Coding Ch. 1

Question 1

AAPC

Answer 1

professional association, previously known as the American Academy of Professional Coders, established to provide a national certification and credentialing process, to support the national and local membership by providing educational products and opportunities to networks, and to increase and promote national recognition and awareness of professional coding

Question 2

AAMA

Answer 2

American Association of Medical Assistants (AAMA) enables medical assisting professionals to enhance and demonstrate the knowledge, skills, and professionalism required by employers and patients; as well as protect medical assistants’ rights to practice

Question 3

AHIMA

Answer 3

American Health Information Management Association (AHIMA) founded in 1928 to improve the quality of medical records, and currently advances the health information management (HIM) profession toward an electronic and global environment, including implementation of ICD-10-CM and ICD-10-PCS in 2013.

Question 4

bonding insurance

Answer 4

an insurance agreement that guarantees repayment for financial losses resulting from the act or failure to act of an employee. It protects the financial operations of the employer

Question 5

business liability insurance

Answer 5

protects businesses assets and covers the cost of lawsuits resulting from bodily injury, personal injury and false advertising

Question 6

claims examiner

Answer 6

employed by third-party payers to review health-related claims to determine whether the charges are reasonable and medically necessary based on the patient’s diagnosis

Question 6

Centers for Medicare and Medicaid Services (CMS)

Answer 6

formerly known as Health Care Financing Administration (HCFA); an administrative agency within the federal Department of Health and Human Services (DHHS)

Question 6

coding

Answer 6

process of reporting diagnoses, procedures, and services as numeric and alphanumeric characters (called codes) on the insurance claim

Question 7

Current Procedural Terminology (CPT)

Answer 7

published by the American Medical Association; includes five-digit numeric codes and descriptors for procedures and services performed by providers (e.g. 99203 identifies a detailed office visit for a new patient)

Question 8

embezzle

Answer 8

the illegal transfer of money or property as a fraudulent action; to steal money from an employer

Question 9

errors and omissions insurance

Answer 9

see professional liability insurance

Question 10

ethics

Answer 10

principle of right or good conduct; rules that govern the conduct of members of a profession

Question 11

explanation of benefits (EOB)

Answer 11

report that details the results of processing a claim (e.g., payer reimburses provider $80 on a submitted charge of $100)

Question 12

HCPCS level II codes

Answer 12

national codes published by CMS, which include five-digit alphanumeric codes for procedures, services, and supplies not classified in CPT

Question 13

health care provider

Answer 13

physician or other health care practitioner (e.g., physician’s assistant)

Question 14

health information technician

Answer 14

professionals who manage patient health information and medical records, administer computer information systems, and code diagnoses and procedures for health care services provided to patients

Question 15

health insurance claim

Answer 15

documentation submitted to an insurance plan requesting reimbursement for health care services provided (e.g., CMS-1500 and UB-04 claims)

Question 16

health insurance specialist

Answer 16

person who reviews health-related claims to match medical necessity to procedures or services performed before payment (reimbursement) is made to the provider; see also reimbursement specialist

Question 17

Healthcare Common Procedure Coding System (HCPCS)

Answer 17

coding system that consists of CPT, national codes (level II), and local codes (level III); local codes were discontinued in 2003, previously known as HCFA Common Procedure Coding System

Question 18

hold harmless clause

Answer 18

policy that the patient is not responsible for paying what the insurance plan denies

Question 19

independent contractor

Answer 19

defined by the ‘Letric Law Library’s Lexicon as “a person who performs services for another under an express or implied agreement and who is not subject to the other’s control, or right to control, of the manner and means of performing the services. The organization that hires an independent contractor is not liable for the acts or omissions of the independent contractor.”

Question 20

Internal Classification of Diseases, 10th revision, Modification (ICD-10-CM)

Answer 20

coding system to be implemented on October 1, 2015, and used to report diseases, injuries and other reasons for inpatient and outpatient encounters

Question 21

International classification of Diseases, 10th Revision, Procedural Coding System (ICD-10-PCS)

Answer 21

coding system to be implemented on October 1, 2015, and used to report procedures and services on inpatient claims.

Question 22

internship

Answer 22

nonpaid professional practice experience that benefits students and facilities that accept students for placement; students receive on-the-job experience prior to graduation, and the internship assists them in obtaining permanent employment

Question 23

medical assistant

Answer 23

employed by a provider to perform administrative and clinical tasks that keep the office or clinic running smoothly

Question 24

medical malpractice insurance

Answer 24

a type of liability insurance that covers physicians and other health care professionals for liability claims arising from patient treatment

Question 25

medical necessity

Answer 25

involves linking every procedure or service code reported on an insurance claim to a condition code (e.g., disease, injury, sign, symptom, other reason for encounter) that justifies the need to perform that procedure or service

Question 26

national codes

Answer 26

commonly referred to as HCPCS level II codes; include five-digit alphanumeric codes for procedures, services, and supplies that are not classified in CPT (e.g., J-codes are used to assign drugs administered)

Question 27

professional liability insurance

Answer 27

provides protection from liability as a result of errors and omissions when performing their professional services; also called errors and omissions insurance

Question 28

professionalism

Answer 28

conduct or qualities that characterize a professional person

Question 29

property insurance

Answer 29

protects business contents (e.g., buildings and equipment) against fire, theft, and other risks

Question 30

reimbursement specialist

Answer 30

see health insurance specialist

Question 31

remittance advice (remit)

Answer 31

electronic or paper-based report of payment sent by the payer to the providers; includes patient name, patient health insurance claim (HIC) number, facility provider number/name, dates of service (from date/thru date), type of bill (TOB), charges, payment information, and reason and/or remark codes

Question 32

respondeat superior

Answer 32

latin for “let the master answer”; legal doctrine holding that the employer is liable for the actions and omissions of employees performed and committed within the scope of their employment

Question 33

scope of practice

Answer 33

health care services, determined by the state, that a NP and PA can perform

Question 34

workers’ compensation insurance

Answer 34

insurance program, mandated by federal and state governments, that requires employers to cover medical expenses and loss of wages for workers who are injured on the job or who have developed job-related disorders

Question 35

Health insurance overview

Answer 35

most health care practices in the United States accept responsibility for filing health insurance claims, and some third-party payers (e.g., BlueCross BlueSheild) and government programs (e.g., Medicare) require providers to filed claims.

