MA Office Financial Management, Billing, Insurance
A. prevent claim rejection due to ineligibility or non-active status. Rationale This also ensures the correct insurer is billed and facilitates timely reimbursement for the provider. The medical assistant should scan into the EHR or make a copy of both sides of the patient's current insurance card.
1. The main purpose for verifying a patient's insurance coverage at every visit is to A. prevent claim rejection due to ineligibility or non-active status. B. maintain confidentiality of protected health information. C. expedite the age analysis process of delinquent accounts. D. establish rapport and respectful approach to care.
C. explain the non-coverage billing policies. Rationale Making sure that the office has a policy in place to let your patients know what you expect of them and what they can expect of you. A well-crafted policy will prevent patients from being surprised about their financial obligation when they receive billing for your services. It will also give your practice some legal protection should a patient fail to pay what you are entitled to collect. The policy should be tailored to the medical office policy and practice. Being up front with the patients prevents future error or misunderstandings.
10. A patient has refused to pay for a medical procedure that was performed six months ago. The medical procedure was not listed under the patient's schedule of benefits, and she is now fully responsible for all costs. Her account has now been turned over to a collection agency. This scenario is most likely an example of failure of the medical office assistant to properly A. code the procedure. B. bill the procedure. C. explain the non-coverage billing policies. D. explain the statute of limitations.
A. the patient Rationale If the medical office assistant received a full payment from the insurance company, the medical office assistant would refund the patient for any overpayment for services provided.
11. The medical office assistant receives payments in full from both a primary private insurance company and a 65-year-old patient. At the end of the day she realizes there was an overpayment on the patient's account. Which of the following should the overpayment be refunded to? A. the patient B. the insurance company C. Medicare D. the physician
C. precertification. Rationale Precertification is the process where a medical office finds out if a medical service or procedure is covered by the patients insurance carrier. A predetermination of benefits is a review by the insurer's medical staff to decide if they agree that the treatment is right for a patient's health needs. Preauthorization is sought when a doctor requires approval from an insurance company before certain services or medicines are covered. Preexisting refers to a condition that a patient had prior to being covered by an insurance company.
12. The process of finding out if a service or procedure is covered under a patient's insurance policy is called A. predetermination. B. preauthorization. C. precertification. D. preexisting
A. Medicare Part A Rationale Medicare Part A is designed to cover services that are considered a medical necessity or a chronic medical condition. Medicare Part B is the medical insurance component of Medicare, covering cost to treat health problems BEFORE they become more serious. Medicare Part C is an option where the consumer can be covered by a private company. Medicare Part D covers the costs of prescription drugs.
13. A patient comes into a provider's office with a diagnosis CHF due to a medical emergency. The provider admits the patient to a local hospital for care. Which Medicare plan will cover the hospital admission? A. Medicare Part A B. Medicare Part B C. Medicare Part C D. Medicare Part D
B. employ less than 25 full-time employees. Rationale Medicare Part A and B can be submitted in a non-electronic format when the medical practice employs less than 25 full-time employees. The medical office uses Form CMS-1500 to bill for services. Medicare sends a confirmation or acknowledgement report, which indicates the number of claims accepted and the total dollar amount transmitted.
14. ASCA requires that hospital claims submitted to Medicare Part A and B must be submitted electronically, but will accept non-electronic claims on behalf of providers that A. have been in business for less than 90 days. B. employ less than 25 full-time employees. C. also participate in the Medicaid program. D. offer both inpatient and outpatient services.
C. Worker's Compensation Rationale Whenever a patient claims a workplace injury, the health care provider should call the employer to see if a worker's compensation claim has been filed. If so, billing will first go through that claim. The other options listed in this scenario would be follow-up based on whether or not a worker's compensation claim has been filed.
15. A patient presents to the provider's office with a complaint of a migraine. The patient has Medicare and Medicaid. The patient also has a Worker's Compensation claim with a diagnosis of head injury. After the provider assesses the patient, the final diagnosis is a concussion. Where should this claim be submitted first? A. Medicare B. the patient's employer C. Worker's Compensation D. Medicaid
D. Separate financial and health records must be used. Rationale The proper procedure for medical office record keeping in this case is to keep separate financial and health records. HIPAA Privacy Rules dictates that records dealing with a claim can be accessed by certain entities to the health information of individuals who are injured on the job or who have a work-related illness to process claims, or to coordinate care under workers' compensation systems. A patients private medical records, not in connection with the issue relating to the Workers Comp claim, are private and confidential under HIPAA rules. This also applies to financial records.
16. Which is the correct procedure for keeping a Worker's Compensation patient's financial and health records when the same physician is also seeing the patient as a private patient? A. The same financial record may be used, but a separate health record must be maintained. B. The same health record may be used, but a separate financial record must be maintained. C. The same financial and health records may be used. D. Separate financial and health records must be used.
International Classification of Diseases (ICD) Rationale The International Classification of Diseases (ICD) is the standard diagnostic tool for epidemiology, health management and clinical purposes. ICD codes are used to classify diseases, monitor the incidence and prevalence of diseases and other health problems.
17. A medical office assistant is reviewing a chart with the following documentation: indigent patient presented with a complaint of itchy, red bumps on her chest and neck. Diagnosis: Urticaria, Procedure: Expanded Office Visit. The reference manual that would contain the term Urticaria and the associated code is the A. Current Procedural Terminology (CPT) B. Health Care Financing Administration Common Procedure Coding System (HCPCS) C. Centers for Medicare and Medicaid Services (CMS) D. International Classification of Diseases (ICD)
C. HCPCS Rationale This would be found in the HCPCS.
18. The provider prescribed and ordered a wheelchair for a patient with a below-the-knee amputation. Which of the following manuals should the medical office assistant use to code these services? A. ICD-CM B. CPT C. HCPCS D. CPT-assistant
B. claim Rationale Once submitted, claims are reviewed by the insurance company and paid out to the insured (or authorized billing representative) when approved.
19. Request for payment under the terms of a health insurance policy is referred to as which of the following? A. deductible B. claim C. preauthorization D. copayment
B. assignment of benefits Rationale If a patient's health insurance contract allows for assignment of benefits, the patient first fills out a form giving permission that any allowable benefit payment be sent to the medical provider. Without the AOB, any reimbursement would then be issued to the patient, then they would have to be billed by the medical office for payment. The AOB process cuts out the extra step.
