Certified Billing & Coding Specialist Exam Review – COMPLETE SOLUTIONS 394 Questions with 100% Correct Answers

Certified Billing & Coding Specialist Exam Review – COMPLETE SOLUTIONS 394 Questions with 100% Correct Answers What are Medical Ethics? - ✔✔Standards of conduct based on moral principle. they are generally accepted a ...

Certified Billing & Coding Specialist Exam Review – COMPLETE SOLUTIONS 394 Questions with 100% Correct Answers What are Medical Ethics? - ✔✔Standards of conduct based on moral principle. they are generally accepted as a guide for behavior towards pt's, dr's, coworkers, the gov, and ins co's What does acting within ethical behavior boundaries mean? - ✔✔Carrying out one's responsibilities with integrity, dignity, respect, honesty, competence, fairness, and trust Compliance regulations - ✔✔Most billing-related cases are based on HIPAA and False Claims Act Health Insurance Portability & Accountability Act (HIPAA) - ✔✔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 2 provisions of HIPAA? - ✔✔Title 1: Insurance Reform Title 2: Administrative Simplification What is Title 1 of HIPAA? - ✔✔Insurance Reform-primary purpose is to provide continuous coverage for workers & their dependents when they change or lose jobs. Also Limits the use of pre-existing conditions exclusions Prohibits discrimination from past or present poor health Guarantees certain employees/ individual the right to purchase new health insurance coverage after losing job Allows renewal of health insurance coverage regardless of an individuals health condition that is covered under the particular policy What is Title 2 of HIPAA? - ✔✔Administrative Simplification- goal is to focus on the health care practice setting to reduce administrative cost & burdens. Has 2 parts1) 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)? - ✔✔Federal law that prohibits submitting a fraudulent claim or making a false statement or representation in connection with a claim. Also protects & rewards whistleblowers What is the National Correct Coding Initiative (NCCI)? - ✔✔Developed by CMS to promote the national correct coding methodologies & to control improper coding that lead to inappropriate payment of Part B health insurance claims How many edits does NCCI include? - ✔✔2: 1.Column 1/ Column 2 (previously called Comprehensive/ Component) Edits 2.Mutually Exclusive Edits Column 1/ Column 2 edits (NCCI) - ✔✔Identifies code pairs that should not be billed together because 1 code (Column 1) includes all the services described by another code (Column 2) Mutually Exclusive Edits (NCCI) - ✔✔ID's code pairs that, for clinical reasons, are unlikely to be preformed on the same patient on the same day What are the possible consequences of inaccurate coding and incorrect billing? - ✔✔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 medicine Who has the task of investigate and prosecuting health care fraud & abuse? - ✔✔The Office of Inspector General (OIG) Fraud - ✔✔knowingly & intentionally deceiving or misrepresenting info that may result in unauthorized benefits. it is a felony and can result in fines and or prisonWho audits claims? - ✔✔State & Federal agencies as well as private insurance companies What are common forms of fraud? - ✔✔billing for services not furnished, unbundling, and misrepresenting diagnosis to justify payment Abuse - ✔✔incidences or practices, not usually considered fraudulent, that are inconsistent with the accepted medical business or fiscal practices in the industry What are examples of Abuse? - ✔✔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 and liabilities associated with abuse? - ✔✔Risk Management Patient Confidentiality - ✔✔All patient's have right to privacy and all info should remain privileged. Only discuss patient info when necessary to do job. Obtain a signed consent form to release medical info to insurance company or other individual When may a provider use PHI (Protected Health Information) without