a federal and state basis. A lien is defined as __________.
securing a debtor's property as security or payment for a debt
Workers compensation plans allow an employer to set aside a state-mandated percentage of capital funds to cover employee compensation and benefits are
self-insurance plans
Employers with sufficient capital can
self-insure
A Medicaid card issued for the "unborn child of..." is good for
services that promote the life and health of the unborn child
The initial enrollment period (IEP) for Medicare Part A and Part B is:
seven months.
A medicaid voided claim
should not have been paid originally
A secondary health insurance plan generally provides coverage that is ........
similar to that of a primary health insurance plan.
Block 24 of CMS Claim is limited to reporting how many services?
six services
For TRICARE CLAIMS WHAT IS USED AS THE INSURED'S ID
social security number
Supporting documentation which is attached to the CMS-1500 claim form is either copied from patient's chart or developed (e.g. letter delineating unlisted services). The latter is referred to (in the CPT coding manual) as a
special report
A federally mandated program that requires states to cover just the Medicare Part B premium for a person whose income is slightly over the poverty level is the:
specified low-income Medicare beneficiary
HCPCS furnishes healthcare providers and suppliers with a _________ language for reporting professional services, procedures, supplies, and equipment.
standardized
BBA the Balance Budget Act
states children health program (SCHIP) was implemented in accorance
The transmission of claims data to payers or clearinghouses is called claims ______.
submission
When a patient is covered by the same primary and secondary commercial health insurance plan,
submit just one CMS-1500 to the payer.
What is included in a couples combined recources accourding to the Spousal Impoverishment Protection legislation
summer home
Which form is considered the financial source document?
superbill or encounter form
Blocks 24A-24J of the CMS-1500 contain shaded rows, which can contain
supplemental information, per payer instructions.
Excision
surgical removal of a body part or tissue which is use in the CPT coding manual to identify the technique.
The death benefits paid to eligible dependents are called _______ benefits.
survivor
Hospice is an autonomous, centrally administered program of coordinated inpatient and outpatient palliative services for:
terminally ill patients and their families
AMA- America Medical Assocation
the approving agency for accreditation of new Blue Shield programs
What does patient record serve as?
the business record for a patient encounter and is maintained in a paper or automated format.
What is requested by third-party payers?
the copies of reports for the patient reocrd to process insurance claims.
What do CPT modifiers use to indicate?
the description on the procedure performed has been altered.
What has to be linked?
the diagnosis with the procedure/service is to prove medical necessity.
Workers' compensation law states that when a patient requests treatment for a work-related injury, the patient has given consent for
the filing of compensation claims and reports.
Medicare
the largest single medical benefits program in the United states.
A Medicare benefit period is defined as beginning the first day of hospitalization and ending when:
the patient has been out of the hospital for 60 consecutive days.
If it is possible that scheduled tests, services, or procedures may be found "medically unnecessary" by Medicare.....
the patient must sign an advance beneficiary notice (ABN).
What did AMA halted?
the project to revise E/M code descriptions using clinical examples in 2004. However, previously devloped clinical examination exmples are still included in Appendix C.
The insured ID entered on the TRICARE claim form is what?
the sponsor's social security number
hospice care
this program is for pts' for whom the provider can do nothing fruther to stop the progression of disease, the pt is treated only to relieve pain or other discomfort.
Why should updated coding manuals be purchased and/or billing systems be updated with coding changes?
to avoid billing delays and claim rejections
NCHS works with the World Health Organization (WHO) to do what?
to coordinate official disease classification activities for ICD-10-CM, including the use, interpretation, and periodic revision of the classification system.
If a patient is covered by two different policies, the usual procedure for submitting a claim would be __________.
to submit all claims to all payers at the same time
How many locations are diagnostic test results documented?
two locations.
A physician or practitioner with a Medicare private contract agrees not to bill for any service or supplies provided to any Medicare beneficiary for at least:
two years
community spouse
under the improvishment protection legislation, the spouse residing at home.
Reporting ICD-10-CM codes on insurance claims results in what?
uniform reporting of medical reasons for health care services provided.
When completing a CMS-1500 claim using computer software, text should be entered in ______ case.
upper
How many majors does health care providers use?
use two major formats for documenting clinic notes.
