CERTIFIED BILLING & CODING
SPECIALIST EXAM REVIEW WITH
COMPLETE SOLUTIONS
What yare yMedical yEthics? y- ycorrect yanswers y-Standards yof yconduct ybased yon
ymoral yprinciple. ythey yare ygenerally yaccepted yas ya yguide yfor ybehavior ytowards
ypt's, ydr's, ycoworkers, ythe ygov, yand yins yco's
What ydoes yacting ywithin yethical ybehavior yboundaries ymean? y- ycorrect yanswers y-
Carrying yout yone's yresponsibilities ywith yintegrity, ydignity, yrespect, yhonesty,
ycompetence, yfairness, yand ytrust
Compliance yregulations y- ycorrect yanswers y-Most ybilling-related ycases yare ybased
yon yHIPAA yand yFalse yClaims yAct
Health yInsurance yPortability y& yAccountability yAct y(HIPAA) y- ycorrect yanswers y-
Enacted yin y1996, ycreated yby ythe yHealth yCare yFraud y& yAbuse yControl yProgram-
,yenacted yto ycheck yfor yfraud yand yabuse yin ythe yMedicare/ yMedicaid yPrograms yand
yprivate ypayers
What yare y2 yprovisions yof yHIPAA? y- ycorrect yanswers y-Title y1: yInsurance yReform
Title y2: yAdministrative ySimplification
What yis yTitle y1 yof yHIPAA? y- ycorrect yanswers y-Insurance yReform-primary ypurpose
yis yto yprovide ycontinuous ycoverage yfor yworkers y& ytheir ydependents ywhen ythey
ychange yor ylose yjobs. yAlso yLimits ythe yuse yof ypre-existing yconditions yexclusions y
Prohibits ydiscrimination yfrom ypast yor ypresent ypoor yhealth y
Guarantees ycertain yemployees/ yindividual ythe yright yto ypurchase ynew yhealth
yinsurance ycoverage yafter ylosing yjob
Allows yrenewal yof yhealth yinsurance ycoverage yregardless yof yan yindividuals yhealth
ycondition ythat yis ycovered yunder ythe yparticular ypolicy
What yis yTitle y2 yof yHIPAA? y- ycorrect yanswers y-Administrative ySimplification- ygoal
yis yto yfocus yon ythe yhealth ycare ypractice ysetting yto yreduce yadministrative ycost y&
yburdens. y
Has y2 yparts
1) ydevelopment yand yimplementation yof ystandardized yhealth yrelated yfinancial y&
yadministrative yactivities yelectronically
2) yimplementation yof yprivacy y& ysecurity yprocedures yto yprevent ythe ymisuse yof
yhealth yinfo yby yensuring yconfidentiality
What yis ythe yFalse yClaims yAct y(FCA)? y- ycorrect yanswers y-Federal ylaw ythat
yprohibits ysubmitting ya yfraudulent yclaim yor ymaking ya yfalse ystatement yor
yrepresentation yin yconnection ywith ya yclaim. yAlso yprotects y& yrewards ywhistle-
blowers
What yis ythe yNational yCorrect yCoding yInitiative y(NCCI)? y- ycorrect yanswers y-
Developed yby yCMS yto ypromote ythe ynational ycorrect ycoding ymethodologies y& yto
ycontrol yimproper ycoding ythat ylead yto yinappropriate ypayment yof yPart yB yhealth
yinsurance yclaims
How ymany yedits ydoes yNCCI yinclude? y- ycorrect yanswers y-2: y
1.Column y1/ yColumn y2 y(previously ycalled yComprehensive/ yComponent) yEdits
y2.Mutually yExclusive yEdits
Column y1/ yColumn y2 yedits y(NCCI) y- ycorrect yanswers y-Identifies ycode ypairs ythat
yshould ynot ybe ybilled ytogether ybecause y1 ycode y(Column y1) yincludes yall ythe
yservices ydescribed yby yanother ycode y(Column y2)
Mutually yExclusive yEdits y(NCCI) y- ycorrect yanswers y-ID's ycode ypairs ythat, yfor
yclinical yreasons, yare yunlikely yto ybe ypreformed yon ythe ysame ypatient yon ythe ysame
yday
,What yare ythe ypossible yconsequences yof yinaccurate ycoding yand yincorrect ybilling?
