Download CMM FINAL STUDY GUIDE QUESTIONS WITH 100% CORRECT ANSWERS!! GRADED A+ NEW UPDATE!! and more Exams Nursing in PDF only on Docsity!
CMM FINAL STUDY GUIDE QUESTIONS
WITH 100% CORRECT ANSWERS!!
GRADED A+ NEW UPDATE!!
Steps of Revenue Cycle - CORRECT ANSWER -Patient Registration & Check in/
Clinical encounter/ Accurate Coding and Billing/ Claims Generation and Transmittal/ Processing Payments/ Preparation and Transmittal of Patient Statements/ Collections and Finalizing Payments/ Denials, Appeals & Refunds
Coding analysis - CORRECT ANSWER -involves analyzing the financial impact of
proper vs. improper coding procedures in practice What type of codes reflect the accurate level of medical necessity that justfies each
CPT and HCPC level II code? - CORRECT ANSWER -ICD-
Why is it important to have accurate coding - CORRECT ANSWER -minimizes
denials and rejections while ensuring the practice is reimbursed the full amount All electronic opportunities to verfy active patient insurance and benefits should be
utilized ___-_____ hours before visit - CORRECT ANSWER -24-48 hours
If the patient does not have insurance, has a lapse in coverage, or cannot pay service, protect the practice by having the patient sign a _____ _____ Notice or Notice of Non-
coverage prior to being seen - CORRECT ANSWER -Advance Beneficiary Notice
Electronic Medical Record and Practice Management Systems that are certified by CMS and the Office of the National Coordinator for Health Information Technology (ONC)
require to have built in _________ Verification Systems. - CORRECT ANSWER -
Insurance Verification Systems (IVS). NOTE: Once activated they will automatically ping the insurance company IVS will come back to the Practice management system (PMS) will highlight the
appointment as Green, Yellow, or Red. What does each color mean? - CORRECT
ANSWER -Green - Verified and Approved
Yellow - There may be a problem with this insurance Red - Insurance is not active or out of network and do not participate
Most PMS systems have the ability to capture the IVS information in an electronic footprint that occurs in the system. The information is held as a ______ ______ -
CORRECT ANSWER -Virtual Envelope
Even if the practice does not use EHR or EHR is not interfaced with the PMS, do they
still have the ability to access IVS system? - CORRECT ANSWER -Yes
Most insurance denials are due to what three reasons? - CORRECT ANSWER -
Incorrect patient demographics invalid insurance information ICD-10 code that is missing a seventh character required for that condition The claims process is streamlined and clean claims are paid electronically within ____ -
____ days - CORRECT ANSWER -14-
Examples of what a CMM should do to achieve optimum reimbursement and
compliance - CORRECT ANSWER -Send staff to coding seminars or webinars
regular due to frequent and signifcant changes Hire certified coders and billing specialists Ensure coding and billing staff are knowledgeable and familiar with reimbursement schedules of insurance plans (pages 8-9 for more information)
NCCI - CORRECT ANSWER -National Correct Coding Initiative
Four parts of Medicare - CORRECT ANSWER -Part A
Part B Part C Part D
What does Medicare Part A Cover? - CORRECT ANSWER -Inpatient care in a
hospital Skilled nursing facility care Nursing home care (inpatient care in a skilled nursing facility that's not custodial or long- term care) Hospice care Home health care
What does Medicare Part B Cover? - CORRECT ANSWER -Medically necessary
services: Services or supplies that are needed to diagnose or treat your medical condition and that meet accepted standards of medical practice.
Medicare Write-offs for Non-assigned Claims - What to ALWAYS write off? -
CORRECT ANSWER -Covered services that have been denied if:
The patient's waiver of liability has not been obtained Your appeal rights have been exhausted or you choose not to appeal
Medicare Write-offs for Non-assigned Claims - What NOT to write off? - CORRECT
ANSWER -Patients 20 percent co-insurance
Patients yearly deductible Covered services that have been denied if the patient Waiver of Liability has been obtained The difference between your actual charge and the payment received from Medicare Common reasons claim is considered "unclean" due to claims data errors (7) -
CORRECT ANSWER -Missing or invalid patient identification number of other
patient information Missing or invalid subscriber information (medicare number) Failure to check the assignment box Invalid dates of service Missing or invalid modifers Missing or invalid providers information Incorrect place of services
What is a clearing house? - CORRECT ANSWER -A clearing house is a financial
institution formed to facilitate the exchange of payments, securities, or derivatives transactions. The clearing house stands between two clearing firms. Its purpose is to reduce the risk of a member firm failing to honor its trade settlement obligations.