Format and Typeface
uses an indented format for ease in reference. Index subterms associated with an index entry's main term are indented 2 spaces, with second and third qualifiers associated with the main term further indented by 2 and 4 spaces, respectively. If an index entry requires more than one line, the additional text is printed on the next line and indented 5 spaces.
demonstrations
usually apply to a group of people and or are offered only in specific areas.
A clearinghouse that coordinates with other entities to provide additional services during the processing of claims is a
value-added network
When a child who is covered by two or more plans lives with his married parents, the primary policyholder is the parent
whose birthday occurs first in the year.
When should you contact the regional contractor's representative when there has been no response on a claim?
within 45 days of filing the claim.
When did provider-based offices and health care facilities implement ICD-10-CM codes for diagnoses?
October 1,2014
New Patient
One who has not received any professional services from the physician or from another physician of the same specialty who belongs to the same group practice, within the past three years.
Established Patient
One who has received professional services from the physician or from another physician of the same specialty who belongs to the same group practice, within the past three years.
TRICARE outpatient claims will be denied if they are filed more than.....
One year after the date of service.
A patient was treated by his primary care physician on 01/25/YYYY for a wrist fracture that occurred on the job. On 02/02/YYYY, the patient was evaluated for symptoms of severe high blood pressure and a recheck of the wrist fracture. Where should the provider document treatment from the visit on 02/02/YYYY?
Only the fracture recheck is to be recorded in the workers' compensation record
Device used for optical character recognition.
Optical Character Reader (or recognition) [OCR]
Uses a device (e.g., scanner) to convert printed or handwritten characters into text that can be viewed by an optical character reader.
Optical Scanning
Category II Codes
Optional performance measurement tracking codes that are assigned an alphanumeric identifier with a letter in the last field (e.g., 1234A); these codes will be located after the Medicine section; their use is optional.
IDS
Organization of affiliated providers' sites that offer joint healthcare services to subscribers.
SOAP Note
Outline format for documenting health care; "SOAP" is an acronym derived from the first letter of the headings used in the note: Subjective, Objective, Assessment, and Plan.
OCE
Outpatient Claims Editing Software
documentation
Patient record ____________ must justify and support the medical necessity of procedures and services reported to payers
A military treatment facility (MTF) catchment area is
Defined by code boundaries within a 40-mile radius of an MTF.
closed-panel HMO
Health care is provided in an HMO-owned center or satellite clinc or by physicians who belong to a specially formed medical group that serves the HMO.
Although the majority of procedures and services are reported using CPT (HCPCS level I), that coding system does not describe ______ (services) and certain other services reported on claims submitted for Medicare and some Medicaid patients.
DMEPOS
Which of the following steps would occur first?
Health insurance specialist completes electronic or paper-based claim.
diagnoses, procedures, and services
Health insurance specialists review the patient record when assigning codes to ________________________
The number of TRICARE regions has _______ since 1999
Decreased
computer system that contains up-to-date Defense Department Workforce personnel information
Defense Enrollment Eligibility Reporting Systems (DEERS)
To prepare for implementation of ICD-10-CM/PCS, health care professionals should assess their coding staff to determine their needs and offer appropriate education and training to:
- Apply advanced knowledge of anatomy and physiology, medical terminology, and pathophysiology - Effectively communicate with members of the medical staff - Interpret patient record documentation - Interpret and apply coding guidelines that apply to the assignment of ICD-10-CM/PCS codes
ICD-10-CM and ICD-10-PCS also include updated medical terminology and classification of diseases, provide codes to allow for the comparison of mortality and morbidity data, and provide better data for:
- Conducting research - Designing payment systems - Identifying fraud and abuse - Making clinical decisions - Processing claims - Tracking public health
ICD-10-CM and ICD-10-PCS incorporate much greater specificity and clinical information, which results in:
- Decreased need to include supporting documentation with claims - Enhanced ability to conduct public health surveillance - Improved ability to measure health care services - Increased sensitivity when refining grouping and reimbursement methodologies
The first column of the table lists generic names of drugs and chemicals (although some publishers have added brand names) with six columns for:
- Poisoning: Accidental (Unintentional) - Poisoning: Intentional Self-harm - Poisoning: Assault - Poisoning: Undetermined - Adverse effect - Underdosing
What are the four general criteria used to determine medical necessity?
- Purpose - Scope - Evidence - Value
Which CPT modifier will require supporting documentation for payment?
-22(unusual procedural services)
Which modifier is reported if a third-party payer requires a second opinion for a surgical procedure?
-32 mandated services
Which modifier is used to describe the services of a clinical psychologist?
