NHA - Certified Billing and Coding Specialist (CBCS) Study Guide – COMPLETE SOLUTIONS

NHA - Certified Billing and Coding Specialist (CBCS) Study Guide – COMPLETE SOLUTIONS Document Content and Description Below NHA - Certified Billing and Coding Specialist (CBCS) Study Guide – COMPLETE SOLUTIONS The symbol "O" in the Current Procedural Terminology reference is used to indicate what? - Reinstated or recycled code In the anesthesia section of the CPT manual, what are considered qualifying circumstances? - Addon codes As of April 1, 2014 what is the maximum number of diagnoses that can be reported on the CMS-1500 claim form before a further claim is required? - 12 What is considered proper supportive documentation for reporting CPT and ICD codes for surgical procedures? - Operative report What action should be taken first when reviewing a delinquent claim? - Verify the age of the account A claim can be denied or rejected for which of the following reasons? - Block 24D contains the diagnosis code A coroner's autopsy is comprised of what examinations? - Gross Examination Medigap coverage is offered to Medicare beneficiaries by whom? - Private third-party payers What part of Medicare covers prescriptions? - Part C What plane divides the body into left and right? - SagittalWhere can unlisted codes be found in the CPT manual? - Guidelines prior to each section Ambulatory surgery centers, home health care, and hospice organizations use which form to submit claims? - UB-04 Claim Form What color format is acceptable on the CMS-1500 claim form? - Red Who is responsible to pay the deductible? - Patient A patient's health plan is referred to as the "payer of last resort." What is the name of that health plan? - Medicaid Informed Consent - Providers explain medical or diagnostic procedures, surgical interventions, and the benefits and risks involved, giving patients an opportunity to ask questions before medical intervention is provided. Implied Consent - A patient presents for treatment, such as extending an arm to allow a venipuncture to be performed. Clearinghouse - Agency that converts claims into standardized electronic format, looks for errors, and formats them according to HIPAA and insurance standards. Individually Identifiable - Documents that identify the person or provide enough information so that the person can be identified. De-identified Information - Information that does not identify an individual because unique and personal characteristics have been removed. Consent - A patient's permission evidenced by signature.Authorizations - Permission granted by the patient or the patient's representative to release information for reasons other than treatment, payment, or health care operations. Reimbursement - Payment for services rendered from a third-party payer. Auditing - Review of claims for accuracy and completeness. Fraud - Making false statements of representations of material facts to obtain some benefit or payment for which no entitlement would otherwise exist. Upcoding - Assigning a diagnosis or procedure code at a higher level than the documentation supports, such as coding bronchitis as pneumonia. Unbundling - Using multiple codes that describe different components of a treatment instead of using a single code that describes all steps of the procedure. Abuse - Practices that directly or indirectly result in unnecessary costs to the Medicare program. Business Associate (BA) - Individuals, groups, or organizations who are not members of a covered entity's workforce that perform functions or activities on behalf of or for a covered entity. What is the main job of the Office of the Inspector General (OIG)? - The OIG protects Medicare and other HHS programs from fraud and abuse by conducting audits, investigations , and inspections. Medicare - Federally funded health insurance provided to people age 65 or older, and people 65 and younger with certain disabilities. Medicaid - A government-based health insurance option that pays for medical assistance for individuals who have low incomes and limited financial resources. Timely Filing Requirements - Within 1 calendar year of a claim's date of service.Electronic Data Interchange (EDI) - The transfer of electronic information in a standard form. Coordination of Benefits Rules - Determines which insurance plan is primary and which is secondary. Conditional Payment - Medicare payment that is recovered after primary insurance pays. Crossover Claim - Claim submitted by people covered by a primary and secondary insurance plan. Assignment of Benefits - Contract in which the provider directly bills the payer and accepts the allowable charge. Allowable Charge - The amount an insurer will accept as full payment, minus applicable cost sharing. Clean Claim - Claim that is accurate and complete. They have all the information needed for processing, which is done in a timely fashion. Dirty Claim - Claim that is inaccurate, incomplete, or contains other errors. Medicare Administrative Contractor (MAC) - Processes Medicare Parts A and B claims from hospitals, physicians, and other providers. Remittance Advice (RA) - The report sent from the third-party payer to the provider that reflects any changes made to the original billing. Explanation of Benefits (EOB) - Describes the services rendered, payment covered, and benefit limits and denials. National Provider Identifier (NPI) - Unique 10-digit code fro providers required by HIPAA.Heath Maintenance Organization (HMO) - Plan that allows patients to only go to physicians, other health care professionals, or hospitals on a list of approved providers, except in an emergency. Modifier - Additional information about types of services, and part of valid CPT or HCPCS codes. By signing block 12 of CMS-1500 form, a patient is doing what? - Authorizes the release of medical information. Claim - Complete record of the services provided by the health care professional, along with appropriate insurance information. Where does the NPI number go on the CMS-1500 form? - 17b What are two pieces of information that need to be collected from patients? - Full name and date of birth. Deductible - The amount of money a patient m just pay out of pocket before the insurance company will start to pay for covered benefits. Coinsurance - the pre-established percentage of expenses paid by the insurance company after the deductible has been met. Copayment - A fixed dollar amount that must be paid each time a patient visits a provider. Medicare Part A - Provides hospitalization insurance to eligible individuals. Medicare Part B - Voluntary supplemental medical insurance to help pay for physicians' and other medical professionals' services, medical services, and medical-surgical supplies not covered by Medicare Part A.Medicare Advantage (MA) - Combined package of benefits under Medicare Parts A and B that may offer extra coverage for services such as vision, hearing, dental, health and wellness, or prescription drug coverage. Medicare Part D - A run by private insurance companies and other vendors approved by Medicare. Medigap - A private health insurance that pays for most of the charges not covered by Parts A and B. What are the three major kinds of government insurance plans? - Medicare, Medicaid, and State Children's Health Insurance Program (SCHIP) Referral - Written recommendation to a specialist. Precertification - A review that looks at whether the procedure could be performed safely but less expensively in an out patient setting. Predetermination - A written request for a verification of benefits. Who is usually the gatekeeper? - Primary care physician Preauthorization - Approval from the health plan for an inpatient hospital stay or surgery. Formulary - A list of prescription drugs covered by an insurance plan. Tier 1 - Providers and facilities in a PPO's network. Tier 2 - Providers and facilities within a broader, contracted network of the insurance company. Tier 3 - Providers and facilities out of the network.Tier 4 - Providers and facilities not on the formulary Preferred Provider - Tier 2 provider What's the difference