NCCT Insurance & Coding Practice Test (solved)

An insurance and coding specialist is reviewing a patient's encounter form that is documented in the medical record prior to competing a CMS-1500 form. She notices that the physician upcoded the encounter form. The specialist has the ethical obligation to first - Answer- query the physician A patient had surgery two weeks ago to repair a dislocated ankle, and returns today to have a flexor tendon in the hand repaired. Which of the following modifiers should be reported for today's service? - Answer- -79 A patient has called to schedule an appointment for an office visit to see the doctor tomorrow for an earache. It is discovered during the scheduling process that the insurance policy on file has been cancelled. Which of the following should the insurance and coding specialist do next? - Answer- Advise the patient to bring current insurance information to the appointment. An established patient is being seen by the physician today. The patient owes $25.00 for the visit. The amount collected for the office visit is called the - Answer- copayment Applying the birthday rule, a minor child comes in. Both parents have remarried and the child is listed on the mother's, father's, and both step-parents' policies. The mother's birthday is April 16, stepfather's birthday March 19, father's birthday is February 19th, and the stepmother's birthday is January 20th. Which of the following is correct? - Answer- Father's plan is primary, mother's plan is secondary. A provider performed a right sided facet joint injection using fluoroscopic guidance. The billed codes were 64493 and 77003. An EOB was returned denying the charge of 77003. Why was this charge denied? - Answer- Imaging guidance is an inclusive component of 64493. A patient was seen in the office. Charges were recorded and submitted to the patient's insurance, and an EOB was received by the office with a payment of $70.89. These transactions should be recorded in the - Answer- patient ledger. A new HIM director was recently hired at a hospital. She was advised her health insurance benefits become available in 90 days. Which of the following is correct regarding her health insurance? - Answer- She will be able to keep her current medical insurance from her previous job through COBRA. A claim submitted with all the necessary and accurate information so that it can be processed and paid is called a - Answer- clean claim. A patient has two health insurance policies-a group insurance plan through her full-time employer and another group insurance plan through her husband's employer. Which of the following policies should be billed as primary? - Answer- her policy. An insurance and coding specialist is reviewing Appendix M in the CPT book. Which of the following is she most likely performing? - Answer- checking for renumbered codes A Medicare patient has an 80/20 plan. The charged amount was $300.00. The amount allowed was $100.00. Which of the following is the patient's coinsurance? - Answer- $20 The Fair Debt Collection Practices Act restricts debt collectors from engaging in conduct that includes - Answer- calling before 8:00 AM or after 9:00 PM, unless permission is given. A third party payer made an error while adjudicating a claim. Which of the following should the insurance and coding specialist do? - Answer- Resubmit the claim with an attachment explaining the error. A Medicare patient presents to an outpatient hospital facility for a scheduled hysterectomy. To which Medicare plan should the facility submit the claim? - Answer- Part B A physician performed a bilateral L4/L5 Laminectomy on a patient in an ambulatory surgical center. Which of the following place of service codes should be used on the CMS 1500? - Answer- 24 A 72-year-old patient is undergoing a corneal transplant. An anesthesiologist is personally performing monitored anesthesia care. Which of the following modifiers should be reported for the anesthesia? - Answer- -AA-QS Based on the CMS manual system, when updating or maintaining the billing code database, which of the following does the "R" denote? - Answer- Revised Collecting statistics on the frequency of copay collection at time of service is a step in the process of - Answer- managing A/R. Claims are often rejected because a provider needs to obtain - Answer- pre-authorizations. Collection agencies are regulated by the - Answer- Fair Debt Collections Practice Act. Developing an insurance claim begins - Answer- when the patient calls to schedule an appointment. Encounter forms should be audited to ensure the - Answer- payer's address and phone are current. HIPAA allows a health care provider to communicate with a patient's family, friends, or other persons who are involved in the patient's care regarding their mental health status providing - Answer- the patient does not object. How often should the encounter form CPT codes be updated? - Answer- annually If the insurance and coding specialist suspects Medicare fraud she should contact the - Answer- OIG. In order to have claims paid as quickly as possible, the insurance specialist must be familiar with which of the following? - Answer- payer's claim processing procedures If the insurance carrier's rate of benefits is 80%, the remaining 20% is known as - Answer- coinsurance. If a married couple is covered under both spouses' health insurance and the husband wishes to schedule an appointment for an annual exam, he should call his primary care provider and - Answer- schedule an appointment using both his insurance benefits and his wife's insurance benefits. If a provider refuses to accept assignment, when must the patient pay for services? - Answer- time of service The Stark Law was enacted to govern the practice of - Answer- physician referrals to facilities that she has a financial interest in. The patient opted to have a tubal ligation performed. Which of the following is needed in order for the third party payer to cover the procedure? - Answer- pre-certification The most effective method to manage patient statements and other financial invoices as well as avoid payment delays is to - Answer- collect fees at the time of service. The patient was hospitalized for diabetes. Upon release the patient consults with a registered dietician. Which of the following Level II HCPCS modifiers should be assigned? - Answer- AE The patient's total charges are $300. The allowed amount is $150. Benefits pay at 60%. Which of the following will the patient have to pay? - Answer- $60 The patient is sent a statement for an office visit. The total amount of the bill is $100.00 and this amount must be paid before the insurance company will pay on the claim. Which of the following is this called? - Answer- deductible The insurance and coding specialist is billing the insurance company of a 66-year-old woman who has Medicare and is covered under her husband's private insurance. Which of the following should be billed first? - Answer- the husband's insurance The provider is paid the same rate per patient whether or not they provide services and no matter which services were provided. This payment is known as - Answer- capitation. The insurance and coding specialist calls a carrier to verify a patient's insurance and the representative states that the patient's insurance was cancelled three months ago. Which of the following