-AH
Punctuation
-Colons -Parentheses -Brackets
Which modifiers is used to describe the right upper eyelid?
-E3
The conventions are incorporated into ICD-10-CM as instructional notes, and they include the following:
-Format and typeface - Eponyms - Abbreviations - Punctuation - Tables - Includes notes, excludes notes, and inclusion terms -Other, other specified, and unspecified codes - Etiology and manifestation rules - And - Due - With - Cross-references, including, see, see also, see category, and see condition
Which is the format of EIN?
00-0000000
sprained wrist
A patient is seen in the office and is diagnosed with a sprained wrist. He complains of pain and upon examination the provider notes bruising and edema of the wrist. What diagnosis should be reported to third-party payers?
TRICARE has established a good-faith policy for assigned claims to protect the provider when
A patient presents an invalid ID card when treatment was rendered and billed.
Medicare can assign a claim conditional primary payer status for payment processing. Which of the following would warrant this type of conditional status
A patient who is mentally impaired failed to file a claim with the primary payer
A regional MAC will receive claims that contain which HCPCS level II codes?
B,E,K, L
Defense Enrollment Eligibility Reporting System. Verifies enrollment & eligibility
DEERS
The database that maintains up-to-date defense department workforce personnel information is called
DEERS
Beatrice Blue holds a private commercial health care policy, and she wishes to have payment from health insurance company sent directly to her provider. How is this reported on the CMS-1500?
Beatrice Blue will sign Block 13.
Who assists TRICARE sponsors with information about the health program, along with other matters affecting access to health care(e.g. appointment scheduling)
Beneficiary services representive.
TRICARE As long as active duty for 30 days or more. Coverage for 3 years after the death of the sponsor of cost-shared claims. Surviving spouses covered until they remarry. Children covered until age 21.
Benefits for survivors of veterans who died in the line of duty
The legal business name of the provider's practice.
Billing Entity
When a Medicaid patient has a third party payer coverage and a claim has been rejected, the rejection code is reported in which block of the Medicaid CMS-1500 claim
Block 11
When laboratory tests are performed in the office, enter an X in the NO box of
Block 20.
The patient was required to obtain an authorization number before being treated by a specialist. Where is the authorization number entered in the CMS-1500 claim?
Block 23
When payment has been recieved by a primary payer, the payment amount is entered in which block of the medicaid CMS-1500 claim
Block 29
What is the abbreviation for the computer system that contains up-to-date Defense Department workforce personnel information and used to verify TRICARE eligibility?
DEERS
Electronic claims are
Checked for accuracy by billing software programs or a healthcare clearinghouse
CHAMPVA
Civilian Health and Medical Program of the Department of Veterans Affairs
CHAMPVA means
Civilian Health and Medical Program of the Department of Veterans Affairs
Which is considered a voided claim
Claim that Medicaid should not have originally paid and results in a deduction from the lump-sum payment made to the provider
Which of the following steps would occur first?
Clearinghouse transmits claims data to payers.
Lead Agent of selected military treatment facilities (MTFs) hold what rank?
Commander
Which type of health insurance covers the medical expenses of individuals (e.g., private health insurance) and groups (e.g., employer group health insurance)?
Commercial
Which type of automobile insurance pays for loss of or damage to a covered vehicle, such as that caused by fire, flood, hail, impact with an animal, theft, vandalism, or wind?
Comprehensive
The base period of a disability policy usually covers 12 months and is divided into four __________ quarters.
Consecutive
Medicaid-covered services are paid only when the service is determined by the provider to be medically necessary, which means the services are
Consistent with the patient's symptoms, diagnosis, condition, or injury
Assessment
Contains the diagnositc statement and may include the physician's rationale for the diagnosis.
direct contract model HMO
Contracted healthcare services are delivered to subscribers by individual physicians in the community.
PPO
Contracted network of healthcare providers that provide care to subscribers for a discounted fee.
Newborn Care
Covers examinations of normal or high-risk neonates in the hospital or other locations, subsequent newborn care in a hospital, and resuscitation of high-risk babies.
HEDIS
Created standards to assess managed care systems in terms of membership, utilization of services, quality, access, health plan management and activities, and financial indicators.
CPT Coding
Current Procedural Terminology Codes. Describes types of patient visits, procedures, and lab tests performed.