2. Which of the following must be filled out by the patient in order to forward payment to the physician's office? A. coordination of benefits B. assignment of benefits C. remittance advice D. explanation of benefits
B. benefits Rationale Payments of premiums must be maintained to keep an insurance policy in active status. Referrals and adjustments do not affect benefits received from insurance coverage. Kickbacks are mostly known as questionable practice within the insurance industry and is coming under increased scrutiny.
20. Premiums are payments made systematically to insurance companies in exchange for which of the following? A. kickbacks B. benefits C. referrals D. adjustments
C. deductible Rationale The patient's out-of-pocket expense due prior to insurance company coverage taking effect is known as the deductible. Part of the deductible can be met with copays (the amount the patient pays at the time of service- generally a set amount based on in-network or out-of-network visits). The premium is the amount of money the insurance company charges for coverage. Coverage (which procedures, visits, etc. are eligible for insurance payment) can vary among insurance plans. The more coverage an insured person has, the higher the insurance premiums.
21. Which of the following is the predetermined amount of total eligible charges a patient must pay before insurance plan benefits begin? A. premium B. coverage C. deductible D. copay
B. Part B Rationale A monthly premium and meeting an annual deductible are standard to qualify, after which an 80% reimbursement rate will take effect - the insured is responsible for the 20% coinsurance. [Part A - hospital insurance, Part B - helps to offset costs not covered by Part A, Part C - Medicare Advantage, allows beneficiaries to select a managed care plan as their primary coverage Part D - prescription drug coverage, helps with coverage of some medications.]
22. Which part of Medicare covers office visits with a primary care provider? A. Part A B. Part B C. Part C D. Part D
A. copayment Rationale Amounts of copayments are pre-determined by the insurance carrier (ex. $25 for an office visit or $50 for a specialty visit). A deductible is a specified amount of money that the insured must pay before an insurance company will pay a claim. Coinsurance is a type of insurance in which the insured pays a share of the payment made against a claim. The out-of-pocket maximum is the most you pay during a policy period (usually one year) before your health insurance or plan starts to pay 100% for covered essential health benefits.
23. The set dollar amount collected at the time of each visit for a patient's portion of health care costs is referred to as which of the following? A. copayment B. deductible C. coinsurance D. out-of-pocket maximum
C. in-network. Rationale Insurance can be tricky. One way providers and insurance companies work together is to pre-negotiate rates for services. The provider is then considered in-network (also called participating, authorized, or network provider). Those providers who do not have an accepted rate agreement are considered out of network (or non-network). For-profit and not-for-profit status should not affect the medical care received. The main difference is the accounting: When for-profits make money, the shareholders make money. Non-profit organizations don't typically have shareholders and they get income and property tax exemptions that for-profits don't.
24. A provider who has a contractual agreement to accept an insurance company's pre-negotiated rate for health care services is considered to be A. for-profit. B. not-for-profit. C. in-network. D. non-network
A. the plan of the policyholder whose birthday comes first in the calendar year Rationale The birthday rule applies to month and day, not year. Example: The plan of the parent whose birthday is in January would become the primary insurance policy for the child if the other parent's birthday is in June.
25. A child is covered by the insurance policies of each of his parents: United Health Care and Blue Cross/Blue Shield. According to the birthday rule, which of the following plans should become the primary insurance? A. the plan of the policyholder whose birthday comes first in the calendar year B. the plan of the policyholder whose birthday comes last in the calendar year C. the plan of the policyholder that is least expensive per month D. the plan of the policyholder that has the lowest annual deductible
C. Promptly verify the patient's insurance coverage with their employer. Rationale It would be promptly necessary to ensure compliance for care reimbursement. In order to do that, the MA would verify the patient's insurance coverage with their employer. The goal of worker's compensation laws are to provide prompt care to the patient in order to restore optimum health, and allow them to return to maximum earning capacity as soon as possible. The medical assistant should verify the employer's coverage for work-related illness or injury. A claim may be rejected if not filed within the statutory time limit. Examples: an overexertion injury from lifting, or a slip on a wet surface that causes the person to fall to the floor or ground.
26. Which of the following actions should the medical assistant take when handling a workers' compensation claim? A. Ensure the patient has obtained legal representation prior to seeking care. B. Process the claim according to disability income insurance guidelines. C. Promptly verify the patient's insurance coverage with their employer. D. Bill the patient directly to collect outstanding reimbursement for treatment.
C. 23 year old woman that has been blind since birth. Rationale Medicare is a Federal health insurance program which provides coverage for those who qualify over age 65 or under age 65 with a disability (unable to work). All other individuals could utilize their retirement insurance benefits through their work, long term disability or workers compensation or even Medicaid depending on their circumstances.
27. Which of the following patients below meet Medicare's eligibility criteria? A. 45 year old man who suffered a back injury and hasn't been able to work for 9 months. B. 61 year old woman who recently retired from the local school district. C. 23 year old woman that has been blind since birth. D. 53 year old man who received a liver transplant.
A. deductible not met Rationale The total cost of services for this visit is $252. Insurance paid $140 (plus patient co-pay $20 = $160 paid on a $252 charge). 252-160= $92 The outstanding balance is the patient's responsibility because the deductible is not met. The deductible is $1000. The co-pay is $20. 1000-20= $980 to meet deductible.
28. A patient questions an outstanding balance when insurance coverage is active and the co-pay has been paid. Which of the following is the most likely reason the balance is the patient's responsibility? A. deductible not met B. premiums due C. the birthday rule applies D. pre-authorization not obtained
D. collect fees at the time of service. Rationale It is considered to be most effective for health care providers to collect fees at the time of service when possible. This eliminates the need to mail out a bill and periodic reminders. If a bill is unpaid at the time of service, then a bimonthly billing service would be a good choice. Periodic reminders may be necessary if the patient does not return payment after the bill has been sent. A collection agency may become involved if the patient does not pay an outstanding balance in a reasonable time (after a bill and reminders have been issued).