Co-payment - CORRECT ANSWER -a flat amount that patient owes at the time of
each services
Deductibles - CORRECT ANSWER -The annual amount a patient must pay
before the insurance will pay anything.
Three common patient billing methods - CORRECT ANSWER -Method 1 - patient
statements generated on the 25th or 30th of each month (requries many hours devoted to billing) Method 2 - calls for half of accounts to be billed on 15th of the month and the other half billed on the 30th (less time consuming) Method 3 (most common) - accounts billed cyclically according to the letter of the alphabet (allows for even cash flow and less stress on billing staff) A-F billed week 1 G-L billed week 2 M-s billed week 3 T-Z billed week 4
Arranging payments must follow which two federal laws? - CORRECT ANSWER -
Fair Debt Collection Practices Act (FDCPA) and Telephone Consumer Protection Act (TCPA)
Keys to successful collecting - CORRECT ANSWER -Assign collection process to
one employee as a primary responsibility Contacting the patient by telephone is more effective than letter or email turn over accounts delinquent 120 or more to collection agency strict adherence to the collection process is required to maintain a healthy cash flow The Medical Debt Protection Act of 2019 should be understood
Laws of Harassment when collecting payments - CORRECT ANSWER -Calling
after 9pm or before 9am Making excessive calls Calling friends, family, employers, relatives Making threats Falsely claiming that credit rating will be hurt Demanding payment for amounts not owed
Benefits of a Voluntary Compliance Program - CORRECT ANSWER -Compliance
programs enhance speed of proper payment of claims, minimize billing mistakes, reduce chances of audit by CMS or OIG, Avoid conflicts with the self-referral and anti- kickback statues
Erroneous Vs. Fraudulent Claims to Federal Health Programs - CORRECT
ANSWER -Unintentional Vs. Intentional fraud - wording was changed during the
Affordable Care Act in 2009
OIG Guidance Manual - CORRECT ANSWER -The manual lists the Seven Basic
Components of a Voluntary Compliance Program Seven Basic Components of a Voluntary Compliance Program (OIG Guidance Manual)
- CORRECT ANSWER --Conducting internal monitoring and auditing through the performance of periodic audits -Implementing compliance and practice standards through the development of written standards and procedures -Designating a compliance officer or contact to monitor compliance efforts and enforce practice standards -Conducting appropriate training and education on practice standards and procedures -Responding appropriately to detected violations through the allegations and the disclosure of incidents to appropriate government entities -Developing open lines of communication (staff meetings how to avoid fraud and community bulletin boards -Enforcing disciplinary standards through well-publicized guidelines
OIG Manual - Summary of Appendices - Appendix A - CORRECT ANSWER -
Additional Risk Area (page 27 for review)
OIG Manual - Summary of Appendices - Appendix B - CORRECT ANSWER -
Criminal Statues
OIG Manual - Summary of Appendices - Appendix C - CORRECT ANSWER -Civil
and Administrative Statues
OIG Manual - Summary of Appendices - Appendix D - CORRECT ANSWER -
Contact Information ( Last Appendix) OIG Roadmap for New Physicians - five main federal fraud and abuse laws (Avoiding
Medicare and Medicaid Fraud and Abuse) - CORRECT ANSWER --the false
claims act -the anti-kickback statue -the stark law
-the exclusion statute -the civil monetary penalties law
OIG Roadmap - Summary of Introduction - CORRECT ANSWER -When
reimbursing physicians and hospitals for services provided to program beneficiaries, the Federal Government relies on physicians to submit accurate and truthful claims information. The brochure assists physicians in understanding how to comply with the Federal laws by identifying red flags Three types of relationships that physicians frequently encounter in their career -
CORRECT ANSWER -relationship with the payer
relationship with fellow physicians and providers relationship with vendors
OIG Roadmap - Summary of Fraud and Abuse Laws section - CORRECT
ANSWER -page 28 of study guide - please read and study
False Claims Act - CORRECT ANSWER -The False Claims Act, also called the
"Lincoln Law", is an American federal law that imposes liability on persons and companies who defraud governmental programs. It is the federal government's primary litigation tool in combating fraud against the government.
