CBCS Exam Study Guide || QUESTIONS WITH 100%
VERIFIED ANSWERS; A+ GUARANTEED!!
Medical Billing & Coding as a Career correct answers *Claims assistant professional or
claims manager, *Coding Specialist, * Collection Manager, *Electronic Claims Processor,
*Insurance Billing Specialist, * Insurance Coordinator, *Insurance Counselor, *Medical
Biller, *Medical & Financial Records Manager, * Billing & Coding Specialist
What are Medical Ethics? correct answers Standards of conduct based on moral principle.
They are generally accepted as a guide for behavior towards pt's, dr's, co-workers, the gov,
and ins co's.
What does acting within ethical behavior boundaries mean? correct answers carrying out
one's responsibilities w/ integrity, dignity, respect, honesty, competence, fairness, & trust.
Legal Aspects of of Medical Billing & Coding: correct answers ...
Compliance regulations: correct answers Most billing-related cases are based on HIPPA and
False Claims Act
Health Insurance Portability & Accountability Act (HIPPA) correct answers Enacted in 1996,
created by the Health Care Fraud & Abuse Control Program-enacted to check for fraud and
abuse in the Medicare/Medicaid Programs and private payers
What are the 2 provisions of HIPPA? correct answers Title I: Insurance Reform
Title II: Administrative Simplification
What is Title I of HIPPA? correct answers Insurance Reform-primary purpose is to provide
continuous ins coverage for worker & their dependents when they change or lose jobs. Also
*Limits the use of preexisting conditions exclusions *Prohibits discrimination from past or
present poor health *Guarantees certain employees/indv the right to purchase new health ins
coverage after losing job *Allows renewal of health ins cov regardless of an indv's health
cond. that is covered under the particular policy.
What is Title II of HIPPA? correct answers Administrative Simplification-goal is to focus on
the health care practice setting to reduce administrative cost & burdens. Has 2 parts- 1)
development and implementation of standardized health-related financial & administrative
activities electronically 2) Implementation of privacy & security procedures to prevent the
misuse of health info by ensuring confidentiality
What is the False Claims Act (FCA)? correct answers Federal law that prohibits submitting a
fraudulent claim or making a false statement or representation in connection w/ a claim. Also
protects & rewards whistle-blowers.
What is the National Correct Coding Initiative (NCCI)? correct answers Developed by CMS
to promote the national correct coding methodologies & to control improper coding that lead
to inappropriate payment of Part B health ins claims.
,How many edits does NCCI include? correct answers 2: 1)Column 1/Column 2 (prev called
Comprehensive/Component) Edits
2) Mutually Exclusive Edits
Column 1/Column 2 edits (NCCI) correct answers Identifies code pairs that should not be
billed together b/c 1 code (Column 1) includes all the services described by another code
(Column 2)
Mutually Exclusive Edits (NCCI) correct answers ID's code pairs that, for clinical reasons,
are unlikely to be performed on the same pt on the same day
What are the possible consequences of inaccurate coding and incorrect billing? correct
answers *delayed processing & payment of claims *reduced payments, denied claims *fine
and/or imprisonment *exclusion from payer's programs, loss of dr's license to practice med
Who has the task of investigate and prosecuting health care fraud & abuse? correct answers
The Office of Inspector General (OIG)
Fraud correct answers knowingly & intentionally deceiving or misrepresenting info that may
result in unauthorized benefits. It is a felony and can result in fines and/or prison.
Who audits claims? correct answers State & federal agencies as well as private ins co's
What are common forms of fraud? correct answers billing for services not furnished,
unbundling, & misrepresenting diagnosis to justify payment
Abuse correct answers incidences or practices, not usually considered fraudulent, that are
inconsistent w/ the accepted medical business or fiscal practices in the industry.
What are examples of Abuse? correct answers submitting a claim for services/procedures
performed that is not medically necessary, and excessive charges for services, equipment or
supplies.
What is a method use to minimize danger, hazards, & liabilities associated w/ abuse? correct
answers Risk Management
Patient Confidentiality correct answers All pt's have right to privacy & all info should remain
privileged. Only discuss pt info when necessary to do job. Obtain a signed consent form to
release medical info to ins co or other individual.