should the insurance and coding specialist do first? - Answer- Ask the patient for another form of insurance coverage. When posting transactions for electronic claim submission, it is necessary to enter which of the following items onto the claim? - Answer- physician's office fee Which of the following patient information is needed to determine a Medicaid sliding fee scale? (Select the three(3) correct answers.) - Answer- *salary *poverty level *number of dependents Which of the following is the most likely cause of the deposits not agreeing with the credits on the day sheet or the patient ledgers? - Answer- Payment is misplaced. When using the EHR to schedule a patient visit, which of the following screens should be used to complete the scheduling process? - Answer- patient search Which of the following must a patient sign prior to an insurance claim being processed? - Answer- an Authorization to Release Information Which of the following is the correct procedure for keeping a Workers' Compensation patient's financial and health records when the same physician is also seeing the patient as a private patient? - Answer- Separate financial and health records must be used. When there is a professional courtesy awarded to a patient's account the insurance and coding specialist should post the amount under the - Answer- adjustment column. Which of the following information is necessary to post payment from the RA/EOB? (Select the three (3) correct answers.) - Answer- *date of service *patient's name *billed CPT codes When a capitation account is applied to the ledger it is also known as a - Answer- monthly prepayment amount. When following up on a denied claim, an insurance and coding specialist should have which of the following information available when speaking with the insurance company? (Select three (3) correct answers.) - Answer- *date of service *physician's NPI *patient's insurance ID number Which of the following forms provides information from the Managed Care Organization that paid on the claim? - Answer- EOB Which of the following modifiers is required for a return to the operating room for an unplanned related procedure or service by the same physician during the postoperative period? - Answer- -78 Which of the following federal regulations requires disclosure of finance charges, late fees, amount, and due dates for all payment plans? - Answer- Truth in Lending Act Which of the following processes makes a final determination for payment in an appeal board? - Answer- arbitration Which of the following forms should be transmitted to obtain reimbursement following a physician's office visit for a patient with active Medicaid coverage? - Answer- CMS-1500 Which of the following are necessary to complete a CMS 1500 form? (Select the three (3)correct answers.) - Answer- *physician information *demographic information *diagnosis and CPT codes Which of the following should an insurance and coding specialist do when checking for completion of a new patient's registration form? (Select the three (3) correct answers.) - Answer- *Make sure that the patient's name matches the insurance card. *Make sure that the registration form is signed and dated. *Check that demographics are completed. Which of the following regulations prohibits the submission of a fraudulent claim or making a false statement or representation in connection with a claim? - Answer- Federal False Claims Act Which of the following fees posted to the patient's account is an example of "usual, customary, and reasonable?" - Answer- allowed amount Which of the following MCOs always requires an authorization before seeing a specialist? - Answer- HMO When the patient has signed the assignment of benefits form, the payment for services should be sent to the provider unless the provider is - Answer- out of network. When is a referral from a provider required? - Answer- when contained in the individual policy. Which of the following information should be used to capture charges from an encounter form? - Answer- services rendered and reason for visit Which of the following is an appropriate way to open the discussion when explaining practice fees to a patient? - Answer- "Do you have any questions about the cost of today's visit?" Which of the following reports is used to follow up on outstanding claims to third party payers? - Answer- aging When posting an insurance payment via an EOB, the amount that is considered contractual is - Answer- insurance allowed amount. Which of the following items are mandatory in patient financial policies? (Select the three (3) correct answers.) - Answer- *statement that responsibility for payment lies with patient. *provider fee schedule. *expectation of payment due at time of service. When patients sign Block 13 of the CMS-1500 claim to instruct the payer to directly reimburse the provider, it is known as - Answer- assignment of benefits. Which of the following Medicare parts covers inpatient hospital stays? - Answer- Part A Which of the following financial reports produces a quarterly review of any dollar amount a patient still owes after all insurance carriers claim payments have been received? - Answer- aging Which of the following must be verified to process a credit card transaction? (Select the three (3) correct answers.) - Answer- *account number *security code *credit card number When reviewing the charges for a patient procedure using computer assisted coding software (CAC), the insurance and coding specialist should first - Answer- review the chart for needed information. When should a provider have a patient sign an ABN? - Answer- when the items may be denied and prior to performing the service. When the patient calls to inquire about an account, which of the following does the insurance and coding specialist need to ask for before discussing the account? (Select the three (3) correct answers.) - Answer- *patient's name *patient's date of birth *patient's insurance ID number When filing an electronic insurance claim, the insurance and coding specialist processes which of the following forms? - Answer- CMS-1500 When a document is changed in an EHR, the original documentation is - Answer- hidden. When using an EHR system to enter CPT codes on a CMS 1500 claim form for electronic submission, which of the following should be entered on the claim form first? - Answer- the most resource-intensive procedure or service Which of the following defines the maximum time that a debt can be collected from the time it was incurred or became due? - Answer- statute of limitations Which of the following are violations of the Stark Law? (Select the two (2) correct answers.) - Answer- *referring patients to facilities where the provider has a financial interest. *accepting gifts in place of payment from patients. Which of the following protects federal healthcare programs from fraud and abuse by healthcare providers who solicit referrals? - Answer- Anti-Kickback Statute A patient presents to the ED with severe abdominal pain and constipation. X-rays were ordered to rule out a blockage in the intestine. Which of the following is the correct ICD-10-CM coding? - Answer- R10.0, K59.00 The patient has returned to the operating room to aspirate a hematoma that has developed from a surgical procedure performed two days ago. a 16-gauge needle is used to aspirate 600 cc's of non-cloudy fluid. Whic