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Glossary of Medical Billing and Coding

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1. Disability income insurance provides benefits for work-related disability.

TRUE OR FALSE
FALSE
2. Ambulatory payment classification (APC) are based on diagnoses.

TRUE OR FALSE
FALSE
3. V-codes are used for coding adverse effects.

TRUE OR FALSE
FALSE
4. Waiting periods affect workers’ compensation medical and hospital benefits.

TRUE OR FALSE
FALSE
5. The OSHA act provides that if a state submits an OSHA plan and it is approved by the government, then the state may assume responsibility for carrying out OSHA policies and procedures and is excluded from federal jurisdiction.

TRUE OR FALSE
TRUE
6. Progress reports subsequent to the initial report for workers’ compensation patients may be narrative and are not necessarily completed on the special forms available in most states.

TRUE OR FALSE
TRUE
7. An industrial record should include only objective findings and not subjective factors.

TRUE OR FALSE
FALSE
8. In an industrial case, the physician’s office may collect all amounts not covered by the workers’ compensation fee schedule.

TRUE OR FALSE
FALSE
9. Medical etiquette refers to
a. consideration of others.
b. moral principles or practices.
c. laws.
d. the Oath of Hippocrates
a. consideration of others.
10. An attachment to an insurance policy that excludes certain illnesses or disabilities that would otherwise be covered is referred to as a/an
a. waiver
b. exclusion
d. grace period
d. deductible
a. waiver
11. An organization of physicians, sponsored by a state or legal medical association, concerned with the development and delivery of medical services and the cost of health care is known as a/an
a. competitive medical plan (CMP)
b. exclusive pr
c. foundation for medical care
12. A type of managed care organization created by the 1982 Tax Equity and Fiscal Responsibility Act (TEFRA), that allows for enrollment of Medicare beneficiaries into managed care plans, is a/an
a. preferred provider organization (PPO)
b. comp
b. competitive medical plan (CMP)
13. What is the diagnosis called that is the main reason for the patient encounter?
a. secondary diagnosis
b. principal diagnosis
c. primary diagnosis
d. procedure diagnosis
b. principal diagnosis
14. When is the principal diagnosis applicable?
a. inpatient hospital coding
b. outpatient hospital coding
c. physician coding
d. all of the above
a. inpatient hospital coding
15. The Internal Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) was published by the Department of Health Services in
a. 1956
b. 1968
c. 1979
d. 1986
c. 1979
16. When insurance carriers do not pay claims in a timely manner, what effect does this have on the medical practice?
a. increased cash flow
b. decreased cash flow
c. decreased accounts receivable
d. decreased copayments
b. decreased cash flow
17. What plan allows members of Kaiser Permanente Medical Care Program to seek medical help from non-Kaiser physicians?
a. health maintenance organizations (HMO)
b. point of service (POS)
c. independent practice association (IPA)
d. f
b. point of service (POS)
18. How are physicians paid who work for a prepaid group practice model?
a. salary paid by independent group
b. salary paid by a health plan
c. fee for service
d. usual, customary, and reasonable charges
a. salary paid by independent group
19. In an independent practice association (IPA), physicians are
a. paid salaries by their own independent group
b. paid salaries by the practice association
c. not employees and are not paid salaries
d. not paid until the end of the
c. not employees and are not paid salaries
20. An organization that gives members freedom of choice among physicians and hospitals and provides a higher level of benefits if the providers listed on the plan are used is called a/an
a. health maintenance organization (HMO)
b. managed care
c. preferred provider organization (PPO)
