Ch 12, 13,14, & 15

Question 1

In the ICD-10 which section includes guidelines for reporting additional diagnoses in non-outpatient settings

Answer 1

Section III

Question 2

What is underdosing

Answer 2

taking less medication than prescribed by a healthcare provider or manufacturer, or when a healthcare professional provides a lower dose than needed

Question 3

In the Alphabetic Index, what does “see also” mean

Answer 3

points out to additional codes or code ranges in the Alphabetic Index that may be useful to the code found in the original search

Question 4

What period of pregnancy does peripartum apply to

Answer 4

the period from the last month of pregnancy to 5 months after giving birth

Question 5

Which letter in the IDC-10 is reserved by the World Health Organization to assign new diseases with uncertain etiology

Answer 5

U

Question 6

Which volumes of the IDC-9 are used for diagnostic coding (Volume 1, 2 and/or 3)

Answer 6

volumes 1 and 2

Question 7

Does the code for HIV indicate, the HIV virus is present

Answer 7

yes

Question 8

What is the second most common medical document from which diagnostic statements can be extracted

Answer 8

Progress notes

Question 9

How are burns coded

Answer 9

Code each burn separately unless specific combination codes are given in Tabular List
Most burn codes are found in chapter 19
ICD-10-CM makes a distinction between burns and corrosions
Corrosions are caused by chemicals; thermal burns are caused by heat source
by site and degree and by the extent of body surface involvement, all burn cases should have at least two codes and a third if the wound is infected. Burn codes use the fifth character for other information. Therefore, the diagnoses require an additional code to indicate infection. The burn codes are used for: thermal burns (except sunburns) caused by a heat source, such as fire or hot appliance; burns resulting from electricity; and burns resulting from radiation. Current burns (T20-T25) are classified by depth, extent, and burn agent (X code). Depth is categorized as first degree (redness), second degree (blistering), and third degree (full-thickness involvement). Burns on the eye and internal organs (T26-T28) are classified by site but not by degree

Question 10

Babies are considered newborn or perinatal for the first _____ days

Answer 10

28 days

Question 11

What is the CPT code for cardiopulmonary resuscitation

Answer 11

(CPR) 92950

Question 12

What is the CPT code for biopsy of external ear

Answer 12

69100

Question 13

What is the CPT code for initial hospital observation care, N/P

Answer 13

99218-99220

Question 14

What is the CPT code for thoracentesis, puncture of pleural cavity for aspiration, initial or subsequent

Answer 14

32421

Question 15

What is the CPT code for of hospital discharge day management, 45 minutes

Answer 15

99239

Question 16

What is the CPT code for for suture of recent wound on the eyelid

Answer 16

67930 and 67935. Code 67930 is for a partial-thickness suture, while 67935 is for a full-thickness suture

Question 17

CPT code for serum folic acid

Answer 17

82746

Question 18

CPT code for N/P office visit, comprehensive history and examination, high-complexity decision making

Answer 18

99205

Question 19

CPT code for N//P initial inpatient consultation

Answer 19

99251-99255 depends on the complexity and time spent on the consultation

Question 20

CPT code for liver function study with hepatobiliary agents, with serial images

Answer 20

78220

Question 21

CPT code for basic metabolic panel

Answer 21

80048

Question 22

E/P, home patient, problem-focuses interval history and examination, straightforward MDM

Answer 22

99347

Question 23

CPT code for initial nursing facility care, detailed or comprehensive history or examination, straightforward or low-complexity decision making

Answer 23

99304

Question 24

What type of medical documents/reports are used for procedural coding

Answer 24

encounter form; history and physical report (H&P); progress notes; discharge summary; operative report; pathology report; anesthesia record; radiology report

Question 25

What is modifier -26 used for

Answer 25

Professional component. This modifier is used when a physician supervises the technician performing the service or provides a professional opinion

Question 26

What is modifier -50 used for

Answer 26

Bilateral procedure. If the procedure was performed on both sides of the body (e.g., both knees, both eyes) and the code description does not indicate that the procedure or service was performed bilaterally, modifier -50 is used

Question 27

What are the disadvantages of manage care

Answer 27

Many require each patient to choose a primary care provider (PCP) (gatekeeper); require referrals; preauthorization process can requirements; almost every MCO requires precertification

Question 28

What is an insurance premium

Answer 28

The amount paid or to be paid by the policy holder for coverage under the contract, usually in periodic installments

Question 29

What is an utilization review

Answer 29

a review of individual cases by a committee to make sure that services are medically necessary and to study how providers use medical care resources

Question 30

What is an allowable amount

Answer 30

AKA fee schedule; maximum amount that an insurance company will pay for covered health services

Question 31

What are self-funded plans

Answer 31

Large companies or organizations have enough employees that they can fund their own insurance programs. Technically, a self-funded plan does not fit the true definition of insurance. The employer pays the employee's healthcare cost from the funds collected from the employee's monthly premiums. Usually, the costs of benefits and premiums for self-funded plans are similar to those for group plans. Self-funded plans tend to work best for companies that are large enough to offer good benefit coverage and reasonable premium rates and are able to pay large claims for expensive medical services. Self-funded healthcare is an arrangement in which an employer provides health or disability benefits to employees with its own funds. The employer assumes the direct risk for payment of the claims for benefits.

Question 32

The amount payable by an insurance company for a monetary loss to aid an individual insured by that company, under each coverage is called the ______

Answer 32

benefit

Question 33

What is an IPA

Answer 33

Independent Practice Association

Question 34

What type of referral is usually processed immediately

Answer 34

STAT referral -used in a emergency situation

Question 35

Which individuals qualify for Medicare

Answer 35

individuals at least 65 years of age; people who are disabled; and patients who have been diagnosed with end-stage renal disease (ESRD)

Question 36

Which TRICARE option is similar to preferred provider network

Answer 36

preferred provider organization (PPO)

Question 37

How are health insurance benefits determined

Answer 37

by a complex interplay of factors, including the insurance plan type (e.g., PPO, HMO), the specific coverage provided by the plan (deductibles, co-pays, out-of-pocket maximums), and whether the plan is offered through an employer or purchased individually

Question 38

What expenses are paid by Medicare Part B

Answer 38

outpatient hospital care, durable medical equipment, provider's services, and other medical services

Question 39

What do Medigap policies cover

Answer 39

AKA Medicare Supplement Insurance plan, is designed to help cover out-of-pocket costs associated with Original Medicare (Parts A and B) Medicare deductible, Medicare co-insurance, and Services not covered under Medicare

Question 40

On the CMD-1500 form, what block is the insured's name found in

Answer 40

4

Question 41

How many diagnoses can be reported on the CMS-1500 form

Answer 41

up to 12

Question 42

Which MCO typically has the lowed monthly premiums with lower patient financial responsibility

Answer 42

HMOs (Health Maintenance Organizations)

Question 43

Which type of referral can be approved online when it is submitted through the provider's Web portal to the utilization review department

Answer 43

regular, urgent, and even STAT referralsSTAT referral

Question 44

Are "fees for service provided" reviewed by a utilization review committee

Answer 44

No

Question 45

To examine claims for accuracy and completeness before they are submitted is to _____ the claims

Answer 45

Audit

Question 46

Procedures performed on the patient are found in block _____

Answer 46

24d

Question 47

The secondary plan is noted in what block

Answer 47

9

Question 48

What is a "dirty" claim

Answer 48

claims with incorrect, missing, or insufficient data