CPB Chapter 9 – Billing Exam Study Guide with Complete Solutions

CPB Chapter 9 – Billing Exam Study Guide with Complete Solutions Money owed to the practice for services rendered and billed - Answer️️ - Account Receivables A review and evaluation of healthcare procedures and documentation for the purpose of comparing the quality of services provided in a given situation - Answer️️ -Audit Under the birthday rule, the health plan of the parent whose birthday comes first in the calendar year (not including the year) is designated as the primary plan - Answer️️ -Birthday Rule A hospital-specific electronic list that includes all hospital procedures, services, supplies, and drugs that are billed to payers. Synonymous with charge description master (CDM) - Answer️️ -Chargemaster A software program that reviews claims for key components before the claims are presented to an insurance company - Answer️️ -Claim scrubber A claim with no errors - Answer️️ -Clean claim The standard claim form used by non-institutional provider or supplier to bill claims - Answer️️ -CMS 1500 Form ©SOPHIABENNET@ Thursday, August 22, 2024 10:21 AM Certified Professional Biller By: American Academy of Professional Coders(AAPC) 2 Current Procedural Terminology is a five digit code used to describe medical, surgical, radiology, laboratory, anesthesiology, and evaluation/management services of physicians, hospitals, and other healthcare providers - Answer️️ -CPT Alphanumeric codes and primarily include non-physician services, such as ambulance services and prosthetic devices, and represent items and supplies and non-physician services. - Answer️️ -HCPCS Level II Describes the process of transferring data electronically between providers and insurance payers - Answer️️ -Electronic data interchange (EDI) A list of fees the physician establishes is the fair price for the services they provide - Answer️️ -Fee schedule when a contractor or fiscal intermediary makes a ruling as to whether a service or item can be reimbursed - Answer️️ -Loal Coverage Determination (LCD) rulings specify the Medicare coverage of specific services on a national level - Answer️️ -National Coverage Determination (NCD) A requirement that a physician obtain approval from a health plan to receive a specific procedure or prescribe a specific medication - Answer️️ -Prior authorization ©SOPHIABENNET@ Thursday, August 22, 2024 10:21 AM Certified Professional Biller By: American Academy of Professional Coders(AAPC) 3 When an insurance company attempts to recoup expenses for a paid claim when another payer should have been responsible - Answer️️ - Subrogation Cost based fee schedules are developed by determining - Answer️️ -total cost of all of the procedures the physician will perform Cost based fee schedules are developed by accounting for all the costs involved with providing a procedure or service. What does this include? - Answer️️ -lease or rental payments; utilities; office supplies and equipment; loan fees; maintenance fees; employee labor; malpractice and/or liability insurance; and health insurance and other benefit costs. The physician payment schedule is determined by the - Answer️️ - Insurance payer - The physician payment schedule is set by the payer, either government (CMS) or private. The payer determines the amount that will be reimbursed to the physician or qualified healthcare professional for services or procedures rendered. Failure to post a contractual adjustment to a patient's account will - Answer️️ -leave a balance on the patient's account that the patient should not be responsible for paying. When a provider agrees to accept the ©SOPHIABENNET@ Thursday, August 22, 2024 10:21 AM Certified Professional Biller By: American Academy of Professional Coders(AAPC) 4 amount the payer reimburses as payment in full, the provider must adjust off any remaining balances due from the patient. Which of the following tasks is the most basic element in the billing process - Answer️️ -data entry The function of a claim scrubber is to - Answer️️ -identify errors that will prevent a claim from being paid. The function of a claim scrubber is to check claims for data entry errors, verify that the ICD-10-CM codes support medical necessity for LCD/NCD and identify bundled services as well as payer rei