MCBC CERTIFIED BILLING & CODING SPECIALIST
EXAM REVIEW
What are Medical Ethics? - Answer -Standards of conduct based on moral principle.
they are generally accepted as a guide for behavior towards pt's, dr's, coworkers, the
gov, and ins co's
What does acting within ethical behavior boundaries mean? - Answer -Carrying out
one's responsibilities with integrity, dignity, respect, honesty, competence, fairness, and
trust
Compliance regulations - Answer -Most billing-related cases are based on HIPAA and
False Claims Act
Health Insurance Portability & Accountability Act (HIPAA) - Answer -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 2 provisions of HIPAA? - Answer -Title 1: Insurance Reform
Title 2: Administrative Simplification
What is Title 1 of HIPAA? - Answer -Insurance Reform-primary purpose is to provide
continuous coverage for workers & their dependents when they change or lose jobs.
Also Limits the use of pre-existing conditions exclusions
Prohibits discrimination from past or present poor health
Guarantees certain employees/ individual the right to purchase new health insurance
coverage after losing job
Allows renewal of health insurance coverage regardless of an individuals health
condition that is covered under the particular policy
What are the possible consequences of inaccurate coding and incorrect billing? -
Answer -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 medicine
Who has the task of investigate and prosecuting health care fraud & abuse? - Answer -
The Office of Inspector General (OIG)
Fraud - Answer -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? - Answer -State & Federal agencies as well as private insurance
companies
,What are common forms of fraud? - Answer -billing for services not furnished,
unbundling, and misrepresenting diagnosis to justify payment
Abuse - Answer -incidences or practices, not usually considered fraudulent, that are
inconsistent with the accepted medical business or fiscal practices in the industry
What are examples of Abuse? - Answer -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 and liabilities associated with
abuse? - Answer -Risk Management
Patient Confidentiality - Answer -All patient's have right to privacy and all info should
remain privileged. Only discuss patient info when necessary to do job. Obtain a signed
consent form to release medical info to insurance company or other individual
When may a provider use PHI (Protected Health Information) without specific
authorization under the HIPAA Privacy Rule? - Answer -When using TPO, Treatment
(primarily for the purpose of discussion of patient's case with other Dr's)
Payment (providers submit claims on behalf of patients)
Operations (for purposes such as training staff and quality improvement)
What is Employer Liability? - Answer -Means physicians are legally responsible for their
own conduct and any actions of their employees (designee) performed within the
context of their employment. Referred to as "vicarious liability" A.K.A " respondent
superior"- "let the master answer". Means employee can be sued & brought to trial
What is Employee Liability? - Answer -"Errors & Omissions Insurance"- protection
against loss of monies caused by failure through error or unintentional omission on the
part of the individual or service submitting the claim. ***Some Dr.'s contract with a billing
service (clearinghouse) to handle claims submission and some agreements contain a
clause stating that the Dr. will hold the co harmless from "liability resulting from claims
submitted by the service for any account", means Dr. is responsible for mistakes made
by billing service, errors and omissions is not needed in the instance.***
However, if the Dr. ever asks the insurance biller to do the least bit questionable, such
as write off patients balances for certain patients automatically, make sure you have a
legal document or signed waiver of liability relieving you of responsibility for such
actions.
