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

NHA - Certified Billing and Coding Specialist (CBCS) Study Guide 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? Add-on 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? Sagittal Where 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.