Medical Billing and Coding Certificate Exam Solved 100%

Chief Complaint (element 1 of history) - Answer History of present illness, Review symptom, Past, Family, and Social history History Levels (Element 2 of history) and Examination Levels (Element 3 of History) - Answer Problem focused, expanded problem focused, detailed, Comprehensive Medical Decision Making Complexity Levels (element 4 of history) - Answer Straightforward, Low, Moderate, High straightforward - Answer Minimal diagnosis Minimal risk Minimal complexity of data Low - Answer Limited diagnosis Limited/low risk to patient Limited data Moderate - Answer Multiple diagnosis Moderate risk to patient Moderate amount and complexity of data high - Answer Extensive diagnosis high risk to patient extensive amount and complexity of data truncated coding (error in coding) - Answer using diagnosis codes that are not as specific as possible assumption coding (fraudulent coding) - Answer reporting items of services that are not actually documented errors of the coding process - Answer -altering documentation after services are reported -coding without documentation -reporting services provided by unlicensed or unqualified clinical personnel -coding a unilateral service twice instead of choosing the bilateral -not satisfying the condition of coverage for a particular service -codes that report more than one diagnosis with one code is a combination code Unbundling codes - Answer when multiple codes are used to code a procedure when a single code should be used Upcoding - Answer using a procedural code that provides a higher reimbursement rate than the correct code Downcoding - Answer the document does not justify the level of service Most common billing errors - Answer Billing non-covered services Billing over limit services Upcoding Downcoding Billing without signatures Using outdated codes External Audits Internal Audits Retrospective audits - Answer Types of Audits done to avoid billing and coding errors External Audits - Answer a private payer or government investigator's review of selected records of a practice for compliance Internal Audits - Answer self-audit conducted by a staff member or consultant Retrospective Audits - Answer conducted after the claim has been send the remittance advice has been received Adjustments - Answer amounts added to or taken away from the balance of an account Two methods to determine rates to be paid to providers - Answer Charge; Resource Charge - Answer based fees are established using the fees of providers providing similar services resource - Answer -how difficult is it for the provider to do the procedure -how much office overhead is involved -the relative risk the procedure presents to the patient and the provider Clearing Houses - Answer Edits and transmits batches of claims to insurance companies Fee schedule - Answer Payment is predetermined according to a table of diagnoses and their eligible fees usual - Answer fee normally charged for a given service Customary fee - Answer fee in the range of usual fees charged by physicians of similar training experience for the same service within the same specific and limited socioeconomic are resonable fee - Answer fee that meets both usual or customary fees or is considered justifiable by responsible medical opinion considering special circumstances of the particular case in question relative value studies (rvs) - Answer a list of 5 digit procedure codes for services with unit values that indicate the value for each procedure Capitation - Answer physician has a contract with an insurance company to be paid whether he sees the patient of not precertification - Answer A process required by some insurance carriers in which the provider must prove medical necessity before performing a procedure. predetermination - Answer finding out the maximum dollar amount insurance will pay for the procedure Preauthorization - Answer Prior approval for treatment and procedures Types of referrals - Answer Formal Direct Verbal Self Formal referral - Answer An authorization request (telephone, fax, or completed form) required by the managed care organization contract to determine medical necessity and grant permission before services are rendered or procedures performed. Direct referral - Answer authorization request form is completed and signed by the physician and handed to the patient Verbal referral - Answer A primary care physician informs the patient and telephones to the referring physician that the patient is being referred for an appointment. self-referral - Answer A patient who refers himself to a specialist. Medicaid - Answer Federal program that provides medical benefits for low-income persons. Medicare - Answer A federal program of health insurance for persons 65 years of age and older Medicare Part A(Inpatient) - Answer Hospital insurance for the aged and disabled. Covers institutional providers for inpatient, hospice, home health services and services within hospital. Medicare Part B - Answer Referred to as supplementary Medical insurance. Supplement of part A that covers outpatient, services by physicians, durable medical equipment, clinical lab services and ambulatory services. Medicare Part C (Medicare Advantage Plans) - Answer Health coverage option includes part A & part b & operated by private insurance companies that are approved by & under contract w medicare Medicare part D - Answer Prescription drug coverage participating physician - Answer Accepts assignment payment sent to physician nonparticipating physician - Answer Does not accept assignment payment sent to patient patient pays physician Temporary disability (TD) - Answer patient cannot perform all functions of his or her job for a limited period of time weekly benefits are based on employees earnings Permanent Disability - Answer Injured worker is left with a residual disability Sometimes patient can be rehabilitated in another line of work When a patient case becomes permanent and stationary and no further improvement is expected, the case is rated to the percentage of permanent disability and adjudicated so a monetary settlement can be made.