CDI Medical Necessity, CMS 1500 & UB-04, Insurance that Affect Claim Processing

Question 1

Coding Compliance

Answer 1

conformity to established coding guidelines and regulations

Question 2

Medical Review

Answer 2

program to reduce payment errors by addressing provider billing errors from initial coding

Question 3

Unbundling

Answer 3

charging for multiple CPT codes

Question 4

Physician query

Answer 4

process to request clarification

Question 5

Medical Necessity

Answer 5

linking procedure of service code reported on claim to a condition code

Question 6

CMS 1500 (HCFA 1500)

Answer 6

for provider billing

Question 7

UB-04 (CMS 1450)

Answer 7

facility billing

Question 8

“Incident to”

Answer 8

Non-physician practitioner (NPP)

Question 9

UB-04 examples

Answer 9

ambulance companies, ASCs, Home health care, hospitals, psychiatric drug/alcohol, skilled nursing facilities, subacute facilities, walk-in clinics, stand alone clinics/labs

Question 10

Group Health Insurance

Answer 10

subsidized by employers or other organizations

Question 11

Individual Insurance

Answer 11

-Regulated by states
-traditional plans
-high-risk pool
-short term medical
-managed care: HMO, PPO

Question 12

Large employers have how many employees?

Answer 12

100 or more

Question 13

Medium-sized employers have how many employees?

Answer 13

50-99

Question 14

Small businesses have how many employees?

Answer 14

fewer than 50

Question 15

Automobile Insurance

Answer 15

medical payments

Question 16

Disability Insurance

Answer 16

short term= 3-6 months
long term= over 6 months

Question 17

Liability Insurance

Answer 17

Policy that covers losses to a third party caused
by the insured either by an object owned by the
insured, or on the premises owned by the
insured