MEDICAL BILLING AND CODING EXAM
QUESTIONS WITH COMPLETE
SOLUTIONS
HIPAA Security Rule - Answer-Law that requires covered entities to establish
administrative, physical, and technical safeguards to protect the confidentiality,
integrity and availability of health information
HIPAA Electronic Health Care Transactions and Code Sets standards - Answer-
HIPAA standards governing that every provider doing business electronically must
use same standards for transactions and code sets.
Covered entities under HIPAA - Answer-electronically transmit HIPAA-protected
information. CEs are (1) health plans, (2) health care clearinghouses, and (3) health
care providers.
Business associates work for covered entities and include services such as law
firms, accounting practices, IT consultants, and collection agencies. States that
covered entities must:
Have appropriate privacy practices
Notify patients about their privacy rights
Train employees on the privacy practices
Appoint a privacy official responsible for the adoption and following of privacy
practices
Safeguard patients' records
Protected Health Information (PHI) - Answer-Medical record
Other personal health information
that is transmitted or maintained by electronic
media
Treatment Payment and healthcare Operations (TPO) - Answer-Treatment-
Providing and coordinating medical care
Payment- The exchange of information with health plans
Operations- General business management functions
legitimate reasons for sharing patients protected health information without
authorization. Use minimum necessary standard- only release health information to
the extent that it is needed.
minimum necessary standard - Answer-The HIPAA standard that requires covered
entities to release only the minimum amount of patient health data to meet the need
of the request.
(DRS) Designated Record Set- - Answer-Providers = medical and billing records
Health plans = enrollment, payment, claim decisions, and medical management
system data
,Patients can= Access, copy, and inspect information
Request amendments
Obtain accounting of disclosures
Receive information by other means
Complain about alleged violations
Standard Code Sets - Answer-Examples: ICD-9-CM, CPT, CDT, HCPCS. Coding
systems for
diseases;
treatments and
procedures; supplies.
National Patient ID (Individual Identifier) - Answer-unique individual identification
system to be created under HIPAA national identifiers.
Employer Identification Number (EIN)
National Provider Identifier (NPI)
Fraud - Answer-Act of deception used to take advantage of another person, (Lie).
Example - billing when the task was not done.
Abuse - Answer-Act that misuses public funds.
Example - billing when the task was not necessary. Filing something TRUTHFULLY
because it was done but something that was not necessary..."abusing the
system"...fine the "loop holes"
.
False claims act - Answer-Prohibits submitting fraudulent claim or making false
statements or representation in connection with a claim.
Federal law that prohibits fraudulent claims to the government.
Compliance Plans - Answer-"Billing rules", Parts of a compliance plan: Employer is
responsible for employee's actions.
1. Consistent written policies and procedures
2. Appointment of a compliance officer and committee
3. Training
4. Communication
5. Disciplinary systems
6. Auditing and monitoring
7. Responding to and correcting errors
NP = New patient - Answer-someone who has not received any services from the
provider or has not received services in the past three years.
EP = established patient - Answer-Patient who has seen provider in the past three
years.
Coordination of Benefits - Answer-If the patient has one policy, it is primary
, If the patient has coverage under two plans, the patient's longest running plan is
primary and the other plan is secondary. A third, or tertiary, plan or a supplemental
plan may also be in effect.
A patient's plan is also primary if the patient is:
Listed as a dependent on another person's plan
Covered under a government-sponsored plan, that is in addition to an employer's
plan
Retired, but covered under a working spouse's plan
birthday rule - Answer-If the dependent child is covered under both parents. The
guideline that determines which of two parents with medical coverage has the
primary insurance for a child; the parent whose day of birth is earlier in the calendar
year is considered primary.
"Exception to birthday rule":
If the patient is a dependent child of divorced or separated parents, primary
insurance is determined in the following order:
1) plan of custodial parent
2) plan of spouse of custodial parent if remarried
3) plan of parent without custody
(PAR) participating provider - Answer-provider who agrees to provide medical
services to a payer's policyholders according to a contract
(non PAR) : nonparticipating provider - Answer-provider who does not join a
particular health plan
Payer Adjudication - Answer-Payers review claims by following the adjudication
process
Puts the claim through a series of steps designed to judge whether it should be paid
or not
The payer's decision is explained on a report sent back to the provider with the
payment.
Ethics - Answer-Values, Standards of behavior shared by those in the medical
profession.
Etiquette - Answer-Manners, Describes proper protocol and behavior in a medical
practice.
