cstep 2

Question Answer
PICA is a measurement of text used in design and print true
Preauthorization and precertification numbers generally are written with spaces and punctuation. false
SOF on a claim form means Signature Off File. false
A Worker's Compensation claim and an automobile accident claim both require the date of injury or accident. true
Third-party payers are not permitted access to a patient's medical record. false
If the patient's name appears as “Martin Smith” on the insurance card, but he tells you that his name is “Martin Smith, Junior,” then you should include the “Jr.” notation on the CMS-1500 form. false
Typewriters are obsolete and medical billers and coders are not to use them. false
Place of service codes are standard for each third-party payer. true
Automobile accident claims are handled(the same, differently) than other visits. differently
(EOB, POS) are internal codes that physician's offices can create to distinguish one hospital from another if the physician(s) goes to multiple hospitals. POS
Billing subsequent hospital days is an example of(billing multiple patients, billing multiple units) . billing multiple units
The diagnosis pointer is the corresponding number from the(diagnosis codes, diagnosis dates) . diagnosis codes
If a code is transposed, a claim would be sent back as(nonintelligent, unprocessable) . unprocessable
Sections of the CMS-1500 form are broken down into(fields, colored codes) . fields
Employer's Identification Number is represented by the initials(EINO, EIN) . EIN
The date of the(first, most recent) symptom recorded in the health record should be used if the claim is for illness. first
When entering the total amount billed on the claim form,(do, do not) use dollar signs. do not
A software program designed to determine MS-DRGs and typically contains Medicare code edits. comorbid condition
A method to identify various situations based upon assigned ICD-10-CM codes. medicare code edits
Defined by Medicare to have a higher severity of illness impact on a patient. major complication/comorbid condition (MCC)
A broad classification of conditions typically grouped by body systems diseases. major diagnostic category (MDC)
When patients who were considered inpatients at healthcare facilities leave the facility to go to another location. The status indicates the new location of the patient. discharge status
The sum of all MS-DRG weights, divided by the total number of Medicare discharges for the same time period. case mix index (CMI)
A numeric factor defined by Medicare that considers the geographic location of hospitals. This factor is used in the reimbursement calculations for facilities to account for geographic differences. hospital wage index
A type of discharge status in which a patient chooses to leave the facility even though all medical personnel recommend the patient stays for treatment. against medical advice
Abbreviation for complications and comorbid conditions CC
A condition that arises during the hospital stay which prolongs the length of stay by at least one day in approximately 75% of the cases. complication
Procedures which may or may NOT be performed in a surgical operating suite; however, the procedure codes affect MS-DRG assignment. non-operating room procedure
Procedures identified as requiring the use of an operating room suite. The identified codes influence MS-DRG assignment. operating room procedure
Hospital cases with specific circumstances that place the admission extremely outside the normal or average admission. Additional payment may be received for such outliers. outliers
A set payment amount to a facility for each day the patient stayed at the facility. For MS-DRG purposes, the amount is paid to the facility that transferred the patient. outliers
Categories established by Medicare where cases are automatically assigned without applying all the MS-DRG logic. These cases are usually high-risk, lower volume admissions, such as organ transplants. pre-MDC
Condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care. principal diagnosis
Procedure performed for definitive treatment rather than diagnostic or exploratory; or to treat a complication. This procedure is typically related to the principal diagnosis. principal procedure
MS-DRG reflecting an average patient’s consumption. The higher the # value represents greater resources used to care for patient. This # is used in calculating the MSDRG reimbursement amount a facility receive. The higher , the higher amount receive. relative weight (RW
Ordering of surgical cases from the most to least resource intensive. surgical heirarchy
A patient may be moved to many different types of facilities, such as to skilled nursing facility, or another acute care facility. There are different discharge status codes to assign depending upon the type of facility. transfer
The number of patients in each MS-DRG. The volume of patients in specific DRGs is important when reviewing the case mix index volume
Reimbursement amounts for MS-DRGs are calculated by multiplying the MS-DRG relative weight by facility base rate
MS-DRGs are affected by race
TRUE The number of payers listed in FL 50 may affect the number of entries in FLs 51, 52, 53, 54, 58 and 59
TRUE Codes in FL 34 only require one date to be entered with each code
When listing codes in FLs 39–41, codes that begin with letters come first false
2:21 A.M. would be coded as 02 for FLs 13 and 16. true
Condition codes are reported in a two-digit format. true
12191977 is a proper date entry for FL 6. false
12191977 is a proper date entry for FL 10. true
Code 3 would be used to indicate an emergency in FL 14. false
FLs 31–34 are to be filled out left to right before moving on to the second row. true
FL 29 is required for all submissions. false
The filling out of a CMS-1500 claim form requires very few pieces of documentation. false
states that the patient or physician signature is in a file SOF
All chargemasters or fee schedules contain which item(s)? procedure code, description, charge ANSWER IS ALL OF THE ABOVE
The healthcare provider's comprehensive price list of all supplies, services, and equipment usage fees is referred to as the chargemaster or _____. CDM
The fees on the chargemaster _____. vary from provider to provider
How often is the chargemaster or fee schedule updated? Every year (at a minimum)
charge description also known as item description
CPT or HCPCS code identifies the specific service or procedure
revenue code four-digit code identifying accommodation, ancillary service, or billing calculation required for Medicare
charge fee for the service
Department code used for accounting purposes to distribute revenue to appropriate location
charge code internally assigned unique number identifying each item listed
