NHA CBCS Exam Prep

What actions should be taken when a claim is billed for a level four office visit and paid at a level three? - Submit an appeal with documentation The standard medical abbreviation "ECG" refers to a test used to assess which of the body systems? - cardiovascular system- test checks electricity of heart According to HIPAA standards, what identifies the rendering provider on the CMS-1500 claim form in Block 24J? - NPI On the CMS-1500 claim form, blocks 14 through 33 contain information about? - The patient's condition and the provider's information Which block should the BCS complete on the CMS-1500 form for procedures, services, or supplies? - 24D Which term describes when a plan pays 70% of the allowed and the patient pays 30%? - Coinsurance is a percentage of the cost for covered services that is approved by the insurance company A provider charges $500 to a claim that had an allowable amount of $400. What should happen to the non-allowed charge? - Write Off or adjustment Patient: Justin Austin; Social Security NO.: ; Medicare ID NO.: A; DOB: 05/22/1945. Claim information entered: Austin, Jane; Social Security No.: ; Medicare ID No.: 555- 33-2222A; DOB: 052245. What is a reason the claim was rejected? - The DOB is entered incorrectly - the format is two digits for the month and four digits for the year. A patient's health plan is referred to as the "payer of last resort." The patient is covered by which health plan? - Medicaid The physician bills $500 to a patient. After submitting the claim to the insurance company, the claim is sent back with no payment. The patient still owes $500 for the year. This amount is called what? - Deductible Ambulatory surgery centers, home health care, and hospice organizations use what form? - UB-04 Form A physician ordered a comprehensive metabolic panel for a 70-year-old patient who has Medicare as her primary insurance. Which form is required so the patient knows she may be responsible for payment? - Advanced Beneficiary Notice is a form that is required for Medicare recipients Which of the following should the BCS complete to be reimbursed for the provider's services? - CMS-1500 claim form What is the maximum number of diagnoses that can be reported on the CMS-1500 claim form before a further claim is required? - 12 Describe a delinquent claim? - It is considered delinquent when it is overdue for payment, 120 days or older What are considered proper supportive documentation for reporting CPT and ICD codes for surgical procedures? - Operative reports are required to support surgical procedures When submitting a clean claim with a diagnosis of kidney stones, which of the following procedure names is correct? - Nephrolithiasis The destruction of kidney stones The BCS should first divide the e/m code by which of the following? - Place of service which narrows down the specific code as one of the three deciding factors Appeal the decision with a provider's report - Which of the following actions should be taken if an insurance company denies a service as not medically necessary? Which departments should a patient be seen for psoriasis? And what body system is involved? - Dermatology, related to the integumentary system which includes hair, skin, and nails Which block requires the patient's authorization to release medical information to process a claim? - Block 12 What is the purpose of precertification? - Verification of Coverage A provider performs an examination of a patient's sore throat during an office visit. What describes the level of the examination? - Problemfocused examination is a specific examination of an affected organ. What is the verbal or written agreement that gives approval to some action, situation, or statement, and allows the release of patient information? - Consent agreement On the CMS-1500 claim form, blocks 1 through 13 include what information? - The patient's demographics are found in Blocks 2,3,5, and 7 What is the main function of the respiratory system? - Oxygenating blood cells Which section of the medical record is used to determine the correct E/M code used for billings and coding? - History and physical Describe the birthday rule. - The parent whose birthday comes first in the calendar year is the Primary Insurance. What is used to code diseases, injuries, impairments, and other healthrelated problems? - International Classification of Diseases A patient has AARP as secondary insurance. In which block on the CMS-1500 claim form should this information be entered? - Block 9 is for secondary insurance. What is the difference between informed and implied consent? - informed consent=explaining procedures or diagnosis as well as surgical intervention. implied consent=patient voluntarily undergoes treatment, the assume consent. A physician is contracted with an insurance company to accept the allowed amount. The insurance company allows $80 of a $120 billed amount, and $50 of the deductible has been met. How much should the physician write off the patient's account? - $40 - this is the difference between the amount billed and amount allowed. What is the difference between fraud and abuse? - fraud=intentional misrepresenting services rendered for the purpose of receiving higher pay. abuse=practices that are done unknowingly as a result of poor business practices. What is the difference between consent and authorization? - consent=used for treatment authorization=used to release information and not treatment. What does disclosure refer to? - The way health information is given to an outside person or organization What does the Stark Law state? - Physicians can't refer patients to practitioners with whom they have a financial relationship. What do you check for when auditing? - review claims for accuracy and completeness. What does the OIG do? - Office of Inspector General Fights against fraud. What is the health program for people over the age of 65 or people under 65 with disabilities and people of all ages in end-stage kidney failure? - Medicare. Name two causes of claim transmission errors - missing or invalid patient ID number and lack of authorization or referral number. What is the difference between co-pay and coinsurance? - co-pay=flat fee that a patient pays for visiting a provider or purchasing meds, varies. coinsurance=is a percentage of the covered benefits paid by both the insurance and the patient usually 80%/20% What are three major kinds of government insurance plans? - Medicare, Medicaid and children's health insurance program (SCHIP)