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CPB Final Exam
| Question | Answer |
|---|---|
| HIPAA requires that privacy practice notices be provided in several circumstances. Which if the following is NOT required? | Must be placed into the patient’s file |
| The regulation of finance charges or interest applied to outstanding balances in the medical practice is under what law? | Truth in Lending Act |
| HIPAA of 1996 includes a Security Rule that is established to provide what national standards for protecting and transmitting patient data. Which of the following is NOT true | The Security Rule applies only to the entity that initiates the release of protected health information. |
| A physician billed claims to Medicare and Medicaid for procedures that were not performed on 800 patients resulting in loss of 2.6 million dollars. Is this fraud or abuse? | Fraud; subject to the False Claims Act |
| When a subpoena is received by the practice for medical records, in what circumstances may the records be released according to the HIPAA Privacy Rule? | The subpoena is accompanied by a court order or the patient is notified and given a chance to object. |
| Federal healthcare plans include what payers? | Medicare, Medicaid, TRICARE |
| One of the most severe penalties that can be associated with violations of the Social Security Act is exclusion from federal health care plans. Which of the following statements is true of excluded individuals? | Physicians that have been excluded are prohibited from billing for any services to a federally administered health plan. |
| A physician received office space at a reduced rate for referring patients to the hospital’s out- patient physical therapy center. What law does this violate? | Anti-kickback statute |
| A claim is received by a payer that subsequently requests the medical records for the date of service on the claim. What procedure should be followed by the practice? | Only the date of service on the claim should be sent to the payer. The records can be sent as part of HIPAA based on treatment, payment, and operations (TPO). |
| Eight standard transactions were adopted for Electronic Data Interchange (EDI) under HIPAA. Which of the following is NOT included as a standard transaction? | Physician unique identifier number |
| Which insurance is a healthcare benefit program for military personnel in all seven uniformed branches? | TRICARE |
| Under the Patient Protection and Affordable Care Act (ACA), what is banned? | Lifetime limits |
| She can choose any provider she wishes for her consultations, but she will save money if she sees a specialist that is in her network. She does not require a referral for her consultation. What type of insurance does the patient have? | PPO |
| A Medicaid patient presents for services on the first day of the month. He has a $50 spenddown and has had no services this month. The visit for today was $100.00. If the patient wants to be covered as long as possible from today’s visit, what can he do? | Turn the receipt in to his caseworker and be eligible for two months of coverage |
| Why must a provider obtain an NPI number? | To submit claims, To be HIPAA compliant |
| Her employer has set up special accounts for each employee, there is no limit to the amount the employer can contribute and the balances roll over from year to year. What type of account is this? | Traditional Healthcare Reimbursement Arrangement (HRA) |
| The large group practice has 800 covered members under this plan as is paid on a monthly basis with a set amount that is based on the number of members covered and their ages. What type of plan is this? | Capitation |
| What type of insurance is paid for by employers for employees and takes advantage of purchasing power of having large member numbers. | Group health plan |
| What are the options for a provider with regards to participation with Medicare? | Providers may participate, may choose not to participate, or may opt-out of Medicare |
| The mother (DOB 02/08/93) is the custodial parent and is remarried. She has an individual policy. The father (DOB 10/10/92) is covered by a policy from work. The step-father is also covered at work. Which of the following is correct? | The mother’s insurance is primary |
| Listed below are examples of patient reminders for appointments. Which one is HIPAA compliant? | "This is the doctor’s office calling to remind you of your appointment Tuesday, April 12 at 9 am." |
| HIPAA Section 164.508 states that covered entities may not use or disclose protected information without a valid authorization. In what circumstances can a practice NOT release protected information? | Records requested for life insurance |
| The insurance claim process begins with: | Scheduling an appointment |
| Which of the following statements is TRUE regarding patient demographics? | Patient demographic information entered incorrectly can result in claim denials. |
| What is the parent with who the child resides with considered to be? | Custodial parent |
| Patient insurance card will contain vital information that will allow a claim to be processed. Which of the following is NOT provided on the insurance card? | Claim number, CPT code, diagnosis |