y- ycorrect yanswers y-delayed yprocessing y& ypayment yof yclaims, yreduced ypayments,
ydenied yclaims yfine yand yor yimprisonment, yexclusion yfrom ypayer's yprograms, yloss
yof yDr.'s ylicense yto ypractice ymedicine
Who yhas ythe ytask yof yinvestigate yand yprosecuting yhealth ycare yfraud y& yabuse? y-
ycorrect yanswers y-The yOffice yof yInspector yGeneral y(OIG)
Fraud y- ycorrect yanswers y-knowingly y& yintentionally ydeceiving yor ymisrepresenting
yinfo ythat ymay yresult yin yunauthorized ybenefits. yit yis ya yfelony yand ycan yresult yin
yfines yand yor yprison
Who yaudits yclaims? y- ycorrect yanswers y-State y& yFederal yagencies yas ywell yas
yprivate yinsurance ycompanies
What yare ycommon yforms yof yfraud? y- ycorrect yanswers y-billing yfor yservices ynot
yfurnished, yunbundling, yand ymisrepresenting ydiagnosis yto yjustify ypayment
Abuse y- ycorrect yanswers y-incidences yor ypractices, ynot yusually yconsidered
yfraudulent, ythat yare yinconsistent ywith ythe yaccepted ymedical ybusiness yor yfiscal
ypractices yin ythe yindustry
What yare yexamples yof yAbuse? y- ycorrect yanswers y-submitting ya yclaim yfor
yservices/ yprocedures yperformed ythat yis ynot ymedically ynecessary, yand yexcessive
ycharges yfor yservices, yequipment yor ysupplies
What yis ya ymethod yuse yto yminimize ydanger, yhazards yand yliabilities yassociated
ywith yabuse? y- ycorrect yanswers y-Risk yManagement
Patient yConfidentiality y- ycorrect yanswers y-All ypatient's yhave yright yto yprivacy yand
yall yinfo yshould yremain yprivileged. yOnly ydiscuss ypatient yinfo ywhen ynecessary yto
ydo yjob. yObtain ya ysigned yconsent yform yto yrelease ymedical yinfo yto yinsurance
ycompany yor yother yindividual
When ymay ya yprovider yuse yPHI y(Protected yHealth yInformation) ywithout yspecific
yauthorization yunder ythe yHIPAA yPrivacy yRule? y- ycorrect yanswers y-When yusing
yTPO, yTreatment y(primarily yfor ythe ypurpose yof ydiscussion yof ypatient's ycase ywith
yother yDr's) y
Payment y(providers ysubmit yclaims yon ybehalf yof ypatients)
Operations y(for ypurposes ysuch yas ytraining ystaff yand yquality yimprovement)
What yis yEmployer yLiability? y- ycorrect yanswers y-Means yphysicians yare ylegally
yresponsible yfor ytheir yown yconduct yand yany yactions yof ytheir yemployees
y(designee) yperformed ywithin ythe ycontext yof ytheir yemployment. yReferred yto yas
y"vicarious yliability" yA.K.A y" yrespondent ysuperior"- y"let ythe ymaster yanswer". yMeans
yemployee ycan ybe ysued y& ybrought yto ytrial
, What yis yEmployee yLiability? y- ycorrect yanswers y-"Errors y& yOmissions yInsurance"-
yprotection yagainst yloss yof ymonies ycaused yby yfailure ythrough yerror yor
yunintentional yomission yon ythe ypart yof ythe yindividual yor yservice ysubmitting ythe
yclaim. y***Some yDr.'s ycontract ywith ya ybilling yservice y(clearinghouse) yto yhandle
yclaims ysubmission yand ysome yagreements ycontain ya yclause ystating ythat ythe yDr.
ywill yhold ythe yco yharmless yfrom y"liability yresulting yfrom yclaims ysubmitted yby ythe
yservice yfor yany yaccount", ymeans yDr. yis yresponsible yfor ymistakes ymade yby ybilling
yservice, yerrors yand yomissions yis ynot yneeded yin ythe yinstance.***
However, yif ythe yDr. yever yasks ythe yinsurance ybiller yto ydo ythe yleast ybit
yquestionable, ysuch yas ywrite yoff ypatients ybalances yfor ycertain ypatients
yautomatically, ymake ysure yyou yhave ya ylegal ydocument yor ysigned ywaiver yof
yliability yrelieving yyou yof yresponsibility yfor ysuch yactions.
