CH.11,12,13

Question 1

What does the meaning of outpatient mean?

Answer 1

one who has not been formally admitted to a healthcare facility or a patient admitted for observation.

Question 2

One reason for using a standard coding system to report diagnoses and procedures make in the medical office is?

Answer 2

to facilitate payment from third party payers

Question 3

Define medical necessity?

Answer 3

The term that insurance companies use to refer to a procedure being performed for appropriate reason

Question 4

What does ICD-10-CM stand for?

Answer 4

International Classification of Diseases-10th Revision-Clinical Modification

Question 5

What is the ICD-10-CM code for low back pain?

Answer 5

M54.5

Question 6

What is the universal claim form called?

Answer 6

CMS-1500

Question 7

ICD-10-CM considered protected health information ?

Answer 7

true

Question 8

What are the four levels of history?

Answer 8

Problem focused, expanded problem focused, detailed, comprehensive.

Question 9

Five digit codes that begin with the number 9 include: 
A. outline
B. E/M codes
C. CPT-4 codes
D. no codes begin with 9

Answer 9

B. E/M codes

Question 10

In the anesthesia section of the CPT manual the codes are usually divided first by which of the following

Answer 10

anatomic site and by specific type of procedure

Question 11

Downcoding and upcoding are illegal practices, and medical assistants can be prosecuted for either practice T/F

Answer 11

T

Question 12

define upcoding

Answer 12

Reporting codes that are not supported by documentation in the patient record for the purpose of increasing reimbursement.

Question 13

define ectomy

Answer 13

surgical removal

Question 14

An insurance plan that is self-funded often has an agency that handles the claims and payments. This agency is:
A) A health maintenance organization
B) A peer-review organization
C) A third-party administrator
D) A group members agency
E) None of the above

Answer 14

C) A third-party administrator

Question 15

When a patient has coverage from more than one insurance company, the primary insurance is:
A) The one that is billed first
B) The company that is billed for the remainder of the charges when payment has been received
C) The only insurance company that is chosen to be billed
D) The company that pays first
E) Paid by the employee

Answer 15

A) The one that is billed first

Question 16

The denial of an insurance claim may be caused by:
A) Appealing an insurance claim
B) Confirmation that the patient is covered under the policy
C) Complete patient information
D) Inappropriate diagnostic and procedural coding
E) All of the above

Answer 16

D) Inappropriate diagnostic and procedural coding

Question 17

Electronic claims submission occurs:
A) Only when a clearinghouse is used
B) When payment is directly deposited in the medical practice bank account
C) When insurance claim forms are completed with black or blue ink and faxed to the insurer
D) When claims are printed using a computer and printer and mailed within 1 day
E) When claims are submitted immediately with a computer and modem

Answer 17

E) When claims are submitted immediately with a computer and modem

Question 18

Which part of Medicare pays for physician fees, diagnostic tests, and some screening tests?
A) Part A
B) Part B
C) Parts A and B
D) Part C
E) None of the above

Answer 18

B) Part B

Question 19

The list that shows what a physician's office charges for a particular service is the:
A) Price list
B) Explanation of benefits
C) Assignment of benefits
D) Fee schedule
E) Insurance

Answer 19

D) Fee schedule

Question 20

Betsy Kennedy must pay a percentage of her medical expenses according to the managed care program that she is enrolled in. This is known as:
A) A deductible
B) A copayment
C) Assignment of benefits
D) Coinsurance
E) None of the above

Answer 20

D) Coinsurance

Question 21

Medicare Part A

Answer 21

the part of the Medicare program that pays for hospitalization, care in a skilled nursing facility, home health care, and hospice care

Question 22

Medicare Part B

Answer 22

The part of the Medicare program that pays for physician services, outpatient hospital services, durable medical equipment, and other services and supplies.

Question 23

Medicare Part C

Answer 23

Managed Healthcare plans that offer regular Part A and Part B Medicare coverage and additional coverage for certain other services are called:

Question 24

Medicare Part D

Answer 24

Prescription drug reimbursement plans offered to Medicare beneficiaries.

Question 25

Workers' Compensation

Answer 25

- Provides benefits for employers' liability | - This insurance became the sole source of remedy

Question 26

What is a "Fee for Service (Indemnity) plan"?

Answer 26

Health insurance that reimburses individuals for part or all of the expenses they incur from health care providers - Individuals are free to decide to seek care from a primary care physician or a specialist

Question 27

The___is the amount a patient must pay before his or her insurance begins to pay for services

Answer 27

deductible

Question 28

define copay

Answer 28

copay is the amount you will pay overtime you use medical services.

Question 29

An eligible patient is one who: A) Has received services from the physician B) Is not covered under the insurance plan C) Has family members who are covered under the insurance plan D) Has current coverage under a health insurance plan E) None of the above

Answer 29

D) Has current coverage under a health insurance plan

Question 30

``` Timmy Wall, a 5-year-old patient, is covered under his mother's insurance plan. In this case, Timmy is a: A) Carrier B) Child C) Dependent D) Group member E) Participant ```

Answer 30

C) Dependent

Question 31

True or False? Relative value unit × national conversion factor = Medicare allowed amount.

Answer 31

True

Question 32

True or False? A physician who does not choose to participate with a particular third-party payer is still obligated to extend credit to patients.

Answer 32

False

Question 33

Incomplete data cause an insurance denial

Answer 33

A claim that is not paid due to incorrect information must be corrected and sent to the payer according to its procedures

Question 34

Managed care insurance programs generally require precertfication and referrals ? T/F

Answer 34

F

Question 35

If a physician or hospital in a managed care plan is paid a fixed, per capita amount for each patient enrolled regardless of the type and number of services rendered, this is a payment system known as

Answer 35

capitation