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medical billing > Medical Billing and US Healthcare > Flashcards

Medical Billing and US Healthcare Flashcards

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USMLE® Step 1 flashcards
1
Q

Where do we list ICD-10 codes on the billing form?

A

box 21 A-L on the claim form

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2
Q

CMS

A

Center of Medicare and Medicaid Services

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3
Q

SSN

A

Social Security Number

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4
Q

What EDI is used for ERA?

A

EDI 835

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5
Q

What is the CPT range for pathology and laboratory procedures?

A

80047-89398

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6
Q

EHR

A

Electronic Health Record

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7
Q

What others names do we use for Tricare?

A

CHAMP-VA and CHAMP-US

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8
Q

Indicator use for Supervising provider?

A

DQ

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9
Q

Payer Adjudication Cycle

A

Adjudication is the process of reviewing and paying, or denying, claims that have been submitted by a healthcare provider

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10
Q

What are POS codes? Example

A

Indicates the appropriate order of importance in relation to the service being performed

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11
Q

How do you define global period?

A

Period of time starting with a surgical procedure and ending some period of time after the procedure

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12
Q

Name all steps in the RCM.(name atleast 7)

A

Patient Scheduling
Patient Visit
Charge Entry
Claim Submission
Payment Posting
Denial Management
AR Follow Up

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13
Q

What is the purpose of receiver ID?

A

It is used for ERA enrollment

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14
Q

What EDI is used for ERA?

A

835

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15
Q

Types of patients’ responsibilities?

A

PR=1 Deductibles, PR2=Co Insurance, PR3=Co payment

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16
Q

What are non-covered benefits?

A

These services are not paid for at all by your health insurance plan

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17
Q

Name two federal insurances.

A

Medicare, Medicaid, Tricare

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18
Q

What is prior authorization?

A

Prior authorization in health care is a requirement that a provider (physician, hospital, etc.) obtains approval from your health insurance plan before prescribing a specific medication for you or performing a particular medical procedure

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19
Q

PTAN

A

Provider Transaction Access Number

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20
Q

Difference between Co-insurance and Co-payment?

A

Your coinsurance is the percentage of the treatment cost that you are expected to cover.
Your copays are fixed fees that partially pay for medical services

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21
Q

Indicator use for Referring provider?

A

DN

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22
Q

What are POS codes? Example

A

Place or service e.g., 11 for office, 12 for home

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23
Q

What goes in the box 24J of the CMS 1500 form?

A

Rendering Provider ID

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24
Q

Two types of Medical Billing?

A

Institutional and Professional

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25
Q

Difference between an HMO plan and a PPO plan? Briefly explain.

A

HMO:
Out of pocket cost is low
In network coverage only
Restricted network of doctors and hospitals
PCP referral is always required

PPO:
Out of pocket cost is high
In and out of network coverage
Does not require any referrals

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26
Q

Name any two Clearing houses?

A

Change Healthcare
Availity
Waystar
Optum

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27
Q

Different ways to check eligibility?

A

Real-time
By Call
Payer’s Portal
Coverage and Discovery Tool

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28
Q

Difference between EIN and NPI?

A

Employer identification number or tax id.
National Provider Identifier. (difference?)

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29
Q

EMR

A

Electronic Medical Record

30
Q

What is Scheduling?

A

Patient registration, appointment management, eligibility

31
Q

FFS

A

Fee for Service

32
Q

In which box do you add the ICD codes on the CMS 1500 form?

A

Box 21 A-L

33
Q

CMP or Civil Monetary Penalties Law (CMPL)

A

Services to impose civil money penalties, an assessment, and program exclusion for various forms of fraud and abuse involving the Medicare and Medicaid programs.

34
Q

TFL

A

Timely Filling Limit

35
Q

Difference between MCR Fraud & Abuse?

A

Fraud is an intentional deception or misrepresentation of fact that can result in unauthorized benefit or payment. Abuse is misuse or exploitation of authority for unlawful gains.

36
Q

What goes in the box 17a of the CMS 1500 form?

A

NPI (National Provider Identifier)

37
Q

EDI use for professional claims submission?

A

837p

38
Q

Types of documents required to verify medical procedures? Any two types

A

Doctor’s notes
Lab Results
X-rays
Requisitions

39
Q

Difference between denial and rejection?

