In each blank, try to type in the
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If your not sure what answer should be entered, press the space bar and the next missing letter will be displayed. When you are all done, you should look back over all your answers and review the ones in red. These ones in red are the ones which you needed help on. Question: Medical areAnswer: Standards of conduct based on moral principals. Acting within ethical behavior boundries means carrying out one's responsibilities with integrity, decency, respect, honesty, competence, fairness and . Question: RegulationsAnswer: Most billing related cases are based on HIPAA and the False Act Question: HIPAA is an forAnswer: Health Insurance Portability and Act of 1996. Question: 1 CPT codesAnswer: Procedures Question: 2 CPT codesAnswer: Supplemental Codes for Measures Question: Category 3 CPT Answer: Emerging Question: Add on Answer: Used for procedures that are always performed during the same operative , as another surgery in addition to the primary service/procedure and is never performed separately. Question: Anesthesia is Answer: 00100-01999, -99140 Question: Evaluation and Management (E&M) Answer: Are listed first in the CPT because they are used by all the different specialties. Question: BracketsAnswer: Used to synonyms, alternative wording or and explanatory phrase Question: BulletsAnswer: Represents a new procedure or code added since the previous edition of the manual. Question: Complaint (CC)Answer: The reason the patient came to see the . Question: Circle with a line itAnswer: from modifier 51 Question: CPTAnswer: Used to report services and by physicians Question: E&M Answer: -99499 Question: are Found?Answer: At the beginning of each section and used to specific coding rules for that section. Question: (HX)Answer: The set of information the physician gathers from the patient he past. Question: History of Illness (HPI)Answer: A chronological account of the development of the complaint from the first sign or symptom that the patient to the present. Question: Indented Answer: Listed under associate and alone codes Question: E CodesAnswer: For durable medical equipment for use in Question: Level 1 Answer: found in the CPT manual Question: Level 2 Answer: National codes for and non-physician service not found in the CPT Level 1 Question: 3 codesAnswer: Used locally or regionally and have been eliminated by the CMS since the implementation of Question: The List of Modifiers is found where in the Answer: A and in the front of the book. Question: 50Answer: bilateral Question: Modifier Answer: Attach to E/M service code when service is provided during postoperative period to indicate the the service is not part of postoperative care and not included in the Package Question: Modifier Answer: Provider only provided the professional Question: Modifier Answer: Used more than on procedure during the same surgical Question: Modifier 57Answer: Modifier 57 is used on E/M services the day before or day of surgery when the initial decision to perform the surgery is identified. Question: Modifier Answer: must return to Operating Room to address complication stemming from initial procedure Question: 79 Answer: Procedure or service during postoperative period not associated with initial procedure. Question: Answer: Reporting indicators that indicate that the procedure or service has been altered by specific circumstance but has not changed in it's of code. Question: Answer: Used to supplementary words, non-essential modifiers Question: Past, Family and History (PFSH)Answer: Consists of patients personal experiences with illnesses, surgeries, and injuries; Information of illnesses predominant in family; educational background, occupation, marital status and other factors Question: and LaboratoryAnswer: -89356 Question: Plus sign Answer: add on Question: RadiologyAnswer: -79999 Question: of Symptoms (ROS)Answer: of the constitutional symptoms regarding the various body systems Question: Alone CodesAnswer: full description to the procedure for a code. Question: Sideways triangle Answer: in wording between triangles Question: Bullet Answer: new procedure Question: Circle with a line it means Answer: modifier 51 code Question: Six of CPTAnswer: E&M, Anatomical Site, Condition or Disease, Synonym or , Abbreviation. Question: Three Components for E*M Answer: 1.History 2.Physical Exam 3.Medical -Making Question: Three Catagories for E*M Answer: Category I: Procedures that are with contemporary medical practice and are widely performed.Category II: Supplementary tracking used for performance measures.Category III: Temporary codes for emerging technology, services & procedures. Question: 4 contributing factors for E&M Answer: New or existing , History, Physical Exam, Medical Decision making, Time spent can be a 5th factor Question: Medicare part Answer: Part A is hospital insurance provided by Medicare. Most people do not pay a premium for this . Question: Medicare part Answer: Part B is insurance to pay for medically necessary services and supplies provided by Medicare. (Doctors, outpatient care, Phys. and Occ. Therapists etc.) Question: Medicare part Answer: Part C is the combination of Part A and Part B. The main in Part C is that it is provided through private insurance companies approved by Medicare. Question: Medicare part Answer: Part D is stand-alone prescription drug insurance. Question: MedicaidAnswer: free or low-cost insurance coverage through the state Question: Medicaid catagorically Answer: A distinction for individuals who fall into a category (or criteria)of mandatory Medicaid eligibility established by the federal government. These categories apply to every state Medicaid program. Question: Medicaid Medically Answer: provide Medicaid to certain groups not otherwise eligible for Medicaid.must cover: •Pregnant women •Children under 18.: States have option to cover:•Children up to 21•Parents and other caretaker relatives•Elderly•Individuals with Question: Who is the of Last Resort?Answer: Medicaid is always the of last resort. Question: TRICAREAnswer: health care program