specific authorization under the HIPAA Privacy Rule? - ✔✔When using TPO, Treatment (primarily for the purpose of discussion of patient's case with other Dr's) Payment (providers submit claims on behalf of patients) Operations (for purposes such as training staff and quality improvement) What is Employer Liability? - ✔✔Means physicians are legally responsible for their own conduct and any actions of their employees (designee) performed within 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? - ✔✔"Errors & Omissions Insurance"- protection against loss of monies caused by failure through error or unintentional omission on the part of the individual or service submitting the claim. ***Some Dr.'s contract with a billing service (clearinghouse) to handle claimssubmission and 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 and omissions is not needed in the instance.*** However, if the Dr. ever asks the insurance biller to do the least bit questionable, such as write off patients balances for certain patients 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? - ✔✔Documentation of the patients social and medical history, family history, physical exam findings, progress notes, radiology and lab results, consultation reports and correspondence to patients Is the foremost tool of clinical care and communication What is a medical report? - ✔✔part of the medical record & is a permanent legal document that formally states the consequences of the patients exam or treatment in letter or report form IT IS THIS RECORD THAT PROVIDES INFO NEEDED TO COMPLETE THE INSURANCE CLAIM FORM Reasons for Documentation - ✔✔Important that every patient seen by Dr. has comprehensive legible documentation about patients illness, treatment and plans for following reasons: * Avoidance of denied or delayed payment by insurance company investigating the medical necessity of service * Enforcement of medical record-keeping rules by insurance company's 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 - ✔✔Is governed by state & local laws & may vary from state-to-state. Most Dr. are required to retain records indefinitely, deceased patient records should be kept for at least 5 years -algia - ✔✔pain -emia - ✔✔blood condition-itis - ✔✔inflammation -megaly - ✔✔enlargement -meter - ✔✔measure -oma - ✔✔tumor, mass -osis - ✔✔abnormal condition -pathy - ✔✔disease condition -rrhagia - ✔✔bursting forth of blood -rrhea - ✔✔discharge, flow -sclerosis - ✔✔hardening -scopy - ✔✔to view/ visual examination -centesis - ✔✔surgical puncture -ectomy - ✔✔removal, resection, excision -gram - ✔✔record -graphy - ✔✔process of recording-lysis - ✔✔separation, breakdown, destruction -pexy - ✔✔surgical fixation -plasty - ✔✔surgical repair -rrhapy - ✔✔suture -stomy - ✔✔opening -therapy - ✔✔treatment -tomy - ✔✔incision, to cut into a, an- - ✔✔without ante- - ✔✔before anti- - ✔✔against brady- - ✔✔slow dys- - ✔✔painful, difficult endo- - ✔✔inside, within epi- - ✔✔upon, aboveex- - ✔✔out, out of hemi- - ✔✔half, partial hypo- - ✔✔below, deficient infra- - ✔✔below inter- - ✔✔between neo- - ✔✔new oligo- - ✔✔scanty, little pan- - ✔✔all para- - ✔✔beside per- - ✔✔through poly- - ✔✔many pre- - ✔✔before, in front of pseudo- - ✔✔false sub- - ✔✔undersupra- - ✔✔above, beyond tetra- - ✔✔four arth/o - ✔✔cartilage cephal/o - ✔✔head cardi/o - ✔✔heart cholecyst/o - ✔✔gall bladder chondro/o - ✔✔cartilage colp/o - ✔✔vagina derm/o - ✔✔skin enter/o - ✔✔intestine episi/o - ✔✔vulva gastr/o - ✔✔stomache gloss/o - ✔✔tongue hepat/o - ✔✔liverhyster/o - ✔✔uterus lapar/o - ✔✔abdomen lact/o - ✔✔milk lith/o - ✔✔stone mast/o - ✔✔breast my/o - ✔✔muscle nat/o - ✔✔birth oophor/o - ✔✔ovary oste/o - ✔✔bone pneum/o - ✔✔lung rhin/o - ✔✔nose salping/o - ✔✔fallopian tubes stomat/o - ✔✔mouth Anterior, Ventral - ✔✔front surface of the bodyPosterior, Dorsal - ✔✔back side of the body Superior - ✔✔above another structure Inferior - ✔✔below another structure Anterior, Ventral - ✔✔front surface of the body Proximal - ✔✔near the point of attachment Distal - ✔✔far from point of attachment to the trunk Medial - ✔✔pertaining to the side Lateral - ✔✔pertaining to the side Frontal, Coronal - ✔✔vertical plane dividing the body into anterior and posterior portions Sagittal - ✔✔vertical plane dividing the body into right and left sides Transverse, Cross-sectional - ✔✔horizontal plane dividing the body into upper and lower portions Anatomy & Physiology - ✔✔a professional medical coder must have knowledge of anatomy and physiology so that coding assignment is quick and accurate What is the 1st body system for which medical procedures are described in the CPT manual? - ✔✔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? - ✔✔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? - ✔✔to protect the deeper tissues from excessive loss of minerals, heat and water. it also provides protection from diseases by providing a barrier. it accomplishes its diverse functions with assistance from the hair, nails and glands Sebaceous (oil) glands & Suddoriferious (sweat) glands - ✔✔produce secretions that allow the body to be moisturized or cooled How many layers to the skin? - ✔✔3: Epidermis, Dermis, Subcutaneous Epidermis - ✔✔thin, cellular membrane layer that contains keratin Dermis - ✔✔dense, fibrous, connective tissue that contains collagen Subcutaneous - ✔✔thicker and fatter tissue Hair - ✔✔composed of tight fused meshwork of cells filled with hard protein called karatin. has its roots in the dermis and together with their coverings, is called HAIR FOLLICLES. main function is to assist in regulating body temp. holds heat when body is cold by standing on end and holding a layer of air as insulation Nails - ✔✔covers and protects dorsal surface of the distal bones of the fingers and toes. part that is visible is nail body, nail root is under skin at 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? - ✔✔lunula What is the eponychium? - ✔✔the cuticle at the lower part of the nail sometimes referred to as suchSebaceous Glands - ✔✔located in the dermal layer of the skin over the entire body, except for palm of hands and soles of feet. Secrete oily substance called Sebum. Sebum contains lipids that help lubricate the skin and minimize water loss. it is the overproduction of sebum during puberty that contributes to acne in some people Suddoriferous Glands - ✔✔sweat glands that are tiny, coiled glands 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? - ✔✔2: eccrine & apocrine Eccrine sweat glands - ✔✔most common Apocrine sweat glands - ✔✔secrete odorless sweat What organ secretes hormones? - ✔✔the adrenal glands, they secrete epinephrine and steriods Albino - ✔✔deficient in pigment (melanin) Collagen - ✔✔structural protein found in the skin and connective tissue Melanin - ✔✔major skin pigment Lipocyte - ✔✔a fat cell Macule - ✔✔discolored, flat lesion (freckles) Polyp - ✔✔benign growth extending from the surface of the mucous membrane Fissure - ✔✔groove or crack like soreNodule - ✔✔solid, round or oval elevated lesion (more than 1 cm in diameter) Ulcer - ✔✔open sore on the skin or mucous membrane Vesicle - ✔✔small collection of clear fluid (blister) Wheal - ✔✔smooth, slightly elevated, edematous (swollen) area that is redder or paler than the surrounding skin Alopecia - ✔✔absence of hair from areas where it normally grows (baldness) Gangrene - ✔✔death of tissue associated with the loss of blood supply Impetigo - ✔✔bacterial inflammatory skin disease characterized by lesion, pustules, and vesicles Multigravida - ✔✔a pregnant woman who has had at least one previous pregnancy The Musculoskeletal System - ✔✔includes bones, muscles and joints. acts as a framework for the organs, protects many of those organs, and also provides the body with the ability to move What are bones connected to one another by? - ✔✔by fibrous bands of tissues called Ligaments What are muscles attached to the bone by? - ✔✔tendons What is the fibrous covering of