What is a Medical Record & what is it comprised of? - Answer -Documentation of the
patients social and medical history, family history, physical exam findings, progress
notes, radiology and lab results, consultation reports and correspondence to patients
Is the foremost tool of clinical care and communication
,What is Title 2 of HIPAA? - Answer -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)? - Answer -Federal law that prohibits submitting a
fraudulent claim or making a false statement or representation in connection with a
claim. Also protects & rewards whistle-blowers
What is the National Correct Coding Initiative (NCCI)? - Answer -Developed by CMS to
promote the national correct coding methodologies & to control improper coding that
lead to inappropriate payment of Part B health insurance claims
How many edits does NCCI include? - Answer -2:
1.Column 1/ Column 2 (previously called Comprehensive/ Component) Edits
2.Mutually Exclusive Edits
Column 1/ Column 2 edits (NCCI) - Answer -Identifies code pairs that should not be
billed together because 1 code (Column 1) includes all the services described by
another code (Column 2)
Mutually Exclusive Edits (NCCI) - Answer -ID's code pairs that, for clinical reasons, are
unlikely to be preformed on the same patient on the same day
What is a medical report? - Answer -part of the medical record & is a permanent legal
document that formally states the consequences of the patients exam or treatment in
letter or report form
IT IS THIS RECORD THAT PROVIDES INFO NEEDED TO COMPLETE THE
INSURANCE CLAIM FORM
Reasons for Documentation - Answer -Important that every patient seen by Dr. has
comprehensive legible documentation about patients illness, treatment and plans for
following reasons:
* Avoidance of denied or delayed payment by insurance company investigating the
medical necessity of service
* Enforcement of medical record-keeping rules by insurance company's requiring
accurate documentation that supports procedure & diagnosis codes
* Subpoena of medical records by state investigators or the court for review
* Defense of professional liability claim
Retention of Medical Records - Answer -Is governed by state & local laws & may vary
from state-to-state. Most Dr. are required to retain records indefinitely, deceased patient
records should be kept for at least 5 years
, -algia - Answer -pain
-emia - Answer -blood condition
-itis - Answer -inflammation
-megaly - Answer -enlargement
-meter - Answer -measure
-oma - Answer -tumor, mass
-osis - Answer -abnormal condition
-pathy - Answer -disease condition
-rrhagia - Answer -bursting forth of blood
-rrhea - Answer -discharge, flow
-sclerosis - Answer -hardening
-scopy - Answer -to view/ visual examination
-centesis - Answer -surgical puncture
-ectomy - Answer -removal, resection, excision
-gram - Answer -record
-graphy - Answer -process of recording
-lysis - Answer -separation, breakdown, destruction
-pexy - Answer -surgical fixation
-plasty - Answer -surgical repair
-rrhapy - Answer -suture
-stomy - Answer -opening
-therapy - Answer -treatment
-tomy - Answer -incision, to cut into
EXAM REVIEW
What are Medical Ethics? - Answer -Standards of conduct based on moral principle.
they are generally accepted as a guide for behavior towards pt's, dr's, coworkers, the
gov, and ins co's
What does acting within ethical behavior boundaries mean? - Answer -Carrying out
one's responsibilities with integrity, dignity, respect, honesty, competence, fairness, and
trust
Compliance regulations - Answer -Most billing-related cases are based on HIPAA and
False Claims Act
Health Insurance Portability & Accountability Act (HIPAA) - Answer -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 2 provisions of HIPAA? - Answer -Title 1: Insurance Reform
Title 2: Administrative Simplification
What is Title 1 of HIPAA? - Answer -Insurance Reform-primary purpose is to provide
continuous coverage for workers & their dependents when they change or lose jobs.
Also Limits the use of pre-existing conditions exclusions
Prohibits discrimination from past or present poor health
Guarantees certain employees/ individual the right to purchase new health insurance
coverage after losing job
Allows renewal of health insurance coverage regardless of an individuals health
condition that is covered under the particular policy
What are the possible consequences of inaccurate coding and incorrect billing? -
Answer -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 medicine
Who has the task of investigate and prosecuting health care fraud & abuse? - Answer -
The Office of Inspector General (OIG)
Fraud - Answer -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? - Answer -State & Federal agencies as well as private insurance
companies
,What are common forms of fraud? - Answer -billing for services not furnished,
unbundling, and misrepresenting diagnosis to justify payment
Abuse - Answer -incidences or practices, not usually considered fraudulent, that are
inconsistent with the accepted medical business or fiscal practices in the industry
What are examples of Abuse? - Answer -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 and liabilities associated with
abuse? - Answer -Risk Management
Patient Confidentiality - Answer -All patient's have right to privacy and all info should
remain privileged. Only discuss patient info when necessary to do job. Obtain a signed
consent form to release medical info to insurance company or other individual
When may a provider use PHI (Protected Health Information) without specific
authorization under the HIPAA Privacy Rule? - Answer -When using TPO, Treatment
(primarily for the purpose of discussion of patient's case with other Dr's)
Payment (providers submit claims on behalf of patients)
Operations (for purposes such as training staff and quality improvement)
What is Employer Liability? - Answer -Means physicians are legally responsible for their
own conduct and any actions of their employees (designee) performed within the
context of their employment. Referred to as "vicarious liability" A.K.A " respondent
superior"- "let the master answer". Means employee can be sued & brought to trial
What is Employee Liability? - Answer -"Errors & Omissions Insurance"- protection
against loss of monies caused by failure through error or unintentional omission on the
part of the individual or service submitting the claim. ***Some Dr.'s contract with a billing
service (clearinghouse) to handle claims submission and some agreements contain a
clause stating that the Dr. will hold the co harmless from "liability resulting from claims
submitted by the service for any account", means Dr. is responsible for mistakes made
by billing service, errors and omissions is not needed in the instance.***
However, if the Dr. ever asks the insurance biller to do the least bit questionable, such
as write off patients balances for certain patients automatically, make sure you have a
legal document or signed waiver of liability relieving you of responsibility for such
actions.