| Which of the following does NOT qualify a patient for coverage under Medicare? | Low-income individual |
| What is a claim that is sent for reimbursement that contains all the required data elements to process the claim referred to as? | Clean Claim |
| Child presents for care with the father. Both parents have coverage, date of birth for mother is 3/21 and date of birth for father is 6/20. The mother is covered by a COBRA. What is the primary coverage for the child? | The father’s insurance is primary because the mother has COBRA |
| What is/are the correct code(s) for a patient with acute on chronic maxillary sinusitis? | J01.00, J32.0 |
| How many chapters does ICD-10-CM contain? | 22 |
| Which sections of ICD-10-CM does a biller use to code for a physician’s office? | ICD-10-CM Alphabetic Index and Tabular List |
| What is/are the correct code(s) for a patient with type 1 diabetic neuropathy? | E10.40 |
| What general guideline is addressed in I.C.1.a.2.c.? | Whether the patient is newly diagnosed |
| If a patient has acute diastolic heart failure, what is the main term that is used in the ICD-10-CM Alphabetic Index? | Failure |
| What are the correct codes for benign hypertensive heart disease and stage 3a chronic kidney disease? | I13.10, N18.31 |
| Which statement is TRUE regarding the ICD-10-CM codebook? | The abbreviation that indicates a provider has documented a specific diagnosis but there is not a code for that specificity is NEC. |
| A patient is seen for a follow-up visit in the hospital. A problem focused interval history, an expanded problem focused exam, and MDM of low complexity. What E/M code is reported? | 99231 |
| Which reporting option below is correct use of the modifier 50? | 19318-50 |
| Which option shows the correct way to report procedure code 22515? | 22514, 22515 |
| A patient is seen in the ED after having an auto accident. The patient is new to this provider. What subcategory of E/M is reported? | Emergency Department Services |
| What CPT® code is reported for an MRI of the brain without contrast? | 70551 |
| Which reporting option below is correct use of a modifier with an E/M code? | 99213-25 |
| A 43-year-old established patient is seen for his annual preventive exam by the family physician. A medically appropriate history and exam, and medical decision making of low complexity are performed. What E/M code is reported? | 99396 |
| What CPT® coding is reported for removal of two skin tags? | 11200 |
| Which reporting option below is correct for immunization administration for vaccines or toxoids? | 90460, 90474 |
| A provider orders a lipid panel. According to the practice standards, this includes a complete blood count (85027), total cholesterol (82465), HDL cholesterol (83718), and triglycerides (84478). What is reported on the claim form? | 80061, 85027 |
| Select the supply code for an insertion tray that has a two way all silicone Foley catheter with a drainage bag? | A4315 |
| What abbreviation is used for a drug or biological given into the subdural space of the spinal cord? | IT |
| What codes are NOT reported by Medicare? | S codes |
| A female patient is getting a right and left breast mastectomy bra with integrated form breast prosthesis. What HCPCS Level II code is reported? | L8002 |
| What is the correct code and units to report for 80 mg of Depo-Medrol given IM? | J1040 x 1 |
| When 8 mg of Dilaudid® are given intravenously, how many units are reported? | 2 |
| What HCPCS Level II code and unit(s) is reported for 4 boxes of alcohol wipes? | A4245 x 4 |
| An audiologist provided a battery for a hearing device to a patient. What HCPCS Level II code is reported for the battery? | V5266 |
| What are C codes used for in the HCPCS Level II codebook? | Reporting outpatient services used by hospitals paid under the ACS and OPPS |
| Patient is given 15 mg of methotrexate sodium IM for rheumatoid arthritis given from 5 mg vials. What HCPCS Level II code and unit(s) is reported? | J9250 x 3 |
| The NCCI edits have column 1 and Column 2 codes and provide an indicator to determine whether a modifier is allowed to be used. Which indicator is used to tell the biller a modifier is never allowed? | 0 |
| A patient has a breast biopsy with placement of localization device (19083) with subsequent mastectomy (19301) at the same session after the biopsy is proven to be malignant. What modifier would be used for this scenario? | 58 |
| Which of the following statements is TRUE about medical necessity? | Medical necessity is a determination made by the payer to decide if a service is necessary for treatment or to diagnose a patient. |
| What is an MUE? | Edits showing the maximum number of times a procedure can be performed for one beneficiary in one date of service. |
| NCCI policy specifically discusses what 3 modifiers? | 25, 58, 59 |
| Who were the NCCI edits originally developed to be used by? | Medicare Administrative Contractors |
| What are services that are a standard of medical/surgical practice? | Integral and included in the procedure |
| A patient is admitted to the hospital with pneumonia. Which FL would be used to report the patient’s admitting diagnosis? | FL 69 |
