CPB Practice EXAM B Top exam Questions and answers, 100% Accurate, rated A

CPB Practice EXAM B Top exam Questions and answers, 100% Accurate, rated A What is the term for the total amount of covered medical expenses a policyholder must pay each year out-of-pocket before the health insurance company begins to pay any benefits? A. Copayment B. Deductible C. Secondary Payment D. Coinsurance - -A deductible is the amount a policyholder pays for health care services before the health insurance begins to pay. Which type of insurance covers physicians and other healthcare professionals for liability as to claims arising from patient treatment? A. Business liability B. Bonding C. Medical malpractice D. Workers' compensation - -Medical malpractice insurance is a type of liability insurance that covers physicians and other healthcare professionals for liability as to claims arising from patient treatment. Which of the following does NOT fall under group policy insurance? I. The premium is paid for by the employee. II. The premium is paid for (or partially paid for) by an employer. III. The employer selects the plan(s) to offer to employees. IV. Physical exams and medical history questionnaires are a mandatory part of the application process. V. V. Employee can make changes to the policy. VI. The employee's spouse and children are not eligible for coverage. A. III, IV, V B. II - VI C. II, IV, V D. I, IV, V, VI - -Group health insurance coverage is a type of health policy that is purchased by an employer and is offered to eligible employees of the company, and to eligible dependents of employees. With group health insurance, the employer selects the plan (or plans) to offer to employees. With an individual policy, you are the only one who can make changes to your policy and you are the only one who can cancel the coverage. You have full control over your own policy. Applicants for individual health insurance will need to complete a medical history questionnaire and have a physical exam when applying for coverage. Dr. Wallace is in a capitation contract with Belleview Managed Care Health Plan.He received $25,000 from the health plan to provide services for the 175 enrollees on the health plan. The services provided by Dr. Wallace to the enrollees cost $23,000. Based on the information, what must be done? A. Dr. Wallace can keep the $2,000 profit under the terms of the capitated plan. B. Dr. Wallace experienced a loss under the capitated plan and will need to pay $2,000 to the health plan. C. Dr. Wallace will need to payout the $2,000 to the 175 enrollees. D. Dr. Wallace is required to put the $2,000 in a mutual fund. - -A capitated plan is where a provider accepts a pre-established payment for providing healthcare services to enrollees in a health insurance plan. It is a fixed, pre-arranged monthly payment received by a physician, clinic, or hospital per patient enrolled in a health plan with a capitated contract. Monthly payment is calculated one year in advance and remains fixed for that year, regardless of how often the patient needs services. If the provided services cost less than the capitation amount, there is profit the provider can keep. If the services by the provider to enrollees cost more than the capitation amount the physician loses money. What is the deadline for filing a Medicare claim? A. One year from the date of service B. 30 days from the date of service C. 90 days from the date of service D. Two years from the date of service - -Medicare claims must be filed no later than 12 months (or 1 full calendar year) after the date when the services were provided. If a claim isn't filed within this time limit, Medicare can't pay its share. For example, if you see your doctor on February 1, 2017 the Medicare claim for that visit must be filed no later than February, 1, 2018. A provider sees a patient who has TRICARE Standard. The provider is not contracted with TRICARE but is certified by the regional TRICARE Managed Care Support Contractor (MCSC). The provider charges $200 for the office visit. TRICARE allows $160 and pays $140. How much can the provider bill the patient for? A. $0.00 B. $20.00 C. $60.00 D. $160.00 - -TRICARE non-network providers must be certified by the regional TRICARE MCSC but is not required to accept the TRICARE allowable charge. Because TRICARE paid $140, the difference between the charge and the payment can be billed to the patient. Non-network providers can choose to participate on a claim-by-claim basis. What organization is responsible in evaluating the medical necessity, appropriateness, and efficiency of the use of healthcare services and procedures? A. Utilization Review Organization B. External Quality Review Organization C. Quality Assurance Organization D. Managed Care Organization - -A Utilization Review Organization (URO) is an entity that has established one or more utilization review programs, to monitor and evaluate the medical necessity, appropriateness, and efficiency of the use of health care services and procedures. Medicaid providers are forbidden by law to: A. Refer patients to specialists B. Bill patients for non-covered services C. Balance bill patients D. Accept co-payments - -Medicaid providers are forbidden by law to bill patients for Medicaid covered services (balance billing). A patient may be billed for any non-covered procedures. States are allowed to require deductibles, co-insurance, or co-payments for certain services provided to some Medicaid recipients. Which statement is FALSE about Local Coverage Determinations (LCDs)? A. LCDs list covered codes, but do not include coding guidelines. B. If a Medicare Administrative Contractor (MAC) develops an LCD, it applies only within the area serviced by that contractor. C. National Coverage Determination (NCD) takes precedence when an NCD and LCD exist for the same procedure. D. CMS develops LCDs when there is no National Coverage Determination - -Medicare Administrative Contractors (MACs) develop LCDs when there is no National Coverage Determination (NCD) or when there is a need to further define an NCD. When a minor procedure is performed on a Medicare patient, what is the global period and what timeframe is covered? A. 90-day global period - the day of the procedure and 90 days following the procedure. B. 10-day global period - the day before the procedure and 10 days following the procedure. C. 90-day global period - the day before the procedure and 90 days following the procedure. D. 10-day global period - the day of the procedure and 10 days following the procedure. - -Minor procedures for Medicare can