Question 36

health insurance claim

Answer 36

is the documentation submitted to a third-party payer or government program requesting reimbursement for health care services provided.

Question 37

hold harmless clause

Answer 37

If an insurance plan has a hold harmless clause, (patient is not responsible for paying what the insurance plan denies) in the contract, the health care provider cannot collect the fees from the patient. It is important to realize that not all insurance policies contain hold harmless clases.

Question 38

no balance billing

Answer 38

many policies contain a no balance billing clause that protects patients from being billed for amounts not reimbursed by payers (except for copayments, coinsurance amounts, and deductibles).

Question 39

patients referred to nonparticipating providers incur significantly

Answer 39

higher out-of-pocket costs than they may have anticipated (e.g., physician who does not participate in a particular health care plan). Competitive insurance companies are fine-tuning procedures to reduce administrative costs and overall expenditures.

Question 40

Cost reduction campaign forces closer scrutiny of the entire claims process, which in turn increases the time and effort medical practices must devote to billing and filing claims according to the insurance policy filing requirements. Poor attention to claims requirements will result in lower reimbursement rates to the practices and increased expenses

Question 41

health care providers sign

Answer 41

managed care contracts as a way to combine health care delivery and financing of services to provide more affordable quality care

Question 42

Each new provider-managed care contract increases the practice’s patient base, the number of claims requirements and reimbursement regulations,

Answer 42

the time the office staff must devote to fulfilling contract requirements, and the complexity of referring patients for speciality care.

Question 43

Each insurance plan has its own

Answer 43

authorization requirements, billing deadlines, claims requirements, and list of participating providers or networks.

Question 44

Insurance specialist should be sure they are on mailing lists to receive newsletters from third-party payers.

Answer 44

It is important to remain current regarding news released from the CMS, which is the administrative agency within the federal Department of Health and Human Services (DHHS).

Question 45

The Secretary of the DHHS, as often reported on by:

Answer 45

the media, announces the implementation of new regulations about government programs (e.g., Medicare, Medicaid)

Question 46

Coding

Answer 46

is the process of assigning ICD-10-CM, ICD-10-PCS, CPT and HCPCS level II codes, which contain alphanumeric and numeric characters, to diagnoses, procedures, and services.

Question 47

Diagnoses

Answer 47

are documented conditions or disease process (e.g., hypertension). Procedures are performed for diagnostic (e.g., lab test) and therapeutic (e.g., cholecystectomy) purposes, and services are provided to evaluate and manage patient care

Question 48

Coding systems incldue:

Answer 48

-International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM)
-International Classification of Diseases, 10th Revision, Procedural Coding System (ICD-10-PCS)
-Healthcare Common Procedure Coding System (HCPCS)

Question 49

ICD-10-CM

Answer 49

coding system used to report diseases, injuries, and other reasons for inpatient and outpatient encounters, such as an annual physical examination performed at a physician’s office

Question 50

ICD-10-PCS

Answer 50

coding system used to report procedures and services on inpatient hospital claims

Question 51

HCPCS

Answer 51

which currently consists of two levels: CPT and HCPCS Level II codes

Question 52

CPT (Current Procedural Teminology)

Answer 52

coding system published by the American Medical Association that is used to report procedures and services performed during outpatient and physician office encounters, and professional services provided to inpatients

Question 53

HCPCS level II codes

Answer 53

(or national codes): coding system published by CMS that is used to report procedures, services and supplies not classified in CPT

Question 54

December 31, 2003, CMS phased out the use of HCPCS level III codes. However, some third-party payers continue to use the codes

Answer 54

In addition to an increase in insurance specialist positions available in health care practices, opportunities are also increasing in other settings.
These opportunities include:
-claims benefit advisors in health, malpractice, and liability insurance companies
-coding or insurance specialists in state, local, and federal government agencies legal offices, private insurance billing offices and medical societies
-Medical billing and insurance verification specialists in health care organizations
-Educators in schools and companies specializing in medical office staff training
-Writers and editors of health insurance textbooks, newsletters, and other publications
-Self-employed consultants who provide assistance to medical practices with billing practices and claims appeal procedures
-Consumer claims assistance professionals who file claims and appeal low reimbursement for private individuals. In the latter case, individuals may be dissatisfied with the handling of their claims by the health care provider’s insurance staff.
-Practices with poorly trained health insurance staff who are unwilling or unable to file a proper claims appeal
-Private billing practices dedicated to claims filing for elderly or disabled patients

Question 55

Medical Necessity

Answer 55

involves linking every procedure or service code reported on the claim to a condition code (e.g., disease, injury, sign, symptom, other reason for encounter) that justifies the need to perform that procedure or service

Question 56

According to the Department of Labor-Bureau of Labor Statistics the result for an increase in claims adjusters and examiners

Answer 56

result from more claims being submitted on behalf of a growing elderly population

Question 57

Health Insurance specialists (or reimbursement specialists)

Answer 57

review health-related claims to match medical necessity to procedures or services performed before payment (reimbursement) is made to the provider.