When may providers use PHI (Protected Health Information) w/o specific authorization
under the HIPPA Privacy Rule? correct answers When using for TPO, Treatment (primarily
for the purpose of discussion of pt's case w/ other dr's) Payment (providers submit claims on
behalf of pt's) & Operations (for purposes such as training staff & quality improvement)
What is Employer Liability? correct answers Means physicians are legally responsible for
their own conduct and any actions of their employees (designee) performed w/in the context
of their employment. Referred to as "vicarious liability. A.K.A "respondent superior"-"let the
master answer". Means employee can be sued & brought to trial
, What is Employee Liability? correct answers "Errors & Omissions Insurance"-protection
against loss of monies caused by failure through error or unintentional omission on the part of
the indv or service submitting the claim. ****Some dr's contract w/ a billing service
(clearinghouse) to handle claims submission, & some agreements contain a clause stating that
the dr will hold the co harmless from "liability resulting from claims submitted by the service
for any account", means dr is responsible for mistakes made by billing service, errors &
omissions is not needed in the instance. ******However, if dr ever asks the ins biller to do
the least bit questionable, such as write of pt's balances for certain pt's automatically, make
sure you have a legal document or signed waiver of liability relieving you of responsibility
for such actions.
What is a Medical Record & what is it comprised of? correct answers documentation of the
pt's social & medical history, family history, physical exam findings, progress notes,
radiology & lab results, consultation reports and correspondence to pt- Is the foremost tool of
clinical care and communication.
What is a medical report? correct answers part of the medical record & is a permanent legal
document that formally states the consequences of the pt's exam or treatment in letter or
report form. IT IS THIS RECORD THAT PROVIDES INFO NEEDED TO COMPLETE
THE INS CLAIM FORM.
Reasons for Documentation correct answers Important that every pt seen by dr has
comprehensive legible documentation about pt's illness, treatment, & plans for following
reasons:
*Avoidance of denied or delayed payment by ins co investigating the medical necessity of
services
*Enforcement of medical record-keeping rules by ins co requiring accurate documentation
that supports procedure & diagnosis codes.
*Subpoena of medical records by state investigators or the court for review
*Defense of professional liability claim
Retention Of Medical Records correct answers Is governed by state & local laws & may vary
from state-to-state. Most dr are required to retain records indefinitely, deceased pt records
should be kept for @ least 5 years
Med Term correct answers ...
Diagnosis suffixes: correct answers ...
-algia correct answers pain
-emia correct answers blood condition
-itis correct answers inflammation
-megaly correct answers enlargement
-meter correct answers measure
-oma correct answers tumor, mass
VERIFIED ANSWERS; A+ GUARANTEED!!
Medical Billing & Coding as a Career correct answers *Claims assistant professional or
claims manager, *Coding Specialist, * Collection Manager, *Electronic Claims Processor,
*Insurance Billing Specialist, * Insurance Coordinator, *Insurance Counselor, *Medical
Biller, *Medical & Financial Records Manager, * Billing & Coding Specialist
What are Medical Ethics? correct answers Standards of conduct based on moral principle.
They are generally accepted as a guide for behavior towards pt's, dr's, co-workers, the gov,
and ins co's.
What does acting within ethical behavior boundaries mean? correct answers carrying out
one's responsibilities w/ integrity, dignity, respect, honesty, competence, fairness, & trust.
Legal Aspects of of Medical Billing & Coding: correct answers ...
Compliance regulations: correct answers Most billing-related cases are based on HIPPA and
False Claims Act
Health Insurance Portability & Accountability Act (HIPPA) correct answers Enacted in 1996,
created by the Health Care Fraud & Abuse Control Program-enacted to check for fraud and
abuse in the Medicare/Medicaid Programs and private payers
What are the 2 provisions of HIPPA? correct answers Title I: Insurance Reform
Title II: Administrative Simplification
What is Title I of HIPPA? correct answers Insurance Reform-primary purpose is to provide
continuous ins coverage for worker & their dependents when they change or lose jobs. Also
*Limits the use of preexisting conditions exclusions *Prohibits discrimination from past or
present poor health *Guarantees certain employees/indv the right to purchase new health ins
coverage after losing job *Allows renewal of health ins cov regardless of an indv's health
cond. that is covered under the particular policy.
What is Title II of HIPPA? correct answers Administrative Simplification-goal is to focus on
the health care practice setting to reduce administrative cost & burdens. Has 2 parts- 1)
development and implementation of standardized health-related financial & administrative
activities electronically 2) Implementation of privacy & security procedures to prevent the
misuse of health info by ensuring confidentiality
What is the False Claims Act (FCA)? correct answers Federal law that prohibits submitting a
fraudulent claim or making a false statement or representation in connection w/ a claim. Also
protects & rewards whistle-blowers.