charge status activity date element
Outdated chargemasters can result in over or undercharging. true
The chargemaster maintenance ideally should be done by one person. false
There is a high risk that one error in the CDM can replicate and cause multiple errors. true
CPT codes change every 2 years, and this is the recommended time to perform maintenance. false
All departments that create charges should be represented on the Chargemaster Committee. true
Revenue codes are reported on both the CMS-1500 and UB-04 claim forms. false
A charge sheet can be used as a substitute for a medical coder. false
The chargemaster is the price list of all the supplies, services, and equipment usage fees for patient care. true
Demographic information is used to determine who has responsibility for payment of medical services. true
All providers refer to the form used to track individual patient charges as a charge sheet. false
Physician's offices only use the CMS-1500 form for billing. true
The billing and coding process at a physician's clinic begins with procedures codes from CPT. :false
A large physician's office will have a different billing procedure than a small one. :false
A physician who sees patient's in outside facilities will have the services coded by his or her own staff. true
The physician's staff will use only a CMS-1500 form when billing for his or her work at an outside facility. true
If a physician brings supplies with him when visiting an outpatient facility, it is billed on a UB-04. false
ICD-10-CM codes are used in the diagnosis coding and billing process for professional services. true
The professional services performed by a physician are billed on the CMS-1500 claim form. true
Procedures performed at a physician’s office are reported with CPT® codes. true
The coding and billing of non-physician professional services are coded and billed differently than physician professional services. false
Emergency room services are billed on the UB-04 claim form. true
all facility charges are reported on the UB-04 claim form. false
All facility charges are billed on the CMS-1500 claim form. false
ICD-10-PCS codes are not reported for outpatient services. true
The charges for Medicare patients seen in an ambulatory surgical center are billed on the CMS-1500 claim form true
Which types of codes are reported for tracking purposes only for outpatient facility coding? ICD-10-PCS codes
When a medical coder is working for an ambulatory surgical center, the services are reported on the CMS-1500 claim form for which third-party payer? Medicare
In the outpatient billing process which of the following is an example of demographic information? third-party payer name
A 56-year-old gentleman presents to the emergency room with an ingrown toenail on his left first toe. He receives a toe block, using 1% lidocaine. Appropriate local analgesia is obtained, under sterile fashion, and the patient receives a partial nail bed UB-04
Which form would the emergency room physician services for the ingrown toenail care described in the previous question be billed on? CMS-1500
Revenue codes describe the type of services rendered. Who enters the revenue codes on the UB-04 claim form? medical biller
What is the last step in the medical billing process? patient statement and claim form
A 76-year-old male,presents with 1-week history of right upper quadrant pain which is constantly there. The patient was seen in the emergency room one week ago with normal laboratories and normal chest x-ray. The pain was felt to be pleuritic in nature CMS-1500
In the outpatient billing process the medical coder’s main responsibility is to assign which of the following diagnosis and procedure codes
The patient is a 55-year-old male who is referred to a consulting physician for evaluation of his right knee. He has had a 4-month history of right knee pain.He underwent lateral meniscectomy, and did receive considerable benefit CMS-1500
In which healthcare setting is there is an exception to which claim form Medicare patient services are reported on? ambulatory surgical center
This 16-month-old white male is noted to have increased swelling of right groin area. The patient presents at this time to the same day surgery unit of Sunshine Hospital for orchiopexy and repair of hernia. Which claim form would the surgery facility use UB-04
On an inpatient bill, accommodations are described by the assignment of revenue codes. What claim form is used to bill inpatient facility charges including accommodations (room) and ancillary charges? UB-04
types of bills (TOBs). A common TOB number is 0131 (for hospital outpatient services). The 0 is just a leading 0, The first 1 stands for the type of facility – hospital The 3 stands for the classification of the bill – outpatient, The final 1 stands for the frequency of
Processing The third-party payer receives the claim and gathers information related to the case (specifics about the patient, the case, and the coverage).
Adjudication adjudication means rendering a decision or making a judgment. The third-party payer’s process of checking the details of the claim against the information they have on the patient and his/her insurance benefits. This process also checks for completeness
Payment A financial payment is made by the third party payer and received by the provider. The payment may be a lump sum for multiple claims or a single payment for one claim. The third-party payer also submits a remittance advice to the healthcare provider and a
Reconciliation The process the healthcare provider analyzes received payment information compared to submitted claim information for accuracy. If the provider believes a claim was inappropriately denied by the payer, the dispute process begins until satisfactory reconci
Local Coverage Determinations (LCDs) indicate which items and services Medicare considers reasonable, medically necessary, and appropriate.
The UB-04 is the claim form used to bill inpatient and outpatient facility charges: surgery centers, freestanding radiology clinics, laboratories, hospitals, skilled nursing, and emergency rooms
CMS-1500 is the claim form used to bill professional services: surgeon’s fees for a surgery performed at an outpatient surgery center or an emergency physician’s fee for professional services provided in the emergency room
CLEARING HOUSE is a company contracted by the third-party payers to handle and format submissions, screen claims, and make data available to providers.
CLEAN CLAIM is a complete and accurate claim form that includes all provider and member information, as well as records, additional information, or documents needed from the member or provider to enable the payer to process the claim.