Question 58

Claims examiner

Answer 58

employed by a third-party payer reviews health-related claims to determine wether the charges are reasonable and for medical necessity

Question 59

The claims review process requires verification of the claim for completeness and accuracy, as well as comparison with third-party payer guidelines to:

Answer 59

1. authorize appropriate payment or
2. refer the claim to an investigator for a more thorough review

Question 60

Medical Assistant

Answer 60

is employed by a provider to perform administrative and clinical task that keep the office or clinic running smoothly. Medical assistants who specialize in administrative aspects of the profession answer telephones, greet patients, update and file patient medical records, and complete insurance claims, process correspondence, schedule appointments, arrange for hospital admission and laboratory services, and manage billing and bookkeeping

Question 61

Health Insurance specialists and medical assistants obtain employment in clinics, healthcare clearinghouses (process health insurance claims), healthcare facility billing departments, insurance companies, and physician offices, as well:

Answer 61

as with third-party administrators (TPAs) (process health insurance claims and provide employee benefits management and other services). When employed by clearinghouses, insurance companies, and TPAs, employees often have the opportunity to work at home, where they process and verify health care claims using an Internet-based application server provider (ASP). Health information technicians also perform insurance specialist functions by assigning codes to diagnoses and procedures and, when employed in a provider’s office, by processing claims for reimbursement.

Question 62

Health information technicians

Answer 62

manage patient health information and medical records, administer computer information systems, and code diagnoses and procedures for health care services provided to patients

Question 63

In addition to an increase in insurance specialist positions available in health care practices, opportunities are also increasing in other settings. These opportunities include:

Answer 63

-Claims benefit advisors in health, malpractice, and liability insurance companies
-Coding or insurance specialists in state, local and federal government agencies, legal offices, private insurance billing offices, and medical societies
-Medical billing and insurance verification specialists in health care organizations
-Educators in schools and companies specializing in medical office staff training
-Writers and editors of health insurance textbooks, newsletters, and other publications
-Self-employed consultants who provide assistance to medical practices with billing practices and claims appeal procedures
-Consumer claims assistance professionals who file claims and appeal low reimbursement for private individuals. In the latter case, individuals may be dissatisfied with the handling of their claims by the health care provider’s insurance staff.
-Practices with poorly trained health insurance staff who are unwilling or unable to file a proper claims appeal
-private billing practices dedicated to claims filing for elderly or disabled patients

Question 64

Education and training

Answer 64

training and entry requirements vary widely for health insurance specialists, and the Bureau of Labor Statistics’ Occupations Outlook Handbook states that opportunities will be best for those with a college degree. Academic programs should include coursework in general education (e.g., anatomy and physiology, English composition, oral communications, human relations, physiology, English composition oral communications, human relations, computer applications, and so on) and health insurance specialist education (e.g., health information management, medical terminology, pharmacology, coding and reimbursement, insurance processing, and so on). The characteristics of a successful health insurance specialist include an ability to work independently, a strong sense of ethics, ,attention to detail, and the ability to think critically.)

Question 65

Ethics

Answer 65

Defined by the American Heritage Concise Dictionary as the priciples of right or good conduct, and rules that govern the conduct of members profession

Question 66

Training requirements for health insurance specialists

Answer 66

-anatomy and physiology, medical terminology, pharmacology, and pathophysiology
-diagnosis and procedure/service coding
-verbal and written communication
-critical thinking
-data entry
-internet access

Question 67

anatomy and physiology, medical terminology, pharmacology, and pathophysiology

Answer 67

knowledge of anatomic structures and physiological functioning of the body, medical terminology, and essentials of pharmacology are necessary to recognize abnormal conditions (pathophysiology). Fluency in the language of medicine and the ability to use a medical dictionary as a reference are crucial skills

Question 68

Diagnosis and Procedure/Service coidng

Answer 68

understanding the rules, conventions, and applications of coding systems ensures proper selection of diagnosis and procedure/service codes, which are reported on insurance claims for reimbursement purposes

Example: patient undergoes a simple suture treatment of a 3-cm facial laceration. When referring to the CPT index, there is no listing for “Suture, facial laceration.” There is, however, an instructional notation below the entry for “Suture” that refers the coder to “repair.” When “repair” is referenced in the index, the coder must then locate the subterms “skin,” “wound”, and “simple”. The cod range in the index is reviewed, and the coder must refer to the tabular section of the coding manual to select the correct code

Question 69

Verbal and Written Communication

Answer 69

Health insurance specialists explain complex insurance concepts and regulations to patients and must effectively communicate with providers regarding documentation of procedures and services (to reduce coding and billing errors.) Written communication skills are necessary when preparing effective appeals for unpaid claims.

Question 70

critical thinking

Answer 70

differentiating among technical descriptions of similar procedures requires critical thinking skills

Example: Patient is diagnosed with spondylosis, which is defined as any condition of the spine. A code from category M47 of ICD-10-CM would be assigned. If the diagnosis was mistakenly coded as spondylolysis, which is a defect of the articulating portion of the vertebra, ICD-10-CM category Q76 (if congenital) or M43 (if acquired) codes would be reported in error.

Question 71

Data entry

Answer 71

Federal regulations require electronic submission of most government claims, which means that health insurance specialists need excellent keyboarding skills and basic finance and math skills. Because insurance information screen with different titles often contain identical information, the health insurance specialist must carefully and accurately enter data about patient care.

Example: Primary and secondary insurance computer screens require entry of similar information. Claims are rejected by insurance companies if data are missing or erroneous.

Question 72

Internet access

Answer 72

online information sources provide access to medical references, insurance company manuals and procedure guidelines. The federal government posts changes to reimbursement methodologies and other policies on websites. Internet forums allow health insurance specialists to network with other professionals

Question 73

internship

Answer 73

benefits students and facilities that accept students for placement. Students receive on-the-job experience prior to graduation, and the internship assists them in obtaining permanent employment. Facilities benefit from the opportunity to participate in and improve the formal education process.