29. The most effective method to manage patient statements and other financial invoices, and avoid payment delays is to A. use a bimonthly billing system. B. issue periodic reminders. C. use a collection agency. D. collect fees at the time of service.
B. CMS-1500 Rationale The CMS-1500 is the form to be used to enable the provider or medical facility to receive reimbursement directly from a patient's insurance company.
3. Which of the following documents does the provider or facility need to submit in order to receive reimbursement from an insurance company? A. ABN B. CMS-1500 C. medical consent form D. explanation of benefits
B. pathology and lab Rationale A urine screen is performed in a laboratory, so a payment should post under pathology and laboratory services. X-rays, scans, etc. would post under radiology services. Routine annual physicals, mammograms, etc. would post under evaluation and management services. Medicine services would encompass codes that are not routine or otherwise defined
30. When coding for a urine screen, under which of the following sections of the CPT® is this service line found? A. E&M B. pathology and lab C. radiology D. medicine
A. credit card number B. expiration date E. CVC number Rationale In order to process a credit card payment over the phone, specific information is needed: the card number, expiration date, and CVC code (also known as CVV, CSC, etc). The 3 digit code on the back of a credit card is a card validation/verification/security code. The actual initials vary among credit card carriers, but the function is to protect against fraud.
31. Which of the following information must be gathered when processing a credit card payment by telephone? (Select the three (3) correct answers.) A. credit card number B. expiration date C. bank routing number D. checking account number E. CVC number
C. the insurance adjustment. Rationale An Explanation of Benefits (EOB) is a document from the insurance company to the patient that includes detailed information regarding a claim that was paid to the health care provider. Once a provider accepts the allowed charges (fee schedule) for a particular procedure, it is accepting assignment. The provider agrees to accept the contractual amount (insurance adjustment) as payment in full from the insurance company. An adjustment is basically a billing discount in accordance with a contract between the health care provider and insurance company. Participating (PAR) and Non-Participating (NON-PAR) providers choose whether to participate in the Medicare program and either accept or not accept assignment on Medicare claims.
32. When posting an insurance payment via an EOB, the amount that is considered contractual is A. the insurance allowed amount. B. the NON-PAR payment allowable. C. the insurance adjustment. D. the patient responsibility.
B. explanation of benefits Rationale The medical assistant examines the explanation of benefits (EOB) for accuracy, and posts payments and/or adjustments on the patient's account. For Medicare reimbursement, this is called Explanation of Medicare Benefits (EOMB). It is known as a Remittance Advice (RA) for Medicaid.
33. Which of the following insurance related forms includes a detailed description of benefits paid, reduced, or denied on a claim? A. coordination of benefits B. explanation of benefits C. service benefit plan D. assignment of benefits
B. encounter form Rationale An encounter form is a preprinted form (also referred to as a superbill, fee slip, or charge ticket) used to facilitate coding, billing, and reimbursement in the medical office. The other forms listed would not be used in this situation.
34. During an office visit, which of the following records accompanies each patient's chart and lists treatments and procedures with respective codes to assist in billing? A. health information B. encounter form C. preauthorization D. CMS-1500
D. adjustment column. Rationale A professional discount is a discount given to a health care provider, by choice of the providing medical practitioner. The discounted amount is taken off the account as a write off. It is not a charge or a reference and would be documented in the adjustment column by the person keeping the books.
35. When there is a professional discount awarded to a patient's account, the medical assistant should post the discounted amount under the A. reference column. B. balance column. C. charges column. D. adjustment column.
A. provide an overall financial status update. Rationale A day sheet is a journal of the daily charges, payments and deposits of the practice. Each patient payment is logged. This includes all payments that come by EFT and mail.
36. Daily transactions are posted onto a day sheet in order to A. provide an overall financial status update. B. accurately track office supply inventory. C. monitor the accuracy of electronic health records. D. ensure correct CPT codes are assigned.
A. the patient Rationale In case of an overpayment, it is first necessary to verify whether or not the extra money is applied to the same procedure with the same diagnosis code on the same date of service. If all are the same, then the patient would receive the refund. Occasionally, the insurance company will pay more than the anticipated covered amount.
37. The medical office assistant receives payments from both insurance company and patient. At the end of day she realizes there was an overpayment on the patient's account. Which of the following should the overpayment be refunded to? A. the patient B. the insurance C. Medicaid D. the physician
D. single-entry Rationale A checkbook register has a single line entry for each transaction, as does a single-entry daily tracking system. The transaction is only associated with one single account. Double-entry systems are considered to be the standard method, but is more complex than single-entry. Two accounts are associated with a double-entry system (credits and debits). A pegboard (write-it-once) system includes an encounter form, ledger card, journal entry, and receipt. It also uses a daysheet. The daysheet lists all entries for patients seen with their financial charges/payments. At the end of the day, the entries are calculated and totals are posted.
38. Daily tracking of which of the following bookkeeping systems is managed similarly to a checkbook register? A. double-entry B. daysheet C. pegboard D. single-entry
B. 76-4/1049 Rationale An ABA routing transit number (ABA RTN) is a nine digit code, used in the United States, which appears on negotiable instruments such as checks to identify the financial institution on which it was drawn. It represents the area (geographical region) of the bank and the identifier associated with that institution. This number links the check to the proper bank.
39. Which number on the check represents the ABA number? A. 0597 B. 76-4/1049 C. 1234560597 D. 123456789
C. assignment of benefits Rationale If a patient's health insurance contract allows for assignment of benefits, the patient first fills out a form giving permission that any allowable benefit payment be sent to the medical provider. The CMS-1500 is the basic form for the Medicare and Medicaid programs for claims from physicians and suppliers. A UB-04 form is the electronic format of the CMS-1450 claim form. A consent form does not allow for payments from an insurance carrier, only for the patient to consent to accept medical treatment.
4. Which of the following forms is used by the medical office to ensure that insurance payments are made directly to the physician? A. CMS 1500 B. patient consent C. assignment of benefits D. UB-04
B. assignment of benefits Rationale A patient can authorize payment directly from the insurance company to the health care provider with an assignment of benefits. Coordination of benefits is needed when a patient is covered by one or more plan (i.e. insurance and Medicare) to determine how much and for which services each plan is responsible for paying. A remittance advice (RA) and an explanation of benefits (EOB) each explain what payments/adjustments will be made for services received. The RA is submitted to the provider, whereas an EOB is sent directly to the insured patient.
