NHA Medical Coding and billing exam 2023 with verified questions and answers

Place of Service Billing and coding specialists should first divide the E & M Code by Privacy Officer Compliant with HIPPA the following position should be assigned in each office Principal Diagnosis Coding on the UB-04 Form, must sequence the diagnosis code. Which is the first listed diagnosis? Urethratresia Obstruction of the urethra is UB04 Forms Ambulatory surgery centers, home health center, and hospice use what form? Encounter forms Form that contains of DOS, CPT, ICD codes, fees and copay information is called Add on Codes Anesthesia section of CPT manual which are considered qualifying circumstances Title 11 Patient presents with chest pain & shortness of breath with abnormal ECG provider call a cardiologist. What portion of the HIPPA allows this Code set standards pertain to all providers HIPPA compliance guideline affecting EHR Red Color formats on CMS 1500 form acceptable Patient Ledger account Financial record generated by a provider office Coding Compliance Plan Which of the following includes procedures and best practices for correct coding Sagittal Which of the following planes divides the body into left and right Claim adjudication:( The term used in the industry to refer to the process of paying claims submitted on denying them after comparing claims to the benefit or coverage requirements) 3rd Party payer validates a claim which takes place next NCCI ( National Correct Coding Initiative) Developed to reduced Medicare Program expenditure by detecting in appropriate codes & eliminating improper coding 0% Beneficiary of Medicaid/ Medicare crossover claim is responsible for the percentage Internal monitoring and auditing Which of the following steps would be part of a physicians practice compliance program HIPPA Which of the following acts applies to the administrative simplification guidelines? Accounts recievable Patient charges that have not been paid will appear in which of the following adjudication Which of the following is considered the final determination of the issues involving settlement of an insurance claim A billing worksheet from the patient account A prospective billing account audit prevents fraud by reviewing & comparing a completed claim for with which of the following documents Lymphatic system Which of the following parts of the body system regulates immunity Billing using 2- digit CPT Modifiers to indicate a procedure as preformed differs from its usual 5 digit code Which of the following is allowed when billing procedural codes Direct Data entry A biller will electronically submit a claim to the carrier via which of the following? A Providers office with fewer than 10 fulltime employees Medicare enforces mandatory submission of electronic claims for most providers. Which of the providers is allowed to submit paper claims to Medicare? (RAC) Recovery audit Contractor Which of the following organizations identifies improper payments made on CMS claims Bone and bone marrow IF a patient has osteomyelitis he has problems with which of the following areas? Preauthorization form Which of the following is a requirement of some third-party payers before a procedure is performed? Precertification Ensure appropriate insurance coverage for an outpatient procedure by first using the following process History Key component if an evaluation and management service 837 Format used to submit electronic claims and 3rd Party payer Office of the Inspector General (OIG) Entity that defines the essential element of a comprehensive compliance program National Coverage Determination Medicare Policy determines if a particular item or service is covered Left upper quadrant Location of the stomach, spleen, part of the pancreas and liver 18% Coding a front torso burn, what % should be used? An italicized code used as the 1st listed diagnosis Result of a claim being denied Charging excessive fees Example of Medicare abuse Codes must correspond to the diagnosis pointer in block 24E Diagnostic codes in Block 21 of the CMS form (S) Subjective Soap note to indicate patient level of pain to provider HIPPA Standard transaction Standardized format used in electronic filing of claims 3rd Party Payer Insurance Carrier is a Remittance Advice (RA)- A letter sent to a patient from insurance provider stating that their invoice is paid When send a claim to a 2nd payer you need to send a copy of Contractual allowance- difference between what hospitals bill and what they receive in payment from 3rd Party Payers Remark code from a EOB document-(EOB)- statement sent by a health insurance company covered individual explaining what medical treatments and/ or services were paid for on their behalf Professional component- Provided by a physician, may include supervision, interpretation, and writer report CPT code used to indicate provider supervised and interpreted Informed consent Providers explain medical or diagnostic procedures, surgical interventions, and the benefits and risks involved, giving the patients opportunity to ask questions before medical intervention is provided. Signature is required Implied consent A patient presents for treatment, such as extending an arm to all venipuncture to be performed. Signature is NOT required Clearinghouse Agency, that converts claims into standardized electronic format, looks for errors, and formats them according to HIPPA and insurance standards De- identifiable information Information that does not identify and individual because unique and personal characteristics have been removed Consent A patients permission evidenced by signature Authorization Permission granted by the patient or the patients representative to release information for reasons other than treatment, payment, or health care operations Reimbursment Payment for services rendered from a 3rd Party Payer Auditing Review of claims for accuracy and completeness Upcoding Assigning a diagnosis or procedure code at a higher level than the documentation supports, such as single code that describes all steps of the procedure Unbundling Using multiple codes that describe different components of a treatment instead of using a single code that describes all steps of the procedure Fraud Making false statements of representations of material facts to obtain some benefit or payment for which no entitlement would otherwise exist Abuse Practices that directly or indirectly result in unnecessary cost to the Medicare program What is the Difference between Fraud and abuse? Fraud is intentionally misrepresenting services rendered for the purpose if receiving a higher payment. Abuse refers to practices that are often done unknowingly as a result of poor business practices, directly or indirectly resulting in unnecessary costs to the program through improper payments. What is the main job of the office inspector general?