Confidential information includes:

Everything that is heard, read or seen regarding the patient.

What is the correct response when a relative calls asking about a patient?

Ask the relative to put the request in writing and include the patient's signed authorization.

Confidentiality is automatically waived in cases of:

Gunshot wounds, child abuse, and extremely contagious diseases.

An emancipated minor is:

A person younger than the age of 18 who lives independently.

The reason for a coordination of benefits statement in a health insurance policy is:

To prevent duplication or overlapping of payments for the same medical expense.

The SOAP in a patient medical record charting is defined as:

S-subjective, O-objective, A-assessment, P-plan.

When is exclusion from program participation mandatory?

Once an individual has been found guilty of committing a Medicare or Medicaid program-related crime.

All of the following cases should NOT use fax transmission:

Transmission of documents relating to information on sexually transmitted diseases, any routine transmission of patient information, or transmission of documents relating to alcohol treatment.

What does the abbreviation MSHP designate?

Multiskilled health practioner.

A physician's legal responsibility for his/her own actions as well as his/her employees' is called?

Vicarious liability or respondeat superior.

In 1980, the American Medical Association (AMA) adopted a modern code of ethics called:

The Principles of Medical Ethics.

One of the eight C's of effective caller service is Contagious. This means to:

Model the behavior you want from your callers.

Tracnsactions in which health care information is accessed, processed, stored, and transferred using electronic trechnologies are known as:

E-health Information Management (eHIM).

What is the primary purpose of HIPAA Title I: Insurance Reform?

To provide continuous insurance coverage for workers and their insured dependents when they change or lose jobs.

Why was diagnostic coding developed?

For medical research, evaluation of hospital use, and for the process of tracking diseases.

What is the consequence when a medical practice does not use diagnostic codes?

It affects the physician's level of reimbursement for inpatient claims, claims can be denied, and fines or penalties can be levied.

The key to substantiating procedure and diagnostic code selections for proper reimbursement is:

Supporting documentation in the health record.

Reasons for documentation are:

Defense of a professional liability claim and because insurance carriers require accurate documentation that supports procedure and diagnostic codes.

When a patient fails to return for needed treatment, documentation should be made:

In the patient's medical record, in the appoitment book and on the financial record or ledger card.

What does comorbidity mean?

Underlying diseases or other conditions present at the time of visit.