40. Which of the following must be completed by the patient to authorize payment directly from the insurance company to the physician's office? A. coordination of benefits B. assignment of benefits C. remittance advice D. explanation of benefits
A. accounts receivable report. Rationale A daily accounts receivable report provides a list of account balances with amounts owed to the medical practice. The disbursement report is the opposite; it is a report of the expenditures made by the practice (a.k.a. money spent). An aging summary report would list amounts owed by clients based on how many days they are past the due date. The insurance aging report would list the outstanding claims that the medical practice still needs to receive from insurance providers.
41. A list of all account balances and the amounts owed to the medical practice at the end of the day is called a(n) A. accounts receivable report. B. aging summary analysis. C. disbursement report. D. insurance aging report.
A. coding Rationale The medical assistant understands that coding assigns a certain numeric value to a medical diagnosis, surgery, procedure, symptom(s) of a disease and medical care for insurance processing and reimbursement. Example: CPT or ICD-CM. Annotation involves explanation through notes/commentary. Indexing is performed by entering information into a database or record for historical storage and retrieval. The labeling process for files, charts, etc. can utilize an alpha-numeric system.
42. Which of the following front office tasks performed by the medical assistant describes the translation of words into numbers so that insurance claims may be filed? A. coding B. annotating C. indexing D. alpha-numeric labeling
B. assess average blood sugar control in a patient with diabetes. Rationale Two of the main laboratory tests that monitor diabetics or those at risk of diabetes are glucose and hemoglobin A1c (HbA1c). The glucose test measures the immediate levels in the blood. HbA1c provides an overview of how well glucose levels have been maintained over the previous 3 month time frame. Hemoglobin (HGB) would be used to evaluate a patient for iron deficiency anemia. Erythrocyte sedimentation rate (ESR) and C-reactive protein are tests used to evaluate a patient with Crohn's disease for active inflammation. Electrolytes (Lytes) assess the electrolyte balance in a patient with dehydration.
43. The medical assistant processes a patient's lab requisition for a HbA1c. The purpose of this test is to A. evaluate a patient for iron deficiency anemia. B. assess average blood sugar control in a patient with diabetes. C. evaluate a patient with Chron's disease for active inflammation. D. assess the electrolyte balance in a patient with dehydration.
D. Gastrointestinal Rationale EGD= Esophagogastroduodenoscopy. This is a procedure performed to examine the upper gastrointestinal (GI) tract with an endoscope. An EGD is performed for a variety of reasons. Patients with Crohn's disease and cirrhosis of the liver are candidates for an upper GI. Also, upper GI testing is performed on patients with new or unexplained symptoms of heartburn, anemia, regurgitation, or vomiting blood.
44. The patient is scheduled for an EGD. When assigning a CPT® code, the medical assistant understands which of the following body systems is primarily involved? A. Cardiac B. Endocrine C. Reproductive D. Gastrointestinal
A. thyroid gland enlargement Rationale A goiter is an enlarged thyroid gland, which is located in the neck. Iodine deficiency is the world's leading cause of goiter - but this is rare in North America. In developed countries, goiter is usually caused by an autoimmune disease. A goiter is not due to profound muscle weakness, lateral spine deformity, or chronic back pain.
45. The patient with goiter has which of the following abnormalities? A. thyroid gland enlargement B. profound muscular weakness C. lateral spine deformity D. chronic back pain
D. ultrasound Rationale An Ultrasound is a noninvasive procedure that produces images by exposing part of the body to high frequency sound waves. (Also called a sonogram.) An MRI is an magnetic resonance imaging used in radiology, a CT Scan uses a computer that takes data from several X-ray images of structures inside a human's or animal's body and converts them into pictures on a monitor and a KUB is a plain frontal supine radiograph of the abdomen.
46. Which of the following diagnostic procedures makes internal structures visible by recording the reflections of sound waves directed into the tissues? A. MRI B. CT Scan C. KUB D. ultrasound
B. CMS-1500 Rationale CMS-1500 is a standardized claim form that healthcare providers submit for Medicare reimbursement (Universal Claim Form - Centers for Medicare and Medicaid Services). A patient can authorize payment directly from the insurance company to the health care provider with an assignment of benefits. An explanation of benefits (EOB) explains what payments/adjustments will be made for services received. The EOB is sent directly to the insured patient. Assumption of liability relates to a patient assuming liability for any expenses incurred (either the balance of what insurance does not pay or the entire bill).
47. Which of the following forms should the medical assistant submit to request insurance reimbursement for a physician's office visit? A. Assignment of Benefits B. CMS-1500 C. Assumption of Liability D. Explanation of Benefits
B. upcoding Rationale This is an example of upcoding, a deliberate upgrading of medical coding to gain benefit. It is illegal to purposely "upcode" an encounter for any reason. The coding system is specific and should be diligently followed. Adding a modifier to codes can further explain circumstances of a particular visit. E/M codes are for evaluating and management of the patient's care, billed and paid by the amount of time that a physician has spent with the patient and the vitals measured during the intake. Capitation is a payment method used by managed care offering a fixed amount for services rendered, no matter how many times a covered patient seeks care.
48. The physician asks the medical assistant to choose an E/M code indicating 40 minutes were spent on an office visit that actually took less than 15 minutes. This is an example of which of the following? A. adding a modifier B. upcoding C. unbundling D. capitation
C. HCPCS Rationale A wheel chair is classified as durable medical equipment. A prescription for a wheel chair would be coded for in the HCPCS. Healthcare Common Procedure Coding System (HCPCS) level II codes address durable medical equipment and other services not in the level I Current Procedural Terminology (CPT) codes. ICD (International Classification of Disease) codes are associated with the diagnosis/disease instead of procedures
49. The provider prescribed and ordered a wheel chair for a patient with a below the knee amputation. Which of the following manuals should the medical office assistant use to code these services? A. ICD-10-CM B. CPT C. HCPCS D. CPT-assistant
D. Payment is misplaced. Rationale The first step of reconciliation is to first determine if a payment is misplaced. Then issues of duplication or misplaced monies can be addressed. Transactions involving a possible bank error would be the last thing to check before checking the medical office records.
