MEDICAL CODING REVIEW EXAM SET
QUESTIONS AND ANSWERS
Electronic Data Interchange - Answer-The transfer of electronic information in a
standard format
Coordination of Benefits - Answer-If patient has more than one insurance policy, the
rule is the primary insurance pays first then secondary pays the rest
CLEAN AND DIRTY CLAIMS - Answer-Dirty Claims are those that are inaccurate,
incomplete or contain other errors, they are delayed because they are sent back to
the provider for corrections and resubmission.
Clean Claims are accurate and complete.
CMS-1500 FORM - Answer-Revised by the National Uniform Claim Committee
(NUCC) submitted to Medicare for claims
BLOCK 11 determines whether a good faith effort has been made to indicate which
is the primary insurance and which is secondary
BLOCK 17 name of the referring or ordering physician goes here. (Stark Law)
BLOCK 17B NPI # National provider Identifier goes here. It is a unique 10-digit code
for providers required by HIPAA
Administration Simplification Compliance Act ASCA - Answer-Part of HIPAA. EST in
2012 mandated that health care claims be submitted electronically. Exception is that
paper claims maybe sent to clearinghouses, which convert the claims into a
standardized electronic format.
2 pieces of information that need to be collected from patients - Answer-FULL NAME
AND DATE OF BIRTH SOCIAL SECURITY #
Verify Insurance! - Answer-Before submitting a claim it is important to make sure that
the insurance is valid and the services are a covered benefit
Birthday Rule - Answer-Applies to parents who both have health insurance and list
children as dependents. The health plan of the parent whos birthday comes first in
the current year is the primary and will be billed first for insurance claims.
3 KINDS OF INSURANCE INFORMATION needed to be collected from Patient -
Answer--Correct Policy number
-Group Number
-Policy effective date
-type of policy
Insurance Premium - Answer-a weekly, monthly or annual cost for the plan or
insurance coverage.
, COINSURANCE PERCENTAGE - Answer-Amount provider is allowed for service
and the amount he was paid. a common % split is 80% for insurance carrier and
20% for patient.
3 Major kinds of government insurance plans - Answer-Medicare
Medicaid
State children's Health insurance Program (SCHIP)
Private Health Insurance vs Employer Self-insured plans - Answer-Private health
insurance is paid by individuals int he form of premiums to the insurance company.
Employer Self-insured plans are purchased in mass by the employer and can be
more cost effective. Employers fund the health insurance plans
REFERRAL - Answer-Written recommendation to a specialist
Precertification - Answer-A review that looks at whether the procedure could be
performed safely but less expensively in an outpatient setting
Predetermination - Answer-A written request for a verification of benefits
HCPCS CODES BACKGROUND - Answer-have 3 levels
-cpt codes
-hcpcs level ii codes (separate book, ambulance transport, drugs
-category iii codes - tracking ends in "T" for temporary
HCPCS means - Answer-Healthcare Financing Administration
Common
Procedure
Coding
System
Created by Medicare in 1983. Used by Medicaid system also
CPT - Answer-Current Procedural Terminology
-5-digit numeric codes
-Physician services (E&M codes) Evaluation and Management
-Procedures, Diagnostic and Therapeutic
-2 digit modifiers
-modifiers faciliate alteration of a service/procedure due to specific circumstances
FIRST PUBLISHED IN 1966
nomenclature - Answer-The devising or choosing of names for things especially in
science
AMA - Answer-American Medical Association
CPT LAYOUT - Answer-99201-99499 EVAL AND MANAGEMENT
00100-01999 Anesthesia
10021-69990 Surgery 1-69990
70010-79999 Radiology
80047-89398 Pathology (and Lab)
QUESTIONS AND ANSWERS
Electronic Data Interchange - Answer-The transfer of electronic information in a
standard format
Coordination of Benefits - Answer-If patient has more than one insurance policy, the
rule is the primary insurance pays first then secondary pays the rest
CLEAN AND DIRTY CLAIMS - Answer-Dirty Claims are those that are inaccurate,
incomplete or contain other errors, they are delayed because they are sent back to
the provider for corrections and resubmission.
Clean Claims are accurate and complete.
CMS-1500 FORM - Answer-Revised by the National Uniform Claim Committee
(NUCC) submitted to Medicare for claims
BLOCK 11 determines whether a good faith effort has been made to indicate which
is the primary insurance and which is secondary
BLOCK 17 name of the referring or ordering physician goes here. (Stark Law)
BLOCK 17B NPI # National provider Identifier goes here. It is a unique 10-digit code
for providers required by HIPAA
Administration Simplification Compliance Act ASCA - Answer-Part of HIPAA. EST in
2012 mandated that health care claims be submitted electronically. Exception is that
paper claims maybe sent to clearinghouses, which convert the claims into a
standardized electronic format.
2 pieces of information that need to be collected from patients - Answer-FULL NAME
AND DATE OF BIRTH SOCIAL SECURITY #
Verify Insurance! - Answer-Before submitting a claim it is important to make sure that
the insurance is valid and the services are a covered benefit
Birthday Rule - Answer-Applies to parents who both have health insurance and list
children as dependents. The health plan of the parent whos birthday comes first in
the current year is the primary and will be billed first for insurance claims.
3 KINDS OF INSURANCE INFORMATION needed to be collected from Patient -
Answer--Correct Policy number
-Group Number
-Policy effective date
-type of policy
Insurance Premium - Answer-a weekly, monthly or annual cost for the plan or
insurance coverage.
, COINSURANCE PERCENTAGE - Answer-Amount provider is allowed for service
and the amount he was paid. a common % split is 80% for insurance carrier and
20% for patient.
3 Major kinds of government insurance plans - Answer-Medicare
Medicaid
State children's Health insurance Program (SCHIP)
Private Health Insurance vs Employer Self-insured plans - Answer-Private health
insurance is paid by individuals int he form of premiums to the insurance company.
Employer Self-insured plans are purchased in mass by the employer and can be
more cost effective. Employers fund the health insurance plans
REFERRAL - Answer-Written recommendation to a specialist
Precertification - Answer-A review that looks at whether the procedure could be
performed safely but less expensively in an outpatient setting
Predetermination - Answer-A written request for a verification of benefits
HCPCS CODES BACKGROUND - Answer-have 3 levels
-cpt codes
-hcpcs level ii codes (separate book, ambulance transport, drugs
-category iii codes - tracking ends in "T" for temporary
HCPCS means - Answer-Healthcare Financing Administration
Common
Procedure
Coding
System
Created by Medicare in 1983. Used by Medicaid system also
CPT - Answer-Current Procedural Terminology
-5-digit numeric codes
-Physician services (E&M codes) Evaluation and Management
-Procedures, Diagnostic and Therapeutic
-2 digit modifiers
-modifiers faciliate alteration of a service/procedure due to specific circumstances
FIRST PUBLISHED IN 1966
nomenclature - Answer-The devising or choosing of names for things especially in
science
AMA - Answer-American Medical Association
CPT LAYOUT - Answer-99201-99499 EVAL AND MANAGEMENT
00100-01999 Anesthesia
10021-69990 Surgery 1-69990
70010-79999 Radiology
80047-89398 Pathology (and Lab)