Question 74

Job responsibilities

Answer 74

In practices where one or two persons work with insurance billing, each individual must be capable of performing all the listed responsibilities. In multispecialty practices that employ many health insurance specialists, each usually processes claims for a limited number of insurance companies (e.g., an insurance specialist may be assigned to processing only Medicare claims). Some practices have a clear division of labor, with specific individuals accepting responsibility for only a few assigned tasks. Typical tasks are listed in the following job description. Regardless of the employment setting, health insurance specialists are guided by a scope of practice, that defines the profession, delineates qualifications and responsibilities, and clarifies supervision requirements

Question 75

Scope of practice

Answer 75

health care services, determined by the state, that an NP and PA can perform

Question 76

Scope of practice for health insurance specialists

Answer 76

-Definition of Professional
-Qualifications
-Responsibilities
-Supervision Requirements

Question 77

definition of professional

Answer 77

one who interacts with patients to clarify health insurance coverage and financial responsibility, completes and processes insurance claims, and appeals denied claims

Question 78

Qualifications

Answer 78

Graduate of health insurance specialist certificate or degree program or equivalent. One year of experience in health insurance or related field. Detailed working knowledge and demonstrated proficiency in at least one insurance company’s billing and/or collection process. Excellent organizational skills. Ability to manage multiple tasks in a timely manner. Proficient use of computerized registration and billing systems and personal computers, including spreadsheet and word processing software applications. Certification through AAPC, AHIMA, AMBA, or NHA

Question 79

Responsibliities

Answer 79

use medical management computer software to process health insurance claims, assign codes to diagnoses and procedures/services, and manage patient records. Communicate with patients, providers and insurance companies about coverage and reimbursement issues. Remain up-to-date about coverage and reimbursement issues. Remain up-to-date regarding changes in health care industry laws and regulations

Question 80

Supervision Requirements

Answer 80

Active and continuous supervision of a health insurance specialist is required. However, the physical presence of the supervisor at the time and place that responsibilities are performed its not required.

Question 81

Health Insurance Specialist Job Description

Answer 81

1. Review patient record documentation to accurately code all diagnoses, procedures, and services using ICD-10-CM for diagnoses and CPT HCPCS level II for procedures and services.
2. Research and apply knowledge of all insurance rules and regulations for major insurance programs in the local or regional area
3. Accurately post charges, payments and adjustments to patients accounts and accounts receivable records.
4. Prepare or review claims generated by the practice to ensure that all required data are accurately reported and to ensure prompt reimbursement for services provided (contributing to the practice’s cash flow)
5. Review all insurance payments and remittance advice documents to ensure proper processing and payment of each claim The patient receives and EOB from the third0party payer, which is a report detailing the results of processing a claim (e.g., payer reimburses provider $80 on a submitted charge of $100). The provider receives a remittance advice (or remit), which is a notice sent by the insurance company that contains payment information about a claim.
6. Correct all data errors and resubmit all unprocessed or returned claims
7. Research and prepare appeals for all underpaid, underpaid unjustly recoded, and denied claims
8. Rebill all claims not paid within 30-45 days, depending on individual practice policy and payers’ policies
9. Information health care providers and staff of changes in fraud and abuse laws, coding changes, documentation guidelines, and third-party payer requirements that may affect the billing and claims submission procedures
10. Assist with timely updating of the practice’s internal documents, patient registration forms, and billing forms as required by changes in coding or insurance billing requirements
11. Maintain an internal audit system to ensure that required pretreatment authorizations have been received and entered into the billing and treatment records. Audits comparing provider documentation with codes assigned should be performed
12. Explain insurance benefits, policy requirements, and filing rules to patients
13. Maintain confidentiality of patient information

Question 82

Independent Contractor and Employer Liability

Answer 82

Health insurance specialists who are self-employed are considered independent contracts. The “Lectric Law Library’s Lexicon” defines an independent contractor as “a person who performs services for another under an express or implied agreement and who is not subject to the other’s control, or right to control, of the manner and means of performing the services. The organization that hires an independent contractor is not liable for the acts or omissions of the independent contractor.

Independent contractors should purchase professional liability insurance (or errors and omissions insurance) which provides protection from liability as a result of errors or omissions when performing their professional services (e.g., coding audits). Professional associates often include a membership benefit that allows purchase of liability insurance coverage at reduced rates

Question 83

Determining Independent Contractor Status

Answer 83

One way to determine independent contractor status is to apply the common law “right to control” test, which includes five factors:
1. Amount of control the hiring organization exerted over the worker’s activities
2. Responsibility for costs of operation (e.g., equipment and supplies)
3. Method and form of payment and benefits
4. Length of job commitment made the worker
5. Nature of occupation and skills required
The internal Revenue Service applies a 20-factor independent contractor test to decide whether an organization has correctly classified a worker as an independent contractor for purposes of wage withholdings. The Department of Labor uses the “economic reality” test to determine worker status for purposes of compliance wit hthe minimum wage and overtime requirements of the Fair Labor Standards Act

Question 84

A health Care facility (or facility)that employs health insurance specialists is legally responsible for employees’ actions performed within the context of their employment.

Answer 84

This is called respondent superior, Latin for “let the master answer,” which means that the employer is liable for the actions and omissions of employees as performed and committed within the scope of their employment. Employers purchase many types of insurance to protect their business assets and property.

Question 85

Professional insurance purchased by Employers

Answer 85

bonding insurance
business liability insurance
property insurance
workers’ compensation insurance

Question 86

Bonding Insurance

Answer 86

an insurance agreement that guarentees repayment for financial losses resulting from an employee’s act or failure to act. It protects the financial operations of the employer.

