Chapter 6
The Correct Coding Initiative (CCI) is a program of
Medicare
Medically Unlikely Edits (MUE's) are a program of
Medicare. (MUE's have been developed as an edit by Medicare.)
The ________ lists the types of medical billing and reporting practices that the Office of Inspector General intends to investigate in the coming year.
OIG Work Plan (The OIG Work Plan lists the types of medical billing and reporting practices that the Office of Inspector General intends to investigate in the coming year.)
What type of coding uses a procedure code that provides a higher reimbursement rate than the correct code?
upcoding (Upcoding uses a procedure code that provides a higher reimbursement rate than the correct code.)
What type of fees are defined as those that physicians charge to most of their patients most of the time under typical conditions?
usual fees (Usual fees are defined as those that physicians charge to most of their patients most of the time under typical conditions.)
UCR is the abbreviation for
usual, customary, and reasonable. (UCR stands for usual, customary, and reasonable.)
If a RAC's request is not answered within an appropriate amount of time, which of the following might occur?
An error is declared and penalties may result. (RAC's requests not answered within an appropriate amount of time will result in an error being declared and penalties may result.)
Global periods for a major procedure have which of the following postoperative periods?
90 days (Major procedures have a postoperative period of 90 days.)
What is the purpose of X modifiers?
Define subsets of modifier 59. (X modifiers define specific subsets of modifier 59, Distinct Procedural Service)
The ________ is the method used to set fees for Medicare.
RBRVS (RBRVS is the method used to set fees for Medicare.)
________ is a normal fee charged by a provider.
Usual fee (A usual fee is a normal fee charged by a provider.)
A write-off is required when
a participating physician's usual fee is higher than the payer's allowed charge. (A write-off is required when a participating physician's usual fee is higher than the payer's allowed charge.)
RACs use a software program to analyze a practice's claims, looking for... excessive number of units billed. medically unnecessary treatment. obvious "black and white" coding errors. all of these are analyzed.
all of these are analyzed. (RACs use a software program to analyze a practice's claims, looking for obvious "black and white" coding errors (such as a well-woman exam billed for a male patient); medically unnecessary treatment or wrong setting of care when information in the medical record does not support the claim; and multiple or excessive number of units billed.)
Maximum charge a plan pays for a service or procedure may be referred to as maximum allowable fee..... allowed amount. allowed charge. all of these are correct.
all of these are correct. (Allowed charge is a maximum charge a plan pays for a service or procedure. The allowed charge is also called a maximum allowable fee, maximum charge, allowed amount , allowed fee, or allowable charge.)
Which of the following modifiers is important for compliant billing? -91 -25 -59 all of these are important
all of these are important (All of these modifiers are important for compliant billing.)
A relative value scale assigns a higher relative value to a procedure that requires more... time. skill. effort. all of these.
all of these. (A relative value scale assigns a higher relative value to a procedure that requires more skill, effort, or time.)
Which of the following is considered a formal examination?
audit (An audit is a formal examination.)
The "provider withhold" required by some managed care plans may
be repaid to the physician. (The "provider withhold" required by some managed care plans may be repaid to the physician, if the plan's financial goals have been achieved.)
Correct claims report the connection between a billed service and a diagnosis. This is called
code linkage. (Code linkage is reporting the connection between a billed service and a diagnosis.)
In the CCI, which type of code cannot be billed together with a column 1 code for the same patient on the same day of service?
column 2 (In the CCI, a column 2 code cannot be billed together with a column 1 code for the same patient on the same day of service.)
A charge that is written off is
deducted from patient's account. (A charge that is written off is deducted from the patient's account.)
EMRs have which of the following to assist physicians with their documentation process?
documentation templates (Documentation templates assist physicians with their documentation processes.)
The conversion factor is a(n) ________.
dollar amount.
If a payer judges that a code level assigned by a practice is too high for a reported service, the usual action is to
downcode the reported procedure code. (If a payer judges that too high a code level has been assigned by a practice for a reported service, the usual action is to downcode the reported procedure code.)
Which of the following refers to the payer's review and reduction of a procedure code?
downcoding (Downcoding refers to the payer's review and reduction of a procedure code.)
In the CCI, which type of codes cannot both be billed for a patient on the same day of service?
mutually exclusive (In the CCI, mutually exclusive codes cannot both be billed for a patient on the same day of service.)
Professional courtesy refers to providing free services to
other physicians and their families. (Professional courtesy means that a physician has chosen to waive (not collect) the charges for services to other physicians and their families. Although this has been common practice in the past, many federal and state laws now prohibit professional courtesy.)
Although anyone who comes into contact with a medical record is responsible for the accuracy of his or her own entry, who in the medical practice is ultimately responsible for proper documentation and correct coding?
physician (Ultimately, the physician is responsible for proper documentation and correct coding.)
What type of audit do payers routinely conduct to ensure that claims are compliant with the provisions of their contracts?
postpayment (Payers routinely conduct postpayment audits to ensure that the claims correctly reflect performed services, that services are billed accurately, and that the physicians and other health care providers who participate in the plan comply with the provisions of their contracts.)
PMP is the abbreviation for
practice management program. (PMP is the abbreviation for practice management program.
The amount withheld from a provider's payment by an MCO is called
provider withhold. (Provider withhold is the amount withheld from a provider's payment by an MCO.)
RVS is the abbreviation for
relative value scale. (RVS stands for relative value scale.)
What type of audit is performed internally after claims are submitted?
retrospective audit (A retrospective audit is performed internally after claims are reported and the remittance advice has been received.)
In an allowed charges payment method, if a provider's charge is higher than the allowed amount, the provider's reimbursement is based on
the amount allowed. (If a provider's charge is higher than the allowed amount, the provider's reimbursement is based on the amount allowed.)
Medical necessity is based on
the relationship between the diagnosis and the treatment provided. (Medical necessity is based upon the relationship between the diagnosis and the treatment, not the number of diagnoses.)
Which of the following is not typically a feature of a practice EHR system that, if used correctly, enhances compliant billing?
voice recognition software (Voice recognition software may not be a feature of an electronic health record system.)