CLEAN CLAIM DATE is the date on which all such necessary information has been received
EDI electronic data interchange allows data to be transferred between different computer systems or computer networks
ANSI is the American National Standards Institute
ASC X12 stands for the Accredited Standards Committee X12. This committee is made of government and industry members from North America. This committee was chartered in 1979 by ANSI to create uniform standards for all electronic data interchange documents. This committee me
COMMON DATA FILE is an overview of claims recently filed on the patient.
allowed charge is simply the amount the policy states is payable for a particular procedure
remittance advice contains information of multiple claims to one provider
explanation of benefits (EOB) is one patient’s explanation of the paid services.
Electronic Remit Advice ERA
Standard Paper Remit (SPR)
write-off is the difference between total charge and the allowable amount by the insurance.
PAR (participating) provider
aging report that reconciles claims by date (current, 30 days unpaid, 60 days unpaid, etc.).
revenue cycle management (RCM) Preclaims submission, Claims processing, Accounts receivable, .Claims, reconciliation and collections
(DNFB) discharged not final billed Discharges that have not been billed
Chief Financial Officer (CFO)
peer review is a group of physicians who can review the claim as well as the supporting documentation and arbitrate the differences between the payer and the provider.
National Uniform Claim Committee (NUCC).
The patient registration form This contains the patient’s demographic information and health insurance payer information. This information must be up to date, and most practices will institute a policy of verifying the information upon each visit. This form is usually accompanied by p
The patient health record documentation: The health record is comprised of all of the information pertaining to the assessment and treatment of the patient. Generally, these will be separated by encounter.
The superbill/encounter form: This form will have the diagnosis codes and procedure codes designated by the physician at the completion of the encounter
paper claim refers to any form that is submitted to the third-party payer on paper, whether it is typed or completed on a computer and printed on the computer’s printer.
NPI number HIPAA required all physicians and anyone else who will be reimbursed by insurance companies to apply for one of these numbers. The main purpose was to ease medical information transference. These numbers can be found on the National Plan and Provider Enum
place of service (POS)
Employer Identification Number (EIN). This identifies to the third-party payer which physician or physician practice rendered the services and to whom to make the check payable.
FLs form locators (since they will locate items on the form).
NUBC National Uniform Billing Committee called the Official UB-04 Data Specifications Manual that explains and defines each form locator and explains how to properly complete the form.
types of bills (TOBs). A common TOB number is 0131 (for hospital outpatient services). The 0 is just a leading 0, The first 1 stands for the type of facility – hospital The 3 stands for the classification of the bill – outpatient, The final 1 stands for the frequency of
inquiry A question made to a third-party payer regarding a claim.
adjudication The process of checking the details of the claim against the information the third-party has on the patient and his/her insurance benefits to determine amount of payment.
documentation The collective information pertaining to a patient and/or a claim.
CMS-1500 The standard form on which all physician's office claims are filed.
clearinghouse A company that processes, reviews, formats, and distributes claims.
common data file An overview of claims recently filed on the patient.
pre-edit A process in which a clearinghouse reviews a claim to make sure the information is correct and has been submitted in the proper way.
remittance advice A document listing the patient and claim information and giving an explanation of the benefits covered and payments to be made.
claims processing The third-party payer gathers information related to the case (specifics about the patient, the case, and the coverage).
deductible The amount the policyholder must pay yearly before benefits begin.
If an appeal is disputed, some insurance payers may use a(n) _____ peer review
_____ are claims that have not yet completed the claims processing cycle. open claims
According to Medicare and Medicaid, _____ must be kept for five years. claims
Patients will receive a(n) _____ that explains the payments made and the benefits covered. explanation of benefits
A(n) _____ is used to assign obligation of payment of unpaid claims to the policyholder. financial responsibility form
Healthcare providers will use a(n) _____ to document the codes of each particular visit. encounter form
A clearinghouse is contracted by _____ third-party payers
All electronic and paper submissions must comply with _____ HIPAA
Some offices will use an aging report to maintain financial information pertaining to claims, but some will use a _____ claims log
If a physician does not agree with the judgment and/or decisions made by a third-party payer, he/she may opt to _____ a claim appeal
Which of the following is/are part of the life cycle of a claim? Adjudication, Processing, Disclosing, Outsourcing adjudication, processing
Which of the following pieces of documentation should be created and maintained in order to have complete documentation for a claim submission? A correctly coded encounter form, A completed CMS-1500 Claim Form, A properly completed inquiry form, Up-to-date demographic information
Which of the following are acceptable ways for a claim to be submitted? by mailing in the completed CMS-1500, by having a private company use the documentation to complete and submit the claim form, by completing a CMS-1500 electronically and submitting it electronically
Which of the following are reviewed in the adjudication process? the patient demographic information, the common data file, the diagnosis and procedure codes, the insurance policy
Which of the following would be legitimate reasons for a claims appeal? The third-party payer denies a claim based on a pre-existing condition that the physician does not believe falls under the terms of pre-existing conditions., The payment is denied without reason or a lower payment is made without adequate explanation., A