muscles called? - ✔✔the fascia and the articular cartilage, covers the end of many bones and serves as a protective functionBones - ✔✔complete organs made up of connective tissue called Osseous. inner core of bones is comprised of Hematopoietic tissue. this is where the red bone marrow manufactures blood cells. Other parts of the bones are storage areas for minerals necessary for growth (calcium and phosphorous) How are bones categorized? - ✔✔as belonging to either the Axial Skeleton or the Appendicular Skeleton Axial Skeleton - ✔✔consist of the skull, rib cage and spine Appendicular Skeleton - ✔✔made up of the shoulder, collar, pelvic, arm and legs Long Bones - ✔✔typically very strong, are broad at the ends and have large surfaces for muscle attachment. (humerus and femur) Short Bones - ✔✔are small with irregular shapes, they are found in wrist and ankle Flat Bones - ✔✔are found covering the soft body parts (shoulder blades, ribs and pelvic bones) Sesamoid Bones - ✔✔small, rounded bones that resemble a sesame seed. they are founf near joints and increase the efficiency of muscles near a joint (knee cap) Skull - ✔✔made up of 2 parts: the cranium and the facial bone Cranium - ✔✔includes: Frontal Bone, Parietal Bone, Occipital Bone, Temporal Bone, Ethmoid Bone, Sphenoid Bone Frontal Bone - ✔✔forms the anterior [art of the skull and forhead Parietal Bone - ✔✔forms the sides of the craniumOccipital Bone - ✔✔forms the back of the skull, there is a large hole at the ventral surface in this bone called the foramen magnum, which allows the brain to communicate with the spinal cord Temporal Bone - ✔✔forms the 2 lower sides of the cranium Ethmoid Bone - ✔✔forms the roof of the nasal cavity Sphenoid Bone - ✔✔anterior to the temporal bone Zygoma - ✔✔cheekbone Lacrimal Bones - ✔✔paired bones at the corner of each eye that cradle the tear ducts Maxilla - ✔✔upper jaw bone Mandible - ✔✔lower jaw bone Vomer - ✔✔bone that forms posterior/ inferior part of the nasal septal wall between the nostrils Palatine Bones - ✔✔make up part of the roof of the mouth Spinal/ Vertebral Column - ✔✔is divided into 5 regiions from the neck to the tailbone. there are 26 bones in the spine and are referred to as the Vertabrae Cervical - ✔✔neck bone Thoracle - ✔✔upper back Lumbar - ✔✔lower backSacral - ✔✔sacrum Coccygeal - ✔✔coccyx (tailbone) Rib Cage - ✔✔there are 12 pairs of ribs. the 1st 7 pairs join the sternum anteriorly through the cartilaginous attachments called Costal Cartilage. the True Ribs #'s 1-7 attach directly to the sternum in the front of the body. the False Ribs #'s 8-10 are attached to the sternum by cartilage. ribs 11 & 12 are Floating Ribs, because they are not attached at all Upper Appendicular Skeleton - ✔✔includes the shoulder girdle which is made up of the Scapula, Clavicle and Upper Extremities Scapula - ✔✔shoulder blades are flat bones that help support the arms Clavicle - ✔✔collarbone is curved horizontal bones that attach to the upper sternum at one end, these bones help stabilize the shoulder Upper Extremities - ✔✔consist of : Humerue, Ulna, Radius, Carpals, Metacarples, phalanges Humerus - ✔✔upper arm bone Ulna - ✔✔lower medial arm bone Radius - ✔✔lateral lower arm bone(in line with the thumb) Carpals - ✔✔wrist bones, there are 2 rows of 4 bones in the wrist Metacarpals - ✔✔the 5 radiating bones in the fingers. these are the bones in the palm of the handPhalanges - ✔✔finger bones, each finger has 3 phalanges, except for the thumb. the 3 phalanges are the proximal, middle and a distal phalanx. the thumb has a proximal and distal Lower Appendicular - ✔✔can be divided into the pelvis and the lower extremities Pelvis - ✔✔superior and widest bone Ischium - ✔✔lower portion of the pelvic bone Pubic bone - ✔✔lower anterior part of the bone Lower extremeties - ✔✔include: Femur, Patella, Tibia, fibula, Malleolus, Tarsal, Metatarsal, Phalanx Femur - ✔✔thighbone Patella - ✔✔kneecap Tibia - ✔✔shin Fibula - ✔✔smaller, lateral leg bone