Note: Physician offices should bone employees who have financial responsibilities. The financial responsibilities. The National White Collar Crime Center estimates $400 billion in annual losses to all types of employers due to employees who embezzle (steal money from an employer)

Question 87

embezzle

Answer 87

the illegal transfer of money or property as a fraudulent action; to steal money from an employer

Question 88

Business Liability Insurance

Answer 88

an insurance agreement that protects business assets and covers the cost of lawsuits resulting from bodily injury (e.g., customer slips on wet floor), personal injury (e.g., slander or libel), and false advertising.
Medical malpractice insurance, a type of professional liability insurance, covers physicians, covers physicians and other licensed health care and professionals for liability relating to claims arising from patient treatment.
Note: liability insurance does not protect an employer from nonperformance of a contract, sexual harassment, race and gender discrimination lawsuits, or wrongful termination of employees.
Note: An alternative to purchasing liability insurance from an insurance company is to self-fund, which involves setting aside money to apy damages or paying damages with current operating revenue should the employer ever be found liable. Another option is to join a risk retention or risk purchasing group, which provides lower-cost commercial liability insurance to its members. A third option is to obtain coverage in a surplus lines market that has been established to insure unique risks.

Question 89

Property insurance

Answer 89

an insurance agreement that protects business contents (e.g., buildings and equipment) against fire, theft, and other risks

Question 90

Workers’ Compensation Insurance

Answer 90

Protection mandated by state law that covers employees and their dependents against injury and death occurring during the course of employment. Workers’ compensation is not health insurance, and it is not intended to compensate for disability other than that caused by injury arising from employment. The purpose of workers’ compensation is to provide financial and medical benefits to those with work-related injuries, and their families, regarding of fault

Question 91

Example:

Answer 91

Linda is employed by Dr. Pederson’s office as a health insurance specialist. As apart of the job, Linda has access to confidential patient information. While processing claims, Linda notices that a friend has been a patient and later tells her spouse about the diagnosis and treatment. The friend finds out about the breach of confidentiality and contacts a lawyer. Legally, Dr. Peterson can be sued by the friend. Although Linda could also be named in the lawsuit, termination by her employer is more likely.

Question 92

Professionalism

Answer 92

professionalism, as the conduct, aims, or qualities that characterize a professional person. Health care facility managers establish rules of professional behavior (e.g., codes of conduct, policies, and procedures), so employees know how to behave professionally. Employees are expected to develop the following skills to demonstrate workplace professionalism, which results in personal growth and success.

Question 93

Attitude and Self-Esteem

Answer 93

Attitude impacts an individual’s capacity to effectively perform job functions, and an employee’s attitude is perceived as positive, negative, or neutral. This subconscious transfer or feelings results in colleagues determining whether someone has a positive attitude about work. Self-esteem impacts attitude: low self-esteem causes lack of confidence, a higher self-esteem leads to self-confidence, improved relationships, self-respect, and a successful career

Question 94

Communication

Answer 94

successful interpersonal communication includes self-expression and active listening to develop understanding about what others are saying. To listen effectively, be sure to understand the message instead of just hearing words. This active involvement in the communication process helps avoid miscommunication

Question 95

Conflict management

Answer 95

conflict occurs as a part of the decision-making process, and the ay it is handled makes it positive or negative. People often have different perspectives about the same situation, and actively listening to the other’s viewpoint helps neutralize what could become negative conflict

Question 96

Customer service

Answer 96

health insurance specialists serve as a direct point of contact for a provider’s patients, and they are responsible for ensuring that patients receive an excellent level of service or assistance with questions and concerns. It is equally important to remember that colleagues deserve the same respect and attention as patients.

Question 97

Diversity Awareness

Answer 97

Diversity is defined as differences among people and includes demographics of age, education, ethnicity, gender geographic location, income, language, martial status, occupation, parental status, physical and mental ability, race, religious, beliefs, sexual orientation, and veteran status. Developing tolerance, which is the opposite of bigotry and prejudice, means dealing with personal attitudes, beliefs, and experiences. Embracing the differences that represent that demographics of our society is crucial to becoming a successful health professional

Question 98

Leadership

Answer 98

Leadership is the ability to motivate team members to complete a common organizational goal display. Leaders have earned the trust of their team, which is the reason the entire team is able to achieve its objective and set the standard for productivity, as well as revenue goals. Interestingly, the leader identified by the team might not be the organization because they have demonstrated beliefs, ethics, and values with which team members identify. Mangers who are not threatened by the natural emergence of leaders benefit from team harmony and increased productivity. They receive credit for excellent management skills, and they begin the process to leadership when they begin to acknowledge the work ethic of the team and its leader

Question 99

Managing change

Answer 99

Change is crucial to the survival of an organization because it is necessary response to implementation of new and revised federal and state programs, regulations, and so on. While the organization that does not embrace change becomes extinct, such change disrupts the organization’s workflow (and productivity) and is perceived as a threat to employees. Therefore, it is the role of the organization’s leadership team to provide details about the impending change, including periodic updates as work process undergo gradual revision. Employees also need to understand what is being changed and why, and the leadership team needs to understand employees’ reluctance to change

Question 100

Productivity

Answer 100

Health care providers expect health insurance and medical coding/billing specialists to be productive regarding completion of duties and responsibilities. Pursing professional certification and participating in continuing education helps ensure individual compliance with the latest coding rules and other updates. Increased knowledge leads to increased productivity and performance improvement on the job

Question 101

professional ethics

Answer 101

the characteristics of a successful health insurance specialist include an ability to work independently, attention to detail, ability to think critically, and a strong sense of ethics. The American Heritage Concise Dictionary defines ethics as the principles of right or good conduct, and rules that govern the conduct of members of a profession

Question 102

Team-Building

Answer 102

Colleagues who share a sense of community and purpose work well together and can accomplish organizational goals more quickly and easily because they rely on one another. This means colleagues provide help to, and receive help from, other members of the team. Sharing the leadership role and working together to complete difficult tasks facilitates team-building.

