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NHA CBCS Study Guide (2024/ 2025
Update) | Questions and Verified Answers|
100% Correct| A Grade
QUESTION
Explain the difference between fraud and abuse? Answer: Fraud - intentionally misrepresenting services rendered for the purpose of receiving a higher payment Abuse - refers to practices that are often done unknowingly as a result of poor business practices, directly, or indirectly resulting in unnecessary costs to the program through improper payments
QUESTION
What is the difference between Medicare and Medicaid? Answer: Medicare is federally funded and administered health insurance provided to people age 65 and older, people with certain disabilities, and ESRD Medicaid is a government based health insurance for individuals who have low-income and limited financial resources. Funded at the state and federal level but administered at the state level.
QUESTION
Define abstracting Answer: The extraction of specific data from a medical record, often for use in an external database, such as a cancer registry
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What is the difference between distal and proximal? Answer: Distal - Far away from origin Proximal - Near the origin
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Define root word gastro- Answer: Stomach
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_________________________________ have completed their residency and fellowship requirements. Answer: Attending or staff physicians
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What is a preauthorization? Answer: is approval from the health plan for an inpatient hospital stay or surgery.
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What is an aging report? Answer: identifies the outstanding balances in each account. 30 day increments.
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What is a consent? Answer: A patient's permission evidenced by a signature.
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What are Medicare Advantage Plans? Answer: Provides combined package of benefits under Parts A and B in addition to vision, hearing and dental and can sometimes include drug coverage TAKES THE PLACE OF TRADITIONAL MEDICARE
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What is the purpose of the OIG? Answer: Protects Medicare and HHS programs from fraud and abuse by conducting audits, investigations, and inspections
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charge amount Answer: The amount the facility charges for the procedure or service.
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charge description master
Answer: Information about health care services that patients have received and financial transactions that have taken place.
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charge or service code Answer: Internally assigned number unique to each facility
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claim Answer: a complete record of services provided by a health care professional, along with appropriate insurance information, submitted for reimbursement to a third-party payer
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claims adjustment reason code Answer: provides financial information about claims decisions
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claim scrubber Answer: software that receives a claim prior to submission for correct and complete data, such as accurate gender in alignment with diagnosis/procedure or medical necessity
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conditional payment Answer: Medicare payment that is recovered after primary insurance pays.
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consent Answer: a patient's permission evidenced by signature
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contractural obligation Answer: used when a contractural agreement resulted in an adjustment
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coordination of benefits rules Answer: Determines which insurance plan is primary and which is secondary.
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correction and renewal Answer: used for correcting a prior claim
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cost sharing Answer: The balance the policyholder must pay to the provider.
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crossover claim Answer: Claim submitted by people covered by a primary and secondary insurance plan.
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What is the location method in reference to the CPT book? Answer: Procedure or service Just anatomic site Condition or disease Synonym, eponym, or abbreviation
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What is the Stark Law? Answer: Prohibits a physician from referring patients for certain designated health services (Medicare & Medicaid) to entities with whom the physician has a financial relationship
QUESTION
What is the timely filing limitation for Medicare?
QUESTION
Define meanings of ICD-10 PCS characters 1- 7 Answer:
- Section of the ICD-10 PCS system where the code is indexed
- The body system
- Root operation
- Specific body part
- Approach used
- Device used to perform the procedure
- Qualifier to provide additional information
QUESTION
The department of ____________________________ specializes in the study of disease. Answer: Pathology
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What is the difference between Anterior and Posterior? Answer: Anterior - front of the body Posterior - back of the body
QUESTION
Define suffix - ectomy Answer: surgical removal, resection, excision
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Define root word Cholecyst Answer: Gall Bladder
QUESTION
What is the difference between Implied and Informed Consent? Answer: Informed consent is signed by the patient after the provider explains the procedure Implied consent is when the patient voluntarily undergoes treatment, such as extending your arm for venipuncture.
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What is the difference between transverse and sagittal? Answer: Transverse divides the body into top and bottom sections Sagittal divides the body into right and left sides
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____________________________________ have finished medical school and their internship and are currently receiving training in a specialized area Answer: Resident Physician
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What is a CDM? Answer:
Answer: Opening
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What are the Category III CPT Codes? Answer: Temporary coding for new technology and services that have not met the requirements needed to be added to the main section of the CPT book
QUESTION
What information is requested upon arrival at a hospital, provider's office, or facility? Answer: Demographics
- Name
- Date of Birth
- Gender
- Last 4 of SSN
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What does assignment of benefits mean? Answer: Arrangement by which a patient requests that the payment be made directly to the provider
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de-identified information Answer: Information that does not identify an individual because unique and personal characteristics have been removed.
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demographic information Answer: Date of birth, sex, marital status, address, telephone number, relationship to subscriber, and circumstances of condition.
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description of service Answer: An evaluation and management visit, observation, or emergency room visit.
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diagnosis code Answer: international classification of diseases (ICD- 10 - CM)
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dirty claim Answer: Claim that is inaccurate, incomplete, or contains other errors.
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electronic data interchange Answer:
Answer: Describes the services rendered, payment covered, and benefit limits and denials.
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Fair Debt Collection Practices Act Answer: debt collectors cannot use unfair or abusive practices to collect payments
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false claims act Answer: Protects the government from being overcharged for services provided or sold, or substandard goods or services.
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final rule Answer: strengthens the HIPAA ruling around privacy, security, breach notification, and penalties
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formulary Answer: A list of prescription drugs approved by a health plan.
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fraud
Answer: making false statements or representations of material facts to obtain some benefit or payment for which no entitlement would otherwise exist
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gatekeeper Answer: provider who determines the appropriateness of the health care service; level of health care professional called for, and setting of care
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general ledger key Answer: A two- or three-digit number that makes sure that a line item is assigned to the general ledger in the hospital's accounting system.
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group code Answer: Code that identifies the party financially responsible for a specific service or the general category of payment adjustment.
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group or plan number Answer: unique code used to identify a set of benefits of one group of type of plan
A patient presents for treatment, such as extending an arm to allow a venipuncture to be performed.
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Independent Practice Association (IPA) model Answer: HMO that contracts with the IPA, which in turn contracts with individual health providers
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individually identifiable Answer: Documents that identify the person or provide enough information so that the person could be identified.
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informed consent Answer: providers explain medical or diagnostic procedures, surgical interventions, and the benefits and risks involved, giving patients an opportunity to ask questions before medical intervention is provided
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Managed Care Organization Answer: Organization developed to manage the quality of health care and control costs
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Medicaid Answer: a government-based health insurance option that pays for medical assistance for individuals who have low incomes and limited financial resources. Funded at the state and national level. Administered at the state level
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medical necessity Answer: The documented need for a particular medical intervention.
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Medicare Administrative Contractor (MAC) Answer: Processes Medicare Parts A and B claims from hospitals, physicians, and other providers.
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Medicare Advantage Answer: Combined package of benefits under Medicare Parts A & B that may offer extra coverage for services such a, vision, hearing, dental, health and wellness, or prescription coverage.
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medicare Answer:
