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Exam 4

HIT Classification and Reimbursement

Question	Answer
A payer’s initial processing of a claim screens for	basic errors in claim data or missing information.
Some automated edits are for	patient eligibility, duplicate claims, and noncovered services.
A claim may be downcoded because	the documentation does not justify the level of service.
Payers should comply with the required	claim turnaround time.
What is the next step after the primary payer’s RA has been posted when a patient has additional insurance coverage?	billing the second payer
Appeals must always be filed	within a specified time.
Determine what should be verified after an RA has been checked for the patient’s name, account number, insurance number, and date of service.	that all billed CPT codes are listed
If a patient has secondary insurance under a spouse’s plan, what information is needed before transmitting a claim to the secondary plan?	RA data
What type of codes explain Medicare payment decisions?	MOA
Which of the following appears only on secondary claims?	primary payer payment
A payer may __________ a procedure that it determines was not medically necessary at the level reported.	downcode
What is the correct order for the basic steps of a payer's adjudication process?	initial processing, automated review, manual review, determination, and payment
During the adjudication process, if there are problems during the automated review, the claim is pulled for	development.
The __________ verifies the medical necessity of providers' reported procedures.	claims examiner
When a claim is pulled by a payer for a manual review, the provider may be asked to submit	clinical documentation.
A payer's initial claim review may reject a claim due to	an invalid policy number.
A payer's automated claim edits may result in claim denial because of	any of these. lack of required preauthorization. lack of medical necessity. lack of eligibility for a reported service.
Medical situations in which a patient receives extensive care from two or more providers on the same date of service are called	concurrent care.
Concurrent care is care provided	to a patient on the same date at the same place of service by two or more physicians.
A payer's decision regarding whether to pay, deny, or partially pay a claim is called	determination.
What is done by a payer to determine the appropriateness of medical services?	utilization review
What will a payer do when a claim is submitted with a diagnosis code that is not valid for the date of service?	Payers may deny a claim when outdated codes are used.
The payer's processing of claims is called	adjudication.
A payer's determination means it is going to	pay, deny, or partially pay the claim.
Which of these HIPAA transactions is sent by a payer to answer a question about a submitted claim?	277
The claim turnaround time is the period between	the date of claim transmission and receipt of payment.
An __________ code indicates that a request for more information has been sent.	R
A(n) __________ claim status category code is an acknowledgment that the claim has been received.	A
An insurance aging report lists	unpaid claims transmitted to payers by the length of time they remain due.
A list of claims transmitted and how long they have been in process with the payer is shown in the	insurance aging report.
Prompt-pay laws govern	insurance carriers' payments of providers' claims.
On an aging report, which category describes a current invoice?	0–30 days
A typical aging report groups payments that are due into which of these categories?	0–30 days, 31–60 days, 61–90 days, 91–120 days, and over 121 days
A pending claim is indicated by which claim status category code?	P
The payer's RA shows	both the amount the provider is allowed and the amount patient pays.
Claim adjustment reason codes are used by payers to explain entries on	RAs.
What kind of code appears on payers' electronic reports on the progress of transmitted claims in their adjudication process?	claim status category codes
The payer sends the medical practice	an RA that covers a batch of processed claims.
A paper explanation of benefits (EOB) is sent to patients by payers after claims	are adjudicated.
Remittance advice remark codes are maintained by __________ but can be used by all payers.	CMS
RAs generally have information on any	all of these are correct. errors on the listed claims. denials to the listed claims adjustments to the listed claims.
The first step the medical billing specialist should check when reviewing RAs is to	match up claims with the RA using the unique claim control number.
The advantage(s) of EFT for practices is(are)	funds are available immediately and the transfer is less costly than check deposits.
The process of __________ means verifying that the totals on the RA are mathematically correct.	reconciliation
What does "reconciliation" mean?	to double-check that totals are accurate and consistent
Funds that are electronically transferred from a payer are directly deposited in the	practice's bank account.
The person filing an appeal is known as a(n) __________, regardless of whether that individual is a provider or a patient.	either the claimant or the appellant
The claimant is the	patient or provider who appeals the claim.
The abbreviation MRN stands for	Medicare Redetermination Notice.
In general, how many levels are there when pursuing an appeal?	three
When is an appeal sent to third-party payers?	after a claim is rejected or paid at less than the expected amount
Medicare overpayments must be reported and the amount	must be returned within 60 days.
Filing a grievance with the state insurance commission requires the __________ to investigate the complaint.	state
If a patient has additional insurance coverage, after the primary payer's RA has been posted, the next step is	billing the second payer.
Which of the following statements is true?	Medicaid is the secondary payer to Medicare.
If a Medicare beneficiary receives treatment covered by workers' compensation, the Medicare plan is	secondary.