A

A claim rejection occurs before the claim enters the payer’s adjudication process and most often results from incorrect data.
A claim denial applies to a claim that has been processed and found to be unpayable.

40
Q

What is the purpose of the pointer in the CMS 1500 form?

A

Indicates the CPT performed towards the relevant Dx

41
Q

Difference between EHR and EMR?

A

EHR accumulates data about a patient’s health over time and across medical practices.
EMR is closer to a “medical chart” because it gives patient data from one physician’s office and only provides the healthcare data.

42
Q

Current version of International Classification of Disease being followed in the US?

A

ICD-10

43
Q

EDI used for Claim submission inquiry and response?

A

276 and 277

44
Q

Types of providers?

A

Referring, Rendering and Billing

45
Q

DME

A

Durable Medical Equipment

46
Q

HCFA form or?

A

CMS 1500

47
Q

What are three qualifiers used to identify the role of the practitioner on the CMS 1500 form?

A

DN: Referring provider

DK: Ordering provider

DQ: Supervising provider

48
Q

Difference between EOB and COB?

A

Explanation of Benefits and Co-ordination of Benefits (explain)

49
Q

Name 4 items of patient demographics

A

Name, DOB. Address, Phone, Gender

50
Q

Accepted Assignments?

A

Medicare approved amount

51
Q

What is a clearinghouse?

A

Essentially the middleman between the healthcare providers and the insurance payers

52
Q

CMS-1500 is divided in to which two parts?

A

Block 1-13 (Patient info) Block 14-33 (Physician’s info)

53
Q

What is EDI?

A

Electronic Data Interchange

54
Q

Superbill

A

A Superbill is used by healthcare providers as a primary source of data for creating claims

55
Q

What is retro or retroactive authorization?

A

Retroactive authorizations are given when the patient is in a state (unconscious) where necessary medical information cannot be obtained for preauthorization. In such cases, many insurance providers require authorization for services within 14 days of services provided to the patient

56
Q

What is the main purpose of Modifiers?

A

Elaborates/provides detail of a CPT performed
Coding tool that help inform and explain payers for the services provided
Helps with the documentation of medical claims to avoid denials

57
Q

Two types of claim forms?

A

CMS 1450 and CMS 1500

58
Q

What is a submitter ID?

A

Identification number used to submit medical claims electronically

59
Q

Two main types of HIPAA rules?

A

HIPAA Privacy and HIPAA Security

60
Q

Indicator use for Ordering provider?

A

DK

61
Q

Define MAC?

A

A private health care insurer that has been awarded a geographic jurisdiction to process Medicare Part A and Part B (A/B) medical claims or Durable Medical Equipment (DME) claims for Medicare Fee-For-Service (FFS) beneficiaries

62
Q

How many types of categories are there for the CPTs?

A

Category 1: Largest body of codes, consisting of those commonly used by providers to report their services and procedures
Category 2: Supplemental tracking codes used for performance management
Category 3: Temporary codes used to report emerging and experimental services and procedures (remain in category III for up to 5 years)

63
Q

Define Capitation?

A

Capitation payments are used by managed care organizations to control health care costs

Capitation is a fixed amount of money per patient per unit of time paid in advance to the physician for the delivery of health care services

64
Q

What are LCDs and NCDs?

A

Local coverage determination and National coverage determination

65
Q

EDI used for Eligibility inquiry and response?

A

270 and 271

66
Q

Four types of MCO (managed care organization) plans?

A

HMO (health maintenance organization)
PPO (preferred provider organization)
EMO (exclusive provider organization)
POS (place of service)

67
Q

ERA

A

Electronic Remittance Advice

68
Q

Difference between Credentialing and Contracting?

A

Credentialing is the process of reviewing the doctor’s qualifications.
Contracting is the process of applying for and obtaining participation contracts with insurance plans

69
Q

Payer Adjudication Cycle

A

adjudication is the process of reviewing and paying, or denying, claims that have been submitted by a healthcare provider

70
Q

HCPCS are managed and controlled by?

A

CMS (Center of Medicare and Medicaid Services)

71
Q

CPTs are assigned and maintained by?

A

AMA (American Medical Association)

72
Q

Main function of CPTs?

A

Describes medical, surgical and diagnostic services rendered by the provider

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