What is the National Correct Coding Initiative (NCCI)? correct answers Developed by CMS
to promote the national correct coding methodologies & to control improper coding that lead
to inappropriate payment of Part B health ins claims.
,How many edits does NCCI include? correct answers 2: 1)Column 1/Column 2 (prev called
Comprehensive/Component) Edits
2) Mutually Exclusive Edits
Column 1/Column 2 edits (NCCI) correct answers Identifies code pairs that should not be
billed together b/c 1 code (Column 1) includes all the services described by another code
(Column 2)
Mutually Exclusive Edits (NCCI) correct answers ID's code pairs that, for clinical reasons,
are unlikely to be performed on the same pt on the same day
What are the possible consequences of inaccurate coding and incorrect billing? correct
answers *delayed processing & payment of claims *reduced payments, denied claims *fine
and/or imprisonment *exclusion from payer's programs, loss of dr's license to practice med
Who has the task of investigate and prosecuting health care fraud & abuse? correct answers
The Office of Inspector General (OIG)
Fraud correct answers knowingly & intentionally deceiving or misrepresenting info that may
result in unauthorized benefits. It is a felony and can result in fines and/or prison.
Who audits claims? correct answers State & federal agencies as well as private ins co's
What are common forms of fraud? correct answers billing for services not furnished,
unbundling, & misrepresenting diagnosis to justify payment
Abuse correct answers incidences or practices, not usually considered fraudulent, that are
inconsistent w/ the accepted medical business or fiscal practices in the industry.
What are examples of Abuse? correct answers submitting a claim for services/procedures
performed that is not medically necessary, and excessive charges for services, equipment or
supplies.
What is a method use to minimize danger, hazards, & liabilities associated w/ abuse? correct
answers Risk Management
Patient Confidentiality correct answers All pt's have right to privacy & all info should remain
privileged. Only discuss pt info when necessary to do job. Obtain a signed consent form to
release medical info to ins co or other individual.
When may providers use PHI (Protected Health Information) w/o specific authorization
under the HIPPA Privacy Rule? correct answers When using for TPO, Treatment (primarily
for the purpose of discussion of pt's case w/ other dr's) Payment (providers submit claims on
behalf of pt's) & Operations (for purposes such as training staff & quality improvement)
What is Employer Liability? correct answers Means physicians are legally responsible for
their own conduct and any actions of their employees (designee) performed w/in the context
of their employment. Referred to as "vicarious liability. A.K.A "respondent superior"-"let the
master answer". Means employee can be sued & brought to trial
, What is Employee Liability? correct answers "Errors & Omissions Insurance"-protection
against loss of monies caused by failure through error or unintentional omission on the part of
the indv or service submitting the claim. ****Some dr's contract w/ a billing service
(clearinghouse) to handle claims submission, & some agreements contain a clause stating that
the dr will hold the co harmless from "liability resulting from claims submitted by the service
for any account", means dr is responsible for mistakes made by billing service, errors &
omissions is not needed in the instance. ******However, if dr ever asks the ins biller to do
the least bit questionable, such as write of pt's balances for certain pt's automatically, make
sure you have a legal document or signed waiver of liability relieving you of responsibility
for such actions.
What is a Medical Record & what is it comprised of? correct answers documentation of the
pt's social & medical history, family history, physical exam findings, progress notes,
radiology & lab results, consultation reports and correspondence to pt- Is the foremost tool of
clinical care and communication.
What is a medical report? correct answers part of the medical record & is a permanent legal
document that formally states the consequences of the pt's exam or treatment in letter or
report form. IT IS THIS RECORD THAT PROVIDES INFO NEEDED TO COMPLETE
THE INS CLAIM FORM.
Reasons for Documentation correct answers Important that every pt seen by dr has
comprehensive legible documentation about pt's illness, treatment, & plans for following
reasons:
*Avoidance of denied or delayed payment by ins co investigating the medical necessity of
services
*Enforcement of medical record-keeping rules by ins co requiring accurate documentation
that supports procedure & diagnosis codes.
*Subpoena of medical records by state investigators or the court for review
*Defense of professional liability claim
Retention Of Medical Records correct answers Is governed by state & local laws & may vary
from state-to-state. Most dr are required to retain records indefinitely, deceased pt records
should be kept for @ least 5 years
Med Term correct answers ...
Diagnosis suffixes: correct answers ...
-algia correct answers pain
-emia correct answers blood condition
-itis correct answers inflammation
-megaly correct answers enlargement
-meter correct answers measure
-oma correct answers tumor, mass