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TCCMA 290 Final

Final Fall 2012

Question	Answer
What is "cash flow" in a medical practice?	The actual money available to a medical practice.
What level of education is generally required for one who seeks employment as an insurance coder?	Completion of an accredited program for coding certification.
Medical ethics refers to:	Standards of conduct.
The earliest written code of ethical principles for the medical profession is the:	Code of Hammurabi.
Confidential information includes:	Everything that is heard, read or seen regarding the patient.
What is the correct response when a relative calls asking about a patient?	Ask the relative to put the request in writing and include the patient's signed authorization.
Nonprivileged information about a patient consists of the patient's:	City of residence.
Exceptions to the right of privacy rule include:	Gunshot wound cases.
Confidentiality is automatically waived in cases of:	Gunshot wounds, child abuse, and extremely contagious diseases.
Most physician/patient contracts are:	Implied.
When a patient carries private medical insurance, the contract for treatment exists between:	The physician and the patient.
An emancipated minor is:	A person younger than the age of 18 who lives independently.
The reason for a coordination of benefits statement in a health insurance policy is:	To prevent duplication or overlapping of payments for the same medical expense.
Conditions that existed and were treated before the health insurance policy was issued are called:	Pre-existing.
The SOAP in a patient medical record charting is defined as:	S-subjective, O-objective, A-assessment, P-plan.
Parts of the small and large intestines, right ovary, right uterine tube, appendix, and right ureter are found in the:	Right lower quadrant.
When is exclusion from program participation mandatory?	Once an individual has been found guilty of committing a Medicare or Medicaid program-related crime.
All of the following cases should NOT use fax transmission:	Transmission of documents relating to information on sexually transmitted diseases, any routine transmission of patient information, or transmission of documents relating to alcohol treatment.
What level of education is generally required for entry into an insurance billing or coding specialist accredited program?	High school diploma or GED.
To ensure continuous cash flow, what is an ideal amount of time in which an insurance claim should be submitted?	48-72 hours.
What does the abbreviation MSHP designate?	Multiskilled health practioner.
A physician's legal responsibility for his/her own actions as well as his/her employees' is called?	Vicarious liability or respondeat superior.
Administrative medical office responsibilities include:	Claims submission.
In 1980, the American Medical Association (AMA) adopted a modern code of ethics called:	The Principles of Medical Ethics.
Medical ____________ are not laws, but generally accepted standards of conduct.	Ethics.
One of the eight C's of effective caller service is Contagious. This means to:	Model the behavior you want from your callers.
Tracnsactions in which health care information is accessed, processed, stored, and transferred using electronic trechnologies are known as:	E-health Information Management (eHIM).
An intentional misrepresentation of the facts to deceive or mislead another is called:	Fraud.
What is the primary purpose of HIPAA Title I: Insurance Reform?	To provide continuous insurance coverage for workers and their insured dependents when they change or lose jobs.
A third-party administrator who receives insurance claims from the physicians, performs, edits, and transmits claims to insurance carriers is known as a/an:	Clearinghouse.
If a physician contracts with an outside billing company to manage claims and accounts receivable under HIPAA guidelines, the billing company is considered:	A business associate.
A confidential communication realated to the patient's treatment and progress that may be disclosed only with the patient's permission is known as:	Priviledged communication.
The Office of Civil Rights enforces:	Privacy standards.
If you give, release, or transfer information to another entity, this is known as:	Disclosure.
Telephone conversations by providers in front of other patients should be:	Avoided.
What type of organization provides a wide range of comprehensive healthcare services for a specified group at a fixed periodic payment with an emphasis on preventive care?	HMO.
Why was diagnostic coding developed?	For medical research, evaluation of hospital use, and for the process of tracking diseases.
What must be paid each year by the policy holder before the insurance policy benefits begin?	Deductible.
What is the consequence when a medical practice does not use diagnostic codes?	It affects the physician's level of reimbursement for inpatient claims, claims can be denied, and fines or penalties can be levied.
A charge slip, fee ticket, and superbill are also known as:	An encounter form.
The_______ is a concise statement describing the symptom, problem, condition, diagnosis, physician-recommended return, or other factor that is the reason for the encounter.	A chief complaint.
The ICD-9-CM is updated______ and has _______ volume(s).	Annually, 3.
The underlying disease is always coded:	First.
The main reason for a patient encounter in a doctor's office or outpatient facility is termed the:	Primary diagnosis.
Most states generally set a minimum time required for retention of medical records of:	7-10 years.
The key to substantiating procedure and diagnostic code selections for proper reimbursement is:	Supporting documentation in the health record.
The chronologic recording of pertinent facts and observations about the patient's health is known as:	Charting.
Reasons for documentation are:	Defense of a professional liability claim and because insurance carriers require accurate documentation that supports procedure and diagnostic codes.
When a patient fails to return for needed treatment, documentation should be made:	In the patient's medical record, in the appoitment book and on the financial record or ledger card.
A diseased condition or state is known as:	Morbidity.
What does comorbidity mean?	Underlying diseases or other conditions present at the time of visit.
Who may accept a subpoena?	The prospective witness and another authorized person.
If it was documented, it was not ________	Done.
Diagnoses that relate to a patient's previous medical problem that have no bearing on the patient's present condition should be _______ when coding.	Excluded.
A(n) ________ is a pathalogic reaction to a drugthat occurs when appropriate doses are given to humans for prophylaxis, diagnosis, and therapy.	Adverse affect.
The main code book used for reporting clinical information is called the:	International Classification of Diseases, Ninth Revision, Clinical Modifications (ICD-9-CM)
What type of code may be used when two diagnoses or a diagnosis with a secondary process is present?	Combination code.
An E code may be used in which of these circumstances:	Poisoning.
The volume(s) of the ICD-9-CM used in the physician's office to code diagnoses is/are:	Volumes 1 and 2.
What is the table that contains a classification of substances for identifying poisoning states and external causes of adverse effects?	Tables of drugs and chemicals.
Carcinoma in situ is used to describe:	Cancer that is confined to the site of origin.
Neoplasms are ________ , _________ , and _______ .	New growths, may be malignant, and they may be benign.
The term "malignant" in relation to blood pressure means:	Life-threatening.
Diagnostic codes have from ___ to ___ digits.	3, 5.
Always code to the highest degree of:	Specificity.
A private insurance company might adopt which of the following methods as a basis for its payment of outpatient claims?	Fee schedule, usual, customary and reasonable, relative value of schedules.
In medical insurance coding, the acronym CPT stands for:	Current Procedural Terminology.
The direct delivery by a physician(s) of medical care for a critically ill or injured patient is:	Critical care.
Included in a global surgery policy and a surgical package is/are:	Postoperative visits in and out of the hospital, and digital block or topical anesthesia.
A clean claim:	Is subject to medical review with attached information or forwarded simultaneously with electronic medical claim records.
What type of clean calim is any Medicare claim that contains complete, necessary information but is illogical or incorrect?	Invalid claim.
The CMS-1500 (08-05) insurance claim form is almost always accepted by:	Private insurance carriers, Medicaid and Medicare, and worker's compensation.
What should you avoid using when typing a claim for scanning?	"N/A and DNA".
A(n) _______ claim is submitted to the insurance carrier via a CPU, tape diskette direct data entry, direct wire, dial-in telephone, or personal computer via modem.	Electronic.
When two insurance policies are involved in a claim, one is considered ___ and the other is ___>	Primary, secondary.
OCR guidelines for the CMS-1500 claim form state:	It should not be photocopied because it cannot be scanned.
To conform to CMS-1500 OCR guidelines:	Do not fold insurance claim forms when mailing, do not use symbols with data on insurance claim forms, do not strike over errors when making a correction on an insurance claim form.
A health insurance claim form (CMS-1500) is known as the:	Universal claim form.
An insurance claim form that contains no staples or highlighted areas and on which the bar code area has not been deformed is called:	A physically clean claim form.
If you receive a request, accompanied with the correct authorization, asking to abstract medical information from a patient's medical record:	Send only the information requested.
Office visits may be grouped on the insurance claim form if each visit:	Is consecutive, uses the same procedure code, and results in the same fee.
How should blocks be treated on an OCR CMS-1500 claim form that do not need any information?	Leave the blcok blank.
An electronic claims professor (ECP) is:	An individual who converts to standardized electronic format and transmits electronic claims data.
The brain of the computer is called:	CPU.
What should you do often to prevent losing data you have entered?	Back up.
The most important function of a practice management system is:	Accounts receivable.
The employer's identification number is assigned by:	The Internal Revenue Service
A clearinghouse:	Transmits claims to the insurance payer, performs software edits, and separates claims by carrier.
A modem is a device used to:	Transmit electronic information over a dedicated phone line.
The Health Insurance Portability and Accountability Act (HIPAA) does not establish guidelines for:	Insurance claims.
Another name for the multipurpose billing form is:	Superbill.
The insurance claim was rejected because of an incorrect modifier, so:	Verify and submit valid modiiers with the correct procedure codes for which they are valid.
A group of insurance claims sent at the same time from on facility is known as a:	Batch.
Assigning a code to represent data is known as:	Encryption.
A combination of letters, numbers, or symbols that each individual is assigned to access the computer system is called a/an:	Password.
When coding x-ray films taken of both knees, list:	The proper x-ray code twice and use the modifiers RT (right) with the first code and LT (left)with the second code.
The health insurance claim form (CMS-1500) is known as the:	Universal Claim Form.
A group of insurance claims sent at the same time from one facility is known as a:	Bundle.
If a payment problem develops with an insurance company and the company ignores claims and exceeds time limits to pay a claim, it is prudent to contact the:	State insurance commissioner.
If an insurance claim has been lost by the insurance carrier, the procedure(s) to follow is to:	Ask if there is a backlog of claims at the insurace office.
When downcoding occurs, payment will:	Be less.
The first level of appeal in the Medicare program is:	Redetermination.
Professional courtesy means:	Writing off the balance of an account after an insurance company has paid its portion.
When collecting fees, your goal should always be to:	Collect the full amount.
Accounts receivable are usually aged in time periods of:	30, 60, 90, and 120 days.
Messages included on statements to promote payment are called:	Dun messages.
A significant contribution to HMO development was the:	Health Maintenance Organization Act of 1973
How does an HMO receive payment for the services its physicians provides?	Prepaid health plan.
How are physicians who work for a prepaid group practice model paid?	Salary paid by independent group.
In an independent practice association (IPA), physicians are:	Not employees and are not paid salaries.
When a physician sees a patient more thatn is medically necessary, it is called:	Churning.
When an HMO is paid a fixed amount for each patient served without considering the actual number or nature of services provided to each person, this is known as:	Capitation.
Practitioners in an HMO program may come under peer review by a professional group called a:	Quality improvement organization.
Medicare part A is run by:	The Centers for Medicare and Medicaid services.
Medicare provides a one-time baseline mammographic examination for women ages 35 to 39 and preventive mammogram screenings for women 40 years and older.	Once a year.
The frequency of pap tests that may be billed for a Medicare patient who is low risk is:	Every other year.
Some senior HMOs may provide services not covered by Medicare, such as:	Eyeglasses and prescription drugs.
A claims assistance professional (CAP:	May act on the Medicare beneficiary's behalf as a client representative.
If a check is received from Medicare and it is obvious that it is an overpayment, the insurance billing specialist should:	Deposit the check and then write to Medicare to notify them of the overpayment.
The letter "D" following the identification number on the patient's Medicare card indicates a:	Widow.
The Social Security Act of 1935.	Set up the public assistance programs.
The federal Emergency Relief Administration made funds available to pay for:	Medical expenses of the needy unemployed.
The federal aspects of Medicaid are the responsibilty of the:	CMS.
Medicaid is available to needy and low-income people such as:	The blind, the diabled, the aged (65 and older).