5. Which of the following is the most likely cause of the deposits not agreeing with the credits on the day sheet or the patient ledgers? A. There are duplicate cards. B. The bank made an error. C. Cash is missing. D. Payment is misplaced.
B. five digit codes. Rationale Current procedural terminology (CPT) codes are made up of five numbers. CPT is currently identified by the Centers for Medicare and Medicaid Services (CMS) as Level 1 of the Healthcare Common Procedure Coding System. The Current Procedural Terminology (CPT) was developed by the American Medical Association (AMA). Other types of file identification can include color, alpha, numeric or other coding in addition to CPT.
50. A medical office assistant can recognize Current Procedural Terminology (CPT®) codes because they are A. alpha-numeric codes. B. five digit codes. C. three, four, and five digit codes. D. four digit codes.
C. HCPCS Rationale Healthcare Common Procedure Coding System (HCPCS) level II codes address durable medical equipment and other services not in the level I Current Procedural Terminology (CPT) codes. ICD (International Classification of Disease) codes are associated with the diagnosis/disease instead of procedures. Level III HCPCS codes were used for local supplies and services, previously referred to as miscellaneous codes.
51. When billing for durable medical equipment, a medical office assistant should use which of the following codes? A. CPT B. ICD C. HCPCS D. Level III
B. modifier Rationale The addition of a modifier to a code provides a path for the provider to signify additional information or circumstances were present for a given code. The modifier -50 indicates a bilateral procedure was performed at the same time. V codes are used to indicate an encounter with no current illness or injury. Depending on the medical situation, V codes can be the primary (listed first) or secondary (contributing) code. E/M coding deals with evaluation and management. E codes are considered supplemental. They are used to list an external cause (i.e. what caused the injury).
52. Which of the following should the medical assistant assign to a patient's main CPT® code, indicating unusual circumstances were present related to the procedure? A. E/M code B. modifier C. symbol D. V code
C. V Rationale V codes are used to indicate an encounter with no current illness or injury. Depending on the medical situation, V codes can be the primary (listed first) or secondary (contributing) code. E/M coding deals with evaluation and management. E codes are considered supplemental. They are used to list an external cause (i.e. what caused the injury). "+" is not a commonly used symbol in the medical coding system.
53. A parent brings their four-year old in for a well-child exam. The medical assistant should assign an ICD-CM code beginning with which of the following? A. E B. M C. V D. +
C. ICD-CM Rationale CMS-1500 refers to a standardized claim form that healthcare providers submit for Medicare reimbursement. A portion of this form requires ICD coding. ICD-10-CM stands for: International Classification of Diseases, Tenth Revision, Clinical Modification. This is a classification system which assigns codes for different diagnoses, symptoms and procedures asserted, applied and received during a visit to a health care provider. CPT (Current Procedural Terminology- developed and overseen by the American Medical Association) codes are considered the first level of the HCPCS (Health Care Procedure Coding System). CMS (Centers for Medicare and Medicaid Services) issues every provider of health care in the United States an identification number called an NPI (National Provider Identifier).
54. The physician asks the medical assistant to fill out a CMS-1500 for a patient who came in for a 30 minute office visit and was treated for hypertension. Which of the following should the medical assistant use to locate the code for hypertension? A. CPT B. NPI C. ICD-CM D. HCPCS
D. International Classification of Diseases (ICD) code book Rationale Urticaria is a type of skin rash commonly known as hives. In the scope of medicine, this diagnosis is considered the "disease" and would be found in the International Classification of Disease (ICD) reference manual. CPT and HCPCS are both associated with procedures. CMS is the Centers for Medicare & Medicaid Services and requires forms to be filled out (to include applicable ICD, CPS and HCPCS codes).
55. A medical office assistant is reviewing a chart with the following documentation: patient presented with a complaint of itchy, red bumps on her chest and neck. Diagnosis: Urticaria, Procedure: Expanded Office Visit. The coding reference manual that would contain the term Urticaria and the associated code is the A. Current Procedural Terminology (CPT) code book B. Health Care Financing Administration Common Procedure Coding System (HCPCS) code book C. Centers for Medicare and Medicaid Services (CMS) code book D. International Classification of Diseases (ICD) code book
B. UB-04 Rationale A UB-04 form (a.k.a. CMS-1450) is a standard form used for claims billed to Medicare Administrative Contractors. An ABN is an advanced beneficiary notice and is used when patients choose to have procedures/services that may not be covered by insurance (patient gives informed consent to pay if insurance does not cover). Spend down is terminology that describes a situation where the patient has too many assets (or too high an income) to qualify for benefits such as Medicaid. This requires the patient to use up this money before they reach levels of benefit eligibility.
56. A physician has admitted a Medicare patient to the hospital for shortness of breath. After reviewing the patient's medical record, the hospital coder codes the admission as 99223. On which of the following claim forms should the hospital coder submit this patient's charges? A. spend down B. UB-04 C. ABN D. CMS-1500
B. a medical necessity. Rationale A medically necessary healthcare service is generally the least invasive, most effective treatment that is "reasonable and necessary" for the patient condition (i.e. standard of care). V codes (obsolete as of October 1, 2015) were used for non-injury or non-disease encounters (i.e. suture removal, infectious disease exposure, etc.). Upcoding is the fraudulent act of submitting CPT codes for services that will reimburse at a higher rate than the actual services provided. Part of the audit process is to help reduce fraud or unnecessary treatment billed to insurance.
57. Healthcare services for the evaluation and management of a disease consistent with the standard of care are considered to be A. V codes. B. a medical necessity. C. upcoding. D. part of the audit process
A. Part A Rationale Benefits are received when a person becomes eligible for Social Security. Medicare is for people age 65 or older, and for those who are disabled or are on renal dialysis. Medicare has two parts. Medicare Part A covers hospital stays and other inpatient services. Part B covers physician and other outpatient services, medically necessary services and preventive services, Part D covers the prescription drug coverage and Medicare supplement policies address gaps in coverage.