21. A physician-owned business that has the flexibility to deal with all forms of contract medicine and also offers its own plans is a/an
a. IPA
b. PPO
c. PPG
d. POS
c. PPG
22. The frequency of Pap tests that may be billed for a Medicare patient who is low risk is
a. once every 12 months
b. every other year
c. once every 24 months
d. once every 5 years
c. once every 24 months
23. When a Medicare beneficiary has employer supplemental coverage, Medicare refers to these plans as
a. Medigap
b. Medicaid
c. MSP
d. LGHP
c. MSP
24. An explanation of benefits document for a patient under the Medicare program is referred to as the
a. Medicare remittance advice document
b. reimbursement report
c. summary payment report
d. explanation of Medicare benefits
a. Medicare remittance advice document
25. The Medicaid service for prevention, early detection, and treatment for welfare children is known as
a. CHPS
b. EPSDT
c. EPDT
d. CHAP
b. EPSDT
26. A health care professional, usually a registered nurse, who helps the patient work with his or her primary care manager to locate a specialist or obtain a preauthorization for care is referred to as a/an
a. PCP
b. TSC
c. HCF
d. PC
c. HCF
27. When a case is rated for permanent disability and settled, this is called
a. withdrawal and discharge
b. relief of duty
c. compromise and release
d. surrender and release
c. compromise and release
28. In an industrial case, if the patient is experiencing pain that can be tolerated but will cause some handicap in the performance of the activity precipitating the pain, it is classified as
a. severe pain
b. moderate pain
c. slight pain
c. slight pain
29. State disability insurance (SDI) is also known as
a. unemployment compensation disability (UCD)
b. temporary disability insurance (TDI)
c. Social Security disability insurance (SSDI)
d. both A and B
d. both A and B
30. The form that accompanies the billing claim form for inpatient hospital services is called a/an
a. detail statement
b. summary statement
c. CMS-1500
d. UB-92
a. detail statement
31. The hospital insurance claim form must always be reviewed by the
a. admitting clerk
b. ward clerk
c. insurance billing editor
d. nurse
c. insurance billing editor
32. A tentative DRG is based on
a. admission diagnosis, status of patient, age, and secondary diagnosis
b. admission diagnosis, age, patient’s history, and secondary diagnosis
c. admission diagnosis, scheduled procedures, age, and patien
c. admission diagnosis, scheduled procedures, age, and patient’s history
33. How many major diagnostic categories (MDCs) are there in the DRG-based system?
a. 10
b. 20
c. 25
d. 50
c. 25
34. The statutes for workers’ compensation laws fall under
a. federal compensation laws.
b. state compensation laws.
c. federal and state compensation laws.
d. state and county compensation laws.
c. federal and state compensation laws.
35. State compensation laws that require each employer to accept its provisions and provide for specified benefits are
a. compulsory laws.
b. elective laws.
c. regional laws.
d. local laws.
a. compulsory laws.
36. Final determination involving settlement of an industrial accident is known as
a. adjudication
b. settlement
c. release
d. discharge
a. adjudication
37. The form that contains authorization for the physician to treat the injured employee is the
a. Employer’s Report of Occupational Injury
b. Medical Service Order
c. Physician’s First Report of Occupational Injury or Illness
d.
b. Medical Service Order
38. The First Treatment Medical Report or Physician’s First Report of Occupational Injury or Illness form should be signed
a. in ink by the physician’s representative
b. in ink by the physician
c. using a certified signature stamp
b. in ink by the physician
39. Supplemental report(s) for patients on temporary disability should be sent to the insurance carrier
a. after treatment is completed
b. after every office visit
c. if there is a change in the diagnosis
d. on the first of every mont
b. after every office visit
40. Coding services that were not performed for payment

