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NHA Certified Billing and Coding Specialist (CBCS)
Questions and Answers
The symbol "O" in the Current Procedural Terminology reference is used to indicate what? - Correct answer-Reinstated or recycled code In the anesthesia section of the CPT manual, what are considered qualifying circumstances? - Correct answer-Add-on codes As of April 1, 2014 what is the maximum number of diagnoses that can be reported on the CMS-1500 claim form before a further claim is required? - Correct answer- What is considered proper supportive documentation for reporting CPT and ICD codes for surgical procedures? - Correct answer-Operative report What action should be taken first when reviewing a delinquent claim? - Correct answer- Verify the age of the account A claim can be denied or rejected for which of the following reasons? - Correct answer- Block 24D contains the diagnosis code A coroner's autopsy is comprised of what examinations? - Correct answer- Gross Examination Medigap coverage is offered to Medicare beneficiaries by whom? - Correct answer- Private third-party payers What part of Medicare covers prescriptions? - Correct answer-Part C What plane divides the body into left and right? - Correct answer-Sagittal Where can unlisted codes be found in the CPT manual? - Correct answer- Guidelines prior to each section Ambulatory surgery centers, home health care, and hospice organizations use which form to submit claims? - Correct answer-UB-04 Claim Form What color format is acceptable on the CMS-1500 claim form? - Correct answer-Red Who is responsible to pay the deductible? - Correct answer-Patient
A patient's health plan is referred to as the "payer of last resort." What is the name of that health plan? - Correct answer-Medicaid Informed Consent - Correct 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. Implied Consent - Correct answer-A patient presents for treatment, such as extending an arm to allow a venipuncture to be performed. Clearinghouse - Correct answer-Agency that converts claims into standardized electronic format, looks for errors, and formats them according to HIPAA and insurance standards. Individually Identifiable - Correct answer-Documents that identify the person or provide enough information so that the person can be identified. De-identified Information - Correct answer-Information that does not identify an individual because unique and personal characteristics have been removed. Consent - Correct answer-A patient's permission evidenced by signature. Authorizations - Correct answer-Permission granted by the patient or the patient's representative to release information for reasons other than treatment, payment, or health care operations. Reimbursement - Correct answer-Payment for services rendered from a third- party payer. Auditing - Correct answer-Review of claims for accuracy and completeness. Fraud - Correct answer-Making false statements of representations of material facts to obtain some benefit or payment for which no entitlement would otherwise exist. Upcoding - Correct answer-Assigning a diagnosis or procedure code at a higher level than the documentation supports, such as coding bronchitis as pneumonia. Unbundling - Correct answer-Using multiple codes that describe different components of a treatment instead of using a single code that describes all steps of the procedure.
What is the main job of the Office of the Inspector General (OIG)? - Correct answer- The OIG protects Medicare and other HHS programs from fraud and abuse by conducting audits, investigations , and inspections. Medicare - Correct answer-Federally funded health insurance provided to people age 65 or older, and people 65 and younger with certain disabilities. Medicaid - Correct answer-A government-based health insurance option that pays for medical assistance for individuals who have low incomes and limited financial resources. Timely Filing Requirements - Correct answer-Within 1 calendar year of a claim's date of service. Electronic Data Interchange (EDI) - Correct answer-The transfer of electronic information in a standard form. Coordination of Benefits Rules - Correct answer-Determines which insurance plan is primary and which is secondary. Conditional Payment - Correct answer-Medicare payment that is recovered after primary insurance pays. Crossover Claim - Correct answer-Claim submitted by people covered by a primary and secondary insurance plan. Assignment of Benefits - Correct answer-Contract in which the provider directly bills the payer and accepts the allowable charge. Allowable Charge - Correct answer-The amount an insurer will accept as full payment, minus applicable cost sharing. Clean Claim - Correct answer-Claim that is accurate and complete. They have all the information needed for processing, which is done in a timely fashion. Dirty Claim - Correct answer-Claim that is inaccurate, incomplete, or contains other errors. Medicare Administrative Contractor (MAC) - Correct answer-Processes Medicare Parts A and B claims from hospitals, physicians, and other providers. Remittance Advice (RA) - Correct answer-The report sent from the third-party
payer to the provider that reflects any changes made to the original billing.
coverage. Medicare Part D - Correct answer-A p.an run by private insurance companies and other vendors approved by Medicare.