To control escalating health care costs by curbing unnecessary emergency department visits and emphasizing preventive care, Medicaid reform has involved.	Managed care programs.
TRICARE, formerly known as CHAMPUS, is funded through:	Congress.
The health maintenance organization provided for dependents of active duty military personnel is called:	Tricare PRIME.
The time limit within which a TRICARE inpatient claim must be filed is within	1 year from a patient's discharge from an inpatient facility
What is the protocol to follow on receiving a request for an attending physician's statement from an insurance company on a patient who has applied for health insurance?	Request a fee from the insurance company before sending the attending physician's statement.
What does bundling mean	Grouping codes that are related to a procedure
An organization that gives members freedom of choice among physicians and hospitals and provides a higher level of benefits if the providers listed on the plan are used is called a/an	preferred provider organization (PPO).
The average amount of accounts receivable should be	1.5 to 2 times the charges for 1 month of services
The largest section in the CPT book is the	surgery section.
The Part B Medicare annual deductible is	135
The letters preceding the number on the patient's Medicare identification card indicate	railroad retiree
Basic Maternal and Child Health Program (MCHP) provisions offered in all states include	children with handicap needs who require orthopedic treatment or plastic surgery
Privileged information is related to the treatment and progress of patients.	true
Office visits may be grouped on the insurance claim form if each visit	is consecutive, uses the same procedure code, and results in the same fee
In a bankruptcy case, most medical bills are considered	unsecured debt.
The official American Hospital Association policy states that "abbreviations should be totally eliminated from the more vital sections of the record, such as the	final diagnosis.
B) operative notes.
C) discharge summaries
What is the name of the federal act that prohibits discrimination in all areas of granting credit?	Equal Credit Opportunity Act
Medicaid is administered by the	state government with partial federal funding
When a remittance advice (RA) is received from Medicare, the insurance billing specialist should	post each patient's name and the amount of payment on the day sheet and the patient's ledger card
The physician who is responsible for coordinating and managing all of the health care for the TRICARE Prime patient is referred to as a/an	PCM.
What is the best response when telephoning a patient about an insurance matter and the patient's voice mail is reached?	Use care in the choice of words when leaving the message
The Medicaid program was a direct result of	a law passed by Congress in 1950.
Part B of Medicare covers	diagnostic tests.
What is the correct procedure to collect a copayment on a managed care plan?	Collect the copayment when the patient arrives for the office visit
There are several ways to file pending insurance claims. What is the best way to file so that timely follow-up can be made?	File by date of service
Accounts that are 90 days or older should not exceed	15% to 18% of the total accounts receivable
What action could happen if an employee knowingly submits a fraudulent Medicare or Medicaid claim at the direction of the employer and subsequently the medical practice is audited?	The employee and the employer could be brought into litigation by the state or federal government
Confidential information includes	everything that is heard about a patient.
B) everything that is read about a patient.
C) everything that is seen regarding a patient
Insurance claims transmitted electronically are usually paid in	2 weeks or less
A clearinghouse is a/an	entity that receives transmission of insurance claims, separates the claims, and sends each one electronically to the correct insurance payer
Back-up copies of office records should be stored	away from the office
Which type of bankruptcy is considered "wage earner's bankruptcy	Chapter 13
A concise statement describing the symptom, problem, condition, diagnosis, physician-recommended return, or other factor that is the reason for the encounter is abbreviated as	CC
Part A of Medicare covers	hospice care.
How should blocks be treated on an OCR CMS-1500 claim form that do not need any information?	Leave the block blank
How many levels of review exist for TRICARE appeal procedures	Three
The time limit for submitting a Medicare claim is	the end of the calendar year following the fiscal year in which services were performed
What is the name of an organization of physicians sponsored by a state or local medical association that is concerned with the development and delivery of medical services and the cost of health care	Foundation for medical care
The medically needy aged	require help in meeting costs of medical care
What should be done if an insurance company denies a service stating it was not medically necessary and the physician believes it was?	Rebill with a letter of explanation from the physician
The Medicaid program was a direct result of	a law passed by Congress in 1950
A medical practice has a policy of billing only for charges in excess of $50. When the medical assistant requests a $45 payment for the office visit, the patient states, "Just bill me." How should the medical assistant respond	State the office policy and ask for the full fee.
How should an entry in a patient's medical record be corrected?	Cross out the incorrect entry, substitute the correct information, date and initial the entry
When a service is rendered that is not listed in the CPT codebook	use a code with a description stating "unlisted."
Back-and-forth communication between user and computer that occurs during online real time is called	interactive transaction
A code system used for managing patient electronic health records, information, indexing, and billing laboratory problems is called	SNOMED.
Which of the following cases should NOT use fax transmission?	Transmission of documents relating to information on sexually transmitted diseases
B) Any routine transmission of patient information
C) Transmission of documents relating to alcohol treatment
In a bankruptcy case, most medical bills are considered	unsecured debt
Under the prospective payment system (PPS), hospitals treating Medicare patients are reimbursed according to	preestablished rates for each type of illness treated based on diagnosis.
In the Medicare program, there is mandatory assignment for	clinical laboratory tests
70. The HCPCS national alphanumeric codes are referred to as	Level II codes
When a Medicare beneficiary has employer supplemental coverage, Medicare refers to these plans as	MSP
When insurance carriers do not pay claims in a timely manner, what effect does this have on the medical practice	Decreased cash flow
Exceptions to the right of privacy rule include	gunshot wound cases
The total number of levels of redetermination that exist in the Medicare program is	five
Who may accept a subpoena	The prospective witness
B) An authorized person
An explanation of benefits document for a patient under the Medicare program is referred to as the	Medicare remittance advice document
In what case should a V code be used	Sterilization
Medicare is a	federal health insurance program