Anti-Kickback Statute (AKS) - CORRECT ANSWER -Criminal law that prohibits
knowing and willful payment of "remuneration" to induce or reward patient referrals payable by a federal health care program (e.g. Medicare) Taking anything of value and can take many forms - penalties include fines, jail terms, and exclusion from participation in the Federal health care programs
physician self-referral law - CORRECT ANSWER -Commonly referred to as the
Stark Law, prohibits physicians from referring patients to receive designated health services payable by Medicare or Medicaid from entities with which the physician or an immediate family member has a financial relationship, unless an exception applies
Civil Monetary Penalties Law (CMPL) - CORRECT ANSWER -A law passed by
the Federal Government to prosecute cases of Medicaid fraud. How to Obtain a National Provider Identifier (NPI) - enroll as a Medicare and Medicaid
Provider with CMS - CORRECT ANSWER --Complete the appropriate Medicare
Application -Complete State-specific Medicaid Enrollment Application
I-9 for employees must be kept for a minimum of ____ full years after the last day of work for an employee who is longer with the practice - regardless of the reason the
employee left the practice - CORRECT ANSWER -3 years
Equal Employment Opportunity Commission (EEOC) - CORRECT ANSWER -a
government agency with the power to investigate complaints of employment discrimination and the power to sue firms that practice it EEOC data file require all applicants, current, and past employees. What is information
required to be kept in files - CORRECT ANSWER -race, gender, ethnic
background, veteran status, disability
The department of labor requires the following information: - CORRECT
ANSWER --employees full name as stated in social security records
-social security numbers and employee number if used -home address -date of birth if employee is younger than 19 -the employee's gender (for compliance with equal pay act) -the position employee is employed -the time of day and week workweek begins -regular hourly rate of pay -all benefits -the basis on which the employee's wages are paid -the amount and type of pay for any pay that not included in reg rate -the hours worked -total earnings -date of each payment -total addition or deductions -any agreement/contract -for each deduction, the employer must shoe date, amount, and nature of deduction administers the New Hire Reporting System in support of the Federal Parent Locator
Service - CORRECT ANSWER -The Office of Child Support Enforcement
addresses health information record retention and fees - CORRECT ANSWER -
Affordable Care Act (ADA) and State
Routine low importance records should be kept for how long? - CORRECT
ANSWER -1 year
General records should be kept for how long? - CORRECT ANSWER -3 years
Major, legal, important records should be kept for how long? - CORRECT
ANSWER -permanently
Expired insurance policies (except malpractice) records should be kept for how long? -
CORRECT ANSWER -3 years
Malpractice insurance policies records should be kept for how long? - CORRECT
ANSWER -permanently
Insurance records, current claims, reports, etc. records should be kept for how long? -
CORRECT ANSWER -permanently
Banking record duplicate deposit slip records should be kept for how long? -
CORRECT ANSWER -1 year
Records of cancelled checks should be kept for how long? - CORRECT
ANSWER -7 years
Records for cancelled checks for major items should be kept for how long? -
CORRECT ANSWER -permanently
Monthly bank statement records should be kept for how long? - CORRECT
ANSWER -1 year
tax returns and any documents relating to tax audits and adjustments - CORRECT
ANSWER -permanently
worksheets, list schedules, supporting tax returns should be kept for how long? -
CORRECT ANSWER -7 years
disposed property records should be kept for how long? - CORRECT ANSWER -
7 years after property is disposed
records of deeds, mortgages, and bills should be kept for how long? - CORRECT
ANSWER -permanently
promissory notes receivable and other documents of debt owing to you - CORRECT
ANSWER -keep until fully paid plus 7 years after
the power that comes from your position within the organization. - CORRECT
ANSWER -legitimate power
the degree to which the employee views you as a knowledgable person about specific technical areas determines the employee's readiness to follow what you say -
CORRECT ANSWER -expert power
the degree to which the employee respects and admires the manager determines, in
part, the willingness of the employee to follow directives - CORRECT ANSWER -
referent power
every employee has five needs that must be provided by the supervisor - CORRECT
ANSWER --what the job is
-the opportunity to do the job (time) -training for the job if necessary -a review of how well the employee is doing their job by the supervisor -rewards (promotion, monetary, recognition)
four theories of motivation - CORRECT ANSWER --Maslow's Hierachy of Needs
-Equity Theory -The Path/Goal Approach -Expectancy Theory
three steps of conflict management - CORRECT ANSWER -step 1: examine
specific tasks that require the effort of both the clinical and admin staff step 2: evaluate how each task fits the connection between teh clinical and administrative segments. Look for loose spots and gaps where the task is transferred from one segment to the other step 3: redesign the connection to make the task flow more evenly and smoothly. Honest collaboration of all people involved.
