Medical Coding and Billing

Question 1

Submission

Answer 1

The healthcare provider sends the claim to the third-party payer requesting payment. Submissions are made electronically or occasionally by paper bill.

Question 2

Processing

Answer 2

The third-party payer receives the claim and gathers information related to the case.

Question 3

Adjudication

Answer 3

The third-party payers process of checking the details of the claim against the information they have on the patient and his or her insurance benefits. This process also checks for completeness of the claim, bundling issues for CPT codes, medical necessity, and recent claims (to avoid unnecessary service or duplicate claims).

Question 4

EOB

Answer 4

Explanation of benefits

Question 5

Reconciliation

Answer 5

The process the healthcare provider analyzes receive payment information compared to submit a claim information for accuracy. If the provider believe the claim was inappropriately denied by the payer the dispute process begins until satisfactory reconciliation is achieved by the provider in the third-party payer.

Question 6

ABN

Answer 6

Advance Beneficiary Notice of Noncoverage

Question 7

LCDs

Answer 7

Local coverage determinations

Question 8

NCDs

Answer 8

National coverage determinations

Question 9

MACs

Answer 9

Medicare administrative contractors

Question 10

An ABN should normally be retained for _____

Answer 10

5 years

Question 11

UB-04

Answer 11

Claim form used to bill inpatient and outpatient facility charges: surgery centers, freestanding radiology clinic’s, laboratories, hospitals, skilled nursing, and emergency rooms

Question 12

CMS-1500

Answer 12

The claim form used to bill professional services: surgeons fees for surgery performed at an outpatient surgery center or an emergency physicians fee for professional services provided in the emergency room

Question 13

Administrative law

Answer 13

Created by administrative agencies of government

Question 14

Case law or common law

Answer 14

Based on judicial decision

Question 15

Statutory law

Answer 15

Passed by legislative body

Question 16

CFR

Answer 16

Code of federal regulations

Question 17

HIPAA is what kind of law?

Answer 17

Statutory law

Question 18

HIPAA

Answer 18

Health insurance portability and accountability act

Question 19

PHI

Answer 19

Protected health information

Question 20

OIG

Answer 20

Office of the Inspector General

Question 21

PHR

Answer 21

Personal health record

Question 22

EHR

Answer 22

Electronica health record

Question 23

UHDDS

Answer 23

Uniform hospital discharge data set

Question 24

MPIs

Answer 24

Master patient indexes

Question 25

EMPI

Answer 25

Enterprise wide master patient index

Question 26

Qualitative analysis

Answer 26

Review of the medical record to ensure that standards are met and to determine accuracy of record documentation

Question 27

Quantitative analysis

Answer 27

Review of the medical record to determine its completeness

Question 28

Concurrent review

Answer 28

Review of the medical record carried out while the patient is actively receiving care

Question 29

Occurrence screening

Answer 29

Review technique of medical records of current and discharge patients with the goal of identifying events not consistent with routine.

Question 30

Retrospective review

Answer 30

Review of the medical record after the patient has been discharged.

Question 31

Interoperability

Answer 31

The ability of various systems to actually network and share and exchange information

Question 32

LAN

Answer 32

Local area network

Question 33

WAN

Answer 33

Wide area network

Question 34

VPN

Answer 34

Virtual private network

Question 35

EDI

Answer 35

Electronica data interchange

Question 36

CMS

Answer 36

Centers for Medicare and Medicaid services

Question 37

Clearinghouse

Answer 37

A company contracted by the third-party payers to handle and format submissions, screen clams and make data available to providers

Question 38

Clean claim

Answer 38

A complete and accurate claim form that includes all provider and member information

Question 39

Common data file

Answer 39

Overview of claims recently filed on the patient

Question 40

Coinsurance

Answer 40

The percentage of the bill the patient pays once the deductible is met

Question 41

EOB

Answer 41

Explanation of benefits

Question 41

RA

Answer 41

Remittance advice

Question 42

Wright-off

Answer 42

The difference between total charge and the allowable amount by the insurance