Medigap - Correct answer-A private health insurance that pays for most of the charges not covered by Parts A and B. What are the three major kinds of government insurance plans? - Correct answer- Medicare, Medicaid, and State Children's Health Insurance Program (SCHIP) Referral - Correct answer-Written recommendation to a specialist. Precertification - Correct answer-A review that looks at whether the procedure could be performed safely but less expensively in an out patient setting. Predetermination - Correct answer-A written request for a verification of benefits. Who is usually the gatekeeper? - Correct answer-Primary care physician Preauthorization - Correct answer-Approval from the health plan for an inpatient hospital stay or surgery. Formulary - Correct answer-A list of prescription drugs covered by an insurance plan. Tier 1 - Correct answer-Providers and facilities in a PPO's network. Tier 2 - Correct answer-Providers and facilities within a broader, contracted network of the insurance company. Tier 3 - Correct answer-Providers and facilities out of the network. Tier 4 - Correct answer-Providers and facilities not on the formulary Preferred Provider - Correct answer-Tier 2 provider What's the difference between a copayment and coinsurance? - Correct answer- Copayment is a flat fee that a patient pays; Coinsurance is a percentage of the covered benefits paid by both the insurance company and the patient. What is the advantage of employer-based self-insured health plans? - Correct answer- Due to economies of scale, employer-based self-insured health plans are more reasonably priced than private insurance. What is the coinsurance percentage? - Correct answer-Amount the provider is allowed for the service and the amount he was paid. The patient has coinsurance
Accounts Receivable Department - Correct answer-Department that keeps track of what third-party payers the provider is waiting to hear from and what patients are due to make a payment. Aging Report - Correct answer-Measures the outstanding balances in each account. Charge description Master (CDM) - Correct answer-Information about health care services that patients have received and financial transactions that have taken place. Account Number - Correct answer-Number that identifies specific episode of care, date of service, or patient. Health Record Number - Correct answer-Number the provider uses to identify an individual patient's record. Medicare Summary Notice (MSN) - Correct answer-Document that outlines the amounts billed by the provider and what the patient must pay the provider. Subscriber - Correct answer-Purchaser of the insurance or the member of group for which an employer or association as purchased insurance. Subscriber Number - Correct answer-Unique code used to identify a subscriber's policy. Cost Sharing - Correct answer-The balance the policyholder must pay the provider. Batch - Correct answer-A group of submitted claims. Balance Billing - Correct answer-Billing patients for charges in excess of the Medicare fee schedule. Notice of Exclusions from Medicare Benefits - Correct answer-Notification by the physician to a patient that a service will not be paid. Advance Beneficiary Notice of Noncoverage - Correct answer-Form provided if a provider believes that a service may be declined because Medicare might consider it unnecessary. What does the term reconciliation mean? - Correct answer-Refers to the process the billing office goes through to determine what payments have come in from the third- party payer and what the patient owes the provider.
Write-off - Correct answer-The difference between the provider's actual charge and the allowable charge.
measurement. Category III CPT Code - Correct answer-Code used for 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.