What yis ya yMedical yRecord y& ywhat yis yit ycomprised yof? y- ycorrect yanswers y-
Documentation yof ythe ypatients ysocial yand ymedical yhistory, yfamily yhistory, yphysical
yexam yfindings, yprogress ynotes, yradiology yand ylab yresults, yconsultation yreports
yand ycorrespondence yto ypatients
Is ythe yforemost ytool yof yclinical ycare yand ycommunication
What yis ya ymedical yreport? y- ycorrect yanswers y-part yof ythe ymedical yrecord y& yis ya
ypermanent ylegal ydocument ythat yformally ystates ythe yconsequences yof ythe ypatients
yexam yor ytreatment yin yletter yor yreport yform
IT yIS yTHIS yRECORD yTHAT yPROVIDES yINFO yNEEDED yTO yCOMPLETE yTHE
yINSURANCE yCLAIM yFORM
Reasons yfor yDocumentation y- ycorrect yanswers y-Important ythat yevery ypatient yseen
yby yDr. yhas ycomprehensive ylegible ydocumentation yabout ypatients yillness,
ytreatment yand yplans yfor yfollowing yreasons:
* yAvoidance yof ydenied yor ydelayed ypayment yby yinsurance ycompany yinvestigating
ythe ymedical ynecessity yof yservice
* yEnforcement yof ymedical yrecord-keeping yrules yby yinsurance ycompany's yrequiring
yaccurate ydocumentation ythat ysupports yprocedure y& ydiagnosis ycodes
* ySubpoena yof ymedical yrecords yby ystate yinvestigators yor ythe ycourt yfor yreview
* yDefense yof yprofessional yliability yclaim
Retention yof yMedical yRecords y- ycorrect yanswers y-Is ygoverned yby ystate y& ylocal
ylaws y& ymay yvary yfrom ystate-to-state. yMost yDr. yare yrequired yto yretain yrecords
yindefinitely, ydeceased ypatient yrecords yshould ybe ykept yfor yat yleast y5 yyears
-algia y- ycorrect yanswers y-pain
-emia y- ycorrect yanswers y-blood ycondition
-itis y- ycorrect yanswers y-inflammation
SPECIALIST EXAM REVIEW WITH
COMPLETE SOLUTIONS
What yare yMedical yEthics? y- ycorrect yanswers y-Standards yof yconduct ybased yon
ymoral yprinciple. ythey yare ygenerally yaccepted yas ya yguide yfor ybehavior ytowards
ypt's, ydr's, ycoworkers, ythe ygov, yand yins yco's
What ydoes yacting ywithin yethical ybehavior yboundaries ymean? y- ycorrect yanswers y-
Carrying yout yone's yresponsibilities ywith yintegrity, ydignity, yrespect, yhonesty,
ycompetence, yfairness, yand ytrust
Compliance yregulations y- ycorrect yanswers y-Most ybilling-related ycases yare ybased
yon yHIPAA yand yFalse yClaims yAct
Health yInsurance yPortability y& yAccountability yAct y(HIPAA) y- ycorrect yanswers y-
Enacted yin y1996, ycreated yby ythe yHealth yCare yFraud y& yAbuse yControl yProgram-
,yenacted yto ycheck yfor yfraud yand yabuse yin ythe yMedicare/ yMedicaid yPrograms yand
yprivate ypayers
What yare y2 yprovisions yof yHIPAA? y- ycorrect yanswers y-Title y1: yInsurance yReform
Title y2: yAdministrative ySimplification
What yis yTitle y1 yof yHIPAA? y- ycorrect yanswers y-Insurance yReform-primary ypurpose
yis yto yprovide ycontinuous ycoverage yfor yworkers y& ytheir ydependents ywhen ythey
ychange yor ylose yjobs. yAlso yLimits ythe yuse yof ypre-existing yconditions yexclusions y
Prohibits ydiscrimination yfrom ypast yor ypresent ypoor yhealth y
Guarantees ycertain yemployees/ yindividual ythe yright yto ypurchase ynew yhealth
yinsurance ycoverage yafter ylosing yjob
Allows yrenewal yof yhealth yinsurance ycoverage yregardless yof yan yindividuals yhealth
ycondition ythat yis ycovered yunder ythe yparticular ypolicy
What yis yTitle y2 yof yHIPAA? y- ycorrect yanswers y-Administrative ySimplification- ygoal
