CBCS Exam Study Guide Questions with Complete Rationales

CBCS Exam Study Guide Questions with Complete Rationales 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 Information) w/o specific authorization under the HIPPA Privacy Rule? - ANS: When us