Chapter 3
D50-D89; Diseases of the Blood-forming Organs and Certain Disorders Involving the Immune Mechanism
If the physician charges $500 or higher for care of a TRICARE beneficiary as the result of an accidental injury, , the insurance specialist must submit a...
DD Form 2527 that was completed by the patient.
When the TRICARE patient has been referred by a military treatment facility, attach what form?
DD form 2161
Protection from railroad employer negligence is covered under the
FELA - Federal Employment Liability Act
Which protects information collected by consumer reporting agencies?
Fair Credit Reporting Act
Which federal law protects consumers against harassing or threatening phone calls from collectors?
Fair Debt Collection Practices Act
Portion of medicaid program paid for by federal government is known as
Federal medical assistance percentage (FMAP)
Which is the special report that is completed and submitted to the workers' compensation payer when the patient first seeks treatment for a work-related injury?
First Report of Injury form
Local Coverage Determination
Formerly called local medical review policy (LMRP); Medicare administrative contractors create edits for national coverage determination rules that are called LCDs.
Observation Services
Furnished in a hospital outpatient setting to determine whether further treatment or inpatient admission is needed; when a patient is placed under observation, the patient is categorized as an outpatient; if the duration of observation care is expected to be 24 hours or more, the physician must order an inpatient admission (and the date the physician orders the inpatient stay is the date of inpatient admission).
Chapter 6
G00-G99; Diseases of the Nervouse System
Which code range is assigned to "temporary" HCPCS procedures or professional services?
G0008-G9156
GEMs
General Equivalence Mappings; translation dictionaries or crosswalks of codes that can be used to roughly identify ICD-10-CM codes for their ICD-9-CM equivalent codes and visa versa.
Which HCPCS level two codes are used by state Medicaid agencies and mandated by the state law to separately identify mental health services?
H codes
Chapter 7
H00-H59; Diseases of the Eye and Adnexa
Chapter 8
H60-H95; Diseases of the Ear and Mastoid Process
The specific _______ code determines whether the claim is sent to the primary MAC that processes provider claims or the DME MAC that processes DMEPOS dealer claims.
HCPCS level II
Which would be assigned to report DMEPOS on insurance claims?
HCPCS level II codes
CPT and HCPCS
HCPCS level II modifiers are added to which codes?
Medicare Part A coverage is available to individuals under the age of 65 who
Have end-stage renal disease and meet requirements
open-panel HMO
Health care is provided by individuals who are not employees of the HMO or who do not brlong to a specially formed medical group that serves the HMO.
Medicare regulation which permitted billing Medicare under the physician's billing number for ancillary personnel services when those services were "incident to" a service performed by a physician.
Incident-to Billing
Global Period
Includes all services related to a procedure during a period of time (e.g., 10 days, 30 days, 90 days, depending on payer guidelines).
Hospital Discharge Service
Includes the final examination of the patient, discussion of the hosptial stay with the patient and/or caregiver; instructions for continuing care provided to the patient and/or caregiver; and preparation of discharge records, prescriptions, and referrals forms.
Which is traditional fee-for-service health insurance that covers a portion of services, such as inpatient hospitalizations or physician office visits, with the patient paying the remaining costs?
Indemnity insurance
The Date of Current ______ must be completed in block 14 of the CMS-1500 claim.
Injury
What does ICD-10-CM stand for?
International Classification of Diseases 10th Revision Clinical Modification
History
Interview of the patient that includes the following components: history of the present illness (HPI) (including the patient's chief complaint), a review of systems (ROS), and a past/family/social history (PFSH).
Physician Standby Services
Involve a physician spending a prolonged period of time without patient contact, waiting for an event to occur that will require the physician's services
Chapter 10
J00-J99; Diseases of the Respiartory System
What is the correct way to enter the provider's name and credential in Block 31?
JOHN BROWN MD
Permanent HCPCS level II codes are updated annually on?
January 1
The general enrollment period (GEP) is held every year from
January 1 through March 31
If a service was performed on June 30, the Medicare claim must be submitted for payment and postmarked no later than
June 30 of the next year
Chapter 11
K00-K95; Diseases of the Digestive System
Chapter 12
L00-L99; Diseases of the Skin and Subcutaneous Tissue
Halo procedure, cervical halo incorporated into Milwaukee-type orthosis. Assign the HCPCS level II code.
L0830
capitation
Managed care is financed according to a method called ___, where providers accept pre-established payments for providing healthcare services to enrollees over a period of time.