58. Which part of Medicare covers hospitalization expenses? A. Part A B. Part B C. Part D D. Medicare supplement policies
B. outpatient Rationale Also known as ambulatory care. Example: treatment received at a Dermatology Clinic. Inpatient and Long-term care indicates medical treatment within a medical facility is necessary. Acute care is providing or concerned with short-term medical care especially for serious acute disease or trauma that may or may not include hospitalization.
59. Which of the following classifications of patient care is received at a medical facility on a walk-in basis, where an overnight stay is not required? A. acute B. outpatient C. inpatient D. long-term
A. insurance allowed amount. Rationale An Explanation of Benefits (EOB) is a document from the insurance company to the patient that includes detailed information regarding a claim that was paid to the health care provider. Once a provider accepts the allowed charges (fee schedule) for a particular procedure, it is accepting assignment. The provider agrees to accept the contractual amount (insurance adjustment) as payment in full from the insurance company. An adjustment is basically a billing discount in accordance with a contract between the health care provider and insurance company. Participating (PAR) and Non-Participating (NON-PAR) providers choose whether to participate in the Medicare program and either accept or not accept assignment on Medicare claims.
6. When posting an insurance payment via an EOB, the amount that is considered contractual is the A. insurance allowed amount. B. NON-PAR payment allowable. C. co-insurance. D. patient responsibility.
A. Disability Rationale The purpose of Disability payments is to replace income the patient has lost due to their disability (short term or long term) - claim forms must be proofread carefully and signed by the physician. Workers' compensation is a form of insurance providing wage replacement and medical benefits to employees injured in the course of employment in exchange for mandatory relinquishment of the employee's right to sue his or her employer for the tort of negligence. Medicaid is a joint federal and state program that helps low-income individuals or families pay for the costs associated with long-term medical and custodial care, provided they qualify. Although largely funded by the federal government, Medicaid is run by the state where coverage may vary. Tricare, formerly known as the Civilian Health and Medical Program of the Uniformed Services (CHAMPUS), is a health care program of the United States Department of Defense Military Health System.
60. Which type of insurance begins direct payment to the patient after they have been injured and unable to work for a specific period of time? A. Disability B. Worker's Compensation C. Medicaid D. TRICARE
A. Medicaid Rationale Medicaid is program of medical aid designed for those unable to afford regular medical service and financed jointly by the state and federal governments. A patient's coverage must be verified at each visit, pre-authorization is required for some services to obtain reimbursement. Medicare is a government program of medical care especially for the elderly or handicapped. CHAMPVA is a health benefits program in which the Department of Veterans Affairs (VA) shares the cost of certain health care services and supplies with eligible beneficiaries. Blue Cross/Blue Shield is one of many public insurance companies providing insurance with coverage that may vary by state.
61. Which of the following plans, funded by state and federal funds, exists to aid those with a limited or low income with health care costs? A. Medicaid B. Medicare C. CHAMPVA D. Blue Cross/Blue Shield
C. coordination of benefits Rationale Coordination of benefits is needed when a patient is covered by one or more plan (i.e. insurance and Medicare) to determine how much and for which services each plan is responsible for paying. The primary insurance carrier must be determined (and billed first) to ensure record accuracy. Precertification is the process of finding out if a service or procedure is covered under a patient's insurance policy. Once it's determined that a procedure/service is covered, permission (preauthorization) must be obtained from the insurance provider. Fee-for-service (FFS) delivery systems pay providers for each service rendered. For instance, a separate fee will be paid for the office visit, lab tests, x-ray, etc.
62. Which of the following prevents duplication of payment by more than one insurance carrier? A. fee‑for‑service B. precertification C. coordination of benefits D. pre-authorization
B. Medicare Rationale Persons under 65 years of age with severe disabilities, or permanent kidney failure, or amyotrophic lateral sclerosis (ALS) may also qualify for Medicare coverage. Medicaid is a joint federal and state program that helps low-income individuals or families pay for the costs associated with long-term medical and custodial care, provided they qualify. Although largely funded by the federal government, Medicaid is run by the state where coverage may vary. TRICARE, formerly known as the Civilian Health and Medical Program of the Uniformed Services (CHAMPUS), is a health care program of the United States Department of Defense Military Health System. Workers' compensation protects workers who are injured or become ill on the job.
63. Which of the following government sponsored health insurance programs primarily serves older adults over 65 years of age? A. TRICARE B. Medicare C. Medicaid D. Workers' Compensation
A. TRICARE Rationale Health care providers must be approved to accept patients with TRICARE (formerly CHAMPUS); preauthorization is required for some services. Medicaid is program of medical aid designed for those unable to afford regular medical service and financed jointly by the state and federal governments. Medicare is a government program of medical care especially for the elderly or handicapped. FEHB is only available to Federal employees, retirees and their survivors.
64. Which of the following health care benefit plans primarily serves active duty and retired uniformed military service members and their families? A. TRICARE B. Medicare C. Medicaid D. Federal Employees Health Benefits (FEHB) Program
B. major medical Rationale Major Medical coverage usually takes effect after the patient's deductible and co-insurance have been met. Basic medical insurance covers normal care (i.e. office visits, outpatient care). Some hospitalization and long-term care may still be covered under most primary insurance plans.
65. Which of the following types of coverage provide protection up to a maximum limit in cases of catastrophic or prolonged illness? A. basic medical B. major medical C. hospitalization D. long-term care
A. Proper ICD-10-CM and CPT codes Rationale In many cases, prior authorization is necessary in order for insurance coverage. Some drugs require prior authorization (i.e. a physician may need to request and receive approval before prescribing a drug). The request form should contain the proper ICD-9(10) and CPT codes associated with the particular reason for the request. HCPCS codes are not generally needed in this case.
82. What items are needed to submit a prior authorization request? A. Proper ICD-10-CM and CPT codes B. Proper ICD-10-CM code only C. Proper CPT code only D. Proper HCPCS code only
B. rider Rationale Insurance benefits may be increased or decreased. For instance, a rider (an extra provision in an insurance policy that alters coverage) can exclude coverage for preexisting conditions for a specific period of time or add benefits for long-term care. A referral indicates to the physician to be seen (likely a specialist) that the primary care physician (PCP) feels the patient should seek further care from the other physician (specialist). The patient's out-of-pocket expense due prior to insurance company coverage taking effect is known as the deductible. Precertification is the process of finding out if a service or procedure is covered under a patient's insurance policy.
