CPB Final Exam 2022/2023 Questions and Answers

EPO - ANSWER ...provides benefits to subscribers who are required to receive services from network providers IDS - ANSWER ...organizations of affiliated providers sites that offer joint healthcare services to subscribers HMO - ANSWER ...providers comprehensive healthcare services to voluntarily enrolled members on a prepaid basis POS - ANSWER ...patients can use the managed care panel of providers (paying discounted healthcare cost) or self-refer to out-of-network providers (and pay higher cost) PPO - ANSWER ...contracted network of healthcare providers that provide care to subscribers for a discounted fee When a nonparticipating provider files a claim for a patient to BC/BS, how is the payment processed? - ANSWER The payment is sent to the patient and the patient must pay the provider. Birthday rule - ANSWER the policyholder whose birth month and day occurs earlier in the calendar year holds the primary policy when each parent subscribes to a different health insurance plan Nonparticipating Providers (nonPARs) - ANSWER they expect to be paid the full fee charged for services rendered *In these cases, the patient may be asked to pay the provider in full and then be reimbursed by BCBS the allowed fee for each service, minus the patient's deductible and copayment obligations -even when the provider agrees to file the claim for the patient, the insurance company sends the payment for the claim directly to the patient and not to the provider A patient's Medicare card contains which of the following information? - ANSWER name, medicare claim number, sex, is entitled to, effective date Which of the following services is covered by Early Periodic Screening Diagnostic Treatment (EPSDT)? - ANSWER Pediatric check ups What forms need to be submitted when billing for a work-related injury? - ANSWER First Report of Injury Form, Progress reports and CMS-1500 What is an accountable care organization (ACO)? - ANSWER Groups of doctors, hospitals, and other health care providers who coordinate high quality care for Medicare patients. New patient presents for annual exam and has no complaints. She is scheduled to see the physician assistant (PA). How should services be billed ? - ANSWER bill under the PA According to CMS, which of the following services are included in the global package for surgical procedures? - ANSWER Local infiltration, metacarpal/metatarsal/digital block or topical anesthesia Subsequent to the decision for surgery, one related Evaluation and Management (E/M) encounter on the date immediately prior to or on the date of procedure (including history and physical). Immediate postoperative care, including dictating operative notes, talking with the family and other physicians or other qualified health care professionals. Writing orders Evaluating the patient in the postanesthesia recovery area Typical postoperative follow-up care How should a claim be processed if a procedure code requires more than four modifiers? - ANSWER Report the first four modifiers in Block 24d and all the additional modifiers in Block 19. ? Which of the following indicates the frequency of care on a UB-04 - ANSWER type of bill A HCPCS/CPT® code is assigned "1" in the MUE file. What does this indicate? - ANSWER Electronic Healthcare Transactions and code sets are required to be used by health plans, healthcare clearinghouses and healthcare providers that participate in electronic data interchanges. Which of the following are requirements for the code sets? - ANSWER Pam works for a medical practice. She receives a call from a person stating he is with the patient's insurance company and would like some information on the patient's last visit. What is the most compliant practice regarding releasing the information? - ANSWER Pam tells him that all requests must be in writing. Security involves the safekeeping of patient information by: - ANSWER Setting office policies to protect PHI from alteration, destruction, tampering, or loss Requiring employees to sign a confidentiality statement that details the consequences of not maintaining patient confidentiality, including termination Dr. Taylor's office has a new medical assistant (MA) who is responsible for blood collection for lab specimens. Because the MA is new, she often misses when obtaining blood at the first stick. To be sure the office is billing for all services, the office now has a rule that all patients will be billed a minimum of two blood draws to demonstrate the work that is being done for lab collection. Which statement is true regarding this rule? - ANSWER This action is considered fraudulent. Services duplicated because of provider error should not be billed and the office is billing for services not rendered. An example of an overpayment that must be refunded is _____________? - ANSWER Duplicate processing of a claim Which of the following is true regarding provider credentialing? - ANSWER providers use a standard application and a common database to submit one application to one source to meet the needs of all of the health plans and