for Uniformed Service members, retirees and families Question: TRICARE Answer: option that the most flexibility to TRICARE-eligible beneficiaries. It is the fee-for-service option that gives beneficiaries the opportunities to see any TRICARE-authorized provider. Question: TRICARE (PP0)Answer: A preferred provider option, rather than an annual fee, a yearly deductible is charged. Health care is delivered through a network of civilian health care providers who payments from CHAMPUS and provide services at negotiated, discounted rates Question: PRIME (HMO)Answer: An HMO type plan in enrollees receive health care through a Military Treatment Facilities PCM or a supporting network of civilian providers Question: Answer: comprehensive health care in which the VA shares the cost of covered health care services and supplies with eligible beneficiaries. Question: payer vs Commercial payerAnswer: Private individuals are responsible for securing their own health insurance coverage. Commercial Government, Employer, Group health coverage Question: Health PlansAnswer: An insurance plan that provides healthcare coverage to a select group of people. Group health insurance plans are one of the offered by many employers. These are generally uniform in nature, offering the same benefits to all members of group. Question: insuranceAnswer: Health indemnity insurance is a fee for service insurance that is sometimes used when a person is in between health plans, and will cover some (but not all) Question: Answer: Health Maintenance Organization. A form of health insurance combining a range of coverages in a group basis. A group of doctors and other medical professionals care through the HMO for a flat monthly rate with no deductibles. Question: PPOAnswer: PPO is similar to an HMO, but care is paid for as received instead of in advance in form of a schedule. PPOs may offer more flexibility by allowing for visits to out-of-network professionals. within network require only the payment of a small fee. Question: POINT OF Answer: feature of an insurance plan that allows a patient to choose between in-network care and out-of-network care every time he or she sees a doctor. The patient is allowed the to go to whichever doctor is most convenient, although the cost will vary Question: Disability Answer: Insurance that pays benefits in the event that the policyholder becomes incapable of working. Question: Workman's Answer: Workman's is a job benefit that provides money and services to employees that are injured or become sick on the job. Worker's comp helps injured and sick workers to survive financially as they recover from health problems. Question: Usual Customary and Answer: refer to the base amount that is treated as the standard or most charge for a particular medical service when rendered in a particular geographic area. Question: Relative Value Payment Answer: The payment amount for each service paid under the physician fee schedule is the product of three factors; a uniform relative value for service; a geographic adjustment factor (GAF); a nationally uniform conversion factor for the service. Question: Medicare Resource Based Relative Unit (RVU) Payments/ComponentsAnswer: The schedule assigns certain values to procedures/costs upon Total RVUs. The total consists of three components; work, practice expense, and malpractice. Medicare adjusts payment by geographic price cost index (GPCI) and pays depending on locale. Question: ClaimAnswer: A completed insurance claim form submitted with the program time limit that contains all the information without deficiencies so it can be processed and paid promptly. Question: Dirty Answer: A claim submitted with errors or one that manual processing to resolve problems or is rejected for payment. Question: Invalid Answer: Any Medicare claim that contains complete, necessary information but is or incorrect (e.g., listing an incorrect provider number for a referring physician). Invalid claims re identified to the provider and may be resubmitted Question: Rejected Answer: A rejected claim is an electronically submitted claim that is unprocessable due to missing or invalid information required by the . Question: ABN / Advance Beneficiary Answer: a notice that a doctor, supplier, or provider gives a Medicare beneficiary before furnishing an item or service if the doctor, supplier, or provider believes that Medicare may deny . Question: Paper Claims /CMS Answer: An insurance claim submitted on paper, including those opticaly and converted to an electronic form by the insurance carrier Question: Electronic Answer: An insurance claim submitted to the carrier via a central processing unit (CPU), tape, diskette, direct data entry, direct wire, dial-in telephone, digital fax, or personal computer download or upload Question: CMS 1500 Claim FormAnswer: Developed by the AMA and the Centers for Medicare and Medicaid Services (CMS). Used by physicians and other professionals to bill outpatient services and supplies to , Medicare, some Medicaid programs, and some private insurance/managed care plans Question: Basic Billing Reimbursement Answer: Patient Info, Verify Ins. Prepare encounter form, Code DX & CPT, Review Linkage Protocol, Calculate physicians , Prepare claim, Transmit claim, Follow up on Reimbursement. Question: Review Linkage Answer: Appropriateness of Codes, Payers rules about linkage, Documentation to support codes, Compliance with and guidelines Question: Life of a ClaimAnswer: Submission, Processing, Adjudication, Non-covered, Unauthorized, Medical Necessity Checks, / RA / ERA Question: What does MAC for?Answer: Administrative Contractor Question: "A condition that develops after, the outpatient care has been provided or during an inpatient ."Answer: Question: "A concurrent condition that with the first-listed diagnosis or principal diagnosis, has potential to affect treatment of the aforementioned diagnosis and is an active condition for which the patient is treated and/or monitored."Answer: Question: The process by which the provider contacts the insurance carrier to see if the proposed procedure is by a specific patients insurance policy.Answer: Question: Monies or Funds that are owed to the practice for providedAnswer: Receivable (A/R) Question: Monies being paid from the practice, for instance to pay for supplies, rent, utilities, payroll, etc.Answer: Payable (A/P) Question: What are the of the three tables that appear in the Index to Diseases?Answer: Hypertension