A balance of $12.55 is due to the patient for services provided by Dr. Brown. What is entered in Block 30 of the CMS-1500 claim?
Leave blank
Which type of automobile insurance pays for accidental bodily injury and property damage to others, including medical expenses, pain and suffering, lost wages, and other special damages?
Liability
Which type of insurance covers losses to a third party caused by the insured, by an object owned by the insured, or on premises owned by the insured?
Liability
Chapter 13
M00-M99; Diseases of the Musculoskeletal System and Connective Tissue
When the CMS-1500 claim requires spaces in the data entry of a date, the entry looks like which of the following?
MM DD YYYY or MM DD YY
One of the requirements that a participating provider must comply with is to
Make fee adjustments for the difference between amounts charged to patients for services provided and payer -approved fees
Process of obtaining preauthorization
Make sure the procedure and diagnosis meet medical necessity Obtain any necessary documentation, form, and all codes Contact the insurance company to obtain preauthorization
Which includes health maintenance organizations and preferred provider organizations?
Managed care
When patient tells you this was a work related injury, you must obtain the following info:
Name / address of present employer, Name of immediate supervisor, Date & time of the accident or onset of disease Site where injury occurred Patients' description of the onset of the disorder; if patient is claiming injury due to hazardous chemicals or compounds, these should be included in the patient's description of the problem -In addition the patients' employer must be contacted to obtain the name and mailing address of the compensation payer -ask for a faxed confirmation from the employer of the worker with the on the job injury. If the employer disputes the legitimacy of the claim, you should still file the First Report of Injury. The employer must also file an injury report with the compensation commission/board.
NCHS
National Center for Health Statistics
Unique identifier assigned to health care providers as a 10-digit numeric identifier, including a check digit in the last position.
National Provider Identifier
Was created in 1995 to develop a standardized data set for use by the non-institutional health care community to transmit claim and encounter information to and from all third-party payers.
National Uniform Claim Committee (NUCC.org)
After 30 days of active duty who is eligible for TRICARE benefits
National guard and component members
Should highlighter or other marker be used on original documents?
No, you never use highlighter or other marker on original documents to ensure accracy when coding case reports.
NAS
Nonavailability statement
a certificate issued by MFT that cannot provide needed care to TRICARE Standard beneficiaries.
Nonavailability statement
Chapter 15
O00-O9A; Pregnancy, Childbirth, and the Puerperium
Which box is marked in Block 6 workers' compensation CMS-1500 claims?
OTHER
Transfer of Care
Occurs when a physician who is managing some or all of a patient's problem releases the patient to the care of another physician who is not providing consultative services.
Chapter 16
P00-P96; Certain Conditions Originating in the Perinatal Period
Which is not part of medicare plan that is a medicaid service in states that have selected to include this as an options?
PACE programs for seniors
Preferred Providers network (PPN)
PARs can also contract to participate in the plan's preferred provider network (PPN) a program that requires providers to adhere to managed care provisions. Providers signed a PPN contract, agrees to accepts the rates, which is generally 10 percent lower the the PAR allowed rate.
Which organization is responsible for providing suppliers and manufacturers with assistance in determining HCPCS level two codes to be used?
PDAC
Subjective
Part of the note that contains the chief complaint and the patient's description of the presenting problem.
Direct Patient Contact
Refers to face-to-face patient contact (outpatient or inpatient).
Without Direct Patient Contact
Refers to non-face-to-face time spent by the physician on an inpatient or outpatient basis and occurring before and/or after direct patient care
Types of Services (TOS)
Refers to the kind of healthcare services provided to patients; a code required by Medicare to denote anesthesia services.
Claims are submitted to the TRICARE
Regional contractors
The person or company (laboratory or other facility) who rendered the care.
Rendering Physician
What does Medicare and other third-party payers require providers?
Report HCPCS level II codes than unlisted procedure or service CPT codes.
Critical Care Services
Reported when a physician directly delivers medical care for a critically ill or critically injured patient.
HMO Assistance Act
Required most employers with more than 25 employees to offer HMO coverage if local plans were available.
preadmission review
Review for medical necessity of inpatient care prior to admission.
concurrent review
Review for medical necessity of tests/procedures ordered during inpatient hospitalization.
Auditig Process
Review of patient records and CMS-1500 (UB-04) claims to assess coding accuracy and whether documentation is complete.
auditing process
Reviewing patient records, CMS-1500, UB-04 claims for accuracy
Which is a special clause in an insurance contract that stipulates additional coverage over and above the standard contracts?