The CMS-1500 was created to unify a scattered system of healthcare reimbursement claim styles. true
Most coders/billers will fill out their claim forms by hand. false
The encounter form/superbill is vital because it contains all of the patient's demographic information. false
You will use your codebooks to verify the codes that appear on the documentation from the patient's visit. :true
Demographic information for a patient can change from one visit to the next. true
Which of the following is a correct entry line in the CARRIER section? :220 NORTH LAKE DRIVE
When 'checking' a box in a field, what mark should you use? X
Which of the following would be a correct entry for Item 2? SMITH JONATHON A
All patients will need to provide what information? insurance carrier, insurance identification number, type of insurance held
Which of the following would be a correct entry for Item 3? :08 10 1996
Person who was seen by the healthcare provider. patient
Person or persons covered by an insurance policy. insured
Plan responsible for paying any allowable charges not covered by the primary insurance. secondary coverage
The subscriber who pays the premiums and in whose name the policy is written. policyholder
The payer that pays expenses before any other coverage. primary coverage
The policyholder and the patient are always the same person. false
Since most claim forms today are completed electronically, it is not necessary to have signed permission to release patient records. :false
Authorization is needed by the patient to have the insurance company make payments to the healthcare provider that submitted the claim. true
The insured's birth date must match the policyholder's birth date. true
In Item 10, three fields must be 'checked.' true
When filling out item 14 for an injury, the date entered would be _____. :the date of the injury
Item 18 deals with inpatient hospital length of stay. A patient was in the hospital on February 13, 2014–February 20, 2014. How would the dates appear in item
The dates in item 16 deal with _____. :dates the patient could not work
NPI numbers are required for _____. any healthcare provider seeking reimbursement
An accurate entry for item 17 would be _____. ALLEN A WILSON MD
Unique identifier required by providers. NPI number
Refers to the number of days, dosages, or number of injections administered. units of service
Allows dates to be shown with a beginning and ending date. From ____ To ____ format
Identifies where a service was administered. POS
The physician's SSN or EIN number should be entered exactly how they appear on their SSN or EIN card. false
The SSN or EIN must match that filed for the clinic name in Item 33. true
The physician physically must sign item 31 on all claims submitted. false
If item 29 is left blank, that means no payment has yet been made on the claim. true
Patient account numbers are universal and are assigned by insurance companies. false
_____ is a fixed amount of money designated to cover a related group of services by more than one provider. Global reimbursement
An example of the global prospective payment system is the _____ used to reimburse home health services. Medicare system
The home health prospective payment system is an example of a global prospective payment system. :true
HHPPS, a prospective payment system, projects the cost of home healthcare services and sets the allowable reimbursement amounts for future home healthcare services. true
Under the HHPPS system, each provider receives a separate payment for the services provided. false
Global reimbursement is a fixed payment amount designated to cover a related group of services by multiple providers. :true
Order in which Reimbursement rates under the HHPPS are paid for 30-day blocks of time. 1Your Answer:D. CMS sets reimbursement rates for each APC (ambulatory payment classification).
Order in which Reimbursement rates under the HHPPS are paid for 30-day blocks of time. 2Your Answer:A. Patient receives outpatient services at a hospital.
Order in which Reimbursement rates under the HHPPS are paid for 30-day blocks of time. 3Your Answer:F. Documentation is coded.
Order in which Reimbursement rates under the HHPPS are paid for 30-day blocks of time. 4Your Answer:C. Codes are transferred to claim.
Order in which Reimbursement rates under the HHPPS are paid for 30-day blocks of time. 5Your Answer:G. Claim sent to third-party payer.
Order in which Reimbursement rates under the HHPPS are paid for 30-day blocks of time. 6Your Answer:B. CPT and HCPCS codes are grouped to the appropriate APC (Ambulatory Payment Classification) by third-party payer.
Order in which Reimbursement rates under the HHPPS are paid for 30-day blocks of time. 7Your Answer:E. Claim is reimbursed based on pre-set APC rates.
The APC system does which of the following? bundles CPT and HCPCS codes into a hierarchy of groups to minimize reimbursement
What services are considered bundled into the APC payment? drugs and supplies, recovery room, anesthesia
The new ASC facility payment system links ASC facility payments to Medicare payments to hospital outpatient departments for the same procedure. true
The mechanism for groups ASC procedures is determined by the HHPPS. false
ASC payment rates are calculated using APC relative payment weights. true
Medicare covers_____days in the LTCH. 90
The clinical documentation tool called the Minimum Data Set is used in: skilled nursing facilities
The data collection tool called the IRF PAI is used in: inpatient rehabilitation facility
The average LOS in the LTCH is 15 days. :false
The part of reimbursement that adjusts for case mix in the SNF is the RUG. true
A full healthcare team is involved in the care of the IRF patient. true
All third-party payers use the outpatient prospective payment system as the basis for reimbursement. false
Discounted fee-for-service arrangements are common in prospective payment systems. false
Reimbursement under the outpatient prospective payment system is based on Ambulatory Payment Classifications. :true
All prospective payment systems are considered global payment systems. false
The ambulatory surgical center payment system uses the ambulatory payment classifications as the mechanism for grouping ASC procedures. true
QIO contracts are granted for _____ years at a time. 3