Question 103

Telephone skills for the Health Care Setting

Answer 103

The telephone can be an effective means of patient access to the health care system because a health care team member serves as an immediate contract for the patient. Participating in telephone skills training and following established protocols (policies) allow health care team members to respond appropriately to patients. When processes for handling all calls are developed and followed by health care team members, the result is greater office efficiency and less frustration for health care team members and patients. Avoid problems with telephone communication in your health care setting by implementing the following protocols:
1. Establish a telephone-availability policy that works for patients and office staff.
2. Set up an appropriate number of dedicated telephone lines
3. inform callers who ask to speak with the physician that the physician is with a patient
assign 15 minute time periods ever 2-3 hours when creating the schedule, to allow time for physicians (and other health care providers) to return telephone calls
4. Phyisicall spearate font desk check-in/check out and receptionist/patient appointment scheduling offices
5. Require office employees to learn professional telephone skills

Question 104

Set up an appropriate number of dedicated telephone lines

Answer 104

(e.g., appointment scheduling, insurance and billing) based on the function and size of the health care setting. Publish the telephone numbers on the office’s website and in an office brochure or local telephone directory, and instruct employees to avoid using the lines when making outgoing calls. Another option is to install an interactive telephone response system that connects callers with appropriate staff (e.g., appointment scheduling, insurance and billing, and so on) based on the caller’s keypad or voice responses to instructions provided.

Question 105

Inform callers who ask to speak with the physician (or another health care provider) that the physician (or provider (is with a patient.

Answer 105

Do not state, “the physician is busy,” which implies that the physician is too busy for the patient and could affect the caller. Ask for the caller’s name, telephone number, and reason for the call, and explain that the call will be returned

Question 106

Assign 15-minute time peridos every 2-3 hours when creating the schedule, to allow time for physicians (and other health care providers) to return telephone calls.

Answer 106

This allows the receptionist to tell callers an to tell callers an approximate time when calls will be returned (and patient records can be retrieved)

Question 107

Physically separate front desk check-in/check out and receptionist/patient appointment scheduling offices

Answer 107

It is unlikely that an employee who manages the registration of patients as they arrive at the office (and the check-out of patients at the conclusion of an appointment) has time to answer telephone calls. Office receptionists and appointment schedulers who work in private offices will comply with federal and state patient privacy laws when talking with patients. In addition, appointment scheduling, telephone management, and patient check-in (registration) and check-out procedures will be performed with greater efficiency

Question 108

Require office employees to learn professional telephone skills.

Answer 108

Schedule professional telephone skills training as part of new employee orientation, and arrange for all employees to attend an annual workshop to improve skills. Training allows everyone to learn key aspects of successful telephone communication, which include developing an effective telephone voice that focuses on tone. During a telephone conversation, each person forms an opinion based on how something is said (rather than what is said). Therefore, speak clearly and distinctly, do not speak too fast or too slow, and vary your tone by letting your voice rise and fall naturally. The following rules apply to each telephone conversation:
-When answering the telephone, state the name of the office and your name (e.g., Hornell Medical Center, Shelly Dunham speaking”).
-Do not use slang
-Use the caller’s name
-Provide clear explanations when responding to patients
-Be pleasant, friendly, sincere, and helpful
- Give the caller your undivided attention to show personal interest, and do not interrupt
-Before placing the caller on hold or transferring a call, ask for permission to do so
-When the individual with whom the caller wants to talk is unavailable, ask if you can take a message
-Use a preprinted message form (or commercial message pad) when taking a message. Document the following about each call, and file it in the patient’s record: date of call, name of patient, name of credentials of individual talking with patient, and a brief note about the contents of the telephone conversation

Question 109

Professional Appearance

Answer 109

Appropriate professional attire and personal presentation provide an employee’s first impression to colleagues, managers, physicians, patients or clients, and others. Well-groomed employees convey professional images about themselves and the quality of services provided by the organization. employers establish the dress code policy, which usually conservative and stylish but not trendy, and somewhat require a uniform.

Question 110

An employees appearance provides that important first impression, and well groomed professionals look self-confident, display pride in themselves, and appear capable of performing whatever duties need to be done.