The patient is likely to be the most cooperative in furnishing details necessary for a complete registration process	before any services are provided
The Medicaid service for prevention, early detection, and treatment for welfare children is known as	EPSDT
What should you do if an insurance carrier requests information about another insurance carrier?	Provide the information
If a physician accepts Medicaid patients, the physician must accept	the Medicaid-allowed amount
Medicaid eligibility must always be checked for the	month of service.
B) type of service
The frequency of Pap tests that may be billed for a Medicare patient who is low risk is	once every 24 months
What is the correct response when a relative calls asking about a patient?	Have the physician return the telephone call
Medical etiquette refers to	consideration for others
The reason for a fee reduction must be documented in the patient's	medical record.
Payments to hospitals for Medicare services are classified according to	DRGs
Referral of a patient recommended by one specialist to another specialist is known as	tertiary care.
Organizations handling claims from hospitals, nursing facilities, intermediate care facilities, long-term care facilities, and home health agencies are called	fiscal intermediaries
When a Medicare carrier transmits a Medigap claim electronically to the Medigap carrier, it is referred to as a/an	crossover claim
When is the principal diagnosis applicable	Inpatient hospital coding
A new patient is one who	has not received any professional services from the physician within the past 3 years
The TRICARE fiscal year extends from	October 1 to September 30
The CPT publication is updated and revised	annually
When a medical practice has its own computer and transmits claims electronically directly to the insurance carrier, this system is known as	carrier-direct.
State Children's Health Insurance Programs (SCHIPs)	operate with federal grant support under Title V of the Social Security Act
A participating physician with the Medicare plan agrees to accept	80% of the Medicare-approved charge
What should be done to inform a new patient of office fees and payment policies?	Send a patient information brochure.
B) Send a confirmation letter.
C) Discuss fees and policies at the time of the initial contact
A medical report is a	permanent legal document, part of the health record
A state-based group of doctors working under government guidelines reviewing cases for hospital admission and discharge is known as a:	QIO
Medicare Part A benefit period ends when a patient	has not been a bed patient in any hospital or nursing facility for 60 consecutive days
The CMS-1500 claim form is divided into which of the following major sections?	Patient and physician information
A Medicare prepayment screen	identifies claims to review for medical necessity.
B) monitors the number of times given procedures can be billed during a specific time frame
An example of a technical error on an insurance claim is	duplicate dates of service.
B) transposed numbers.
C) missing place of service code
An established patient is one who	has previously received professional services from a physician or another physician of the same specialty who belongs to the group practice within the past 3 years
An insurance claim submitted with errors is referred to as	a dirty claim
The diagnosis listed first in submitting insurance claims for patients seen in a physician's office is the	primary diagnosis
OSHA stands for	Occupational Safety and Health Administration
FMC	Foundation for Medical Care
IPA	Independant (or individual) practice Association
PPO	Prefered Provider Organization
MCO	Managed Care Organization
HMO	Health Maintenance Organization
EPO	Exclusive Provider Organization
POS	Point Of Service
PPG	Physcian Provider Group
Managed Care Organization (MCO)	A generic term applied to a managed care plan. May apply to EPO, HMO, PPO, integrated delivery system or other managed care arrangemens. MCO's are usually prepaid group plans, and physcians are typially paid by the capitation method
Health Maintenance Organization (HMO)	The oldest of all prepaid health care plans. A comprehensive health care financing and delivery organization that provides a wide range of health care services with an emphasis on preventitive medicine to enrollers within a geographic area through a panel
Exclusive Provider Organization (EPO)	A type of managed health care that combines features of HMO's and PPO's. It is referred to as "exclusive" because it os offered to employers who agree to not contract with any other plan. EPO's are regulated under state health insurance plans.
Physcians Provider Group	A Physcian owned business that has the flexibility to deal with all forms of contact medicine and still offer its own packages to business groups, unions and the general public
Point of Service Plan	A managed care plan in which members are given a choice as to how to receive services, whether through an HMO, PPO, or fee-for service plan. The decision is made at the time the service is necessary (ie "at the point of service") sometimes referred to as
True	T or F-- The Health Maintenance Organization Act of 1973 required most employers to offer HMO coverage to their employees as an alternative to traditional health insurance
True	T or F -- The term "turfing" means to transfer the sickest high-cost patients to other physcians so that the provvider appears as a low utilizer
True	T or F -- In certain manage care plans there is an incentive for the gatekeeper to limit patient referrals to specialists.
False	T or F -- Managed care plans never rquire a CM-1500 claim form to be completed and submitted.
False	T or F -- Usually, there are no deductibles for managed care plans
True	T or F --A copayment in a managed care plan is usually a fixed dollar amount (predetermined fee)
Prepaid health plan	How does an HMO receive payment for th services its physcians provide
Capitation	When an HMO is paid a fixed amount or each patient served without considering the actual number or nature of services provided to each person, this is known as______
Quality improvement organization	Practitioners in a HO program may come under peer review by a professional group called______________
Churning	When a physician sees a patient more than is medically necessary, it is called________________
25	The law states that an employer employing ____ or more persons may offer the services of an HMO clinic as an alernative health treatment plan for employees.
Utilization review	UR is the abreviation for ______________, which is necessary to control costs in the health care setting.
Preauthorization or Prior approval	When a managed care plan requres the primary care physcian to seek approval befoe referring a patient to a specialist, it is called obtaining ___________________________
False	T or F -- All persons age 65 who meet eligibilty requirements for Medicare receive Medicare Part B
True	T or F-- Medicare provides insurance for disabled workeres of any age.
True	T or F-- Patients who elect Medicare part B coverage pay annually increasing basic premium payments
True	T or F -- It is possible for an alien to be eligible for Medicare Part A and Part B
True	T or F -- Employee and employer contributions help pay for Medicare Part A health services.