If a Medicare beneficiary is employed and covered by the employer's group health plan, the Medicare plan is	secondary.
The abbreviation MSP stands for	Medicare Secondary Payer.
If a Medicare beneficiary is covered by a spouse's employer group health plan, the Medicare plan is	secondary
The Medicare Secondary Payer program coordinates the benefits for patients who have both Medicare and	any other insurance coverage.
When talking with someone other than the patient about an overdue bill, collections specialists will	not discuss the patient’s debt.
The day sheet produced by the practice management program shows	the payments and charges that occurred on that date.
During collections, most practices use	letters and calls.
Credit bureaus keep records about a patient’s	credit information.
Collection calls are regulated by the guidelines set by	FDCPA.
Accounts might be considered uncollectible when a patient	files for bankruptcy.
Skip tracing increases the practice’s chances of	locating a patient with an overdue bill.
The practice will need to pay patient refunds if it has	overcharged the patient for a service.
The patient aging report is used to	collect overdue accounts from patients.
Bad debt is defined as	uncollectible A/R.
Effective patient billing begins with	sound financial policies.
A good financial policy is clear to	both patients and the practice staff.
When a practice accepts a credit card payment in advance for payments billed after treatment, what does the practice send the patient?	zero-balance statement
A patient statement is	a bill that is sent to a patient for medical services that have been provided.
Which of the following shows a particular day's transactions?	day sheet
What document is used by the medical insurance specialist to update the patient billing program with the payer's payments and the amount due from the patient?	RA
The __________ totals the transactions that were posted to all patient ledgers on a particular business day.	day sheet
The day sheet in a medical office summarizes	all the transactions that were posted to all patient ledgers on a particular business day.
What is a printed bill that shows the amount a patient owes?	patient statement
The patient statement shows	all of these the balance that a patient owes the practice. the services provided to the patient. how much the insurance paid.
The type of patient billing that spreads out the workload of mailing statements is called	cycle billing.
In cycle billing, how often does the practice mail all patient statements?	at intervals during the month
Patients are grouped under the insurance policyholder in what type of billing?	guarantor billing
Under the Federal Trade Commission's rules, it is illegal to	call multiple times daily.
For most patients, their first notice that their bill is past due is a	collection letter.
The law that regulates calling hours and collections methods is	Telephone Consumer Protection Act.
The __________ report is the start of the process of collecting payments due from patients.	patient aging
The law that regulates collection practices is	FDCPA.
Who is responsible for regulating the hours during which collection calls may be made?	both the FDCPA and the Telephone Consumer Protection Act
Collections from patients are classified as consumer collections and are regulated by __________ and state laws.	federal
Under the Federal Trade Commission's rules, it is not illegal to	call a patient at 8 p.m.
FDCPA is the abbreviation for	Fair Debt Collection Practices Act.
The job of creating and implementing the practice's collections policies is done by	the billing/collections manager.
Embezzlement is a form of	stealing.
What term refers to the stealing of funds?	embezzlement
What term refers to all the activities that are related to patient accounts and follow-up?	collections
The process of following up on overdue accounts is called	collections.
The job of accurately recording the funds coming into and going out of the practice is done by	the bookkeeper.
Which of the following employees learns and applies the correct techniques for effective follow-up of overdue accounts, as well as is most likely to work directly with patients?	collections specialist
Patients may agree to a(n)__________ for expensive procedures before the date of service.	prepayment plan
Which of the following is the cost of a borrower's credit calculated as an annual rate?	annual percentage rate
When patients are scheduled to have major, expensive procedures, the practice's policy may be to set up	prepayment plans.
The __________ process is used to locate a patient who owes an account balance to the practice.	skip tracing
Which law modified the Fair Credit Reporting Act to protect the accuracy and privacy of credit reports?	FACTA
A collection agency is usually	an outside firm the medical practice hires.
FACTA is the acronym for	Fair and Accurate Credit Transaction Act.
FCRA is the abbreviation for	Fair Credit Reporting Act.
Credit bureaus supply information about	how well patients pay their bills.
Collection agencies are outside services that are hired to	collect overdue accounts.
Which law required consumer reporting agencies to have reasonable and fair procedures?	FCRA
The __________ helps a practice decide whether patients are indigent.	means test
__________ is a legal declaration of a person's inability to pay his or her debts.	Bankruptcy
Which of the following requires a practice to follow a specific series of steps before an account can be written off?	both Medicaid and Medicare
Uncollectible accounts refer to	monies owed by patients and payers.
When a person receives a legal declaration of the inability to pay debts, it is called	bankruptcy.
What is the term for monies owed to a patient from the provider?	patient refund
Bad debt includes all collections that are	classified as uncollectible accounts.