CMA - Answer-Certified Medical Assistant
RMA - Answer-registered medical assistant
Fee for Service - Answer-schedule of fees set for services performed by providers
and paid by the patient
QUESTIONS WITH COMPLETE
SOLUTIONS
HIPAA Security Rule - Answer-Law that requires covered entities to establish
administrative, physical, and technical safeguards to protect the confidentiality,
integrity and availability of health information
HIPAA Electronic Health Care Transactions and Code Sets standards - Answer-
HIPAA standards governing that every provider doing business electronically must
use same standards for transactions and code sets.
Covered entities under HIPAA - Answer-electronically transmit HIPAA-protected
information. CEs are (1) health plans, (2) health care clearinghouses, and (3) health
care providers.
Business associates work for covered entities and include services such as law
firms, accounting practices, IT consultants, and collection agencies. States that
covered entities must:
Have appropriate privacy practices
Notify patients about their privacy rights
Train employees on the privacy practices
Appoint a privacy official responsible for the adoption and following of privacy
practices
Safeguard patients' records
Protected Health Information (PHI) - Answer-Medical record
Other personal health information
that is transmitted or maintained by electronic
media
Treatment Payment and healthcare Operations (TPO) - Answer-Treatment-
Providing and coordinating medical care
Payment- The exchange of information with health plans
Operations- General business management functions
legitimate reasons for sharing patients protected health information without
authorization. Use minimum necessary standard- only release health information to
the extent that it is needed.
minimum necessary standard - Answer-The HIPAA standard that requires covered
entities to release only the minimum amount of patient health data to meet the need
of the request.
(DRS) Designated Record Set- - Answer-Providers = medical and billing records
Health plans = enrollment, payment, claim decisions, and medical management
system data
,Patients can= Access, copy, and inspect information
Request amendments
Obtain accounting of disclosures
Receive information by other means
Complain about alleged violations
Standard Code Sets - Answer-Examples: ICD-9-CM, CPT, CDT, HCPCS. Coding
systems for
diseases;
treatments and
procedures; supplies.
National Patient ID (Individual Identifier) - Answer-unique individual identification
system to be created under HIPAA national identifiers.
Employer Identification Number (EIN)
National Provider Identifier (NPI)
Fraud - Answer-Act of deception used to take advantage of another person, (Lie).
Example - billing when the task was not done.
Abuse - Answer-Act that misuses public funds.
Example - billing when the task was not necessary. Filing something TRUTHFULLY
because it was done but something that was not necessary..."abusing the
system"...fine the "loop holes"
.
False claims act - Answer-Prohibits submitting fraudulent claim or making false
statements or representation in connection with a claim.
Federal law that prohibits fraudulent claims to the government.
Compliance Plans - Answer-"Billing rules", Parts of a compliance plan: Employer is
responsible for employee's actions.
1. Consistent written policies and procedures
2. Appointment of a compliance officer and committee
3. Training
4. Communication
5. Disciplinary systems
6. Auditing and monitoring
7. Responding to and correcting errors
NP = New patient - Answer-someone who has not received any services from the
provider or has not received services in the past three years.
EP = established patient - Answer-Patient who has seen provider in the past three
years.
Coordination of Benefits - Answer-If the patient has one policy, it is primary
, If the patient has coverage under two plans, the patient's longest running plan is
primary and the other plan is secondary. A third, or tertiary, plan or a supplemental
plan may also be in effect.
A patient's plan is also primary if the patient is:
Listed as a dependent on another person's plan
Covered under a government-sponsored plan, that is in addition to an employer's
plan
Retired, but covered under a working spouse's plan
birthday rule - Answer-If the dependent child is covered under both parents. The
guideline that determines which of two parents with medical coverage has the
primary insurance for a child; the parent whose day of birth is earlier in the calendar
year is considered primary.
"Exception to birthday rule":
If the patient is a dependent child of divorced or separated parents, primary
insurance is determined in the following order:
1) plan of custodial parent
2) plan of spouse of custodial parent if remarried
3) plan of parent without custody
(PAR) participating provider - Answer-provider who agrees to provide medical
services to a payer's policyholders according to a contract
(non PAR) : nonparticipating provider - Answer-provider who does not join a
particular health plan
Payer Adjudication - Answer-Payers review claims by following the adjudication
process
Puts the claim through a series of steps designed to judge whether it should be paid
or not
The payer's decision is explained on a report sent back to the provider with the
payment.
Ethics - Answer-Values, Standards of behavior shared by those in the medical
profession.
Etiquette - Answer-Manners, Describes proper protocol and behavior in a medical
practice.
CMA - Answer-Certified Medical Assistant
RMA - Answer-registered medical assistant
Fee for Service - Answer-schedule of fees set for services performed by providers
and paid by the patient