yis yto yfocus yon ythe yhealth ycare ypractice ysetting yto yreduce yadministrative ycost y&
yburdens. y
Has y2 yparts
1) ydevelopment yand yimplementation yof ystandardized yhealth yrelated yfinancial y&
yadministrative yactivities yelectronically
2) yimplementation yof yprivacy y& ysecurity yprocedures yto yprevent ythe ymisuse yof
yhealth yinfo yby yensuring yconfidentiality
What yis ythe yFalse yClaims yAct y(FCA)? y- ycorrect yanswers y-Federal ylaw ythat
yprohibits ysubmitting ya yfraudulent yclaim yor ymaking ya yfalse ystatement yor
yrepresentation yin yconnection ywith ya yclaim. yAlso yprotects y& yrewards ywhistle-
blowers
What yis ythe yNational yCorrect yCoding yInitiative y(NCCI)? y- ycorrect yanswers y-
Developed yby yCMS yto ypromote ythe ynational ycorrect ycoding ymethodologies y& yto
ycontrol yimproper ycoding ythat ylead yto yinappropriate ypayment yof yPart yB yhealth
yinsurance yclaims
How ymany yedits ydoes yNCCI yinclude? y- ycorrect yanswers y-2: y
1.Column y1/ yColumn y2 y(previously ycalled yComprehensive/ yComponent) yEdits
y2.Mutually yExclusive yEdits
Column y1/ yColumn y2 yedits y(NCCI) y- ycorrect yanswers y-Identifies ycode ypairs ythat
yshould ynot ybe ybilled ytogether ybecause y1 ycode y(Column y1) yincludes yall ythe
yservices ydescribed yby yanother ycode y(Column y2)
Mutually yExclusive yEdits y(NCCI) y- ycorrect yanswers y-ID's ycode ypairs ythat, yfor
yclinical yreasons, yare yunlikely yto ybe ypreformed yon ythe ysame ypatient yon ythe ysame
yday
,What yare ythe ypossible yconsequences yof yinaccurate ycoding yand yincorrect ybilling?
y- ycorrect yanswers y-delayed yprocessing y& ypayment yof yclaims, yreduced ypayments,
ydenied yclaims yfine yand yor yimprisonment, yexclusion yfrom ypayer's yprograms, yloss
yof yDr.'s ylicense yto ypractice ymedicine
Who yhas ythe ytask yof yinvestigate yand yprosecuting yhealth ycare yfraud y& yabuse? y-
ycorrect yanswers y-The yOffice yof yInspector yGeneral y(OIG)
Fraud y- ycorrect yanswers y-knowingly y& yintentionally ydeceiving yor ymisrepresenting
yinfo ythat ymay yresult yin yunauthorized ybenefits. yit yis ya yfelony yand ycan yresult yin
yfines yand yor yprison
Who yaudits yclaims? y- ycorrect yanswers y-State y& yFederal yagencies yas ywell yas
yprivate yinsurance ycompanies
What yare ycommon yforms yof yfraud? y- ycorrect yanswers y-billing yfor yservices ynot
yfurnished, yunbundling, yand ymisrepresenting ydiagnosis yto yjustify ypayment
Abuse y- ycorrect yanswers y-incidences yor ypractices, ynot yusually yconsidered
yfraudulent, ythat yare yinconsistent ywith ythe yaccepted ymedical ybusiness yor yfiscal
ypractices yin ythe yindustry
What yare yexamples yof yAbuse? y- ycorrect yanswers y-submitting ya yclaim yfor
yservices/ yprocedures yperformed ythat yis ynot ymedically ynecessary, yand yexcessive
ycharges yfor yservices, yequipment yor ysupplies
What yis ya ymethod yuse yto yminimize ydanger, yhazards yand yliabilities yassociated
ywith yabuse? y- ycorrect yanswers y-Risk yManagement
Patient yConfidentiality y- ycorrect yanswers y-All ypatient's yhave yright yto yprivacy yand
yall yinfo yshould yremain yprivileged. yOnly ydiscuss ypatient yinfo ywhen ynecessary yto
ydo yjob. yObtain ya ysigned yconsent yform yto yrelease ymedical yinfo yto yinsurance
ycompany yor yother yindividual
When ymay ya yprovider yuse yPHI y(Protected yHealth yInformation) ywithout yspecific