The main purpose of the QIO program is to _____. ensure that effective, efficient, and quality care is delivered to Medicare beneficiaries
managed care capitation episode-of-care
retrospective payment fee-for-service
self pay fee-for-service
global payment episode-of-care
traditional managed care fee-for-service
prospective payment episode-of-care
_____ uses a per diem system for outpatient physician billing where, regardless of the cost for treatment and/or complexity of the patient's condition, reimbursement is based on a per diem or per encounter rate. The Department of Indian Health Services
Which reimbursement methodology determines reimbursement based on past events? retrospective payment system
Which prospective payment system uses ambulatory payment classifications as the means of determining reimbursement? outpatient prospective payment system
Which reimbursement methodology uses a relative value unit to determine the amount of reimbursement that a physician receives? RBRVS
What is the only government program considered to be health insurance? Medicare
Managed care can operate under a fee-for-service model or under an episode-of-care model. true
The resource-based relative value scale is the reimbursement methodology used by Medicare to determine reimbursement amounts for hospital-based services. false
Under a fee-for-service reimbursement system, reimbursement is based on what services are provided to the patient. true
Episode-of-care reimbursement models pay based on individual services rendered. false
All medical visits produce a third-party medical claim. false
Medical claims are always printed on paper. false
The submission of a claim begins with the healthcare provider. true
Explanations of payments or non-payments are sent to both the healthcare provider and the patient. true
All third-party payers use the exact same methods of processing claims. false
What is a Medicare coverage policy? ncd & lcd
Where are the NCDs and LCDs located? Medicare Coverage Database
Medicare denies claims as not medically reasonable and necessary for: experimental procedures, a procedure that is not indicated for a particular diagnosis, a procedure not considered safe
An ABN should normally be retained for: 5 years
Medicare has frequency limitations on certain services. :true
Organizations may issue an ABN to all beneficiaries to protect themselves. :false
An ABN may be completed by e-mail if needed. :true
A radiological mammogram is a covered diagnostic test under which of the following? A patient has distinct signs and symptoms for which a mammogram is indicated., A patient has a history of breast cancer., A patient is asymptomatic but, on the basis of the patient’s history and other factors the physician considers significant, the phy
It is the patient's responsibility to make sure all up-to-date demographic and insurance information is on file at the healthcare provider. false
A financial responsibility form signed by the patient assigns the patient or guardian responsibility of any part of a claim that is unpaid by the third-party payer. :true
It is illegal for healthcare providers to copy or duplicate patients' insurance cards. false
An insurance policy indicated on a single insurance card can cover more than one person. true
Jim falls on his wrist while skateboarding and goes to the emergency room where he has an x-ray. What form would be used for the x-ray charges? UB-04
What form would be used for the reading of the x-ray charges? CMS-1500
Jim's wrist is put in a cast. Which form would be used to charge for the casting materials? UB-04
What form would be used to charge for the doctor's professional services for casting Jim's wrist? :CMS-1500
Most claims today are filed _____. electronically
The claim itself must be filed on the _____. :CMS-1500
An advantage of the electronic claim is _____. increased speed, decreased errors, decreased cost
A clearinghouse acts as a liaison between _____. the healthcare provider and the third-party payer
One of the duties of the clearinghouse is to _____. :pre-edit claims for errors
adjudication the process of reviewing a claim and deciding what claims are to be paid
coinsurance the percentage of the bill the patient pays once the deductible is met
allowed charge . the amount the policy states is payable for a particular procedure
deductible the amount the insured must pay yearly before benefits begin
common data file an overview of claims recently filed on the patient
Healthcare providers review _______ sent by third party payers. Explanation of Benefits, Remittance Advices
To maintain an accurate record of claims and payments, many healthcare providers will use what? :an aging report
In a physician's office who is ultimately the person in charge of deciding whether or not to follow up on a denied claim? :the physician
How can inquiries pertaining to a claim be made? by mail, electronically, by phone
Which of the following is NOT a reason to make an inquiry about a claim? remittance advice is sent to the healthcare provider.
Documentation is important to making an appeal. true
If a physician believes a treatment was medically necessary but the insurance company does not, the provider can appeal the claim. true
Once an appeal is denied, the appeals process has ended. false
Peer reviews are done by adjudicators from insurance companies. false
Appeals processes vary from one third-party payer to the next. true
inquiry A question made to a third-party payer regarding a claim.
adjudication The process of checking the details of the claim against the information the third-party has on the patient and his/her insurance benefits to determine amount of payment.
documentation The collective information pertaining to a patient and/or a claim.
CMS-1500 The standard form on which all physician's office claims are filed.
clearinghouse A company that processes, reviews, formats, and distributes claims.
common data file An overview of claims recently filed on the patient.
pre-edit A process in which a clearinghouse reviews a claim to make sure the information is correct and has been submitted in the proper way.
remittance advice A document listing the patient and claim information and giving an explanation of the benefits covered and payments to be made.
claims processing The third-party payer gathers information related to the case (specifics about the patient, the case, and the coverage).
deductible The amount the policyholder must pay yearly before benefits begin.