hospitals participating in the CAQH effort. Which Act protects information collected by consumer reporting agencies? - ANSWER Fair Credit Reporting Act There is a written office policy to write off patients co-insurance and copayment amounts as a professional courtesy. Is this appropriate? - ANSWER No, it is considered fraud to write off the patients' responsibility for all patients. What Federal Act are collection agencies required to adhere to when attempting to collect a debt? - ANSWER Fair Debt Collection Practices Act Which of the following is an allowed collection policy after a patient files for bankruptcy? - ANSWER Unpaid insurance claims for dates of service occurring before the date of the Bankruptcy can be collected. A patient with an acute myocardial infarction is brought by ambulance to the emergency room. The patient is taken into the cardiac catheterization lab. Angioplasty and a stent was placed in the LAD. The patient's insurance requires preauthorization for all surgical procedures. Which of the following statements is true for most payers? - ANSWER Because this was an emergency, it is acceptable to obtain authorization following the surgery Which of the following steps should be completed when filling an appeal? - ANSWER What should a biller do when a claim is denied for timely filing? - ANSWER Incorrect entry of the patient demographics can have an effect on many areas of the practice. Choose the areas effected. - ANSWER I. Billing II. Collections III. Appointments IV. Referrals V. Patient care At which point is the superbill/encounter form completed? - ANSWER At the end of the patient visit How many years does CMS require providers to retain copies of insurance claims and all attachments? - ANSWER six When you respond to a patient with "How may I help you, Mrs Jones?", the use of the patient's name - ANSWER Repeating of the patient's name shows your interest and that you are not distracted. It requires very little time to show courtesy. Procedures Performed: 1. Bilateral tympanotomy with insertion of ventilation tubes (69436 RVU 2.01) 2. Adenotonsillectomy (42820 RVU 4.22) - ANSWER 42820, 69436 A dermatologist performed an excision of a squamous cell carcinoma from the patients forehead with a 1.2 cm excised diameter. The excision site required an intermediate wound closure measuring 1.8 cm. What is/are the correct code(s)? - ANSWER What is the correct HCPCS Level II coding for Depo-Provera (medroxyprogesterone acetate) injection of 100 mg? - ANSWER The provider performs an expanded problem focused history, expanded problem focused exam and low MDM to manage the patient's hypertension. The provider also destroys two plantar warts. How is this reported? - ANSWER When a TRICARE covered beneficiary is treated at a provider's office, the TRICARE enrollment card should be copied along with what other card? - ANSWER The common access card (CAC) of the beneficiary should also be copied A patient covered by a PPO is scheduled for knee replacement surgery. The biller contacts the insurance carrier to verify benefits and preauthorize the procedure. The carrier verifies the patient has a $500 deductible which must be met. After the deductible, the PPO will pay 80% of the claim. The contracted rate for the procedure is $2,500. What is the patient's responsibility? - ANSWER The contracted rate is $2500. The patient must pay the deductible ($500) and 20% of $2,000 ($400). The total patient responsibility is $900. In which of the following scenarios is Medicare the secondary payer? - ANSWER A 72-year-old patient who participates in the group health insurance of his employer A 66-year-old patient is injured at work and the employer does not offer health insurance Which guidelines must all billing personnel be knowledgeable about in order to ensure compliance with Medicaid programs? - ANSWER federal and state A female patient who was involved in an auto accident presents to the emergency room for evaluation. She does not have any complaints. The provider evaluates her and determines there are no injuries. The provider informs the patient to come back to the ER or see her primary care physician if she develops any symptoms. How is the claim processes for this encounter? - ANSWER The auto insurance is billed primary and the medical insurance is billed secondary. A document provided to Medicare patients explaining their financial responsibility if Medicare denies a service is a(n): - ANSWER Advanced Beneficiary Notice? GA modifier - ANSWER Advance notice of non-coverage provided Use this modifier to tell us that you provided a notice of Medicare non-coverage to the patient. - If you bill us for non-covered services without using the GA modifier indicating you did not give notice of non-coverage to the patient, Priority Health Medicare will deny your claim. It will go to provider liability - See more at: GY modifier - ANSWER Service is not covered by Medicare by statute Which type of managed care insurance allows patients to self-refer to out-of-network providers and pay a higher co-insurance/copay amount? - ANSWER PPO POS