(OIG) Protects Medicare and other HHS programs from fraud and abuse by conducting audits, investigations, and inspections Timely filing requirment Within 1 Calendar year of a claims date Electronic data interchange (EDI) The transfer of electronic information in a standard format Coordination of benefits rule Determines which insurance plan is primary and which is secondary insurance . Conditional Payment Medicare payment that is recovered after primary insurance pays. Crossover claim Claim submitted by people covered by primary and secondary insurance plan Two causes of a claim transmission errors Missing or invalid patient identification number and lack of authorization or referral number Assignment of Benefits Contract in which the provider directly bills the payer and accepts the allowable charge. Clean claim Claim that is accurate and complete Dirty claim Claim that inaccurate, incomplete, or contains other errors Medicare administrative Contractor (MAC) Processes Medicare Parts A & B claims from hospitals, physicians, and other providers Remittance Advice (RA) The report sent from the third-party payer to the provider that reflects any changes made to the original billing. 2 Pieces of Information that need to be collected from patients Patients name and date of birth Deductible Amount you must pay out of pocket before you begin receiving any benefits from your insurance company Coinsurance Pre established percentage of expenses paid by the insurance company after the deductible has been met Copayment A fixed dollar amount that must be paid each time a patient visits a provider. Coordination of Benefit rules Determines which insurance plan is primary and which is secondary Importance of verifying insurance information Important to make sure that the insurances valid and the services are covered benefits Birthday Rule Parent whose birthday comes 1st in the calendar year is considered primary Third Party Payer Organization other than a patient who pays for services, such as insurance companies, Medicare, and Medicaid. Medicare Part A hospitalization coverage Medicare Part B Voluntary supplemental medical insurance to help pay for physicians and other medical professionals services and medical surgical supplies Medicare Part D Pays for medications Medicare Advantage Combined package of benefits under Medicare Parts A & B that may offer extra coverage for services such a, vision, hearing, dental, health and wellness, or prescription coverage. Medigap Private health insurance that pays for most of the charges not covered parts A& B Referral Written recommendation to a specialist Precertification A review that looks at whether the procedure could be performed safely but less expensively in an outpatient setting. predetermination A written request for a verification of benefits. Who is the gatekeeper primary care physician Preauthorization Approval for the health plan for an inpatient hospital stay or surgery Tier 1 Providers and facilities in a PPO network Tier 2 Providers and facilities within the broader, contracted network Tier 3 Providers and facilities out of the network Tier 4 Providers and facilities not on the formulary Formulary a list of prescription drugs covered by a specific health care plan Charge Description Master (CDM) Information about health care services that patients have received and financial transactions that have taken place. Medicare Summary Notice (MSN) Document that outlines the amounts billed by the provider and what the patient must pay the provider. Cost sharing The balance the policyholder must pay to the provider. Medical Necessity The documented need for a particular medical intervention. 2 reasons a claim may be denied Invalid subscriber name was given or coding error was made V Codes Classify visits when circumstances, and conditions, such as the cause of injury, poisoning, and other adverse events E Codes classify external causes of environmental events, circumstances, or conditions that caused injury, condition, or poisoning (i.e. how an accident happened, if drug overdose was accidental or intentional) CPT Category 1 Codes Primarily cover physicians services but are used for hospital outpatient. Modifiers are used CPT Category II Codes Designed to serve as supplemental tracking codes that can be used for performance measurement. Modifiers are used CPT Category III Temporary coding for new technology and services that have not met the requirements needed HCPS Level II National Codes, Uses modifiers HCPS Level 3 Codes Temporary Codes How many CPT code category sections are listed in the CPT manual? 6 MS-DRG grouper Software that helps coders assign the appropriate Medicare severity diagnosis-related group based on the level of services provided, severity of the illness or injury, and other factors. APC Grouper Determine the appropriate ambulatory payment classification for outpatient encounter NON PAR 15% over fee schedule amount Non medical Code Why a payment was not paid or adjusted A bilateral procedure A billing and coding specialists should add modifier -50 when reporting which procedure The physician agrees to accept payment under the terms of the payers program. Accepting assignment on the CMS-1500 claim form indicates which of the following. The coinsurance, co payment and deductibles are all responsibilities of the patient Which of the following statements is true when determining patient financial responsibility by reviewing the remittance advice. Edema- is swelling caused by excess fluids Which of the following is the appropriate diagnosis for a patient who has an abnormal accumulation of fluid in her lower leg that has resulted in swelling Health care clearinghouse HIPPA transaction standards apply to which of the following entities Block 23 A billing and coding specialists should enter the prior the authorization number on the following blocks. Claims submitted via a secure network Which of the following is an example of electronic claim submission Advance Beneficiary Notice (ABN) Advanced beneficiary notice, or ABN is a form that is required for Medicare recipients. Patients demographics On the CMS 1500 Form blocks 1-13 are A patients signature authorizing the release of any medical information necessary to process the claim. Block 12 Other insured policy or group number Block 9a contains Date of current injury, illness, or LMP Block 14 Name of referring provider Block 17 Referring provider NPI number 17b What block does the diagnosis codes go on CMS 1500 form? Block 21 Dates of services on the CMS 1500 for are to be placed on what block? Block 24A Diagnosis pointer is in what field on the CMS 1500 Block 24E Signature of physcican or supplier is provided in what field Block 31 Billing provider NPI number is on what block on the CMS 1500 form? Block 33a