yauthorization yunder ythe yHIPAA yPrivacy yRule? y- ycorrect yanswers y-When yusing
yTPO, yTreatment y(primarily yfor ythe ypurpose yof ydiscussion yof ypatient's ycase ywith
yother yDr's) y
Payment y(providers ysubmit yclaims yon ybehalf yof ypatients)
Operations y(for ypurposes ysuch yas ytraining ystaff yand yquality yimprovement)
What yis yEmployer yLiability? y- ycorrect yanswers y-Means yphysicians yare ylegally
yresponsible yfor ytheir yown yconduct yand yany yactions yof ytheir yemployees
y(designee) yperformed ywithin ythe ycontext yof ytheir yemployment. yReferred yto yas
y"vicarious yliability" yA.K.A y" yrespondent ysuperior"- y"let ythe ymaster yanswer". yMeans
yemployee ycan ybe ysued y& ybrought yto ytrial
, What yis yEmployee yLiability? y- ycorrect yanswers y-"Errors y& yOmissions yInsurance"-
yprotection yagainst yloss yof ymonies ycaused yby yfailure ythrough yerror yor
yunintentional yomission yon ythe ypart yof ythe yindividual yor yservice ysubmitting ythe
yclaim. y***Some yDr.'s ycontract ywith ya ybilling yservice y(clearinghouse) yto yhandle
yclaims ysubmission yand ysome yagreements ycontain ya yclause ystating ythat ythe yDr.
ywill yhold ythe yco yharmless yfrom y"liability yresulting yfrom yclaims ysubmitted yby ythe
yservice yfor yany yaccount", ymeans yDr. yis yresponsible yfor ymistakes ymade yby ybilling
yservice, yerrors yand yomissions yis ynot yneeded yin ythe yinstance.***
However, yif ythe yDr. yever yasks ythe yinsurance ybiller yto ydo ythe yleast ybit
yquestionable, ysuch yas ywrite yoff ypatients ybalances yfor ycertain ypatients
yautomatically, ymake ysure yyou yhave ya ylegal ydocument yor ysigned ywaiver yof
yliability yrelieving yyou yof yresponsibility yfor ysuch yactions.
What yis ya yMedical yRecord y& ywhat yis yit ycomprised yof? y- ycorrect yanswers y-
Documentation yof ythe ypatients ysocial yand ymedical yhistory, yfamily yhistory, yphysical
yexam yfindings, yprogress ynotes, yradiology yand ylab yresults, yconsultation yreports
yand ycorrespondence yto ypatients
Is ythe yforemost ytool yof yclinical ycare yand ycommunication
What yis ya ymedical yreport? y- ycorrect yanswers y-part yof ythe ymedical yrecord y& yis ya
ypermanent ylegal ydocument ythat yformally ystates ythe yconsequences yof ythe ypatients
yexam yor ytreatment yin yletter yor yreport yform
IT yIS yTHIS yRECORD yTHAT yPROVIDES yINFO yNEEDED yTO yCOMPLETE yTHE
yINSURANCE yCLAIM yFORM
Reasons yfor yDocumentation y- ycorrect yanswers y-Important ythat yevery ypatient yseen
yby yDr. yhas ycomprehensive ylegible ydocumentation yabout ypatients yillness,
ytreatment yand yplans yfor yfollowing yreasons:
* yAvoidance yof ydenied yor ydelayed ypayment yby yinsurance ycompany yinvestigating
ythe ymedical ynecessity yof yservice
* yEnforcement yof ymedical yrecord-keeping yrules yby yinsurance ycompany's yrequiring
yaccurate ydocumentation ythat ysupports yprocedure y& ydiagnosis ycodes
* ySubpoena yof ymedical yrecords yby ystate yinvestigators yor ythe ycourt yfor yreview
* yDefense yof yprofessional yliability yclaim
Retention yof yMedical yRecords y- ycorrect yanswers y-Is ygoverned yby ystate y& ylocal
ylaws y& ymay yvary yfrom ystate-to-state. yMost yDr. yare yrequired yto yretain yrecords
yindefinitely, ydeceased ypatient yrecords yshould ybe ykept yfor yat yleast y5 yyears
-algia y- ycorrect yanswers y-pain
-emia y- ycorrect yanswers y-blood ycondition
-itis y- ycorrect yanswers y-inflammation
