CBCS Exam Study Guide Latest 2022 update

Medical Billing & Coding as a Career - ANSWER *Claims assistant professional or claims manager, *Coding Specialist, * Collection Manager, *Electronic Claims Processor, *Insurance Billing Specialist, * Insurance Coordinat ...

Medical Billing & Coding as a Career - ANSWER *Claims assistant professional or claims manager, *Coding Specialist, * Collection Manager, *Electronic Claims Processor, *Insurance Billing Specialist, * Insurance Coordinator, *Insurance Counselor, *Medical Biller, *Medical & Financial Records Manager, * Billing & Coding Specialist What are Medical Ethics? - ANSWER Standards of conduct based on moral principle. They are generally accepted as a guide for behavior towards pt's, dr's, co-workers, the gov, and ins co's. What does acting within ethical behavior boundaries mean? - ANSWER carrying out one's responsibilities w/ integrity, dignity, respect, honesty, competence, fairness, & trust. Legal Aspects of of Medical Billing & Coding: - ANSWER ... Compliance regulations: - ANSWER Most billing-related cases are based on HIPPA and False Claims Act Health Insurance Portability & Accountability Act (HIPPA) - ANSWER Enacted in 1996, created by the Health Care Fraud & Abuse Control Program-enacted to check for fraud and abuse in the Medicare/Medicaid Programs and private payers What are the 2 provisions of HIPPA? - ANSWER Title I: Insurance Reform Title II: Administrative Simplification What is Title I of HIPPA? - ANSWER Insurance Reform-primary purpose is to provide continuous ins coverage for worker & their dependents when they change or lose jobs. Also *Limits the use of preexisting conditions exclusions *Prohibits discrimination from past or present poor health *Guarantees certain employees/indv the right to purchase new health ins coverage after losing job *Allows renewal of health ins cov regardless of an indv's health cond. that is covered under the particular policy. What is Title II of HIPPA? - ANSWER Administrative Simplification-goal is to focus on the health care practice setting to reduce administrative cost & burdens. Has 2 parts- 1) development and implementation of standardized health-related financial & administrative activities electronically 2) Implementation of privacy & security procedures to prevent the misuse of health info by ensuring confidentiality What is the False Claims Act (FCA)? - ANSWER Federal law that prohibits submitting a fraudulent claim or making a false statement or representation in connection w/ a claim. Also protects & rewards whistle-blowers. What is the National Correct Coding Initiative (NCCI)? - ANSWER Developed by CMS to promote the national correct coding methodologies & to control improper coding that lead to inappropriate payment of Part B health ins claims. How many edits does NCCI include? - ANSWER 2: 1)Column 1/Column 2 (prev called Comprehensive/Component) Edits 2) Mutually Exclusive Edits Column 1/Column 2 edits (NCCI) - ANSWER Identifies code pairs that should not be billed together b/c 1 code (Column 1) includes all the services described by another code (Column 2) Mutually Exclusive Edits (NCCI) - ANSWER ID's code pairs that, for clinical reasons, are unlikely to be performed on the same pt on the same day What are the possible consequences of inaccurate coding and incorrect billing? - ANSWER *delayed processing & payment of claims *reduced payments, denied claims *fine and/or imprisonment *exclusion from payer's programs, loss of dr's license to practice med Who has the task of investigate and prosecuting health care fraud & abuse? - ANSWER The Office of Inspector General (OIG) Fraud - ANSWER knowingly & intentionally deceiving or misrepresenting info that may result in unauthorized benefits. It is a felony and can result in fines and/or prison. Who audits claims? - ANSWER State & federal agencies as well as private ins co's What are common forms of fraud? - ANSWER billing for services not furnished, unbundling, & misrepresenting diagnosis to justify payment Abuse - ANSWER incidences or practices, not usually considered fraudulent, that are inconsistent w/ the accepted medical business or fiscal practices in the industry. What are examples of Abuse? - ANSWER submitting a claim for services/procedures performed that is not medically necessary, and excessive charges for services, equipment or supplies. What is a method use to minimize danger, hazards, & liabilities associated w/ abuse? - ANSWER Risk Management Patient Confidentiality - ANSWER All pt's have right to privacy & all info should remain privileged. Only discuss pt info when necessary to do job. Obtain a signed consent form to release medical info to ins co or other individual. When may providers use PHI (Protected Health Information) w/o specific authorization under the