The symbol "O" in the Current Procedural Terminology reference is used to indicate what? - Ans-Reinstated or recycled code
In the anesthesia section of the CPT manual, what are considered qualifying circumstances? - A
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The symbol "O" in the Current Procedural Terminology reference is used to indicate what? - Ans-Reinstated or recycled code
In the anesthesia section of the CPT manual, what are considered qualifying circumstances? - Ans-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? - Ans-12
What is considered proper supportive documentation for reporting CPT and ICD codes for surgical procedures? - Ans-Operative report
What action should be taken first when reviewing a delinquent claim? - Ans-Verify the age of the account
A claim can be denied or rejected for which of the following reasons? - Ans-Block 24D contains the diagnosis code
A coroner's autopsy is comprised of what examinations? - Ans-Gross Examination
Medigap coverage is offered to Medicare beneficiaries by whom? - Ans-Private third-party payers
What part of Medicare covers prescriptions? - Ans-Part C
What plane divides the body into left and right? - Ans-Sagittal
Where can unlisted codes be found in the CPT manual? - Ans-Guidelines prior to each section
Ambulatory surgery centers, home health care, and hospice organizations use which form to submit claims? - Ans-UB-04 Claim Form
What color format is acceptable on the CMS-1500 claim form? - Ans-Red
Who is responsible to pay the deductible? - Ans-Patient
A patient's health plan is referred to as the "payer of last resort." What is the name of that health plan? - Ans-Medicaid
Informed Consent - Ans-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 - Ans-A patient presents for treatment, such as extending an arm to allow a venipuncture to be performed.
Clearinghouse - Ans-Agency that converts claims into standardized electronic format, looks for errors, and formats them according to HIPAA and insurance standards.
Individually Identifiable - Ans-Documents that identify the person or provide enough information so that the person can be identified.
De-identified Information - Ans-Information that does not identify an individual because unique and personal characteristics have been removed.
Consent - Ans-A patient's permission evidenced by signature.
Authorizations - Ans-Permission granted by the patient or the patient's representative to release information for reasons other than treatment, payment, or health care operations.
Reimbursement - Ans-Payment for services rendered from a third-party payer.
Auditing - Ans-Review of claims for accuracy and completeness.
Fraud - Ans-Making false statements of representations of material facts to obtain some benefit or payment for which no entitlement would otherwise exist.
Upcoding - Ans-Assigning a diagnosis or procedure code at a higher level than the documentation supports, such as coding bronchitis as pneumonia.
Unbundling - Ans-Using multiple codes that describe different components of a treatment instead of using a single code that describes all steps of the procedure.
Abuse - Ans-Practices that directly or indirectly result in unnecessary costs to the Medicare program.
Business Associate (BA) - Ans-Individuals, groups, or organizations who are not members of a covered entity's workforce that perform functions or activities on behalf of or for a covered entity.
What is the main job of the Office of the Inspector General (OIG)? - Ans-The OIG protects Medicare and other HHS programs from fraud and abuse by conducting audits, investigations , and inspections.
Medicare - Ans-Federally funded health insurance provided to people age 65 or older, and people 65 and younger with certain disabilities.
Medicaid - Ans-A government-based health insurance option that pays for medical assistance for individuals who have low incomes and limited financial resources.
Timely Filing Requirements - Ans-Within 1 calendar year of a claim's date of service.
Electronic Data Interchange (EDI) - Ans-The transfer of electronic information in a standard form.
Coordination of Benefits Rules - Ans-Determines which insurance plan is primary and which is secondary.
Conditional Payment - Ans-Medicare payment that is recovered after primary insurance pays.
Crossover Claim - Ans-Claim submitted by people covered by a primary and secondary insurance plan.
Assignment of Benefits - Ans-Contract in which the provider directly bills the payer and accepts the allowable charge.
Allowable Charge - Ans-The amount an insurer will accept as full payment, minus applicable cost sharing.
Clean Claim - Ans-Claim that is accurate and complete. They have all the information needed for processing, which is done in a timely fashion.
Dirty Claim - Ans-Claim that is inaccurate, incomplete, or contains other errors.
Medicare Administrative Contractor (MAC) - Ans-Processes Medicare Parts A and B claims from hospitals, physicians, and other providers.
Remittance Advice (RA) - Ans-The report sent from the third-party payer to the provider that reflects any changes made to the original billing.
Explanation of Benefits (EOB) - Ans-Describes the services rendered, payment covered, and benefit limits and denials.
National Provider Identifier (NPI) - Ans-Unique 10-digit code fro providers required by HIPAA.
Heath Maintenance Organization (HMO) - Ans-Plan that allows patients to only go to physicians, other health care professionals, or hospitals on a list of approved providers, except in an emergency.
Modifier - Ans-Additional information about types of services, and part of valid CPT or HCPCS codes.
By signing block 12 of CMS-1500 form, a patient is doing what? - Ans-Authorizes the release of medical information.
Claim - Ans-Complete record of the services provided by the health care professional, along with appropriate insurance information.
Where does the NPI number go on the CMS-1500 form? - Ans-17b
What are two pieces of information that need to be collected from patients? - Ans-Full name and date of birth.
Deductible - Ans-The amount
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