National Labor Relations Act - CORRECT ANSWER -A 1935 law, also known as
the Wagner Act, that guarantees workers the right of collective bargaining sets down rules to protect unions and organizers, and created the National Labor Relations Board to regulate labor-managment relations.
Title VII of the Civil Rights Act of 1964 - CORRECT ANSWER -Forbids
discrimination on the basis of sex, race, color, religion, or national origin in all areas of the employment relationship
Age Discrimination in Employment Act of 1967 - CORRECT ANSWER -Prohibits
discrimination against workers over the age of 40 and restricts mandatory retirement
Whistle Blower Protection Act (1989) - CORRECT ANSWER -Protects the identity
and jobs of those who report on waste, fraud or abuse.
Fair Labor Standards Act of 1938 - CORRECT ANSWER -established minimum
living standards for workers engaged in interstate commerce, including provision of a federal minimum wage
Occupational Safety and Health Act - CORRECT ANSWER -is a federal law that
establishes and promotes workplace safety standards for businesses.
Vietnam Era Veteran's Readjustment Act of 1974 - CORRECT ANSWER -
requires federal contractors and subcontractors to take affirmative action toward employing veterans of the Vietnam War
Clear Air Act of 1970 - CORRECT ANSWER -law that established national
standards for states, strict auto emissions guidelines, and regulations, which set air pollution standards for private industry
Imigration and nationality act (INA) - CORRECT ANSWER -requires employers
verify the employment eligibility of all individuals hired after November 6th, 1986
Pregnancy Discrimination Act of 1978 - CORRECT ANSWER -Treats
discrimination based on pregnancy-related conditions as illegal sex discrimination
Family and Medical Leave Act of 1993 - CORRECT ANSWER -requires
employers to provide up to 12 weeks of unpaid leave for family and medical emergencies
workers compensation law - CORRECT ANSWER -State statutes establishing an
administrative procedure for compensating workers' injuries that arise out of—or in the course of—their employment, regardless of fault.
the occupational safety and health act (OSHA) - CORRECT ANSWER -Created
to protect worker and health. Its main aim was to ensure that employers provide their workers with an environment free from dangers to their safety and health, such as exposure to toxic chemicals, excessive noise levels, mechanical dangers, heat or cold stress, or unsanitary conditions.
Consolidated Omnibus Budget Reconciliation Act (COBRA) - CORRECT
ANSWER -this federal law requires employers of 20 or more employees to offer
Correcting employment taxes - CORRECT ANSWER -"X" forms are used to
report adjustments to employment taxes to claim refunds of overpaid employment taxes.
Depositing Employment Taxes - CORRECT ANSWER -The practice must deposit
the federal income tax, the employer, and employee social security and medicare taxes on schedule determined by the IRS
Monthly depositor - CORRECT ANSWER -A business classified as a monthly
depositor will make its payroll tax deposits only once each month by the 15th for the amount of Form 941 taxes due from the prior month.