True	T or F -- Medicare covers some services by chiropractors (B)
Center for Medicare and Medicaid Services	Medicare part A is run by the _______
Federal Health Program	Medicare is a _________________________________
Widow	The letter "D" following the identification number on the patient's Medicare card indicates a _________________________
Hospice care	Part A of Medicare covers _________
Diagnostic tests	Part B of Medicare covers_________
The deductible not covered not covered under Medicare and copayments	Medigap insurance may cover____
80% of the Medicare-approved charge	A participating physcian with the Medicare plan agrees to accept__________
65	Medicare provides insurance for people ______ years or older who are retired on Social Security.
both Medicare and Medicaid	What type of coverage does a Medi-Medi patient have? ** also known as crossover claim
True	T or F -- Medicaid is not so much an insurance program as an assistance program
True	T or F -- The Medicaid patient may be responsible for a copayment
True	T or F --It is possible for a Medicaid patient to be on Medicaid 1 month and off Medicaid the next month
True	T or F -- In some cases, the welfare office may grant retroactive eligibility to a patient
True	T or F -- Family planning is a Medicaid basic benifit
True	T or F -- If a service is totally disallowed by Medicaid, a physcian iw within legal rights to bill the patient.
True	T or F-- Managed care Medicaid programs usually save money in health care delivery
False	T or F --Prior approval or authorization is never required in the Medicaid program
True	T or F --All States processing medical claims must bill using the CMS-1500 claim form
the blind, the disabled, the aged (65 or older)	Medicaid is available to needy and low-income people such as_________
False	T or F -- Individuals who qualify for TRICARE are known as subscribers.
True	T or F --A person retired from from a career in the Armed Forces is eligible for TRICARE until 65 years of age
True	T or F-- All dependent 10 years of age or older are required to have a military identification card for TRICARE
True	T or F -- A certifed nurse midwife is an authorized provider of health care for TRICARE benificiaries.
True	T or F -- Providers may choose to accept TRICARE assignment on a case-by-case basis
Congress	TRICARE formally known as CHAMPUS, is funded through______
TRICARE standard, TRICARE Prime and TRICARE Extra	The three choices of health care coverage for families of active duty military personnel, military retirees,and their dependents are___________
Doctors of medicine, doctors of osteopathy, psychologists	Health care professionals who may treat a TRICARE patient are_____________________________
service benefit program	CHAMPVA is a/an
Sponsor	The active duty service member whose family members are covered under TRICARE is called the ___________________________
benificiary	Individuals who qualify for TRICARE are known as ________________
Vetern	A person who has served in the Armed Forces of United States, especially in time of war, who is no longer in the service and has received an honorable discharge is called a/an __________
ChampVa	Dependants of individuals who have died as a result of service-connected injuries qualify to receive __________ benifits
compliance	Meeting regulations, recommendations, state and federal expectations are all part of the process of ____________________________________
EHIM	Transactions in which health care information is accessed, process, stored and transferred are known as____________.
fraud	An intentional misrepresentations of the facts to deceive or mislead another is________
to provide continuous insurance coverage for workers and their insured dependants when they change or lose their jobs	What is the primary purpose of HIPPA title I: Insurance reform?
clearing house	A third party administrator who receives insurance claims from the physcicians, performs edits, and transmits claims to insurance carriers is known as/an ___________
business associate	If a physcian contracts with an outside billing company to manage claims and accounts receiveable under HIPPA guidelines, the billing company is considered a _____________
priviledged communication	A confidential communication related to the patient's treatment and progress that may be disclosed only with the patient's permission is known as ___________________________________
breach of confidentiality	Unauthorized release of patient's health information is known as____________
disclosure	If you give, release, or transfer information to another entity, this is known as ___________
covered entity	Under the HIPPA guidelines, a health care coverage carrier, such as Blue Cross/ Blue Shield that transmits health information in electronic form in connection with a transaction is called a/an_________________
guarantor	Individual who promises to pay the medical bill.
Preauthorization	___________ determines whether a treatment is medically necessary or not.
premium	Money that has to be paid monthy, quarterly, or annually to keep the policy in effect.
consultation	Services from a physcian whose opinion or advice is requested by another physcian is called __________________________________________
worker's compensation	Contract that exists between the physcian and the insurance carrier.
Third party payers	Forms of health insurance coverage in effect in the United States ( private, managed care, government)
predetermination	discovering the maximum dollar amount that the carrier will pay for service.
referral	Not a consultation, but a transfer of care from one physcian to another
precertification	discovering whether a treatment is covered
deductable	A specific amount of money that has to be paid each year before before the policy benifits begin
explanation of benifits	EOB is the abbreviation for____________________
Superbill, charge slip, patient service slip	An encounter form is also known as a ________
Cheddar, soap	Two acronym's used as format for progress notes.
Review of systems	ROS is the abbreviation for__________
Critical care unit or Emergency department	Critical Care takes place in the_________ or ____________
6 to 10 years	Individual states generally set a minimum of ______ to ___________ for keeping records.
Send a letter of withdrawl	How does a physcian have to contact a patient in order to terminate care?
Cannot	An insurance biller can or cannot escape liability by pleading ignorance.
policy holder --- third party payor	Health insurance contract is between the ________ and the ______________________________
False	T or F -- If the patient will oblige, let the patient direct his or her own insurance form to the insurance company.
false	T or F --List all services on the insurance claim form, including "no charge" services.
universal claim form	The health insurance claim form (CMS1500) is known as the __________
a physcially clean form	An insurance claim form that contains no staples or hightlighed areas and on which the bar code area has not been deformed is called ____________
a dirty claim	An insurance claim submitted with errors is referred to as ___________
copayments	At the time of service, if required by the managed care plan, medical assistants collect the _________.
Disclosure statement	Written description of the agreed terms of payment.