66. An added feature to a patient's insurance policy expanding or placing limits on standard coverage is a A. referral. B. rider. C. deductible. D. pre-certification.
B. group policy Rationale The majority of people in the United States (approximately 60%) receive their health insurance through employer-sponsored group plans. Under an indemnity plan, the insurance company pays a percentage of each covered healthcare service after it is rendered. In a Fee-for-service plan, the healthcare providers set the fees for each of the services used on that patient for that visit and the payment is on a per service basis (not bundled). Coinsurance is a form of shared payment usually framed as a percentage. That percentage reflects the patient's responsibility for each instance of care.
67. Employees of a major automobile manufacturer are provided health insurance under a master contract issued to their employer. Which of the following types of coverage does this reflect? A. indemnity plan B. group policy C. coinsurance D. fee-for-service plan
A. CMS-1500 Rationale The specific type of insurance plan is selected in block 1 of the CMS-1500 (Centers for Medicare/ Medicaid Services) claim form. A UB-40 form (a.k.a. CMS-1450) is a standard form used for claims billed to Medicare Administrative Contractors. In a private pay agreement, the patient pays for the service or procedure.
68. Which of the following forms should be transmitted to obtain reimbursement following a physician's office visit for a patient with active Medicaid coverage? A. CMS-1500 B. CMS-1450 C. Private Pay Agreement D. UB-04
A. ICD-10-CM and CPT codes Rationale Proper ICD-CM and CPT codes are key pieces that help to minimize the possibility of a claim being rejected due to missing and/or incorrect information (a.k.a. a "dirty claim"). The explanation of benefits (EOB) and insurance premiums are not a part of the claim form. An explanation of benefits is a document sent to the patient that explains what payments/adjustments will be made for services received. Premiums should be paid by the patient to the insurance company, and the provider is not a part of this process.
69. For reimbursement purposes, the medical assistant should check to make sure that which of the following key pieces are provided on the insurance claim form? A. ICD-10-CM and CPT codes B. EOB and insurance premium C. ICD-10-CM codes and insurance premium D. EOB and CPT codes
A. accounts receivable report. Rationale A record of account balances and amounts owed the medical practice is called an accounts receivable report. Accounts payable is that which is owed to vendors or suppliers of the medical practice. An aging report will only list of outstanding balances due. An insurance aging report provided an aged summary of the medical offices outstanding charges broken down by insurance provide
7. A list of all account balances and the amounts owed to the medical practice at the end of the day is called an A. accounts receivable report. B. aging summary analysis. C. accounts payable report. D. insurance aging report.
D. CMS-1500 Rationale CMS -1500 is a form that is used to process insurance claims for payments, electronic or hard copy, HIPAA waiver is to allow provider to give information regarding your care. Encounter form is the record of the daily, individual visits, and assignment of benefits is stating that the payment can go directly to the provider.
70. When filing an electronic insurance claim, the medical assistant processes which of the following forms? A. HIPAA waiver B. encounter form C. assignment of benefits D. CMS-1500
C. the driver's automobile insurance Rationale In case of an automobile accident, a victim/patient would be covered under the driver's liability/auto insurance. If the patient also has health insurance, this would require a coordination of benefits to decide which coverage would be primary and secondary. The claim in this instance would be first submitted to the driver's insurance. Depending on the policy and other variables, the patient's automobile insurance and the patient's primary health insurance might pay part of the balance unpaid by the driver's auto insurance.
71. A patient sustained broken ribs in an automobile accident in which she was the passenger. After completion of an office follow up visit, which of the following should the medical office assistant submit the insurance claim to first? A. the patient's primary health insurance B. the patient's automobile insurance C. the driver's automobile insurance D. the driver's primary health insurance
D. registration form Rationale The patient registration form would include information that would pertain to the patient information question block section on a CMS-1500 form.
72. Which of the following patient documents should a medical office assistant refer to in order to complete the patient information question block section of the CMS-1500 form? A. health history form B. release form C. HIPAA form D. registration form
C. fraud. Rationale This would be an example of fraud, which is when one person is intentionally deceitful in order to gain money. A clerical error would occur if the provider's assistant or secretary accidentally made a mistake. Abuse can occur in many forms, resulting in someone or something being treated improperly. A HIPAA (Health Insurance Portability and Accountability Act) violation occurs when a healthcare provider discloses information that is supposed to be confidential.
73. If a provider charges for services that were not performed, it is considered A. a clerical error. B. abuse. C. fraud. D. a HIPAA violation.
B. Medicare Part B Rationale This claim should be submitted to Medicare Part B since it is an outpatient medical procedure. Medicare Part A basically covers inpatient care, but can expand to cover hospice and home health in a limited capacity. Medicare Part B is generally referred to as medical insurance that covers outpatient visits, services and supplies. Medicare Part C (a.k.a. Medicare Advantage) is an additional option for private insurance on top of A and B. Medicare Part D is associated with prescription drugs.
74. A Medicare patient presents to an outpatient hospital facility for a scheduled hysterectomy. To which Medicare plan should the facility submit the claim? A. Medicare Part A B. Medicare Part B C. Medicare Part C D. Medicare Part D
C. Determine if a workman's compensation claim has been filed. Rationale Whenever a patient claims a workplace injury, the health care provider should call the employer to see if a workman's compensation claim has been filed. If so, billing will first go through that claim. The other options listed in this scenario would be follow-up based on whether or not a workman's comp claim has been filed.
75. A patient presents to the provider's office with a complaint of persistent migraines three days after acquiring a head injury on the job. After the provider assesses the patient, the final diagnosis is a concussion. Which of the following actions should the medical assistant take next? A. File a claim with the patient's primary insurance carrier. B. Bill the patient's employer directly. C. Determine if a workman's compensation claim has been filed. D. Obtain payment directly from the patient at the time of service.
B. days. Rationale Insurance plans generally list benefits for hospitalization separately from other benefits. Most plans set limits based on a total amount to be paid on the insured's behalf or a maximum number of days in the hospital that will be covered.
76. Hospitalization benefits under insurance plans are usually limited to a total monetary amount or a maximum number of A. patients. B. days. C. sickness. D. hospitals.