Neoplasm
Table of and Chemicals Question: The explanation of payments received from the insurance company is often referred to or called the _____________.Answer: Remittance Question: Billing a patient for the difference between a higher usual fee and a lower allowed charge is called _____________.Answer: Billing Question: ___________ is the national health insurance program for Americans aged 65 and older.Answer: Question: A -benefit program designed for low-income, blind, or disabled patients; needy families; foster children; and children born with birth defects.Answer: "payer of last resort" Question: What is the single largest healthcare program in the United ?Answer: Question: Signed into law in 2010, an act that resulted in access to affordable healthcare coverage and protection from abusive practices by healthcare insurance companies is what?Answer: Care Act (ACA) Question: Person who is responsible for a patients debt is ?Answer: Question: Medicare beneficiaries can also obtain supplemental insurance what?Answer: Medigap Question: What does do?Answer: Helps costs not reimbursed by the original Medicare plan. Question: A writ requiring the appearance of a person at a trial or other proceeding is a ___________.Answer: Question: When does the tertiary pay?Answer: After the and secondary insurers. Question: Healthcare Common Procedure System (HCPCS)Answer: A numeric and alphabetic system used for billing/pricing of procedures, medical supplies, medications, and durable medical equipment (DME). Question: A managed care organization that establishes a network of providers who care for their patients is called a/an _________.Answer: Preferred Provider (PPO) Question: A group that takes nonstandard medical billing software formats and translates them into the Electronic Data Interchange (EDI) formats is called a/an?Answer: Clearinghouse Question: The out-of-pocket payment amount that a policyholder must meet insurance covers the service(s) is called?Answer: Deductible Question: National Provider (NPI) numberAnswer: A unique 10-digit number assigned to providers in the U.S. to identify themselves in all transactions. Question: What is a ?Answer: A payment structure in a health maintenance organization prepays an annual set fee per patient to a physician. Question: A fixed fee collected at the time of the visit.Answer: Question: A fixed percentage of covered charges applied to the patients bill after the has been met.Answer: Coinsurance Question: The charge for keeping the policy in effect.Answer: Question: Coding and billing that is inconsistent with coding and billing practices.Answer: Abuse Question: How does HIPAA fraud?Answer: An intentional deception of . Question: "The difference between fraud and abuse is _______."Answer: Question: Current Procedural (CPT) codesAnswer: codes developed by the American Medical Association (AMA) to standardize medical services and procedures. Question: Is intentional?Answer: No Question: What simplified process was developed to enable Medicare beneficiaries to participate in mass pneumococcal pneumonia virus (PPV) and influenza virus vaccination offered by public health clinics?Answer: Roster Question: A person filing an is called?Answer: Question: Covers injuries caused by insured that on the insured's property.Answer: Liability Question: A detailed accounting of the claims for which payment is being made by an insurance company. The __________ accompanies the payment from the insurance company.Answer: Advice (RA) Question: Authorization by a policyholder that allows a payer to pay directly to a provider is called?Answer: Assignment of Question: A/An ___________ is a person admitted to a hospital or long-term care facility(LTCF) for treatment with the expectation that the patient will remain in the hospital for a period of 24 hours or more.Answer: Question: What is ?Answer: Involves restricting patient access to those with proper authorization and maintaining the security of patient information. Question: The first listed diagnosis can also be referred to as ______________.Answer: diagnosis Question: Physicians who enroll in managed care plans are called ______________. They have contracts with Managed Care Organizations (MCO)s that stipulate their fees.Answer: Participating Question: A formal, written document that describes how the hospital or physician's practice ensures rules, regulations, and standards that are being followed is known as a/an _______________.Answer: Compliance Question: What act the reporting of ICD-9-CM diagnosis codes?Answer: The Medicare Coverage Act of 1988 Question: Transmitting electronic medical insurance claims from providers to payers using the necessary information systems is called ______________.Answer: Data interchange (EDI) Question: "A severe form of with vascular damage and a diastolic pressure reading of 130 mm hg or greater."Answer: Question: and/or controlled hypertension, with no damage to the patient's vascular system or organs."Answer: Benign Question: "No notation of benign or malignant is found in the diagnosis or in the patient's chart."Answer: Question: For coding, the initials CC mean?Answer: Comorbidities and Question: What does mean?Answer: Insurance Question: A person who receives a check in payment is the _________.Answer: Question: Insurer/Insured, Subscriber, Member, Recipient are all terms that to the?Answer: Policyholder Question: True or False, Preferred Provider Organizations (PPO)s allow members to receive care from physicians outside the network.Answer: False, Policyholders may to go out of network, but the may have to pay greater expenses. Question: Everything a medical claims specialist learns about a patient's condition must remain _____________.Answer: |
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