| What regulation requires claims to be sent electronically unless unusual circumstances are met? | Administrative Simplification Compliance Act (ASCA) |
| Prior authorization is reported in Item 23. What other information can be reported in this area of the CMS-1500 claim form? | mammography pre-certification number |
| What revisions does the CMS-1500 claim form undergo? | multiple reviews prior to approval and implementation |
| What is the type of bill code that is reported for a free standing clinic? | 073X |
| Facility charges are reported on which claim form? | UB-04 claim form |
| When reporting procedure codes on the UB-04 claim form, what is FL46- Units of Service? | indicates the number of times the procedure was performed. |
| What is the appropriate POS code to report services rendered in an urgent care facility? | 20 |
| What does the abbreviation FL refer to? | Form locator |
| Which of the following tasks is the most basic element of the billing process: | Data entry |
| What is the physician payment schedule is determined by? | The insurance payer |
| A batch of claims is submitted to the clearinghouse for processing. twenty claims were acknowledged and forwarded on to the payer for payment and ten claims were rejected. What is the next step the medical biller should take in this situation? | Review the status report to identify the reasons for rejection, make needed corrections and resubmit for payment. |
| What will happen if there is failure to post a contractual adjustment to a patient’s account? | It will leave a balance on the patient's account that should not be there. |
| What is the function of a claim scrubber? | To identify errors that will prevent a claim from being paid. |
| A family has health insurance coverage from both the father and mother. The father's birthday is May 29, 1989 and the mother's birthday is May 26, 1990. Which insurance would be primary for their three children? | The mother would be primary based on the month and day of her birthday. |
| What is the purpose of EHNAC? | To develop standards for clearinghouses. To promote interoperability, quality service and regulatory compliance. |
| To submit claims data through EDI, what format must claims data be changed to? | electronic flat files format. |
| When a claim is returned to the provider, at the clearinghouse level, what is it considered to be? | rejected |
| A patient with ABC insurance is seen on May 1st, and the claim is submitted on July 15 of the same year. Has the claim met the timely filing deadline? | Maybe. ABC's timely filing policy should be reviewed to determine if the deadline was met. |
| Which of the following is the highest level of the appeals process of Medicare? | Judicial Review |
| Can a patient be refused treatment due to ability to pay for service? | Yes, a provider can refuse to see a patient if it is not an emergency situation. |
| Which is the best way to handle a denial for incorrect information? | Contact the insurance company and the patient to figure out where the error is and get it corrected |
| Which of the following is a statement sent to the patient from the insurance carrier explaining services paid for on their behalf? | Explanation of Benefits |
| What is a lower level of care denial? | Care provided on an inpatient basis is typically provided on an outpatient basis, Outpatient procedure could have been done in the provider’s office |
| Which denial is when the patient is covered under another insurance? | Coordination of benefits |
| Which federal act states that third-party debt collectors are prohibited from employing deceptive or abusive conduct in the collection of the debt? | Fair Debt Collection Practices Act |
| What is the first step in working a denied claim? | Determine and understand why the claim was denied |
| Which are the two main types of Bankruptcy seen by medical practices and facilities? | Chapters 7 & 13 |
| A Medicare patient receives services from a participating provider on January 6, 2016, but the charges are missed and don’t get entered in to the computer. How long does the office have to bill Medicare for the services? | 12 months |
| The physician has opted out of the Medicare program. The patient and physician have a private contract. The charges for the services rendered are $300.00. Medicare’s approved amount would be $200.00. What can the office charge this patient? | $300.00 |
| A Medicare patient has prescription drug coverage, but does not have Medicare Advantage. What Medicare coverage does the patient have for his medications? | Part D |
| A Medicare patient presents with an injury sustained at his part-time job. His injury status is verified by his company. After services are rendered, in what order are the claims submitted? | The worker’s compensation is primary, and Medicare is secondary |
| A 21 year-old patient presents for fillings for two if his teeth. Are these services covered under EPSDT? | No, because the patient is not under the age of 21. |
