Billing & Insurance, Coding Chap 4,5,6 – Flashcards
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This is the main reason a patient is presenting to the doctor and provides the main term to be coded first.
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primary diagnosis
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In the term, "Complete paralysis", what is the main term
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paralysis
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The first Coding Step says to Review Complete Medical Documentation. This is where you will find the primary diagnosis.
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true
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According to the Steps of Diagnosis Coding, you should verify the code in the Tabular List and then check it in the Alphabetic Index.
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False
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The very last step before submitting a diagnosis code is to
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Check compliance with any applicable Official Guidelines and list codes in appropriate order
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ICD-10 is the _____ version of the diagnostic code set.
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10th
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Which is the correct process for selecting CPT codes
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determine the procedures and services to report, identify the correct codes and determine the need for modifiers
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Upon selecting an Evaluation and Management code, three components are considered: the type of history, the physical examination and the
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medical decision making
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In CPT, E/M is the abbreviation for Evaluation and
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management
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Under CPT's definition, after a referral, who takes responsibility for the patient's care
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the physician to whom the patient is referred
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Codes in CPT's anesthesia section generally cover
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preoperative evaluation and planning care during the procedure routine postoperative care "All of the above"
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Which section of CPT codes is the physical status modifier, such as P1 for normal, healthy patient, exclusively used with
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anesthesia
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Under CPT guidelines, all services related to a surgical procedure are not additionally reimbursed
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during the global period
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What was set up to give healthcare providers a coding system that describes specific products, supplies, and services that patients receive
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HCPCS
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Durable medical equipment (DME) such as wheelchairs covered by the Medicare program are reported using?
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HCPCS codes
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In CPT, what do Category II codes report
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services to track performance measurement
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In CPT, what do Category III codes report
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emerging technology, services and procedures
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In CPT, a plus sign (+) next to code indicates a
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add-on code
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In CPT, a bullet (a solid circle) next to a code indicates a
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new code
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The division of CPT, such as anesthesia and radiology are referred to as
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sections
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In CPT, a lightning bolt symbol next to a code indicates a
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code pending FDA approval
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In CPT, a triangle next to a code indicates a
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revised code descriptor
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in CPT, what do facing triangles that appear in front of a code indicate
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new/revised test other than a code descriptor
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In CPT, what type of code is described by the following entry? + each additional 24 hours (list separately in addition to code for primary procedure)
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add-on code
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The CPT code that is listed first for an encounter is the procedure that
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is the most resource-intensive
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What is required of the physician in order to report the professional component of a CPT code from the Radiology section
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reading the radiological examination and writing a report of interpretation
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In CPT, some codes have both a technical component and another component representing the physician's skill, time and expertise. What is the name of this other component
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professional
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In CPT, a single code grouping laboratory tests is called a
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panel
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The use of CPT Category II codes does not affect reimbursement and is
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optional
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CPT is a publication of the
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American Medical Association
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Which of the following is not a main term in the CPT index
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anatomical site of the procedure abbreviations eponyms "None of the above"
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Which of the following is a cross-reference that might be seen in CPT
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both "see" and "see also" are seen
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CPT was first published in what year
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1966
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The E/M coding method came from
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joint effort of CMS and AMA
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The last step in the coding process is
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determine the need for modifiers
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How many key components are there when evaluating an E/M code
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three
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Which is not a key component in E/M coding
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treatment
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What is the abbreviation HPI used for
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history of present illness
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ROS is the abbreviation for
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review of systems
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In CPT, the term_____ describes services that a provider performs at the request of another provider after which the patient is returned to the requesting provider's care
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consultation
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Most of the surgery section is organized by
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body system
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Which member of the medical practice is ultimately responsible for proper documentation and correct coding
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physician
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Some possible consequences of inaccurate coding and incorrect billing in a medical practice are
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denied claims and reduced payments prison sentences fines "All of the above"
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The Correct Coding Initiative (CCI) is a program of
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Medicare
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If a payer judges that too high a code level has been assigned by a practice for a reported service, the usual action is to
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downcode the reported procedure code
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What type of coding uses diagnoses that are not as specific as possible
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truncated coding
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What type of coding uses a procedure code that provides a higher reimbursement rate than the correct code
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upcoding
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What type of coding uses a lower level code
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downcoding
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Professional courtesy refers to
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discounted charges made for other providers and their families
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Routinely waiving deductibles and copayments is
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illegal
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What type of audit is performed internally before claims are reported
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prospective audit
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What type of audit is performed internally after claims are submitted
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retrospective audit
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What type of external audit is performed by payers before claims are processed
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prepayment
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What type of audit do payers routinely conduct to ensure that claims are compliant
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post-payment
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The CMS/AMA Documentation Guidelines set up the rules for the selection of
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Evaluation and Management codes
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What type of fees are defined as those that physicians charge to most of their patients most of the time under typical conditions?
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usual fees
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Under RBRVs, the nationally uniform relative value is based on
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the provider's work, practice cost, and malpractice insurance costs
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What are the main methods payers use to pay providers
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allowed charges, contracted fee schedule, and capitation
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What is the fixed prepayment for each plan member in a capitation contract called
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capitation rate
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Medical insurance specialists help ensure maximum appropriate reimbursement for services by
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submitting claims that are correct and compliant
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When regulations seem contradictory or unclear, the OIG issues
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advisory opinions
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CCI is an abbreviation for
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Correct Coding Initiative
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The _______ lists the types of medical billing and reporting practices that the Office of Inspector General intends to investigate in the coming year
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OIG Work Plan
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Medical necessity is based on
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the relationship between the diagnosis and the treatment provided
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Which of the following is NOT a medically necessary procedure
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Cosmetic nasal surgery
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What does the term "assumption coding" mean
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That the medical coder coded and reported services that were not documented in the patient's medical record
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Which of the following is not fraudulent
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Using a non-specific diagnosis code
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________ refers to a coding method in which lower-level codes are selected to avoid government investigation
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Downcoding
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____________ refers to a coding problem in which a procedure code is used that provides a higher reimbursement than the correct code
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Upcoding
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Only the codes that ______ should be reported
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are supported by the documentation
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Global periods for a minor procedure have which of the following postoperative periods
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10 days
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Global periods for a major procedure have which of the following postoperative periods
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90 days
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What is a way that upcoding is being monitored by payers
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benchmarking practices' E/M codes with national averages
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Which of the following is considered a formal examination
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audit
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Which of the following means that a physician has chosen to waive the charges for services to other physicians
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professional courtesy
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An audit involves reviewing
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every claim a sample 10% of the claim "All of the above"
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RACs requests for information must be answered in _____ days
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45
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If a RAC's request is not answered in the appropriate amount of time, which of the following might occur
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an error is declared and penalties may result
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Which of the following is not an element of HPI
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location timing context "None of the above"
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_________ is a normal fee charged by a provider
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usual fee
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Most practices set their fees
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slightly above those paid by the highest reimbursing plan
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