Rider
retained by the Medical Center as profit
The Medical Center received a $100,000 capitation payment in January to cover the healthcare costs of 150 managed care enrollees. By the following January, $80,000 had been expended to cover services provided. The remaining $20,000 is ______________.
Who made the ICD-10-CM/PCS Coordination and Maintenance Committee?
The National Center for Health Statistics (NCHS) and the Centers for Medicare and Medicaid Services (CMS)
gatekeeper
The PCP serves as a ___ by providing essential healthcare services at the lowest possible cost, avoiding nonessential care, and referring patients to specialists.
VA
The Veterans Health Information Systems and Technology Architecture(VistA) electronic health record was developed by the_______________
report card
The __ __ contains data regarding a managed care plan's quality, utilization, customer satisfaction, administative effectiveness, financial stability, and cost control.
case manager
The __ __ submits written confirmation, authorizing treatment, to the provider.
PCP
The ___ is responsible for supervising and coordinating healthcare services for enrollees and approves referrals to specialists.
medical necessity
The concept of linking codes with procedure or service codes is called_____________
Which is a characteristic of delinquent commercial awaiting payer reimbursement?
The delinquent claims are resolved directly with the payer
Dr. Cummings has been practicing in town for nearly 30 years. As a courtesy to his loyal Medicare patients, he does not charge the coinsurance. How can this affect Dr. Cumming's practice
The doctor may be subject to large fines and exclusion from the Medicare program
major reason patient sought medical care
The first listed diagnosis reported on a CMS-1500 claim is the ____________
procedure/service
To link the diagnosis with the procedure/service means to match the appropriate diagnosis with the _____________that was rendered to treat or manage the diagnosis.
TRICARE nurse advisors are available 24/7 to assist with
Treatment alternatives and recommendations for care.
Which is primary: TRICARE or Medicaid
Tricare
Most health insurance plans are secondary to liabilty insurance
True
Participationg providers must accept reimbursement at medicaid rates
True
The maximum fee a nonPAR may charge for a covered service is called the
limiting charge
What does diagnosis or condition code have to be linked to?
linked with each procedure or service code on the CMS-1500 claim.
An electronic claim is submitted using _____ as its transmission media.
magnetic tape
The Medicare Catastrophic Coverage Act of 1988
mandated the reporting of ICD-9-CM diagnosis codes on Medicare claims; in subsequent years, private third-party payers adopted similar requirements for claims submission.
Inpatient & outpatients hospital services are considered what type of services under medicaid
mandatory
Assigning the 6th or 7th characters when available for ICD-10-CM codes is?
mandatory because they report information documentation in the patient record.
Legacy Coding System/Legacy Classification System
means it will be used to archive data but will no longer be supported or updated by the ICD-9- Coordination and Maintenance Commitee.
When an insurance claim is submitted to an insurance company that covers the treatment of injured sustained in a motor vehicle accident, the _________ reviews the claim and determines coverage for the injured person.
medical adjuster
When an insurance claim is submitted to an insurance company that covers the treatment of injuries sustained in a motor vehicle accident, the ______ reviews the claim and determines coverage for the injured person.
medical adjuster
Encoding or _____ a computer file makes it safe for electronic transmission so that unauthorized parties cannot read it.
.encrypting
Release of information (ROI) by a covered entity about protected health information (PHI) requires the patient (or representative) to sign an authorization to release information, which is reviewed for authenticity and processed within a HIPAA-mandated _____time limit.
60-day
Which is the physician self-referral law that protects patients and federal health care programs from fraud and abuse by curtailing the corrupting influence of money on health care decisions?
Federal Anti-Kickback Law
The Division of Coal Mine Workers' Compensation administers and processes claims for the
Federal Black Lung Program
Which requires Medicare administrative contractors to attempt the collection of overpayments received by a provider or beneficiary?
Federal Claims Collection Act
Which is a legal newspaper published every business day by the National Archives and Records Administration (NARA), and is available in paper form, on microfiche, and online?
Federal Register
Which authorizes CMS to enter into contracts with entities to perform cost report auditing, medical review, anti-fraud activities, and the Medicare Secondary Payer (MSP) program?
MIP (Medicaid Integrity Program)
Which established the Hospital IQR, RAC, and ZPIC programs?