Answer 110

What have all experienced days when we didn’t feel good about the way we looked, which, in turn, affected our performance. To present yourself in the best possible light, be sure to adhere to the following general guidelines for a professional appearance:
-Cleanliness is the first essential for good grooming. Take a daily bath or shower. Use a deodorant or antiperspirant. Shampoo your hair often. Brush and floss your teeth dialy
-Hand care is critical. Take special care of your hands. Keep hand cream or lotion in convenient places to use after washing your hands. Because this is done frequently, hands tend to chap and crack, which can allow organisms entry into your body – a risk you cannot afford. Also keep your fingernails manicured at a moderate length (and those who provide health care services to patients should not sue false nails because bacteria and fungi can grow beneath such nails). If you work in a uniform and your organization’s policy allows you to use nail polish, choose clear or light shades. Even when wearing street clothes, bright or trendy colors are not appropriate for the office.
-Hair must be clean and away from your face. Long hair should be worn up or at least fastened back. It is not appropriate to keep pushing your hair out of the way while working (because you can add organisms to your environment and perhaps take them home with you.) Patients who receive health care services from employees may also be susceptible to “receiving” something from your hair if you touch them after arranging your hair
-Proper attire may vary vary with medical specialty. When a uniform is not required, it may be appropriate to wear a white laboratory coat over a dress skirt and slacks or a skirt. Depending on the organization (e.g., pediatric office), it might also be acceptable for the laboratory coat to be a color other than white. For instance, many pediatric practices perform that medical assistants wear colorful prints with patterns of cartoon characters that children will recognize to help them to feel more at east. Psychiatry and psychology medical office assistants may not be required to wear uniforms, as their clinical duties would be limited. Looking like a professional will not only encourage the respect of others for your profession, but will also help you feel like an inaugural part of the health care team. When uniforms are required, they must be clean, fit well, and be free from wrinkles. Uniform shoes should be kept clean and have clean shoestrings; hose must not have any runs. PAy attention to the undergarments that you wear beneath the uniform so that they do not show through the fabric of your uniform
-Jewelry, except for a watch or wedding ring, is not appropriate with a uniform. Small earrings may be worn but still may get in the way when you use the telephone. Not only does jewelry look out of place, but it is a great collector of microorganisms. Novelty piercings, such as nose rings and tongue studs, are not appropriate for personal grooming. Save the wearing of these for after work hours.
-Fragrances, such as perfumes, colognes, and aftershave lotions, may be offensive to some patients, especially if they are suffering from nausea. Thus, it is recommended that you not use fragrances.
-Cosmetics should be tasteful and skillfully applied. All major department stores have salespeople who can help you select and learn to apply products that will enhance your appearance
-Gum chewing is very unprofessional A large piece of gum interferes with speech, and cracking gum is totally unacceptable. If you feel you need gum for a breath concern, use a breath mint or mouthwash instead.
-Posture affects not only your appearance but also the amount of fatigue you experience. The ease at which you move around reflects your poise and confidence. To check your posture, back up to a wall, place your feet apart (straight down from your hips), and try to inset your hand through the space between your lower back and wall. If you can need to improve your posture. Pull your stomach in, tuck under your buttocks, and try to place your spine against the wall. Your shoulders should be relaxed with your head held erect. This will probably feel very unnatural, but practice keeping your body straight and head erect when you walk and you will see how much better your look and feel.

Question 111

Professional Associations and Credentials

Answer 111

The health insurance specialist who joins one or more professional associations receives useful information available in several formats, including professional journals and newsletters, access to members-only websites, notification of professional development, and so on. A key feature of membership is an awareness of the importance of professional certification. Once certified, the professional is responsible for maintaining that credential by fulfilling continuing education requirements established by the sponsoring association. Join professional associations by goin to their websites to locate membership links. Membership fees (and testing fees) vary, and some associations allow students to join for a reduced fee. Professional certification examination fees also vary according to association. Once students decide where they want to seek employment (e.g., physician’s office, hospital), they can research each professional associations website (located in Internet links in this chapter) to research certification examinations offered. For example, a physicians’ office will require difference certifications as compared with hospitals. It is important for students to have an excellent understanding about the career path they want to pursue so as to obtain the appropriate certification credentials. For example, hospitals may perform the AHIMA credentials, which a physician’s office may perform the AAPC credentials. Other organizations that offer professional certification include the American Medical Billing Association (AMBA) and Ascend Learning’s National Healthcareer Association (NHA). AMBA provides industry and regulatory education and networking opportunity for members and offers the Certified Medical Reimbursement Specialist (CMRS) certification. The NHA is a national professional certification agency for health care workers and offers the Certified billing & Coding Specialists (CBCS) certification

Question 112

AAPC

Answer 112

professional association, previously known as the American Academy of Professional Coders, established to provide a national certification and credentialing process, to support the national and local membership by providing educational products and opportunities to networks, and to increase and promote national recognition and awareness of professional coding.

Question 113

AAPC

Answer 113

-Founded to elevate the standards of medical coding by providing certification, ongoing education, networking, and recognition for coders
-publishes the Healthcare Business Monthly newsmagazine and hosts continuing education
-Previously known as the American Academy of Professional Coders
-Credentials: Certified Professional Biller (CBP), Certified Professional Coder (CPC), Certified Outpatient Coder (COC), Certified Inpatient Coder (CIC), Certified Risk Adjustment Coder (CRC), Certified Professional Coder-Payer (CPC-P), and speciality credentials in many different fields of expertise

Question 114

American Association of Medical Assistants (AAMA)

Answer 114

Enables medical assisting professionals to enhance and demonstrate the knowledge, skills and professionalism required by employers and patients. as well as protect medical assistants rights to practice.

Question 115

AAMA

Answer 115

Enables medical assisting professionals to enhance and demonstrate knowledge, skills, and professionalism required by employers and patients, and protects medical assistants’ right to practive
-Publishes monthly Certified Medical Assistant Journal
-Credential Certified Medical Assistant, Abbreviated as CMA (AAMA)

Question 116

American Health Information Management Association (AHIMA)

Answer 116

Founded in 1928 to improve the quality of medical records, and currently advances the health information managment (HIM) profession toward an electronic and global environment, including implementation of ICD-10-CM and ICD-10-PCS
-Publishes monthly Journal of AHIMA
-Credentials: Certified Coding Assistant (CCA), Certified Coding Specialist (CCS), and Certified Coding Specialist-Physician based (CCS-P_ (Additional HIM credentials are offered by AHIMA)

Question 117

American Medical Billing Association (AMBA)

Answer 117

Provides industry and regulatory education and networking opportunities for members
-Credential: Certified Medical Reimbursement Specialist (CMRS)

Question 118

What do medical coders do?

