CBCS Exam Study Guide Exam Questions And Answers

CBCS Exam Study Guide Exam Questions And Answers Medical Billing & Coding as a Career - ANS *Claims assistant professional or claims manager, *Coding Specialist, * Collection Manager, *Electronic Claims Processor, *Insurance Billing Specialist, * Insurance Coordinator, *Insurance Counselor, *Medical Biller, *Medical & Financial Records Manager, * Billing & Coding Specialist What are Medical Ethics? - ANS Standards of conduct based on moral principle. They are generally accepted as a guide for behavior towards pt's, dr's, co-workers, the gov, and ins co's. What does acting within ethical behavior boundaries mean? - ANS carrying out one's responsibilities w/ integrity, dignity, respect, honesty, competence, fairness, & trust. Legal Aspects of of Medical Billing & Coding: - ANS ... Compliance regulations: - ANS Most billing-related cases are based on HIPPA and False Claims Act Health Insurance Portability & Accountability Act (HIPPA) - ANS Enacted in 1996, created by the Health Care Fraud & Abuse Control Program-enacted to check for fraud and abuse in the Medicare/Medicaid Programs and private payers What are the 2 provisions of HIPPA? - ANS Title I: Insurance Reform Title II: Administrative Simplification What is Title I of HIPPA? - ANS Insurance Reform-primary purpose is to provide continuous ins coverage for 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 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. What is Title II of HIPPA? - ANS Administrative Simplification-goal is to focus on the health care practice setting to reduce administrative cost & burdens. Has 2 parts- 1) development and implementation of standardized health-related financial & administrative activities electronically 2) Implementation of privacy & security procedures to prevent the misuse of health info by ensuring confidentiality What is the False Claims Act (FCA)? - ANS Federal law that prohibits submitting a fraudulent claim or making a false statement or representation in connection w/ a claim. Also protects & rewards whistle-blowers. What is the National Correct Coding Initiative (NCCI)? - ANS Developed by CMS to promote the national correct coding methodologies & to control improper coding that lead to inappropriate payment of Part B health ins claims. How many edits does NCCI include? - ANS 2: 1)Column 1/Column 2 (prev called Comprehensive/Component) Edits 2) Mutually Exclusive Edits Column 1/Column 2 edits (NCCI) - ANS Identifies code pairs that should not be billed together b/c 1 code (Column 1) includes all the services described by another code (Column 2) Mutually Exclusive Edits (NCCI) - ANS ID's code pairs that, for clinical reasons, are unlikely to be performed on the same pt on the same day What are the possible consequences of inaccurate coding and incorrect billing? - ANS *delayed processing & payment of claims *reduced payments, denied claims *fine and/or imprisonment *exclusion from payer's programs, loss of dr's license to practice med Who has the task of investigate and prosecuting health care fraud & abuse? - ANS The Office of Inspector General (OIG) Fraud - ANS knowingly & intentionally deceiving or misrepresenting info that may result in unauthorized benefits. It is a felony and can result in fines and/or prison. Who audits claims? - ANS State & federal agencies as well as private ins co's What are common forms of fraud? - ANS billing for services not furnished, unbundling, & misrepresenting diagnosis to justify payment Abuse - ANS incidences or practices, not usually considered fraudulent, that are inconsistent w/ the accepted medical business or fiscal practices in the industry. What are examples of Abuse? - ANS submitting a claim for services/procedures performed that is not medically necessary, and excessive charges for services, equipment or supplies. What is a method use to minimize danger, hazards, & liabilities associated w/ abuse? - ANS Risk Management Patient Confidentiality - ANS 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. When may providers use PHI (Protected Health Info