If an appeal is disputed, some insurance payers may use a(n) _____ peer review
_____ are claims that have not yet completed the claims processing cycle. open claims
According to Medicare and Medicaid, _____ must be kept for five years. claims
Patients will receive a(n) _____ that explains the payments made and the benefits covered. explanation of benefits
A(n) _____ is used to assign obligation of payment of unpaid claims to the policyholder. financial responsibility form
Healthcare providers will use a(n) _____ to document the codes of each particular visit. encounter form
A clearinghouse is contracted by _____ third-party payers
All electronic and paper submissions must comply with _____ HIPAA
Some offices will use an aging report to maintain financial information pertaining to claims, but some will use a _____ claims log
If a physician does not agree with the judgment and/or decisions made by a third-party payer, he/she may opt to _____ a claim appeal
Which of the following is/are part of the life cycle of a claim? Adjudication, Processing, Disclosing, Outsourcing adjudication, processing
Which of the following pieces of documentation should be created and maintained in order to have complete documentation for a claim submission? A correctly coded encounter form, A completed CMS-1500 Claim Form, A properly completed inquiry form, Up-to-date demographic information
Which of the following are acceptable ways for a claim to be submitted? by mailing in the completed CMS-1500, by having a private company use the documentation to complete and submit the claim form, by completing a CMS-1500 electronically and submitting it electronically
Which of the following are reviewed in the adjudication process? the patient demographic information, the common data file, the diagnosis and procedure codes, the insurance policy
Which of the following would be legitimate reasons for a claims appeal? The third-party payer denies a claim based on a pre-existing condition that the physician does not believe falls under the terms of pre-existing conditions., The payment is denied without reason or a lower payment is made without adequate explanation., A
The CMS-1500 was created to unify a scattered system of healthcare reimbursement claim styles. true
Most coders/billers will fill out their claim forms by hand. false
The encounter form/superbill is vital because it contains all of the patient's demographic information. false
You will use your codebooks to verify the codes that appear on the documentation from the patient's visit. :true
Demographic information for a patient can change from one visit to the next. true
Which of the following is a correct entry line in the CARRIER section? :220 NORTH LAKE DRIVE
When 'checking' a box in a field, what mark should you use? X
Which of the following would be a correct entry for Item 2? SMITH JONATHON A
All patients will need to provide what information? insurance carrier, insurance identification number, type of insurance held
Which of the following would be a correct entry for Item 3? :08 10 1996
Person who was seen by the healthcare provider. patient
Person or persons covered by an insurance policy. insured
Plan responsible for paying any allowable charges not covered by the primary insurance. secondary coverage
The subscriber who pays the premiums and in whose name the policy is written. policyholder
The payer that pays expenses before any other coverage. primary coverage
The policyholder and the patient are always the same person. false
Since most claim forms today are completed electronically, it is not necessary to have signed permission to release patient records. :false
Authorization is needed by the patient to have the insurance company make payments to the healthcare provider that submitted the claim. true
The insured's birth date must match the policyholder's birth date. true
In Item 10, three fields must be 'checked.' true
When filling out item 14 for an injury, the date entered would be _____. :the date of the injury
Item 18 deals with inpatient hospital length of stay. A patient was in the hospital on February 13, 2014–February 20, 2014. How would the dates appear in item
The dates in item 16 deal with _____. :dates the patient could not work
NPI numbers are required for _____. any healthcare provider seeking reimbursement
An accurate entry for item 17 would be _____. ALLEN A WILSON MD
Unique identifier required by providers. NPI number
Refers to the number of days, dosages, or number of injections administered. units of service
Allows dates to be shown with a beginning and ending date. From ____ To ____ format
Identifies where a service was administered. POS
The physician's SSN or EIN number should be entered exactly how they appear on their SSN or EIN card. false
The SSN or EIN must match that filed for the clinic name in Item 33. true
The physician physically must sign item 31 on all claims submitted. false
If item 29 is left blank, that means no payment has yet been made on the claim. true
Patient account numbers are universal and are assigned by insurance companies. false
FL 2 om UB04 is completed _____. only if the provider needs payments to be sent to an alternate address
FL 5 on ub04 has a space for the EIN. This number is _____. assigned by the IRS
FL 57 on ub04 is used for identifying numbers _____. assigned by the third-party payer
FL 1 on ub04 requires _____. no punctuation
FL 56 on ub04 is _____. is used for a number assigned by the National Plan and Provider Enumeration System
Health Insurance Prospective Payment System (HIPPS)
Since FL 49 on the ub04 is not used 'N/A' should be entered in this space. false
A proper FL 45 entry on ub04 would be 091971. true
The units recorded in FL 46 on ub04 always represent days. false
FL 44 on ub04 may contain a HCPCS code. true
FL 48 on ub04 is used only for elective surgeries. false
Use the UB-04 form for reimbursement. Facilities
The name used to identify the fields (spaces) in the UB-04. Form Locators
A code used to identify whether a diagnosis was present at the time of admission. POA
A code used to encompass all charges related to a procedure into one charge DRG
A space reserved for comments FL 80
A. A federal tax identification number. EIN
Codes used to record events that happen during treatment . occurrence codes
Committee responsible for creation of the UB-04. NUBC
Used on inpatient bills to give information about a patient's stay in a facility. accommodation rates
Used to report injuries, poisonings, or adverse effects. external cause of injury codes
All dates in the UB-04 are to be filled out using the MMDDYY format. false
POA codes are all numeric. false
The Creation date is the date the bill was created. true
All spaces on the UB-04 are completed with alphanumeric codes. false
Unit codes may represent different types of units. true
FL 67 is numbered using a watermark. :true
POA codes can be used as modifiers when added to other codes. true
External cause of injury codes are required on all UB-04s. false
There are FLs on the UB-04 that are not currently used. true
FL 58 is to be completed using the LAST NAME FIRST NAME MIDDLE INITIAL format. true
Many procedures have required preauthorization and this number will be listed on the UB-04. :true
Value codes are not listed in any specific order. false
There are spaces for as many as two third-party payers to be listed on the UB-04. false
Although EIN numbers are hyphenated, the hyphen is not entered when completing the UB-04 electronically. true
Only the attending physician is listed on the UB-04 form. false
The _____ has a manual used to help explain completing the codes and the form. NUBC
The _____ is the physician responsible for ordering services for an outpatient. ordering physician
FL 1 is used for the name and address of the _____ . healthcare provider
_____ are listed in the NUBC manual and contain a charge amount. value codes
FL 13 is used to report the _____ . hour of admission
Department of Health and Human Services (DHHS) PARENT AGENCY GOVERNING AND REGULATING HEALTHCARE
Centers for Medicare and Medicaid (CMS) DEVELOPS RULES AND REGULATIONS
Office of Inspector General (OIG) MONITORS FOR COMPLIANCE AND TURNS SUSPECTED FRAUD AND ABUSE OVER TO THE DOJ
Department of Justice (DOJ) PROSECUTES FRAUD AND ABUSE
health information management) HIM
audit is performed by personnel within a healthcare provider organization, it is called an internal audit.