$50 max	The amount of petty cash to be kept in office for small expences
5 digits	The most specific diagosis code has how many digits?
Fraud	Acts that take advatage of others for personal gain
CPT - current proceedural terminology	Coding reference for physcians when medical services are performed.
send only the information requested	If you receive a request , accompanied with the correct authorization, asking to abstact medical information from a patients medical record, you should __________
Electronic	Claim that is submitte to the insurance carrier via a dial-up modem is referred to as __________.
True	T or F --- The exchange of data in a standardized format through computer connections is known as electronic data exchange. (EDI)
True	T or f -- Encrypted data often look like gibberish to unauthorized users
Batch	A group of insurance claims sent at the same time from one facility is known as a _______
2 weeks or less	Insurance claims transmitted electronically are usually paid in _____.
Signature	For assignment of benifits each patient's ________ must be obtained.
Gives information on the status of a claim-- whether charges paid or denied	What does an electronic remittance advice (RA) do?
decrease cash flow	When insurance carriers do not pay claims in a timely manner, what effect does this have on the medical practice?
s Balance	The amount listed on the patient's financial accounting record is also referred to as the account __________.
Dun message	The statement " this bill is now 30 days past due. Please remit payment" is called a _______
Executrix	In dealing with an estate claim, a call to the _________ can be made peeriodically to check on the status of the estate.
true	T or F -- The Health Maintenance Organization Act of 1973 required most employers to offer HMO coverage to their employees as an alternative to traditional health insurance,
HCPCS	(Hick-picks) Healthcare Common Procedure Coding System
why were hcpcs inrotduced in 1983	Medicare found that its payers were using more than 100 diff coding systems
hcpcs level I	CPT - Current Procedural Terminology
what do hcpcs level II codes identify	Services performed by physician & non-physician providers
Any errors that occur in or from the use of private printings of HCPCS level II codes	CMS has stated not responsible for
who composes hcpcs national panal	BCBSA, Health Insurance Association of America, and CMS
Decisions to change perm national codes made by	unanimous consent of all three parties
hcpcs level II dental codes are located in the	Current Dental Terminology CDT
Temporary codes can remain	temporary indefinitley
hcpcs modifiers provide	Additional information regarding the product or service identifed
Never code directly from the	Index
HCPCS Level II	national codes
Always verify codes in the	tabular list
per day	per diem
ASC can be located within a healthcare facility and still be considered	separate for medicare reimbursement purposes
Clinical Lab fee schedule are developed by	medicare administrative contractors (mac)
case mix	a measure of the types of patients treated
oasis	Outcomes & Assessment Information Set
what does oasis do?	a software program that measures the outcome of all adult patients receiving home health services
Decision trees __ ___ used by coders and billers for reimbursement	are not
The diagnostic & Statistical Manual (DSM) __ ___ used by coders & billers	is not
What is the DSM used for?	a tool to identify psychiatric disorders
RBRVS	Resource based relative value unit
RBRVS is now called	MPFS (Medicare Physician Fee Schedule)
ASC's payment limits were established by adjusting?	RVU's
MPFS - 5% x 115% = limiting charge	Formula to calculate limiting charge for non-pars
medicare summary notice (msn) was previously called	EOMB (explanation of Medicare Benefits)
MSN notifies Medicare Beneficiaries of	actions taken on claims
what is balance billing & is it allowed?	billing write-off or adjustment amounts to beneficiaries - it is prohibited
CMS makes sure Medicare beneficiaries are not required to	pay excessive out of pocket amounts
medicare is secondary to	Federal black lung program - Workers comp - Veterans administrative benefits
non physician practioners	Speech pathologist - NP - PA - Clinical Nurse spclst (CNS)
GEP (general enrollment period is held	Jan 1- March 31 each year
Part A	Medicare Hospital insurance covers:
inpatient, acute care, critical access, skilled nursing facility
benefit period	begins the 1st day of hospitalization and ends when the patient had been out of the hospital for 60 consecutive days
hospice providers	services for terminally ill patients & their families
Medicare limits hospice care to 4 benefit periods	a. Two periods of 90 days each
b. one 30-day period
c. a final "lifetime" extension of unlimited duration
Respite care	temporary hospitalization of a terminally ill dependent hospice pt. to provide relief for the non-paid person who has the major day to day responsibility for care of patient
medicare part D	prescription drug coverage to lower the cost of prescription drugs
medigap	Medicare supplementary insurance (MSI)
Who offers Medigap	Commercial insurance companies & some BCBS
what is medigap for	supplements costs that medicare doesnt cover
Medicare Select	A type of Medigap insurance that requires enrollees to use a network of providers in order to receive full coverage
non-pars can accept assignment on a __ _ __ basis	claim by claim
restrictions for non pars accepting assignment are	a. can not balance bill
b. patient must sign a surgical disclosure for all non-assigned surgical fees over $500
practitioners who must accept assignment	a. anesthesiologist assistants - Certified nurse midwives - certified Rn anesthetist - clinical Nurse spclst - clinical psychologist - clinical social worker - mass immunizations roster billers - NP's - PA's - Registered dietician
ABN	advanced beneficiary notice
ABN's are used when	a claim for services is likely to receive a Medicare medical necessity denial
medical necessity denial	denial of otherwise covered services that were found to be not "reasonable and necessary"
purpose of an ABN	to ensure payment for a procedure or service that might not be reimbursed under Medicare
You should __ obtain an ABN on every procedure	not
medicare is primary	has COBRA coverage - has both Medicare & Medicaid - Tricare coverage
deadline for filing claims	Dec 31 unless services were btwn Oct 1 - Dec 31, the deadline is extended through Dec 31 of the following year
why you would use a cpt code & hcpcs code	Cpt for the injection, hcpcs for the medication injected
CPT is a level of HCPCS	Yes, CPT is HCPCS level I
HCPCS tabular codes are organized according to	type of service/procedure
when will medicare pay for ambulance service	when other means of transportation are contraindicated
A non-physician practitioner who is certified with a Masters Degree working as a provider	nurse practitioner (np)
Most UB04 claims are automatically generated by	chargemaster
medicare part a is avlbl at no cost to indvdls 65 or older who	a. qualify & havent applied or currently receive SSI retirement benefits
b. Had medicare-covered government employment
Waiving Medicare coinsurance amounts as a courtesy is	Illegal
Dentists, Optometrists, and Podiatrists are allowed to	opt out of medicare
entities that roster bill cannot	collect donations from Medicare beneficiaries to share the cost of mass immunizations
