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CBCS Exam Study Guide 2024/2025 graded A+
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CBCS Exam Study Guide 2024/2025 graded A+
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CBCSExam
Study
Guide
Medical
Billing
&
Coding
as
a
Career
-
ANS*Claims
assistant
professional
or
claims
manager,
*Coding
Specialist,
*
Collection
Manager,
*Electronic
Claims
Processor,
*Insurance
Billing
Specialist,
*
Insurance
Coordinator,
*Insurance
Counselor,
*Medical
Biller,
*Medical
&
Financial
Records
Manager,
*
Billing
&
Coding
Specialist
What
are
Medical
Ethics?
-
ANSStandards
of
conduct
based
on
moral
principle.
They
are
generally
accepted
as
a
guide
for
behavior
towards
pt's,
dr's,
co-workers,
the
gov,
and
ins
co's.
What
does
acting
within
ethical
behavior
boundaries
mean?
-
ANScarrying
out
one's
responsibilities
w/
integrity,
dignity,
respect,
honesty,
competence,
fairness,
&
trust.
Legal
Aspects
of
of
Medical
Billing
&
Coding:
-
ANS...
Compliance
regulations:
-
ANSMost
billing-related
cases
are
based
on
HIPPA
and
False
Claims
Act
Health
Insurance
Portability
&
Accountability
Act
(HIPPA)
-
ANSEnacted
in
1996,
created
by
the
Health
Care
Fraud
&
Abuse
Control
Program-enacted
to
check
for
fraud
and
abuse
in
the
Medicare/Medicaid
Programs
and
private
payers
What
are
the
2
provisions
of
HIPPA?
-
ANSTitle
I:
Insurance
Reform
Title
II:
Administrative
Simplification
What
is
Title
I
of
HIPPA?
-
ANSInsurance
Reform-primary
purpose
is
to
provide
continuous
ins
coverage
for
worker
&
their
dependents
when
they
change
or
lose
jobs.
Also
*Limits
the
use
of
preexisting
conditions
exclusions
*Prohibits
discrimination
from
past
or
present
poor
health
*Guarantees
certain
employees/indv
the
right
to
purchase
new
health
ins
coverage
after
losing
job
*Allows
renewal
of
health
ins
cov
regardless
of
an
indv's
health
cond.
that
is
covered
under
the
particular
policy.
What
is
Title
II
of
HIPPA?
-
ANSAdministrative
Simplification-goal
is
to
focus
on
the
health
care
practice
setting
to
reduce
administrative
cost
&
burdens.
Has
2
parts-
1)
development
and
implementation
of
standardized
health-related
financial
&
administrative
activities
electronically
2)
Implementation
of
privacy
&
security
procedures
to
prevent
the
misuse
of
health
info
by
ensuring
confidentiality
What
is
the
False
Claims
Act
(FCA)?
-
ANSFederal
law
that
prohibits
submitting
a
fraudulent
claim
or
making
a
false
statement
or
representation
in
connection
w/
a
claim.
Also
protects
&
rewards
whistle-blowers. What
is
the
National
Correct
Coding
Initiative
(NCCI)?
-
ANSDeveloped
by
CMS
to
promote
the
national
correct
coding
methodologies
&
to
control
improper
coding
that
lead
to
inappropriate
payment
of
Part
B
health
ins
claims.
How
many
edits
does
NCCI
include?
-
ANS2:
1)Column
1/Column
2
(prev
called
Comprehensive/Component)
Edits
2)
Mutually
Exclusive
Edits
Column
1/Column
2
edits
(NCCI)
-
ANSIdentifies
code
pairs
that
should
not
be
billed
together
b/c
1
code
(Column
1)
includes
all
the
services
described
by
another
code
(Column
2)
Mutually
Exclusive
Edits
(NCCI)
-
ANSID's
code
pairs
that,
for
clinical
reasons,
are
unlikely
to
be
performed
on
the
same
pt
on
the
same
day
What
are
the
possible
consequences
of
inaccurate
coding
and
incorrect
billing?
-
ANS*delayed
processing
&
payment
of
claims
*reduced
payments,
denied
claims
*fine
and/or
imprisonment
*exclusion
from
payer's
programs,
loss
of
dr's
license
to
practice
med
Who
has
the
task
of
investigate
and
prosecuting
health
care
fraud
&
abuse?
-
ANSThe
Office
of
Inspector
General
(OIG)
Fraud
-
ANSknowingly
&
intentionally
deceiving
or
misrepresenting
info
that
may
result
in
unauthorized
benefits.
It
is
a
felony
and
can
result
in
fines
and/or
prison.
Who
audits
claims?
-
ANSState
&
federal
agencies
as
well
as
private
ins
co's
What
are
common
forms
of
fraud?
-
ANSbilling
for
services
not
furnished,
unbundling,
&
misrepresenting
diagnosis
to
justify
payment
Abuse
-
ANSincidences
or
practices,
not
usually
considered
fraudulent,
that
are
inconsistent
w/
the
accepted
medical
business
or
fiscal
practices
in
the
industry.
What
are
examples
of
Abuse?