D. Separate financial and health records must be used. Rationale An industrial patient may have a record at a health care provider for a workman's compensation incident. If that patient also uses that same provider for personal medical care, personal health and financial records should be kept separate from the workplace related records. By law, medical records requested for workers' compensation cases should contain information exclusively associated with the injury or condition related to work.
77. Which is the correct procedure for keeping an industrial patient's financial and health records when the same physician is also seeing the person as a private patient? A. The same financial record may be used but a separate health record must be maintained. B. The same health record may be used but a separate financial record must be maintained. C. The same financial and health records may be used. D. Separate financial and health records must be used.
C. Tricare Rationale www.Medicare.gov is a great website for recent information about how to manage multiple government health care providers. A guide to who pays first can be found at the following link: http://www.medicare.gov/Pubs/pdf/02179.pdf. In this case, the patient's veteran status allows coverage under Tricare. The patient is undergoing dialysis, indicating End Stage Renal Disease- ESRD, which qualifies him for Medicare. The disability would also entitle the patient to Medicare coverage, but the fact that the diagnosis is recent translates that the paperwork likely has not gone through on this coverage yet. The Veterans Administration would not be billed because they are not an insurance company and the patient was not in a VA Hospital. Tricare pays the bills for services provided from any federal health care provider, including a military hospital. In this case, even though the patient is entitled to Medicare, Tricare should cover the cost for the services rendered.
78. A 64-year-old indigent veteran (recently diagnosed disabled but has a part-time job) receiving outpatient peritoneal dialysis was referred to his federal primary care provider for stomatitis. The patient then went to his PCP for an assessment plan and IV antibiotics. The patient died at 2:00 pm the following day, on his 65th birthday. Which of the following entities should be billed for the medical expenses? A. Medicare B. Veterans Administration C. Tricare D. Medicaid
B. Cost-containment is a primary goal. Rationale A managed care system manages healthcare services in an effort to control costs. Under such plans, elective procedures are often either not covered or very minimally covered. Emergency care by nature should not require pre-authorization. If the situation is emergent, the patient is allowed to receive care. The managed care system generally links reimbursement to pre-certification of procedures. If a qualifying procedure is not pre-certified, the patient is at risk of not receiving reimbursement.
79. Which of the following statements describes managed care? A. Coverage is normally provided for elective procedures. B. Cost-containment is a primary goal. C. Pre-authorization is required for emergency care. D. Pre-certification is not necessary for reimbursement.
A. patient's claim number B.physician's NPI E. patient's insurance ID number Rationale Before calling an insurance company to find out why a claim was denied, the medical office assistant should have ready; the physician's NPI (national provider identifier), the patient's claim number and insurance ID number. The insurance provider will already have the claim denied date and their customers mailing address with contact information.
8. When following up on a denied claim, a medical office assistant should have which of the following information available when speaking with the insurance company? (Select the three (3) correct answers). A. patient's claim number B. physician's NPI C. date the claim was denied D. patient's mailing address E. patient's insurance ID number
A. pre-authorization Rationale Pre-certification is the process of finding out if a service or procedure is covered under a patient's insurance policy. Once it's determined that a procedure/service is covered, permission (pre-authorization) must be obtained from the insurance provider. Predetermination is based on a medical professional's review of the patient's medical needs to determine if the procedure/service is appropriate. Informed consent is obtained when a provider explains the procedure to the patient and the patient acknowledges that he/she is making an informed decision when consenting to said procedure. Professional liability means that a professional has a legal obligation to offer appropriate standard of care (and not be negligent or omit certain components of care).
80. Prior approval from an insurance company for the cost of services is known as which of the following? A. preauthorization B. informed consent C. professional liability D. assignment of benefits
C. Contact the patient's insurance provider. Rationale Pre-certification (authorization for the service) should be obtained from the insurance provider. In this case, the medical assistant should contact the insurance provider for this authorization. A CMS 1500 form is not warranted at this time, nor would a claim form submitted by the patient be effective here.
81. A patient is referred to a specialist by the primary care provider. Pre-certification is required for this patient's specialty visit. Which of the following actions is required by the medical assistant to obtain authorization? A. Contact the patient's specialist. B. Have the patient submit a paper claim. C. Contact the patient's insurance provider. D. Submit the CMS 1500.
D. verification of benefits and eligibility for the patient. Rationale It is important to verify what benefits and eligibility the patient has under the insurance policy. This will assist all involved in determining the next course of action. If there are options for treatment, the patient and provider need to know what is and what is not covered before choosing a treatment plan. A preauthorization, probable cause, or referral may be indicated, but the first thing to determine is the patients benefits and eligibility, then follow up accordingly.
83. While a new patient is in the examination room with a physician who is explaining treatment options to the patient, the medical office assistant is contacting the insurance carrier to discuss the patient's insurance coverage. This scenario is an example of obtaining A. a preauthorization for the patient. B. a statement of probable cause. C. a disclosure of benefits and eligibility for the patient. D. verification of benefits and eligibility for the patient.
A. pre-certification. Rationale Pre-certification is the process of finding out if a service or procedure is covered under a patient's insurance policy. Once it's determined that a procedure/service is covered, permission (pre-authorization) must be obtained from the insurance provider. Predetermination is based on a medical professional's review of the patient's medical needs to determine if the procedure/service is appropriate. A preexisting condition is one that has been diagnosed at a previous time.
84. The process of finding out if a service or procedure is covered under a patient's insurance policy is called A. predetermination. B. preauthorization. C. precertification. D. preexisting.
C. state and federal guidelines. Rationale State and federal guidelines exist for the collecting of any over due accounts. The length of time that the office has to request payment varies from state to state. Even with a statue of limitations, that does not mean that you cannot still attempt to collect on payment for services. Office policy and circumstances will determine whether it is cost and time efficient to continue to collect such accounts. HIPAA covers the national standard for privacy and security of medical records and the AMA is a group that aims to promote the art and science of medicine and public health.
9. A medical office assistant's knowledge of a statute of limitations for collecting an overdue account is an example of managing the collections process while complying with A. AMA guidelines. B. practice management guidelines. C. state and federal guidelines. D. HIPAA guidelines.