What is a Medical Record & what is it comprised of? - Answer -Documentation of the
patients social and medical history, family history, physical exam findings, progress
notes, radiology and lab results, consultation reports and correspondence to patients
Is the foremost tool of clinical care and communication
,What is Title 2 of HIPAA? - Answer -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)? - Answer -Federal law that prohibits submitting a
fraudulent claim or making a false statement or representation in connection with a
claim. Also protects & rewards whistle-blowers
What is the National Correct Coding Initiative (NCCI)? - Answer -Developed by CMS to
promote the national correct coding methodologies & to control improper coding that
lead to inappropriate payment of Part B health insurance claims
How many edits does NCCI include? - Answer -2:
1.Column 1/ Column 2 (previously called Comprehensive/ Component) Edits
2.Mutually Exclusive Edits
Column 1/ Column 2 edits (NCCI) - Answer -Identifies code pairs that should not be
billed together because 1 code (Column 1) includes all the services described by
another code (Column 2)
Mutually Exclusive Edits (NCCI) - Answer -ID's code pairs that, for clinical reasons, are
unlikely to be preformed on the same patient on the same day
What is a medical report? - Answer -part of the medical record & is a permanent legal
document that formally states the consequences of the patients exam or treatment in
letter or report form
IT IS THIS RECORD THAT PROVIDES INFO NEEDED TO COMPLETE THE
INSURANCE CLAIM FORM
Reasons for Documentation - Answer -Important that every patient seen by Dr. has
comprehensive legible documentation about patients illness, treatment and plans for
following reasons:
* Avoidance of denied or delayed payment by insurance company investigating the
medical necessity of service
* Enforcement of medical record-keeping rules by insurance company's requiring
accurate documentation that supports procedure & diagnosis codes
* Subpoena of medical records by state investigators or the court for review
* Defense of professional liability claim
Retention of Medical Records - Answer -Is governed by state & local laws & may vary
from state-to-state. Most Dr. are required to retain records indefinitely, deceased patient
records should be kept for at least 5 years
, -algia - Answer -pain
-emia - Answer -blood condition
-itis - Answer -inflammation
-megaly - Answer -enlargement
-meter - Answer -measure
-oma - Answer -tumor, mass
-osis - Answer -abnormal condition
-pathy - Answer -disease condition
-rrhagia - Answer -bursting forth of blood
-rrhea - Answer -discharge, flow
-sclerosis - Answer -hardening
-scopy - Answer -to view/ visual examination
-centesis - Answer -surgical puncture
-ectomy - Answer -removal, resection, excision
-gram - Answer -record
-graphy - Answer -process of recording
-lysis - Answer -separation, breakdown, destruction
-pexy - Answer -surgical fixation
-plasty - Answer -surgical repair
-rrhapy - Answer -suture
-stomy - Answer -opening
-therapy - Answer -treatment
-tomy - Answer -incision, to cut into