fall under 0 or 10-days. 10-day global period has no pre-operative period; it is the day of the procedure and count the 10 days following the day of the procedure. Major procedures for Medicare fall under a 90 day global period. Count 1 day before the day of the surgery, the day of surgery, and the 90 days immediately following the day of surgery. (See Medicare Claims Processing Manual, Chapter 12, Sections 40 and 40.1.) If add-on procedure code 11101 is performed twice during an office visit, how is it indicated on the CMS-1500 claim form? A. Code 11101 is reported with a modifier 50 B. Code 11101 is reported twice C. Code 11101 is reported once with the number 2 in box 24G D. Code 11101 is reported twice with the number 2 in box 24G - -Box 24G is most commonly used for multiple visits, units of supplies, anesthesia minutes or oxygen volume. If only one service is performed, the numeral 1 must be entered. When multiple services are provided, enter the actual number provided. If the same procedure is performed twice, report the procedure once with the numeral 2 entered. For anesthesia, show the elapsed time (minutes) in block 24G. Convert hours into minutes and enter the total minutes required for this procedure. Which set of documentation guidelines can be used for E/M services submitted to Medicare for a physician assistant (PA)? A. Physician assistants cannot report E/M services B. Only the 1995 CMS documentation guidelines C. Only the 1997 CMS documentation guidelines D. Either 1995 or 1997 CMS documentation guidelines - -CPT® indicates that E/M services are reported by physicians and other qualified health care professionals. Physician assistant falls under other qualified health care professionals. Either 1995 or 1997 documentation guidelines can be used, whichever one that will benefit the physician or other qualified health care professional the most. "A physician or other qualified 'health care professional' is an individual who is qualified by education, training, licensure/regulation (when applicable), and facility privileging (when applicable) who performs a professional service within his/her scope of practice and independently reports that professional service. Example, physician assistant (PA) and Advanced Registered Nurse Practitioners (ARNP). PAs and ARNPs professionals are separate from 'clinical staff.' A clinical staff member is a person who works under the supervision of a physician or other qualified health care professional and who is allowed by law, regulation, and facility policy to perform or assist in the performance of a specified professional service, but who does not individually report that professional service (Example, Licensed Practical Nurse (LPN))." Select the scenario that meets the incident-to requirements. A. The physician is in the office suite actively treating a patient and the physician assistant in the next room is treating a new patient complaint. B. Care is delivered to an established patient by the physician assistant as part of the physician's treatment plan while the physician is seeing another patient in the same office suite in a different room. C. The physician assistant traveled for the physician to provide the service in the patient's New York City home and the physician is available by phone. D. The physician assistant provided a necessary part of the patient's medical treatment and the physician signed the chart when he returned to the office. - -A physician assistant or a nurse practitioner cannot bill incident-to on new patient complaints. If a physician assistant or nurse practitioner treats a new patient complaint it must be billed under the physician assistant or nurse practitioner, not under the physician. To bill services incident-to under the physician, the services must be as a result of the physician's treatment plan personally performed at an initial service and the physician remains actively involved in the course of treatment. The physician does not need to be in the room, but he/she must be in the office to bill the services incident-to. For example, a nurse administering an injection. If the physician was out of the office seeing patients at the hospital, the services could not be billed because the physician is not providing supervision. Medicare beneficiary is having a screening colonoscopy performed. How is the service reported to Medicare? A. G0121 B. 45378 C. 45378, G0121 D. G0121, 45378 - -Medicare requires the HCPCS Level II code be reported rather than the CPT® code when a code exists in both the same service. Only report the HCPCS Level II code. Which providers submit the CMS-1500 claim form? I. Independent diagnostic testing facilities (IDTFs) II. Emergency department physicians III. Hospice organizations IV. Ambulance companies submitting under their own Medicare number V. Physicians in a group practice VI. Ambulatory surgery centers A. III-VI B. IV and VI C. I, III, IV, and VI D. I, II, IV, V and VI - -Providers billing for professional services such as physicians and other individual practitioners, groups of physicians or practitioners, labs not part of a hospital, ambulance claims submitted by ambulance companies under their own Medicare number, ambulatory surgery centers, and independent diagnostic testing facilities submit the CMS-1500 claim form. Institutional providers that submit the UB-04 claim form include hospitals, Skilled Nursing Facilities (SNFs), End Stage Renal Disease (ESRD) providers, Home Health Agencies (HHAs), hospices, outpatient rehabilitation clinics, Comprehensive Outpatient Rehabilitation Facilities (CORFs), Community Mental Health Centers (CMHCs), Critical Access Hospitals (CAHs), Federally Qualified Health Centers (FQHCs), histocompatibility laboratories, Indian Health Service (IHS) facilities, organ procurement organizations, Religious Non-Medical Health Care Institutions (RNHCIs), and Rural Health Clinics (RHCs). According to CPT® Radiology Guidelines if a patient is given oral contrast for a CT scan of the abdomen which code is reported? A. 74150 Computed tomography, abdomen; without contrast material B. 74160 Computed tomography, abdomen; with contrast material(s) C. 74170 Computed tomography, abdomen; without contrast material, followed by contrast material(s) and further sections D. 74176 Computed tomography, abdomen and pelvis; with contrast material(s) - -According to CPT® Radiology Guidelines oral and/or rectal contrast administration alone does not qualify as a study "with contrast." Which of the following is NOT in the HIPAA Privacy Rule? A. Physician must obtain a patient's written consent