CBCS Exam Study Guide
Study online at https://quizlet.com/_5ifee
1. Medical Billing & *Claims assistant professional or claims manager, *Coding Specialist, * Collection
Coding as a Ca- Manager, *Electronic Claims Processor, *Insurance Billing Specialist, * Insurance
reer Coordinator, *Insurance Counselor, *Medical Biller, *Medical & Financial Records
Manager, * Billing & Coding Specialist
2. What are Medical Standards of conduct based on moral principle. They are generally accepted as a
Ethics? guide for behavior towards pt's, dr's, co-workers, the gov, and ins co's.
3. What does act- carrying out one's responsibilities w/ integrity, dignity, respect, honesty, compe-
ing within ethical tence, fairness, & trust.
behavior bound-
aries mean?
4. Legal Aspects of ...
of Medical Billing
& Coding:
5. Compliance reg- Most billing-related cases are based on HIPPA and False Claims Act
ulations:
6. Health Insurance Enacted in 1996, created by the Health Care Fraud & Abuse Control Program-en-
Portability & Ac- acted to check for fraud and abuse in the Medicare/Medicaid Programs and
countability Act private payers
(HIPPA)
7. What are the 2 Title I: Insurance Reform
provisions of HIP- Title II: Administrative Simplification
PA?
8. What is Title I of Insurance Reform-primary purpose is to provide continuous ins coverage for
HIPPA? 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
, CBCS Exam Study Guide
Study online at https://quizlet.com/_5ifee
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.
9. What is Title II of Administrative Simplification-goal is to focus on the health care practice setting
HIPPA? to reduce administrative cost & burdens. Has 2 parts- 1) development and im-
plementation of standardized health-related financial & administrative activities
electronically 2) Implementation of privacy & security procedures to prevent the
misuse of health info by ensuring confidentiality
10. What is the False Federal law that prohibits submitting a fraudulent claim or making a false state-
Claims Act (FCA)? ment or representation in connection w/ a claim. Also protects & rewards whis-
tle-blowers.
11. What is the Developed by CMS to promote the national correct coding methodologies & to
National Correct control improper coding that lead to inappropriate payment of Part B health ins
Coding Initiative claims.
(NCCI)?
12. How many ed- 2: 1)Column 1/Column 2 (prev called Comprehensive/Component) Edits
its does NCCI in- 2) Mutually Exclusive Edits
clude?
13. Column 1/Col- Identifies code pairs that should not be billed together b/c 1 code (Column 1)
umn 2 edits includes all the services described by another code (Column 2)
(NCCI)
14. Mutually Exclu- ID's code pairs that, for clinical reasons, are unlikely to be performed on the same
sive Edits (NCCI) pt on the same day
15. What are the *delayed processing & payment of claims *reduced payments, denied claims *fine
possible conse- and/or imprisonment *exclusion from payer's programs, loss of dr's license to
quences of in- practice med
accurate cod-
, CBCS Exam Study Guide
Study online at https://quizlet.com/_5ifee
ing and incorrect
billing?
16. Who has the The Office of Inspector General (OIG)
task of investi-
gate and pros-
ecuting health
care fraud &
abuse?
17. Fraud knowingly & intentionally deceiving or misrepresenting info that may result in
unauthorized benefits. It is a felony and can result in fines and/or prison.
18. Who audits State & federal agencies as well as private ins co's
claims?
19. What are com- billing for services not furnished, unbundling, & misrepresenting diagnosis to
mon forms of justify payment
fraud?
20. Abuse incidences or practices, not usually considered fraudulent, that are inconsistent
w/ the accepted medical business or fiscal practices in the industry.
21. What are exam- submitting a claim for services/procedures performed that is not medically nec-
ples of Abuse? essary, and excessive charges for services, equipment or supplies.
22. What is a method Risk Management
use to minimize
danger, hazards,
& liabilities asso-
ciated w/ abuse?
23. Patient Confiden-
tiality
, CBCS Exam Study Guide
Study online at https://quizlet.com/_5ifee
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.
24. When may When using for TPO, Treatment (primarily for the purpose of discussion of pt's
providers use case w/ other dr's) Payment (providers submit claims on behalf of pt's) & Opera-
PHI (Protected tions (for purposes such as training staff & quality improvement)
Health Informa-
tion) w/o specif-
ic authorization
under the HIPPA
Privacy Rule?
25. What is Employer Means physicians are legally responsible for their own conduct and any actions
Liability? 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
26. What is Employ- "Errors & Omissions Insurance"-protection against loss of monies caused by
ee Liability? 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.
27. What is a Medical documentation of the pt's social & medical history, family history, physical exam
Record & what is findings, progress notes, radiology & lab results, consultation reports and corre-
it comprised of? spondence to pt- Is the foremost tool of clinical care and communication.
