Practice Exam 1

Question 1

car accident

Answer 1

bill insurance first to get a denial then submit claim to auto insurance.

Question 2

Managed Care who allows patients to self-refer?

Answer 2

PPO
POS

Question 3

CAQH

Answer 3

handles credentialing for many payers

Question 4

Tricare for active-duty service members?

Answer 4

Tricare Prime

Question 5

Forms needs for work related injusty?

Answer 5

First Report of injury form
Progress report
CMS1500

Question 6

State and Federal guidelines apply to?

Answer 6

Medicaid

Question 7

FDCPA = Fair Debt Collection Practices Act

Answer 7

not allowed to call after odd hours

Question 8

HCPCS/CPT code assigned a “1” means?

Answer 8

one unit of service
on a single DOS

Question 9

ABN Advanced Beneficiary Notice

Answer 9

explains financial responsibility if Medicare denies payment

Question 10

Fair Credit Reporting Act

Answer 10

protects information collected by consumer

Question 11

CMS standard form in which providers agree to?

Answer 11

Submit claims to Medicare
Have authorization from beneficiary
Retain documents and medical records
research/correct claim discrepancies

Question 12

Scenario in which Medicare billed as secondary?

Answer 12

72yo with Employer insurance
66yo injured at work, but no Employer insurance.

Question 13

Dr’s can’t bill for multiple lab draw fee just because the MA misses.

Answer 13

fradulent

Question 14

According to CMS which are included in Global package for surgical procedures?

Answer 14

Surgical procedure performed.

Post Op infection treated in the office.

Question 15

ACO = Accountable Care Organization

Answer 15

Group of doctors, healthcare providers, hospitals who coordinate care to Medicare patients.

Question 16

Medicare will list which of the following?

Answer 16

Effective Date of coverage
Entitled to Part A or B

NOT: address, ss, phone, physician, when coverage ends

Question 17

You discover a claim overpaid by Medicare?

Answer 17

False Claims Act requires a refund

Question 18

EPSDT = Early Periodic Screening Diagnostic & Treatment

Answer 18

Pediatric checkups are covered

Question 19

Policy to write off as courtesy is?

Answer 19

Fraud
can’t write off for any patients.

Question 20

Patient’s insurance requires Preauthorization for all surgical procedures.

Answer 20

NOT if it’s an emergency

Question 21

Security involves safekeeping of PHI

Answer 21

Employer must
Set up policies to protect PHI.
Require employees to sign confidentiality agreement.

Question 22

to prevent incorrect patient information

Answer 22

Photo Id
Ins Card
Registration Form

Question 23

Office policy usually is to follow up on oldest accounts with highest balance.

Answer 23

pay attention to the “age of account” and balance

Question 24

How may I help you Mrs. Jones

Answer 24

Violates HIPAA

Question 25

example of overpayment that must be refunded is?

Answer 25

duplicate processing of a cliam

Question 26

steps to file an appeal

Answer 26

1. form required by payer 2. review reason for denial to see error 3. documentation 4. keep copies 5. appeal asap if you're certain of error

Question 27

when nonparticipating provider files claim to BC/BS, how is payment processed?

Answer 27

the payment is sent to patient and patient must pay the provider.

Question 28

A married couple both have insurance. Who carries primary insurance for their children? Husband: DOB 2/3/87 Wife: DOB 4/4/84

Answer 28

Husband, because month & day are before hers Rule: (year of birth not considered)

Question 29

Claim denied for not submitted timely. What to do?

Answer 29

Check the date. If submitted timely resend to payer.

Question 30

Procedure cost $2500.00 Deductible $500 PPO covers 80% what's the patient responsibility?

Answer 30

$900.00 2500 * .80 is 1600 2500-1600 is 400 (patient pays) add $500 deductible. Total $900

Question 31

An allowed collection policy after patient's bankruptcy?

Answer 31

Any claims after bankruptcy date.

Question 32

CPT code denied as bundled services.

Answer 32

Resubmit CPT with Modifier 59 (To show procedure was distinct from other procedure)

Question 33

CPT code denied as inclusive.

Answer 33

A corrected claim should be filed with the original CPT. (no modifiers mentioned here)

Question 34

Medicare primary. AARP is medigap. On the CMS1500 9d enter (line for insurance name of plan name)

Answer 34

on line 9d enter: COBA medigap claim based identifier ID

Question 35

Frequency of care on UB04 indicates?

Answer 35

Type of Bill

Question 36

New patient. No complaints. Seen by PA. How do you bill?

Answer 36

Bill under PA

Question 37

Office visit. Low MDM required for HBP. also, two planter warts destroyed. How is this reported?

Answer 37

99213 E/M for OP 17110-59 procedure with modifier 59 modifier indicates distinct procedure

Question 38

CPT 19101 open incisional biopsy

Answer 38

Use Modifier 51 to indicate more than one procedure was performed.

Question 39

HCPCS Level 11 for Depo-Provera injection 100 mg

Answer 39

J1050 x 100

Question 40

Excision of squamous cell carcinoma. Requires wound closure.

Answer 40

11642 (removal) 12051-51 repair & 51 more than one procedure was performed.

Question 41

for electronic data interchanges which codes sets are required?

Answer 41

Inpatients are reported with HCPCS Level 11 Outpatients are reported with CPT and HCPCS Level 11

Question 42

Surgery for hernia Paiten f/u visit and has a lump on tailbone. Dr. treats it. Can it be billed?

Answer 42

E/M evaluation & management with Modifier 24 to indicate unrelated to surgery

Question 43

Clearinghouse report shows C44.50 must be valid. What do you do?

Answer 43

Review medical records for 6th character, correct claim, resubmit.

Question 44

Correct sequence. bilateral tympanostomy adenotonsillectomy

Answer 44

42820 69436-50

Question 45

referral for gangrene

Answer 45

E10.52

Question 46

Which elements are incorrect?

Answer 46

CPT code (s) Diagnosis and Correlation

Question 47

cataract surgery insertion of lens

Answer 47

66984 H26.32 T38.0X54

Question 48

Policy f/u on 90 days highest balance

Answer 48

WC 121 days was the oldest and highest amount.