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CBCS Exam Study GuideMedical Billing & Coding as a Career - ANS*Claims assistant expert or claims supervisor,
*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 totally on moral precept. They
are typically familiar as a guide for conduct in the direction of pt's, dr's, co-people, the gov,
and ins co's.
What does acting within ethical conduct obstacles mean? - ANScarrying out one's
obligations w/ integrity, dignity, admire, honesty, competence, fairness, & believe.
Legal Aspects of of Medical Billing & Coding: - ANS...
Compliance regulations: - ANSMost billing-related cases are primarily 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
inside the Medicare/Medicaid Programs and personal payers
What are the 2 provisions of HIPPA? - ANSTitle I: Insurance Reform
Title II: Administrative Simplification
What is Title I of HIPPA? - ANSInsurance Reform-number one purpose is to provide
continuous ins insurance for employee & their dependents when they exchange or lose jobs.
Also *Limits the usage of preexisting situations exclusions *Prohibits discrimination from past
or present terrible fitness *Guarantees positive employees/indv the proper to purchase new
fitness ins insurance after losing job *Allows renewal of health ins cov regardless of an indv's
health cond. This is covered underneath the particular policy.
What is Title II of HIPPA? - ANSAdministrative Simplification-purpose is to cognizance at the
health care exercise placing to lessen administrative price & burdens. Has 2 components- 1)
improvement and implementation of standardized fitness-associated financial &
administrative sports electronically 2) Implementation of privateness & safety strategies to
save you the misuse of fitness data by using making sure confidentiality
What is the False Claims Act (FCA)? - ANSFederal law that prohibits filing a fraudulent claim
or creating a fake statement or illustration in connection w/ a claim. Also protects & rewards
whistle-blowers.
,What is the National Correct Coding Initiative (NCCI)? - ANSDeveloped by using CMS to sell
the countrywide correct coding methodologies & to govern wrong coding that result in
inappropriate price of Part B fitness 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 ought to not be billed
together b/c 1 code (Column 1) consists of all of the services described by using another
code (Column 2)
Mutually Exclusive Edits (NCCI) - ANSID's code pairs that, for medical reasons, are not
going to be performed on the equal pt on the same day
What are the viable outcomes of inaccurate coding and wrong billing? - ANS*behind
schedule processing & charge of claims *decreased bills, denied claims *pleasant and/or
imprisonment *exclusion from payer's packages, loss of dr's license to exercise med
Who has the project of look at and prosecuting fitness care fraud & abuse? - ANSThe Office
of Inspector General (OIG)
Fraud - ANSknowingly & deliberately deceiving or misrepresenting info that could bring
about unauthorized blessings. It is a felony and may result in fines and/or prison.
Who audits claims? - ANSState & federal companies in addition to private ins co's
What are common kinds of fraud? - ANSbilling for services no longer provided, unbundling,
& misrepresenting diagnosis to justify charge
Abuse - ANSincidences or practices, now not generally taken into consideration fraudulent,
which can be inconsistent w/ the usual medical business or financial practices in the
industry.
What are examples of Abuse? - ANSsubmitting a declare for offerings/tactics completed that
isn't medically essential, and excessive fees for offerings, equipment or resources.
What is a way use to minimize hazard, hazards, & liabilities associated w/ abuse? - ANSRisk
Management
Patient Confidentiality - ANSAll pt's have proper to privacy & all information have to remain
privileged. Only talk pt info while necessary to do job. Obtain a signed consent shape to
launch medical info to ins co or different individual.
When may additionally providers use PHI (Protected Health Information) w/o unique
authorization under the HIPPA Privacy Rule? - ANSWhen the use of for TPO, Treatment
(normally for the purpose of debate of pt's case w/ different dr's) Payment (vendors submit
,claims on behalf of pt's) & Operations (for functions inclusive of education workforce &
exceptional improvement)
What is Employer Liability? - ANSMeans physicians are legally accountable for their very
own conduct and any actions in their employees (designee) performed w/inside the context
in their employment. Referred to as "vicarious liability. A.K.A "respondent advanced"-"let the
master solution". Means worker can be sued & brought to trial
What is Employee Liability? - ANS"Errors & Omissions Insurance"-safety in opposition to
lack of monies as a result of failure thru mistakes or accidental omission on the part of the
indv or service filing the claim. ****Some dr's settlement w/ a billing service (clearinghouse)
to handle claims submission, & a few agreements include a clause stating that the dr will
maintain the co harmless from "liability as a consequence of claims submitted by way of the
carrier for any account", means dr is liable for mistakes made by means of billing service,
mistakes & omissions is not needed in the instance. ******However, if dr ever asks the ins
biller to do the least bit questionable, inclusive of write of pt's balances for positive pt's
mechanically, ensure you've got a prison report or signed waiver of liability relieving you of
responsibility for such movements.
What is a Medical Record & what is it constructed from? - ANSdocumentation of the pt's
social & medical records, own family records, physical exam findings, development notes,
radiology & lab results, consultation reports and correspondence to pt- Is the foremost tool of
medical care and verbal exchange.
What is a scientific document? - ANSpart of the clinical record & is a everlasting felony
document that officially states the consequences of the pt's exam or remedy in letter or
record shape. IT IS THIS RECORD THAT PROVIDES INFO NEEDED TO COMPLETE THE
INS CLAIM FORM.
Reasons for Documentation - ANSImportant that every pt seen by means of dr has complete
legible documentation approximately pt's infection, treatment, & plans for following reasons:
*Avoidance of denied or delayed price through ins co investigating the medical necessity of
services
*Enforcement of scientific report-keeping policies with the aid of ins co requiring accurate
documentation that supports method & diagnosis codes.
*Subpoena of clinical records through state investigators or the court for overview
*Defense of expert legal responsibility claim
Retention Of Medical Records - ANSIs ruled with the aid of country & neighborhood legal
guidelines & can also range from state-to-nation. Most dr are required to hold information
indefinitely, deceased pt statistics need to be kept for @ least five years
Med Term - ANS...
Diagnosis suffixes: - ANS...
-algia - ANSpain
, -emia - ANSblood circumstance
-itis - ANSinflammation
-megaly - ANSenlargement
-meter - ANSmeasure
-oma - ANStumor, mass
-osis - ANSabnormal situation
-pathy - ANSdisease condition
-rrhagia - ANSbursting forth of blood
-rrhea - ANSdischarge, drift
-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 restore
-rrhapy - ANSsuture
-scopy - ANSvisual exam
-stomy - ANSopening
-therapy - ANStreatment
-tomy - ANSincision, to reduce into
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