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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 prison

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