Medicare Prescription Drug, Improvement, and Modernization Act (MMA) of 2003
Which is maintained by the Food and Drug Administration (FDA) and identifies prescription drugs and some over-the-counter products?
NDC
Which was created by the Centers for Medicare and Medicaid Services for the purpose of assigning unique identifiers to health care providers and health plans?
NPPES
Which flat file is used to bill physician and noninstitutional services, such as services reported by a general practitioner, on the CMS-1500?
NSF
The Mine Safety and Health Administration (MSHA) is similar in purpose and intent to the
Occupational Safety and Health Administration (OSHA)
Which consists of audits implemented by DHHS that examines the billing practices of physicians at teaching hospitals with the focus on compliance with the Medicare rule affecting payment for physician services provided by residents and whether the level of the physician service was coded and billed properly?
PATH
Which was established to require facilities to identify and reduce improper Medicare payments and the Medicare payment error rate and also established Clinical Data Abstracting Centers?
PEPP
Which is a hospital payment monitoring program that contains hospital-specific administrative claims data for a number of CMS-identified problem areas to compare their performance with that of other hospitals?
PEPPER
Which was implemented to protect the privacy of individuals identified in information systems maintained by federal government hospitals and to give individuals access to records concerning themselves?
Privacy Act of 1974
Which program was implemented to find and correct improper Medicare payments paid to health care providers participating in fee-for-service Medicare?
Recovery Audit Contractor (RAC)
Which prohibits physicians from referring Medicare patients to clinical laboratory services in which the physicians or their family members have a financial ownership/investment interest and/or compensation arrangement?
Stark I
Which agency is responsible for handling appeals for denied workers' compensation claims
State Workers' Compensation Commission
Which flat file is a series of fixed-length records that is currently used to bill institutional services, such as services performed in hospital?
UB-04
The Office of Workers' Compensation Programs ( OWCP)
administers programs that provide medical treatment, vocational rehabilitation, and wage replacement benefits
The Energy Employees Occupational Illness Compensation Program
began providing benefits to eligible employees and former employees of the Department of Energy in 2001
Which of the following is an example of abuse?
billing noncovered services/procedures as covered services/procedures
Material Safety Data Sheets contain information about
chemical and hazardous substances used on site
vocational rehabilitation
claim that covers expenses for vocational retraining for both temporary and permanent disability cases
temporary disability
claim that covers healthcare treatment for illness and injuries, as well as payment for lost wages.
survivor benefits
claim that provides death benefits to eligible dependents, which are calculated according to the employee's earning capacity at the time of illness or injury.
Material Safety Data Sheet ( MSDS )
contains information about chemical and hazardous substances used on site.
The Patient Protection and Affordable Care Act established a Medicare shared savings program to facilitate the _____ to improve the quality of care for Medicare fee-for-service beneficiaries and to reduce unnecessary costs.
coordination and cooperation among health care providers
The Longshore and Harbor Workers' Compensation Program
covers private-industry workers who are engaged in extracting natural resources from the outer continental shelf
The Medicare Integrity Program includes medical review, which is defined by CMS as a review of claims to determine whether services provided are _____, as well as to followup on the effectiveness of previous corrective actions.
medically reasonable and necessary
An electronic signature will result in a unique bit string (or computer code) called a(n) _____, which is encrypted and appended to the electronic document.
message digest
Drew Baker is referred to a health care provider by an employer for treatment of a fracture that occurred during a a fall at work. The physician billed Medicare and did not indicate on the claim that the injury was work related. Medicare benefits were paid to the provider for services rendered. This resulted in Medicare contracting the provider, who is liable for the _____ because of the provider's failure to disclose that the injury was work-related.
overpayment
adjudication
the judicial dispute resolution process in which an appeals board makes a final determination
HIPAA requires payers to implement rules called electronic _____, which result in a uniform language for electronic data interchange.
transaction standards
Which is the official document that contains new and changed Medicare policies and/or procedures that are to be incorporated into a specific CMS program manual?
transmittals
Because the diagnosis and procedure codes reported affect the DRG selected (and resultant payment), some hospitals engage in a practice called _____, which is the assignment of an ICD-10-CM diagnosis code that does not match patient record documentation, for the prupose of illegally increasing reimbursement.
upcoding
The Patient Protection and Affordable Care Act (PPACA) of 2010 includes a health care reform measure that requires implementation of the hospital _____ program to promote better clinical outcomes and patient experiences of care.
value-based purchasing