-
ANSsubmitting
a
claim
for
services/procedures
performed
that
is
not
medically
necessary,
and
excessive
charges
for
services,
equipment
or
supplies.
What
is
a
method
use
to
minimize
danger,
hazards,
&
liabilities
associated
w/
abuse?
-
ANSRisk
Management
Patient
Confidentiality
-
ANSAll
pt's
have
right
to
privacy
&
all
info
should
remain
privileged.
Only
discuss
pt
info
when
necessary
to
do
job.
Obtain
a
signed
consent
form
to
release
medical
info
to
ins
co
or
other
individual.
When
may
providers
use
PHI
(Protected
Health
Information)
w/o
specific
authorization
under
the
HIPPA
Privacy
Rule?
-
ANSWhen
using
for
TPO,
Treatment
(primarily
for
the
purpose
of
discussion
of
pt's
case
w/
other
dr's)
Payment
(providers
submit
claims
on
behalf
of
pt's)
&
Operations
(for
purposes
such
as
training
staff
&
quality
improvement) What
is
Employer
Liability?
-
ANSMeans
physicians
are
legally
responsible
for
their
own
conduct
and
any
actions
of
their
employees
(designee)
performed
w/in
the
context
of
their
employment.
Referred
to
as
"vicarious
liability.
A.K.A
"respondent
superior"-"let
the
master
answer".
Means
employee
can
be
sued
&
brought
to
trial
What
is
Employee
Liability?
-
ANS"Errors
&
Omissions
Insurance"-protection
against
loss
of
monies
caused
by
failure
through
error
or
unintentional
omission
on
the
part
of
the
indv
or
service
submitting
the
claim.
****Some
dr's
contract
w/
a
billing
service
(clearinghouse)
to
handle
claims
submission,
&
some
agreements
contain
a
clause
stating
that
the
dr
will
hold
the
co
harmless
from
"liability
resulting
from
claims
submitted
by
the
service
for
any
account",
means
dr
is
responsible
for
mistakes
made
by
billing
service,
errors
&
omissions
is
not
needed
in
the
instance.
******However,
if
dr
ever
asks
the
ins
biller
to
do
the
least
bit
questionable,
such
as
write
of
pt's
balances
for
certain
pt's
automatically,
make
sure
you
have
a
legal
document
or
signed
waiver
of
liability
relieving
you
of
responsibility
for
such
actions.
What
is
a
Medical
Record
&
what
is
it
comprised
of?
-
ANSdocumentation
of
the
pt's
social
&
medical
history,
family
history,
physical
exam
findings,
progress
notes,
radiology
&
lab
results,
consultation
reports
and
correspondence
to
pt-
Is
the
foremost
tool
of
clinical
care
and
communication.
What
is
a
medical
report?
-
ANSpart
of
the
medical
record
&
is
a
permanent
legal
document
that
formally
states
the
consequences
of
the
pt's
exam
or
treatment
in
letter
or
report
form.
IT
IS
THIS
RECORD
THAT
PROVIDES
INFO
NEEDED
TO
COMPLETE
THE
INS
CLAIM
FORM.
Reasons
for
Documentation
-
ANSImportant
that
every
pt
seen
by
dr
has
comprehensive
legible
documentation
about
pt's
illness,
treatment,
&
plans
for
following
reasons:
*Avoidance
of
denied
or
delayed
payment
by
ins
co
investigating
the
medical
necessity
of
services
*Enforcement
of
medical
record-keeping
rules
by
ins
co
requiring
accurate
documentation
that
supports
procedure
&
diagnosis
codes.
*Subpoena
of
medical
records
by
state
investigators
or
the
court
for
review
*Defense
of
professional
liability
claim
Retention
Of
Medical
Records
-
ANSIs
governed
by
state
&
local
laws
&
may
vary
from
state-to-state.
Most
dr
are
required
to
retain
records
indefinitely,
deceased
pt
records
should
be
kept
for
@
least
5
years
Med
Term
-
ANS...
Diagnosis
suffixes:
-
ANS...
-algia
-
ANSpain
-emia
-
ANSblood
condition
-itis
-
ANSinflammation -megaly
-
ANSenlargement
-meter
-
ANSmeasure
-oma
-
ANStumor,
mass
-osis
-
ANSabnormal
condition
-pathy
-
ANSdisease
condition
-rrhagia
-
ANSbursting
forth
of
blood
-rrhea
-
ANSdischarge,
flow
-sclerosis
-
ANShardening
-scopy
-
ANSto
view
Procedural
Suffixes:
-
ANS...
-centesis
-
ANSsurgical
puncture
-ectomy
-
ANSremoval,
resection,
excision
-gram
-
ANSrecord
-graphy
-
ANSprocess
of
recording
-lysis
-
ANSseparation,
breakdown,
destruction
-pexy
-
ANSsurgical
fixation
-plasty
-
ANSsurgical
repair
-rrhapy
-
ANSsuture
-scopy
-
ANSvisual
examination
-stomy
-
ANSopening
-therapy
-
ANStreatment
-tomy
-
ANSincision,
to
cut
into
Common
Prefixes:
-
ANS...
a,
an
-
ANSwithout
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