HIPAA compliance records must be retained for how many years?	six
A __________ is a log of how long various types of documents must be stored for a particular practice.	retention schedule
The practice's policy about keeping records is summarized in a __________, a list of the items from a record that are retained and for how long.	retention schedule
When the hospital staff collects data on a patient who is being admitted for services, the process is called	registration
Which of the following hospital departments has different procedures for collecting patients’ personal and insurance information?	emergency department
Patient charges in hospitals vary according to	their accommodations and services.
Which of these rules governs the reporting of hospital inpatient services on insurance claims?	UHDDS
Conditions that arise during the patient’s hospital stay as a result of surgery or treatments are called	complications.
In inpatient coding, the initials CC mean	comorbidities and complications.
The code 02103D4 is an example of which type of code?	ICD-10-PCS
Under a prospective payment system, payments for services are	set in advance.
The UB-04 form locator 4 requires the	type of bill.
Under Medicare rules for patients in car accidents, the automobile insurance is	primary
In medical insurance terminology, an emergency is a	situation in which delaying the treatment of a patient would result in a significant increase in the threat to life or to the viability of the body part.
Ambulatory care refers to which kind of care?	outpatient
What is a special approach to caring for people with terminal illnesses?	hospice care
ASU is the abbreviation for	ambulatory surgical unit.
__________ involves a situation that is life-threatening.	Emergency care
What involves a situation in which a delay in treatment would lead to a significant increase in the threat to a patient's life or body part?	emergency care
__________ is palliative care for terminally ill patients.	Hospice care
What type of facility is equipped for patients to stay overnight?	inpatient
A(n) __________ is a person admitted for services that require a stay spanning two midnights.	inpatient
Hospice care is provided	either in a special hospice facility or a patient's home.
ASC is the abbreviation for	ambulatory surgical center.
HHA is the abbreviation for	home health agency.
What category of services includes care given at home, such as physical therapy or skilled nursing care?	home health care
SNF is the abbreviation for	skilled nursing facility.
What type of care covers all types of health services that do not require an overnight hospital stay?	ambulatory care
An ambulatory surgical center is a clinic that provides	outpatient surgery.
At-home recovery care refers to assistance with which of the following?	the activities of daily living, such as bathing and eating
Ambulatory care is provided in a(n)	outpatient facility or setting.
The__________ is the main database of a hospital's patients.	master patient index
Inpatients are admitted to hospitals in a process called	registration.
A charge master contains a hospital's list of all of the following except	staff.
patient's personal and insurance information is gathered before or during hospital admission through which process?	registration process
Patients are listed in a patient register under a unique number, which makes up the	master patient index.
A __________is the hospital's list of the codes and charges for its services	charge master
HIM is the abbreviation for	health information management.
The HIM department in hospitals conducts which of the following	organizes and maintains patient medical records
The major steps related to hospital claims processing are	admission, treatment, and discharge.
Which term is generally used for the hospital admission process?	registration
HINN is the abbreviation for	Hospital-Issued Notice of Noncoverage.
CC is the abbreviation used by the inpatient coder on the medical record for _________.	complications and comorbidities
A patient's other conditions at admission that affect care during the hospitalization being coded are called __________, meaning coexisting conditions.	comorbidities
Which term describes the patient's condition that, after study, is established as the main reason for a hospital admission?	principal diagnosis
Which of these terms refers to coexisting conditions?	comorbidities
UHDDS is the classification system for	inpatient health data.
Which term describes the patient's condition upon hospital admission?	admitting diagnosis
Which term describes the main service performed for the condition listed as the principal diagnosis for a hospital inpatient?	principal procedure
The principal procedure is assigned by the	inpatient medical coder.
MS-DRG is the abbreviation for	Medicare-Severity Diagnosis Related Group.
APC is a __________ payment system.	Medicare
__________are complications caused by avoidable conditions that will not be reimbursed.	Never events
Each MDC is subdivided into __________ MS-DRGs.	medical and surgical
APC is the abbreviation for	ambulatory payment classifications.
DRG is the abbreviation for	diagnosis related group.
The DRG system is now called which of the following	MS-DRGs
The IPPS is the Medicare system for payments to institutions for	inpatients.
Each hospital's __________ is an average of the DRG weights handled for a specific period of time.	case mix index
Each hospital negotiates a rate for MS-DRGs based on which of the following?	all of these are factors in the rate supply costs geographic location labor
A grouper is software used to help calculate and assign	DRGs.
The UB-04 form is also identified as the __________ form.	CMS-1450
Hospitals must submit electronic claims for Medicare Part A reimbursement to MACs using the HIPAA health care claim called	837I.

Created by: shulukong

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