an audit is performed by personnel or agencies outside of the healthcare provider organization, it is called an external audit.
A review done while a patient is actively receiving care is called a(n) _____. concurrent review
A review of the steps in the healthcare documentation process is called a(n) _____. audit
A review done after the patient has received care is called a(n) _____. retrospective review
Healthcare institutions do not have a need for internal audits except when potential problems arise. false
The OIG recommends that all healthcare providers institute an ongoing regulatory compliance program, including an internal auditing program. true
Smaller healthcare operations have little need for internal audits– only large operations need to worry about them. false
Facilities or providers should make changes when problems or issues are discovered in an internal audit. true
Selecting codes at a lower level than the service documented. undercoding
Selecting codes at a higher level than the service documented. upcoding
Billing two or three procedures when the services are typically covered by a single comprehensive code. unbundling
A provider requests the coding specialist to review documentation in patients’ medical records, superbills, verify diagnosis codes, support procedure code assignments, and review third-party payer EOBs. internal audit
This regulatory agency governs and regulates healthcare in the United States. DHHS
Claims filed with the knowledge of falsity on the claim. fraudulent claims
When fraudulent claims are discovered during an external audit, these are turned over to this government organization for investigation. DOJ
This regulatory agency protects the integrity of the Department of Human and Health Services through audits and investigations. OIG
Auditors identify _____ and the provider submits a corrective plan of action to address them. deficiencies
A proactive audit is a _____ audit to check the healthcare provider's compliance with rules and regulations. routine or random
Facilities may choose to participate in a voluntary third-party audit program such as the _____ . Joint Commission
If issues are uncovered and appropriately addressed, healthcare providers can benefit from a _____ . proactive external audit
What step is necessary to prepare for the external coding audit? define goals, secure executive support and prepare coders, identify cases or all of the above all of the above
External audits require significant time, effort, and money. T/F TRUE
Once the audit is complete and the recommendations received, HIM departments are finished. T/F False
Most external coding audits are conducted off-site. T/F false
Random samples with adequate sample size validate current performance across the board and expose unknown problems. true
A review that deals with accuracy is called a _____ . Qualitative analysis
A claim filed with knowledge of falsity of the claim is called a _____. Fraudulent claim
Reactive external audits are the result of _____ concern, or suspicion of wrongdoing. Complaint
A review that deals with completeness is called a _____ . Quantitative analysis
A claim filed with innocent errors due to faulty processes, misinterpretation, or other negligence is called an _____ . Erroneous claim
A proactive external audit is typically performed by either an independent consulting firm or by the staff in the provider's office. T/F False
If evidence of deliberate fraudulent billing is found during an audit process, this information is turned over by the OIG to the DOJ for further investigation. T/F true
The Office of Inspector General offers tools to perform internal audits. T/F true
A reactive audit is performed after a complaint has been filed or a third-party payer suspects fraudulent billing. T/F true
Coding specialists are very busy with their day-to-day jobs so if they do not keep up with the rules and regulations, the Office of the Inspector General will overlook this during an audit. T/F false
If fraud and abuse are suspected during a reactive external audit, they are reported to the _____. DOJ
The OIG recommends every provider have a compliance plan in place. For individuals and small group practices, which of the following is NOT a recommendation? Contract with the OIG to have annual reactive audits performed.
Which of the following statements is NOT true concerning successful internal audit programs? Once an internal audit is performed it never has to be performed again.