Semi-weekly Depositor - CORRECT ANSWER -Deposits made on wednesday,
thursday, and/or friday by the following wednesday. report quarterly or annually by filing form 941 or form 944
Accounts Receivable Turnover Ratio - CORRECT ANSWER -AR Balance/
Average Monthly Receipts
Profit Margin - CORRECT ANSWER -monthly income - total operating costs/
monthly income
cost per outpatient visit - CORRECT ANSWER -total operating costs/ office visits
no show rate - CORRECT ANSWER -# of no shows/ appointments scheduled
average charge per outpatient visit - CORRECT ANSWER -monthly/ office visits
income per outpatient visit - CORRECT ANSWER -monthly income. office visits
net income per outpatient visit - CORRECT ANSWER -income per outpatient visit
- cost per outpatient visit
overhead rate per outpatient visit - CORRECT ANSWER -cost per outpatient visit/
income per outpatient visit
gross collection ratio - CORRECT ANSWER -monthly collections/ monthly
charges
cost to gross charges ratio - CORRECT ANSWER -total operating cost/ monthly
charges
net income to gross charges - CORRECT ANSWER -monthly income - total
operating cost/ monthly charges
employee labor to cost ratio - CORRECT ANSWER -employee labor cost +
employee benefits/ total operating cost
employee absentee rate - CORRECT ANSWER -employee absentee hours/
employee hours scheduled
net income per employee hour - CORRECT ANSWER -monthly income - total
operating cost/ employee hrs. scheduled - employee absentee hours
fixed expenses - CORRECT ANSWER -expenses not affected by patient volume
variable expenses - CORRECT ANSWER -expenses that change in direct
proportion to the number of patients seen
forecasting patient volume - CORRECT ANSWER -before you can accurately
budget variable expenses; you must first determine how patient volume will change
forecasting variable expenses - CORRECT ANSWER -project what the increase
in patient volume will do to the expenses, you must first determine what your current costs are per patient
three steps of forecasting revenue - CORRECT ANSWER -step 1: forecasting
increases in patient volume step 2: determines if and how much of an increase the practice plans to make to the current fee schedule. (apply percent increase to every fee based on factors OR review each fee and increase only certain ones) step 3: forecasting revenue is to determine if the practice plans to offer any new service that will generate additional revenue
accounts payable - CORRECT ANSWER -Amounts to be paid in the future for
goods or services already acquired bills should be paid once a ______ by their due date to keep money in the bank working
as long as possible - CORRECT ANSWER -month
there are ____ levels of appeals for non-urgent reviews before arbitration -
CORRECT ANSWER -three
provider credentialing - CORRECT ANSWER -formal process that helps evaluate
a providers quality of care as compared to the industry standards what are the exceptions to the ADA standard of having safe access to the buildings and
within the buildings - CORRECT ANSWER -no exceptions
PECOS - CORRECT ANSWER -Provider Enrollment, Chain & Ownership System
CME - CORRECT ANSWER -method of measuring hours of continuing education
that are required to maintain a credential
CDSS - CORRECT ANSWER -Clinical Decision Support System; assist
healthcare providers in the actual diagnosis and treatment of patients, analyze data from clinical information systems
CPOE - CORRECT ANSWER -computerized physician order entry
hit - CORRECT ANSWER -Health Information Technology
COTS - CORRECT ANSWER -Customized off-the-shelf system
MOTS - CORRECT ANSWER -modifiable off the shelf
REC - CORRECT ANSWER -Regional extension Center created under HITECH
Purpose: provide technical assistance, best practice information, and education to support implementation and MU; also tasked to support and enable nationwide health information exchange
EHR Steps to Acquisition and Implementation - CORRECT ANSWER -Step 1:
Assess your practice readiness Step 2: Plan your approach including identifying staff roles in the process Step 3: Select or upgrade to certified EHR Step 4: Conduct Training & Implement an EHR System Step 5: Achieve Meaningful use AKA promoting interoperability
Step 6: continuous quality improvement
Vender Contracts - CORRECT ANSWER -pg 110
terms of payment and licensing, training, service agreements, customer support, interfacing details, regulatory provisions, and certifications to use
Feder EHR Certification - CORRECT ANSWER -Whichever EHR type that you
choose, you must use a federally certified EHR to meed the Promoting Interoperability criteria.
ONC - CORRECT ANSWER -Office of the National Coordinator for Health
Information Technology
evidence-based practice (EBM) - CORRECT ANSWER -clinical decision making
that integrates the best available research with clinical expertise and patient characteristics and preferences
Four basic methods used in telehealth - CORRECT ANSWER -Sychronous video
(real-time) Store-and-forward (SFT) - transmitting videos and digital images through secure electronic communication system Remote patient monitoring (RPM) - the collection of data from the patient in one location and the transmission of that data to a clinician in a different location Mobile0health (mHealth) - includes smartphone apps, text alerts, alerts etc
Privacy rule of HIPAA - CORRECT ANSWER -prevents health care plans or
providers from disclosing health information about individuals to others, including their employer
Security Rule of HIPAA - CORRECT ANSWER -established a set of national
standards to protect electronic health information
Breach Notification Rule - CORRECT ANSWER -requires covered entities and
business associates to establish policies and procedures to investigate an unauthorized use or disclosure of PHI to determine if a breach occurred, conclude the investigation, and to notify affected individuals and the secretary of DHHS within 60 days of breach discovery