| A patient has Medicare and a Medigap policy. Box 13, signature on file, is checked off on the electronic claim submission. An EOMB is received with remittance notice MA19. What does the office need to do? | The biller must file the secondary insurance as the cross-over claim is not going to be sent due to missing information. |
| Which coverage under TRICARE is a Medicare wrap around plan? | TRICARE for Life |
| What is true regarding Medigap policies? | They cover deductibles, copayments, and coinsurances usually. |
| The patient is not sure when she had her last PPB. As she is checking out, the front desk rep has her sign an ABN. The service is billed and denied for frequency. Can the patient be balance billed? Why? | No. The ABN must be signed before the service is performed. |
| What is the correct action when a claim has been submitted to BCBS but the provider has not received a response? | Check claim status with the local BCBS carrier. |
| When a provider signs a contract to be a participating provider with an insurance payer they are agreeing to: | Accept the fee schedules set by the insurance company. |
| Which type of insurance plan is a federal and state program that provides coverage to the low-income population? | Medicaid |
| What is the correct action when the three-character prefix is not appended to a BCBS identification number? | Look at the patient's BCBS card and append the appropriate prefix listed on the card. |
| An indemnity plan is also referred to as _____________? | Fee-for-Service |
| Which of the following statements is NOT correct regarding timely filing? | If the physician fails to send a claim during the timely filing limit the balance can be sent to the patient. |
| Which of the following is an account that is usually funded by the employee only and reimburses employees for specified expenses as they are incurred? | FSA |
| Which of the following defines Point-of-Service coverage? | Coverage that allows members to choose medical services as needed within the BCBS network or seek medical care outside of the network. |
| What is the timely filing requirement for Blue Cross Blue Shield? | Claim requirements differ between plans |
| Which of the following includes provisions for the appeals process? | Patient Protection and Affordable Care Act |
| Which denial occurs when the claim is a liability case and was submitted to the health insurance? | Claim covered by other insurer |
| When submitting an appeal to Cigna for timely filing, which of the following is NOT required? | The patient's complete medical chart. |
| According to the policy above, if a denial is received on a UnitedHealthcare claim, a reconsideration must be submitted within what timeframe of the date of the EOB or PRA? | 12 months |
| Which modifier is used to indicate that an E&M service is unrelated to the global service? | 24 |
| For Aetna, how long does a provider have to file a reconsideration? | 180 calendar days from the date of the initial claim decision |
| Significant, separately identifiable evaluation and management service by the same physician or other qualified healthcare professional on the same day of the procedure or other service is which modifier? | 25 |
| Which of the following denials is one of the leading reasons a claim is denied and can be prevented by accurate intake information being collected every time? | Incorrect patient information |
| If a provider wishes to submit for a first level provider payment review form Cigna, what is the timeframe for this type of dispute? | 180 days |
| What is a rejected claim? | A claim that does not contain the necessary information for adjudication. |
| What is the timely filing limit for claims for workers’ compensation services? | Will vary by payer |
| Which program covers postal workers for employment related injuries? | Federal Employees’ Compensation Program |
| What kind of workers are covered under the Longshore and Harbor Workers’ Compensation Program? | Shipbuilders, Longshore worker |
| A 70-year-old patient with complex pneumoconiosis presents after a fall. X-rays are taken and are negative for fracture. The patient gives both a Medicare card and a Federal Black Lung ID card. How should this claim be billed? | Medicare only |
| What type of state worker’s compensation coverage allows an employer to set aside money to cover medical expenses and other related benefits for its employees? | Self-insurance plans |
| Can an employer require an employee to pay a portion of the insurance premiums for the workers’ compensation coverage? Why or why not? | No, the employer is required by law to pay the premiums for coverage |
| Under Workers’ Compensation, when is a worker covered for an injury that occurred on-the-job? | They are covered regardless of who is at fault |
| A patient presents to be seen with chronic beryllium disease that he incurred while under government employment. What coverage would apply to him? | Part B Energy Employees Occupational Illness Compensation Program |
| According to OSHA, who has the highest rate of work-related musculoskeletal disorders? | Nurses' aides |
| What must be submitted to the workers’ compensation payer after an initial employee injury visit? | First Report of Injury form, CMS-1500 claim form, and office encounter note |
Created by:
ehalbhuber