How many CPT code category sections are listed in the CPT manual? - Correct answer- Six Encounter Form - Correct answer-Form that includes information about past history, current history, inpatient record, discharge information and insurance information. Abstracting - Correct answer-The extraction of specific data from a medical record, often for use in an external database, such as a cancer registry. Encoder - Correct answer-Software that suggests codes based on documentation or other input. MS-DRG Grouper - Correct answer-Software that helps coders assign the appropriate Medicare severity diagnosis-related group based on the level of services provided, severity of the illness or injury, and other factors. APC Grouper - Correct answer-Helps coders determine the appropriate ambulatory payment classification (APC) for an outpatient encounter. Computer-assisted Coding (CAC) - Correct answer-Software that scans the entire patient's electronic record and codes the encounter based on the documentation in the record. What is abstracting? - Correct answer-It involves reviewing the health record and/or encounter form and translating the medical documentation into the specific code sets. What are three purposes of ICD-9-CM? - Correct answer-Classifying morbidity and mortality, indexing hospital records by disease and operations and reporting diagnoses by physicians. How does ICD-10-CM improve upon ICD-9-CM? - Correct answer-ICD-10-CM provides more detailed clinical information, updated medical terminology and classification of diseases. What are the goals of ICD-10-PCS? - Correct answer-Improve accuracy and efficiency of coding, reduce training effort, and improve communication with physicians. What character of ICD-10-PCS for medical or surgical procedure would identify the body part? - Correct answer-Character 4
What are HCPCS Level II codes used for? - Correct answer-They were established to report services, supplies, and procedures not represented in CPT. What part of the medical record is used to determine the correct E/M code used for billing & coding? - Correct answer-History and physical Which block on the CMS-1500 claim form is used to bill ICD codes? - Correct answer- 21 Which block should the billing and coding specialist fill out on the CMS-1500 claim form when billing a secondary insurance company? - Correct answer-9a What happens after a third-party payer validates a claim? - Correct answer- Claim adjudication What is the purpose of running an aging report each month? - Correct answer-It indicates which claims are outstanding. What are Z codes used to identify? - Correct answer-Immunizations What type of insurance is considered the payer of last resort? - Correct answer- Medicaid What modifier should be used to indicate a professional service has been discontinued prior to completion? - Correct answer-- What form is used as a financial report of all services provided to patients? - Correct answer-Patient account record What block on the CMS-1500 form should you enter the prior authorization number? - Correct answer- Block 17b on the CMS-1500 claim form should list what information? - Correct answer- Referring physician's national provider identifier number. What is modifier -50 used for? - Correct answer-A bilateral procedure What information is recorded in Block 33a of the CMS-1500 form? - Correct answer- National Provider Identification Number What block on the CMS-1500 claim form is required to indicate a workers' compensation claim? - Correct answer-10a
When submitting claims, what is the outcome if block 13 is left blank? - Correct answer- The third-party payer reimburses the patient and the patient is responsible for reimbursing the provider. What was developed to reduce Medicare program expenditures by detecting inappropriate codes and eliminating improper coding practices? - Correct answer- NCCI What policy determines if a particular item or service is covered by Medicare? - Correct answer-National Coverage Determination (NCD) What is an example of Medicare abuse? - Correct answer-Charging excessive fees. What notice explains why Medicare will deny a particular service or procedure? - Correct answer-Advance Beneficiary Notice (ABN) In the anesthesia section of the CPT manual what is considered qualifying circumstances? - Correct answer-Add-on codes A billing and coding specialist can ensure appropriate insurance coverage for an outpatient procedure by obtaining what? - Correct answer-Precertification What symbol indicates a revised code? - Correct answer-Triangle What standardized formats are used in the electronic filing of claims? - Correct answer- HIPAA standard transactions What formats are used to submit electronic claims to a third-party payer? - Correct answer- The billing and coding specialist should follow the guidelines in the CPT manual for which of the following reasons? - Correct answer-The guidelines define items that are necessary to accurately code. What is a HIPAA compliance guideline affecting electronic health records? - Correct answer-The electronic transmission and code set standards require every provider to use the healthcare transactions, code sets, and identifiers. What block on the CMS-1500 claim form is used to accept assignment of benefit? - Correct answer- What is an example of a remark code from an explanation of benefits document? - Correct answer-Contractual allowance
Stark Law - Correct answer-Prohibits a provider from referring Medicare patients to a clinical laboratory service in which the provider has a financial interest. At what percentage should a front torso burn be coded? - Correct answer-18% What block on the CMS-1500 claim form should be completed for procedures, services and supplies? - Correct answer-24D What national provider identifiers (NPIs) is required in Block 33a of a CMS- claim form? - Correct answer-Billing provider