ILLEGAL, UNETHICAL, or BOTH
BOTH
41. Unbundling services when an available single code includes all services

ILLEGAL, UNETHICAL, or BOTH
BOTH
42. Assigning a code without documentation from the provider

ILLEGAL, UNETHICAL, or BOTH
BOTH
43. Coding a condition as primary when the majority of the treatment is for a preexisting condition

ILLEGAL, UNETHICAL, or BOTH
BOTH
44. Provider who sends the patient for tests or treatment.
Referring physician
45. Failure to make required refunds when services are not reasonable and necessary

ABUSE or FRAUD
ABUSE
46. Billing Medicare beneficiaries at a higher rate than other patients

ABUSE or FRAUD
ABUSE
47. Failure to make a refund when services are not reasonable or necessary

ABUSE or FRAUD
ABUSE
48. A form of health insurance that provides periodic payments to replace income when the insured is unable to work as a result of illness, injury or disease.
Disability income insurance
49. Insurance that covers off-the-job injury or sickness and is paid by deductions from a person’s paycheck.
State disability or unemployment compensation disability (UCD)
50. A contract that insures a person against on-the-job injury or illness.
Workers’ compensation insurance
51. Situation associated with the pain/symptom
Context
52. Services rendered by a physician whose opinion is requested by another physician for evaluating a patient’s illness
Consultation
53. A Medicare claim that is missing required information
Incomplete claim
54. An insurance claim that requires investigation and needs further clarification
Rejected claim
55. A Medicare claim that contains complete, necessary information but is illogical or incorrect
Invalid claim
56. Batch, scrub, edit, and transmit claims

DAILY, WEEKLY, END OF MONTH, DAILY OR WEEKLY
Daily or weekly
57. Review all claim rejection reports

DAILY, WEEKLY, END OF MONTH, DAILY OR WEEKLY
End of month
58. Make follow-up calls to resolve reasons for rejections

DAILY, WEEKLY, END OF MONTH, DAILY OR WEEKLY
Weekly
59. Update practice management system with payer information

DAILY, WEEKLY, END OF MONTH, DAILY OR WEEKLY
End of month
60. Research unpaid claims

DAILY, WEEKLY, END OF MONTH, DAILY OR WEEKLY
Weekly
61. Dollar amount owed to a participating provider for health care services rendered to a plan member according to a fee schedule set by the managed care plan
Charges
62. A reduction in charges for total bed days per year with incremental increases in the discount up to a maximum percentage
Discounts in the form of sliding scale
63. The hospital receives a flat per-admission reimbursement for the service to which the patient is admitted
Differential by service type
64. An interim per diem is paid for each day in the hospital
Sliding scales for discounts and per diems
65. Reimbursement to the hospital on a per-member per-month basis to cover costs for the member of the plan
Capitation or percentage of revenue
66. A single charge per hospital admission paid by the managed care plan
Flat rate
67. For what 4 reasons was diagnostic coding developed?
1) Tracking of disease processes
2) classification of causes of mortality
3) medical research
4) evaluation of hospital service utilization
68. What are 6 major government disability programs?
1) SSDI
2) SSI
3) CSRS
4) FERS
5) Armed Services Disability
6) VA
69. What does the abbreviation “CC” indicate when used with DRGs?
Complications or comorbidities
70. In 1850, the _____________________began offering insurance for nonfatal injury.
Franklin Health Assurance Company of Massachusetts
_________________ developed the standard insurance form.
The Health Insurance Association of AM & AMA
In _______, the Franklin Health Assurance Company of Massachusetts began offering insurance for nonfatal injury.
1850
Electronic claims sent carrier-direct are sent _________________.
directly to a specific carrier
Medical necessity is determined by __________________.
the insurance carrier
A formal regulation or law setting time limits on legal action
Statute of Limitations
prohibits discrimination in all areas of granting credit.
Equal Credit Opportunity Act
States that credit reporting agencies can only provide reports when a court Order is issued, the report is requested by the consumer (patient) or instructions are given by the patient to provide the report, and there is a legitimate business need for the
Fair Credit Reporting Act
Applies to “open end” credit accounts, such as credit cards, and revolving charge accounts for department store accounts. It DOES NOT cover installment contracts such as loans or extensions of credit.
Fair Credit Billing Act
a consumer protection act that applies to anyone who charges interest or agrees on payment of a bill in more than FOUR installments, excluding a down payment.
Truth in Lending Act
What year was the Truth in Lending Act created?
1969
Requires businesses to disclose all direct and indirect costs and conditions related to the granting of credit. All interests, late fees, etc. must be explained UP FRONT.
Truth in Lending Consumer Credit Cost Disclosure
This act DOES NOT apply directly to the physician practices collecting for themselves- a professional health care collector must avoid the actions that are prohibited for collection agencies. It protects consumers from unfair, harassing, or deceptive col
Fair Debt Collection Practices Act
81. To find out the time limit, __________________or refer to provider manuals for the various programs.
read the payment voucher document
82. Ultimately, the decision to appeal rests ________________, NOT the insurance billing specialist.
in the physician’s hands
83. If an appeal IS NOT successful, the physician may want to proceed to the next step, which is _______________.
peer review
The simplest type of workers' compensation claim is
a. temporary disability
b. permanent disability
c. nondisability
d. partial disability



c. nondisability
HIPAA
health insurance privacy and accountability act

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