CBCS Exam 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
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