Study online at https://quizlet.com/_5ifee
1. Medical Billing & *Claims assistant professional or claims manager, *Coding Specialist, * Collection
Coding as a Ca- Manager, *Electronic Claims Processor, *Insurance Billing Specialist, * Insurance
reer Coordinator, *Insurance Counselor, *Medical Biller, *Medical & Financial Records
Manager, * Billing & Coding Specialist
2. What are Medical Standards of conduct based on moral principle. They are generally accepted as a
Ethics? guide for behavior towards pt's, dr's, co-workers, the gov, and ins co's.
3. What does act- carrying out one's responsibilities w/ integrity, dignity, respect, honesty, compe-
ing within ethical tence, fairness, & trust.
behavior bound-
aries mean?
4. Legal Aspects of ...
of Medical Billing
& Coding:
5. Compliance reg- Most billing-related cases are based on HIPPA and False Claims Act
ulations:
6. Health Insurance Enacted in 1996, created by the Health Care Fraud & Abuse Control Program-en-
Portability & Ac- acted to check for fraud and abuse in the Medicare/Medicaid Programs and
countability Act private payers
(HIPPA)
7. What are the 2 Title I: Insurance Reform
provisions of HIP- Title II: Administrative Simplification
PA?
8. What is Title I of Insurance Reform-primary purpose is to provide continuous ins coverage for
HIPPA? 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
, CBCS Exam Study Guide
Study online at https://quizlet.com/_5ifee
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.
9. What is Title II of Administrative Simplification-goal is to focus on the health care practice setting
HIPPA? to reduce administrative cost & burdens. Has 2 parts- 1) development and im-
plementation of standardized health-related financial & administrative activities
electronically 2) Implementation of privacy & security procedures to prevent the
misuse of health info by ensuring confidentiality
10. What is the False Federal law that prohibits submitting a fraudulent claim or making a false state-
Claims Act (FCA)? ment or representation in connection w/ a claim. Also protects & rewards whis-
tle-blowers.
11. What is the Developed by CMS to promote the national correct coding methodologies & to
National Correct control improper coding that lead to inappropriate payment of Part B health ins
Coding Initiative claims.
(NCCI)?
12. How many ed- 2: 1)Column 1/Column 2 (prev called Comprehensive/Component) Edits
its does NCCI in- 2) Mutually Exclusive Edits
clude?
13. Column 1/Col- Identifies code pairs that should not be billed together b/c 1 code (Column 1)
umn 2 edits includes all the services described by another code (Column 2)
(NCCI)
14. Mutually Exclu- ID's code pairs that, for clinical reasons, are unlikely to be performed on the same
sive Edits (NCCI) pt on the same day
15. What are the *delayed processing & payment of claims *reduced payments, denied claims *fine
possible conse- and/or imprisonment *exclusion from payer's programs, loss of dr's license to
quences of in- practice med
accurate cod-
, CBCS Exam Study Guide
Study online at https://quizlet.com/_5ifee
ing and incorrect
billing?
16. Who has the The Office of Inspector General (OIG)
task of investi-
gate and pros-
ecuting health
care fraud &
abuse?
17. Fraud knowingly & intentionally deceiving or misrepresenting info that may result in
unauthorized benefits. It is a felony and can result in fines and/or prison.
18. Who audits State & federal agencies as well as private ins co's
claims?
19. What are com- billing for services not furnished, unbundling, & misrepresenting diagnosis to
mon forms of justify payment
fraud?
20. Abuse incidences or practices, not usually considered fraudulent, that are inconsistent
w/ the accepted medical business or fiscal practices in the industry.
21. What are exam- submitting a claim for services/procedures performed that is not medically nec-
ples of Abuse? essary, and excessive charges for services, equipment or supplies.
22. What is a method Risk Management
use to minimize
danger, hazards,
& liabilities asso-
ciated w/ abuse?
23. Patient Confiden-
tiality
, CBCS Exam Study Guide
Study online at https://quizlet.com/_5ifee
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.
24. When may When using for TPO, Treatment (primarily for the purpose of discussion of pt's
providers use case w/ other dr's) Payment (providers submit claims on behalf of pt's) & Opera-
PHI (Protected tions (for purposes such as training staff & quality improvement)
Health Informa-
tion) w/o specif-
ic authorization
under the HIPPA
Privacy Rule?
25. What is Employer Means physicians are legally responsible for their own conduct and any actions
Liability? 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
26. What is Employ- "Errors & Omissions Insurance"-protection against loss of monies caused by
ee Liability? 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.
27. What is a Medical documentation of the pt's social & medical history, family history, physical exam
Record & what is findings, progress notes, radiology & lab results, consultation reports and corre-
it comprised of? spondence to pt- Is the foremost tool of clinical care and communication.