Answer 118

What does a typical day in the life of a medical coder look like? Generally, your on the job duties will include:
-Documenting medical information as numeric and alphanumeric codes
-Reviewing patients’ medical records
- Abstracting (identifying and collecting) from those records what the physician’s diagnoses, procedures, and medical services are, as well as what supplies may be involved
-Making sure the diagnosis codes justify the procedure codes
-Entering the codes into the practice management software

Question 119

Diagnosis codes

Answer 119

are alphanumeric codes that identify diseases, disorders, symptoms, injuries, and other reasons for patient encounters

Question 120

procedure codes

Answer 120

are numeric codes that identify commonly accepted descriptions of medical procedures, services and supplies

Question 121

What does a medical biller do?

Answer 121

A medical biller turns the physician’s services into a claim for reimbursement- you make sure your practice gets paid. Here are some of the things you will do as a biller:
-Enter the patient’s demographic and insurance information into the practice management software
-prepare and review claims to ensure that all data is accurately reported
-apply knowledge of payer guidelines
-verify that the patient’s insurance covers the medical services provided
-send the claims to the payers
-appeal or correct any denied claims
-post charges, payments, and adjustments to patient accounts
-create bills for patients for amounts not covered by insurance

Question 122

Health insurance claim

Answer 122

is a physician’s request for payment from an insurance company for covered services, procedures, and supplies provided to the patient. A claim also contains the patient’s diagnoses to justify the need for the services, procedures and supplies

Question 123

Payer

Answer 123

a payer is the insurance company that provides healthcare coverage; sometimes referred to as the “third-party payer.”

Question 124

What does a health insurance specialist do?

Answer 124

Some healthcare settings, such as hospitals, large multi-speciality practices, or clinics, employ many individuals individuals who are responsible for specific tasks related to reimbursement. Those employees might only perform one of the following pertaining to the revenue cycle: assign all medical codes as a medical coder, or process and track all insurance claims as a medical biller.
In medical settings where one or two individuals perform everything pertaining to the revenue cycle, each individual must be capable of performing all of the job requirements of both a medical coder and biller. In other words, they are responsible for assigning codes, understanding claims processing policies and guidelines, and appealing denied claims. These employees are referred to as health insurance specialists, reimbursement specialists, or medical billing and coding specialists.
Regardless of the job title, medical billers and coders are guided by a scope of practice that defines the job qualifications, delineates responsibilities , and clarifies supervision requirements.

Question 125

Scope of Practice

Answer 125

Medical billers and coders are not licensed professionals and may only perform certain administrative services that are consistent with their education, training, and experience. This is referred to as their scope of practice.

Question 126

What are some perks of these careers?

Answer 126

Careers in healthcare are in high demand. However, medical billing and coding offers unique benefits that appeal to many people who would rather not deal with the long hours, physical demands, and direct patient contact found in other areas of healthcare. Here are some of these perks:
-You are providing a vital service as part of the healthcare team
-You can work in a variety of healthcare settings
-There are predictable work hours with full-time, part-time and flexible schedules.
-There is job stability, even in a economic downturn
-You will receive a competitive salary and beneftis
-The job is never boring
-You can get into the workforce in as little as one year
-Your skills are needed all over the United States
-Remote positions are becoming increasingly popular
-There is room for advancement

Question 127

The importance of personal and technical qualifications

Answer 127

People who work in this dynamic field often possess certain distinctive personal and technical qualifications
-Personal qualities are the particular characteristics of an individual. They are what make up one’s personality.
-Technical qualifications are the measurable skills that anyone can learn through training and experience
Employers typically consider personal and technical qualifications to be equally important when selecting a new employee. Let’s take a look at the personal and technical qualifications you’ll need to be a success in the field of medical billing and coding

Question 128

AHIMA Code of Ethics

Answer 128

https://www.ahima.org/who-we-are/governance/ethics/

Question 129

AAPC Code of Ethics

Answer 129

https://www.aapc.com/about-us/code-of-ethics

Question 130

Technical Qualifications

Answer 130

In addition to personal qualities, medical billing and coding requires technical qualifications. These skills include:
-Demonstrating proper keyboarding techniques
-Completing basic math operations
-Reading and understanding medical records
-knowing how to operating office equipment, including printer/scanner/copier/fax and paper shredder
-Demonstrating familiarity with computers, tablets, and smart phones

Question 131

Work settings

Answer 131

Job opportunities abound for someone trained in medical billing and coding, and there are many options for places to work. Here are the healthcare settings that employ medical billers and coders:
-Medical offices
-Hospitals
-Skilled Nursing facilities
-rehab facilities
-clinics
-ambulatory surgery centers
-insurance companies
-Government agencies
-Medical suppliers
-Urgent care centers
-Consulting firms
-regional and national billing companies
-pharmaceutical companies

Question 132

Patient Portal

Answer 132

is a secure, Internet-based, interactive website for patient-provider communication and access to a medical office’s databases. To access the practice portal, the patient must have the correct web address, a password or PIN, and a distinctive patient identifier or username that the medical office assigns. In addition, multi-factor verification is often used to ensure the network remains safe. Users would have to provide something personal (such as cell-phone number) that adds an additional identity check.

Question 133

Medical practices benefit greatly when patients commit to using a patient portal. The portal allows patient’s to do all these tasks without having to visit or call the physician’s office:

Answer 133

-manage appointments
-print immunization records
-view test results
-request a copy of their medical records
-send a message to the physician’s staff
-view and pay their bill
-request a prescription refill

Question 134

Scope of Practice

Answer 134

Medical billers and coders are not licensed professionals may only perform certain administrative services that are consistent with tier education, training, and experience

Question 135

Ambulatory

Answer 135

a healthcare setting where services are provided on an outpatient basis, without admission to a hospital or other facility.

Question 136

Healthcare provider

Answer 136

a person licensed, certified or otherwise authorized or permitted by law to administer healthcare and establish the patient’s diagnosis and treatment plan

Question 137

certification

Answer 137

implied that an individual has met competencies in his or her field, ranging from entry-level skills to expert ones