two vaccines that can be roster billed	influenza - pneumonia
Ambulatory Surgical Center can be located in a hospital	true
DRG-decision is not used to calculate reimbursements	true
Limiting charge is calculated by multiplying the reduced MPFS by 115 percent	true
Nurse Practioners	work along side physician and are considered primary care provider
For beneficiaries with Medicare as secondary payer, when should providers obtain information	when they first see a patient
When should the insurance specialist obtain an ABN from the patient	any procedure would likely be denied
Providers that are allowed to opt out are	DENTIST, OPTOMOTRIST, PODIATRISTS
3 Reasons for Medicare to be Primary	disabled, paid 10 years, and
CMS stands for CENTER FOR MEDICARE/MEDICAID SERVICES	true
Case Mix are categories patients are treated	true
MAC stands for MEDICARE ADMINISTRATIVE CONTRACTOR	true
Eligible individuals are automatically enrolled for MEDICARE or they apply for coverage	true
Admission of Liability	Acknowledgement to an employee that the workers' compensation claim has been accepted or approved.
Burial Benefits	Benefits paid to the person who pays a deceased worker's funeral expenses
Death Benefits	Benefits that can replace a portion of lost family income for eligible family members of workers killed on the job.
Designated Doctor	1. Treating physician chosen by the employer for initial treatment of injured employees. 2. An independent physician who has not seen the patient chosen by the Workers' Compensation Insurance Board to examine the patient for an independent medical review.
Disability	A physical or mental handicap, especially one that prevents a person from holding a gainful job.
Disability Compensation Programs	Programs that reimburse a covered individual for wages lost due to a disability that prevents the individual from working.
Final Report	Report filed by the treating physician in a state's workers' compensation case when the patient is released from medical care and is fit to return to work.
Fraud Indicators	In regards to workers' compensation, unusual events or circumstances that sometimes mean an employer, employee, or attorney is attempting to falsify facts for financial gain.
Impairment Income Benefits	Benefits paid to an injured worker if the injured worker is found to have permanent impariment from a work-related injury or illness.
Impairment Rating	With regard to workers' compensation claims, describes the degree, in percentages, of permanent damage done to a worker's body as a whole.
Income Benefits	With regard to worker's compensation claims, benefits that replace a portion of any wages a worker loses because of a work-related injury or illness.
Lifetime Income Benefits	Benefits that an injured worker becomes eligible for from the date of disability if the injury is the loss of both feet at or above the ankle; the loss of both hands at or above the wrist; the loss of one foot at or above the ankle; the loss of one hand a
Maximum Medical Improvement	With regard to workers' compensation claims, the point in time at which an injured worker's injury or illness has improved as much as it is likely to improve.
Medical Benefits	In the context of workers' compensation, medical care that is reasonable and necesary to treat a work-related injury or illness.
Notice of Contest	With regard to workers' compensation claims, notice issued to an employee if his or her employer denies a workers' compensation claim.
Ombudsmen	A representative of workers' compensation insurance plans who can assist the injured worker with the workers' compensation claim at no charge. The ombudsman is not a lawyer but knows the law as it pertains to workers' compensation claims.
Supplemental Income Benefits	With regard to workers' compensation claims, benefits that may be issued to an injured worker due to the percent of impairment rating, or if the worker has not been able to find employment that matches his or her ability to work.
Temporary Income Benefits	With regard to workers' compensation claims, benefits a worker may receive if an injury or illness caused the worker to lose some or all income for 7 days.
Treating Doctor	With regard to workers' compensation claims, doctor who treats the injured worker; also known as the physician of record.
Vocational Rehabilitation	The retraining of an employee so he or she can return to the workforce.
Active duty service member	an active member of the United States government military services
allowable charge	An amount on which TRICARE figures the patient's cost-share for covered care
authorized provider	A business authorized by the IRS to participate in the IRS e-file Program. The business may be a sole proprietorship, a partnership, a corporation, or an organization. Authorized IRS e-file Providers include Electronic Return Originators (EROs), Transmitt
beneficary	the person who gets all the money after you die. usually a spouse, child, or parent
catastrophic cap	a maximum cost limit placed on covered medical bills under TRICARE. The monetary limit that a family of an active duty member would have to pay in any given year.
catchment area	an area, defined by zip code, that is approximately 40 miles in radius from the nearest military hospital
Categorically needy	Aged, blind, or families and children who meet financial eligibility requirements for Aid to Families with Dependent Children, Supplemental Security Income, or and optional state supplement.
Coinsurance	insurance issued jointly by two or more underwriters
co payment	a small fixed fee paid by the patient at the time of an office visit
covered services	Specific services and supplies for which Medicaid will provide remibursement
Early and Periodic Screening, Diagnosis and Treatment	Medicaid's prevention, early detection, and treatment program for eligible children under the the age of 21.
fiscal agent	an organization that processes claims for a government program
Maternal and Child Health Program	(MCHP) A state service organization to assist children younger than 21 years of age who have conditions leading to health problems
Medicaid	a federal and state assistance program that pays for health care services for people who cannot afford them
Medi-Cal	requiring or amenable to treatment by medicine especially as opposed to surgery
medically needy	Medicaid classification for people with high medical expenses and low financial resources, although not sufficiently low to receive cash assistance
prior approval	The requirement for written documentation of permission to use project funds for purposes not in the approved budget, or to change aspects of the program from those originally planned and approved.
receipient	a person who receives an organ or tissue transplant
share of cost	the amount a patient must pay each month before medicaid will pay anything
State Children's Health Insurance Program	allows states to create or expand existing insurance programs, providing more federal funds to states for the purpose of expanding Medicaid eligibility to include a greater number of currently uninsured children.
Supplement Security Income	a federal program established to provide assistance to elderly persons and disables persons

Created by: lb_tc40

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