Which of the following is NOT a problem uncovered during an audit? properly paid claim
The certification and accreditation of this organization is nationally considered a symbol of quality practices. Joint Commission
An audit performed by an individual within the healthcare provider organization. E.internal
An audit that takes place while a patient is still under the provider's care. A.concurrent review
When a provider assigns two or three codes when one comprehensive code is more appropriate. C.unbundling
The practice of assigning a code with a higher claim value when the documentation supports a code with a lower claim. D.upcoding
A documentation audit performed on the record of a patient who is no longer being actively treated. B.retrospective review
An audit performed by an auditor(s) outside of the healthcare provider organization. F.external
A type of discharge status in which a patient chooses to leave the facility even though all medical personnel recommend the patient stays for treatment. against medical advice:
When patients who were considered inpatients at healthcare facilities leave the facility to go to another location. The status indicates the new location of the patient. discharge status:
The sum of all MS-DRG weights, divided by the total number of Medicare discharges for the same time period. Slight increases or decreases impact a hospitals overall reimbursement amount. Facilities routinely monitor the CMI. case mix index (CMI):
A pre-existing condition which, because of its presence, causes an increase in length of stay by at least one day in approximately 75% of the cases. comorbid condition:
A condition that arises during the hospital stay which prolongs the length of stay by at least one day in approximately 75% of the cases. complication:
A software program designed to determine MS-DRGs and typically contains Medicare code edits. grouper:
A numeric factor defined by Medicare that considers the geographic location of hospitals. This factor is used in the reimbursement calculations for facilities to account for geographic differences. hospital wage index:
Complications and comorbid conditions defined by Medicare to have a higher severity of illness impact on a patient. major complication/comorbid condition (MCC):
A broad classification of conditions typically grouped by body systems diseases. major diagnostic category (MDC):
A method to identify various situations based upon assigned ICD-10-CM codes. medicare code edits:
A type of discharge status in which a patient chooses to leave the facility even though all medical personnel recommend the patient stays for treatment. against medical advice:
When patients who were considered inpatients at healthcare facilities leave the facility to go to another location. The status indicates the new location of the patient. discharge status:
The sum of all MS-DRG weights, divided by the total number of Medicare discharges for the same time period. Slight increases or decreases impact a hospitals overall reimbursement amount. Facilities routinely monitor the CMI. case mix index (CMI):
A pre-existing condition which, because of its presence, causes an increase in length of stay by at least one day in approximately 75% of the cases. comorbid condition:
A condition that arises during the hospital stay which prolongs the length of stay by at least one day in approximately 75% of the cases. complication:
A software program designed to determine MS-DRGs and typically contains Medicare code edits. grouper:
A numeric factor defined by Medicare that considers the geographic location of hospitals. This factor is used in the reimbursement calculations for facilities to account for geographic differences. hospital wage index:
Complications and comorbid conditions defined by Medicare to have a higher severity of illness impact on a patient. major complication/comorbid condition (MCC):
A broad classification of conditions typically grouped by body systems diseases. major diagnostic category (MDC):
A method to identify various situations based upon assigned ICD-10-CM codes. medicare code edits:
Procedures which may or may NOT be performed in a surgical operating suite; however, the procedure codes affect MS-DRG assignment. non-operating room procedure:
Procedures identified as requiring the use of an operating room suite. The identified codes influence MS-DRG assignment. non-operating room procedure:
Hospital cases with specific circumstances that place the admission extremely outside the normal or average admission. outliers:
A set payment amount to a facility for each day the patient stayed at the facility. For MS-DRG purposes, the amount is paid to the facility that transferred the patient. per diem rate:
Categories established by Medicare where cases are automatically assigned without applying all the MS-DRG logic. These cases are usually high-risk, lower volume admissions, such as organ transplants. pre-MDC
Condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care. principal diagnosis:
Procedure performed for definitive treatment rather than diagnostic or exploratory; or to treat a complication. This procedure is typically related to the principal diagnosis. principal procedure:
A number assigned to each MS-DRG reflecting an average patient’s resource consumption. The higher the number value represents greater resources used to care for the patient. This number is used in calculating the MS-DRG reimbursement amount a facility rec relative weight (RW):
Ordering of surgical cases from the most to least resource intensive. surgical heirarchy:
A type of discharge status where a patient is moved from one facility to another facility. A patient may be moved to many different types of facilities, such as to skilled nursing facility, or another acute care facility. There are different discharge sta transfer:
The number of patients in each MS-DRG. The volume of patients in specific DRGs is important when reviewing the case mix index. volume:
(DRGs) diagnosis related groups
(IPPS) inpatient prospective payment system
(MS-DRGs) Medicare severity diagnosis groups
an auditor(s) outside of the healthcare provider organization. external
(IPPS) inpatient prospective payment system
Reimbursement amounts for MS-DRGs are calculated by multiplying the MS-DRG relative weight by _____. Facility base rate
MS-DRGs are affected by all of the following ( discharge status, age, race, sex) except _____. RACE
Which diagnosis would be a male only diagnosis? prostate cancer
A type of discharge status in which a patient chooses to leave the facility even though all medical personnel recommend the patient stays for treatment is _____. against medical advice
MDC stands for _____. major diagnostic category
When patients who were considered inpatients at healthcare facilities leave the facility to go to another location. discharge status
The sum of all MS-DRG weights, divided by the total number of Medicare discharges for the same time period. case-mix index
Ordering of surgical cases from the most to least resource intensive. surgical hierarchy
A number assigned to each MS-DRG reflecting an average patient's resource consumption. relative weight
Hospital cases with specific circumstances that place the admission extremely outside the normal or average admission. outliers
Condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care. .principal diagnosis
A software program designed to determine MS-DRGs and typically contains Medicare code edits. grouper
A set payment amount to a facility for each day the patient stayed at the facility. per diem rate
dysmenorrhea .female diagnoses
The prospective payment system utilizes this data to determine a single resource consumption value for the various hospital services provided to patients. This figure determines the relative weight of a single MS-DRG. .inpatient prospective payment system
A pre-existing condition which, because of its presence, causes an increase in length of stay by at least one day in approximately 75% of the cases. comorbid condition
hydrocele male diagnosis

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