HIPPA Privacy Rule? - ANSWER When using for TPO, Treatment (primarily for the purpose of discussion of pt's case w/ other dr's) Payment (providers submit claims on behalf of pt's) & Operations (for purposes such as training staff & quality improvement) What is Employer Liability? - ANSWER Means physicians are legally responsible for their own conduct and any actions of their employees (designee) performed w/in the context of their employment. Referred to as "vicarious liability. A.K.A "respondent superior"-"let the master answer". Means employee can be sued & brought to trial What is Employee Liability? - ANSWER "Errors & Omissions Insurance"-protection against loss of monies caused by failure through error or unintentional omission on the part of the indv or service submitting the claim. ****Some dr's contract w/ a billing service (clearinghouse) to handle claims submission, & some agreements contain a clause stating that the dr will hold the co harmless from "liability resulting from claims submitted by the service for any account", means dr is responsible for mistakes made by billing service, errors & omissions is not needed in the instance. ******However, if dr ever asks the ins biller to do the least bit questionable, such as write of pt's balances for certain pt's automatically, make sure you have a legal document or signed waiver of liability relieving you of responsibility for such actions. What is a Medical Record & what is it comprised of? - ANSWER documentation of the pt's social & medical history, family history, physical exam findings, progress notes, radiology & lab results, consultation reports and correspondence to pt- Is the foremost tool of clinical care and communication. What is a medical report? - ANSWER part of the medical record & is a permanent legal document that formally states the consequences of the pt's exam or treatment in letter or report form. IT IS THIS RECORD THAT PROVIDES INFO NEEDED TO COMPLETE THE INS CLAIM FORM. Reasons for Documentation - ANSWER Important that every pt seen by dr has comprehensive legible documentation about pt's illness, treatment, & plans for following reasons: *Avoidance of denied or delayed payment by ins co investigating the medical necessity of services *Enforcement of medical record-keeping rules by ins co requiring accurate documentation that supports procedure & diagnosis codes. *Subpoena of medical records by state investigators or the court for review *Defense of professional liability claim Retention Of Medical Records - ANSWER Is governed by state & local laws & may vary from state-to-state. Most dr are required to retain records indefinitely, deceased pt records should be kept for @ least 5 years Med Term - ANSWER ... Diagnosis suffixes: - ANSWER ... -algia - ANSWER pain -emia - ANSWER blood condition -itis - ANSWER inflammation -megaly - ANSWER enlargement -meter - ANSWER measure -oma - ANSWER tumor, mass -osis - ANSWER abnormal condition -pathy - ANSWER disease condition -rrhagia - ANSWER bursting forth of blood -rrhea - ANSWER discharge, flow -sclerosis - ANSWER hardening -scopy - ANSWER to view Procedural Suffixes: - ANSWER ... -centesis - ANSWER surgical puncture -ectomy - ANSWER removal, resection, excision -gram - ANSWER record -graphy - ANSWER process of recording -lysis - ANSWER separation, breakdown, destruction -pexy - ANSWER surgical fixation -plasty - ANSWER surgical repair -rrhapy - ANSWER suture -scopy - ANSWER visual examination -stomy - ANSWER opening -therapy - ANSWER treatment -tomy - ANSWER incision, to cut into Common Prefixes: - ANSWER ... a, an - ANSWER without ante - ANSWER before anti - ANSWER against brady - ANSWER slow dys - ANSWER painful, difficult endo - ANSWER inside, within epi - ANSWER upon, above ex - ANSWER out, out of hemi - ANSWER half, partial hypo - ANSWER below, deficient infra - ANSWER below inter - ANSWER between neo - ANSWER new oligo - ANSWER scanty, little pan - ANSWER all para - ANSWER beside per - ANSWER through poly - ANSWER many pre - ANSWER before, in front of pseudo - ANSWER false sub - ANSWER under supra - ANSWER above, beyond tetra - ANSWER four Common Root Words - ANSWER ... arth - ANSWER cartilage cephal - ANSWER head cardi - ANSWER heart cholecyst - ANSWER gall bladder chondro - ANSWER cartilage colp - ANSWER vagina derm - ANSWER skim enter - ANSWER intestine episi - ANSWER vulva gastro - ANSWER stomach gloss - ANSWER tongue hepato - ANSWER liver hyster - ANSWER uterus lapar - ANSWER abdomen lact - ANSWER milk lith - ANSWER stone mast - ANSWER breast myo - ANSWER muscle nat - ANSWER birth oophor - ANSWER ovary oste - ANSWER bone pneum - ANSWER lung rhin - ANSWER nose salping - ANSWER fallopian tubes stomat - ANSWER mouth Directional Terms: - ANSWER ... Anterior, Ventral - ANSWER front surface of the body Posterior, Dorsal - ANSWER back side of the body Superior - ANSWER above another structure Inferior - ANSWER below another structure Proximal - ANSWER near the point of attachment to the trunk Distal - ANSWER far from the point of attachment to the trunk Medial - ANSWER pertaining to the middle of the body Lateral - ANSWER pertaining to the side Frontal, Coronal - ANSWER Vertical plane dividing the body into anterior & posterior portions Sagittal - ANSWER vertical plane dividing the body into right & left sides Transverse, Cross-sectional - ANSWER Horizontal plane dividing the body into upper & lower portions Anatomy & Physiology - ANSWER A professional medical coder must have knowledge of anatomy & physiology so that coding assignment is quick & accurate. What is the 1st body system for which medical procedures are described in the CPT manual? - ANSWER The Integumentary System (the skin and it's accessory organs) Integument means covering. It is a complex system of specialized tissues containing glands, nerves and blood vessels. How much area does the skin cover? - ANSWER an area of 22 sq ft (an average adult). It is the largest organ of the body What is the main function of the skin? - ANSWER To protect the deeper tissues from excessive loss of minerals, heat & water. It also provides protection form diseases by providing a barrier. It accomplishes its diverse functions w/ assistance from the hair, nails and glands. SEBACEOUS (OIL) GLANDS & SUDDORIFERIOUS (SWEAT GLANDS) - ANSWER produce secretions that allow the body to be moisturized or cooled. How many layers to the skin? - ANSWER 3; 1) Epidermis (thin, cellular membrane layer that contains keratin) 2) Dermis (dense, fibrous, connective tissue that contains collagen) 3) Subcutaneous layer (thicker & fatter tissue) Hair, Nail & Glands - ANSWER ... Hair - ANSWER composed of tightly fused meshwork of cells filled w/ hard protein called karatin. Has its roots in the dermis & together w/ their coverings, is called HAIR FOLLICES. Main function is to assist in regulating body temp. Holds heat when body is cold by standing on end & holding a layer of air as insulation. Nails - ANSWER cover & protect the dorsal surface of the distal bones of the fingers & toes. Part that is visible is nail body, nail root is under skin @ the base of the nail and nail bed is the vascular tissue under the nail that appears pink when the blood is oxygenated or blue/purple when it is oxygen deficient. What is the moon like white area of the nail called? - ANSWER lunula What is the eponychium? - ANSWER the cuticle at the lower part of the nail sometime referred to as such SEBACEOUS GLANDS - ANSWER located in the dermal layer of the skin over the entire body, expect for palm of hands and soles of feet. Secrete oily substance called SEBUM. SEBUM CONTAINS LIPIDS THAT HELP LUBRICATE THE SKIN & MINIMIZE WATER LOSS. It is the overproduction of sebum during puberty that contributes to acne in some people SUDDORIFEROUS GLANDS - ANSWER sweat glands that are tiny, coiled gland found on almost all body surfaces. They are most numerous in the palms and soles of feet. Coiled sweat glands originate in the dermis and straighten out to extend up through the epidermis. Tiny opening at surface is called a PORE. How many types of sweat glands? - ANSWER 2; 1) eccrine sweat glands (most common) 2) apocrine sweat glands (secrete orderless sweat) What organ secretes hormones? - ANSWER the adrenal glands, they secrete epinephrine & steriods Integumentery Vocabulary - ANSWER ... Albino - ANSWER deficient in pigment (melanin) Collagen - ANSWER structural protein found in the skin & connective tissue Melanin - ANSWER major skin pigment Lipocyte - ANSWER a fat cell Macule - ANSWER discolored, flat lesion (freckles,, tattoo marks) Polyp - ANSWER benign growth extending from the surface of the mucous membrane Fissure- - ANSWER groove or crack like sore Nodule - ANSWER solid, round or oval elevated lesion more than 1 cm in diameter Ulcer - ANSWER open sore on the skin or mucous membrane Vesicle - ANSWER small collection of clear fluid; blister Wheal - ANSWER Smooth, slightly elevated, edematous (swollen) area that is redder or paler than the surrounding skin Alopecia - ANSWER absence of hair form areas where it normally grows Gangrene - ANSWER death of tissue associated w/ the loss of blood supply Impetigo - ANSWER bacterial inflammatory skin disease characterized by lesion, pustules, and vesicles Multigravida - ANSWER a pregnant woman who has had at least one previous pregnancy The Musculoskeletal System - ANSWER includes bones, muscles & joints. Acts as a framework for the organs, protects many of those organs, and also provides the body w/ the ability to move What are bones connected to one another by? - ANSWER by fibrous bands of tissues called LIGAMENTS