Nha New Cbcs Practice Tests

Medical Ethics - correct answer Standards of conduct based on moral principles. Generally accepted as a guide for behavior towards patients, physicians, co-workers, the government, and insurance compaines. Compliance Regulations - correct answer billing-related cases are based on HIPAA and False Claims Act. Health Insurance Portability and Accountability Act of 1996 (HIPPA) - correct answer Created the Health Care Frad and Abuse Control Prpgram enacted nt check for fraud and abuse in the Medicare and Medicaid programs, and private payers. Two provisions of HIPPA - correct answer Titile I: Insurance Reform Title II: Administrative Simplification Insurance Reform - correct answer -Primary purpose to provide continuous insurance coverage for workers and their dependents when they change or lose their jobs. -Limits the use of preexisting conditions exclusions -Prohibits discrimination for part or present poor health -Guarantees cetraom employees and individuals the right to purchase health insurance coverage after losing a job - Allows renewal of health insurance coverage regardless of an individual's health condition that is covered under the particular policy Administrative Simplification - correct answer -The goal is to focus on the health care practice setting to reduce administrative cost and burdens. Two parts: 1. Development and implementation of standardized health-related financial and administrative activities electronically. 2. Implementation of privacy and security procedures to prevent the misuse of health information by ensuring confidentiality. False Claim Act (FCA) - correct answer Federal law that prohibits submittimg a fraudulent claim or making statement or representation in connection with a claim. National Correct Coding Initiative (NCCI) - correct answer Developed by the CMS to promote national correct coding methodologies and to control improper coding that leads to inappropriate payment of part B health insurance claims. Two type of NCCA edits - correct answer 1. Column1/Column 2(perviously called Comprehensive Component) Edits:identifies code pairs that should not be billed together because one code (Column 1) includes all the services described by another code (Column 2). 2. Muttually Exclusive Edits: identifeis code pairs that, for clinical reason, are unlikely to be performed on the same patient on the same day. Office of Inspector General (OIG) - correct answer Investigates and prosecute health care fraud and abuse. Fraud - correct answer Knowingly and intentionally deceiving or misrepresenting information that may result in unauthorized benefits. Abuse - correct answer Defined as incidents or practices, not usually considered fradulaent that are inconsistant with the accepted medical business or fiscal practices in the industry. Patient Confidentiality - correct answer A;ll patients have the right to privacy, and all information should remain privileged. Discuss patient information with only the patient's physician or office personnel that need cetain information to do their job. Obtained a signed consent form to release medical infomation to the insurance company or other individual. Under HIPPA Privacy Rule, providers may use patient's Protected Health Information (PHI) without specific authorization for - correct answer Treatment: primarily for the purpose of discussion fo the patient's case with other providers. Payment: providers submit claims on behalf of patients. Operations: for purposes such as stafff training and quality improvment. Employern Liability - correct answer Physicians are legally responsible for their own conduct and any action of their employees (their designee) perform within the context of their employment. Refered to as "vacarious liability"also known as "respondent superior" which means "let the master answer". Employee Liabiltiy - correct answer "Errors and omissions insurance" is protection against loss of monies by failure through error or unintentional omission on the part of the individual or service submitting the insurance claim. Medical Records - correct answer Documentaiton of the patient's social and medical history, family history, physical examination findings, progress notes, radiology, and lab results, consultation reports, and correspondence to patient. Information needed when billing the insurance company - correct answer Date of service (DOS), place of service (POS), type of service (TOS), diagnosis (dx or DX), and procedures. Retention of Medical Records - correct answer Governed by state and local laws and may bary from state-to-state. Most physicians are required to retain records indefinitley; deceased patient records should be kept for at least (5) years. New patient - correct answer one who has not received any medical services within the last 3 years Established patient - correct answer someone who has received medical services in the last 3 years from the physician or another physician of the same specialty who belong to the same group practice. cheif complaint - correct answer brief statement describing they symptom, problem, diagnosis, or condition that is the reason a patient seeks medical care. 3 volumns of ICD-9 manal - correct answer Volumn 1-Diseases: Tabular List Volumn 2-Diseases: Alphabetic Index Volumn 1 and 2 are used in the inpatient and outpatient setting Volumn 3- Procedures:Tabular List and Alphabetic Index Volumn 1 - Diseases: Tabular List - correct answer -contains the diease and condition code and the descriptions - also contains the V codes and E codes Volumn 2 - Diseases: Alphabetic Index - correct answer alphabetic index of volumn 1 Volumn 3 - Tabular List and Alphabetic Index - correct answer contains codes for surgical, therapeutic, and diagnostic procedures; used primarily by hospitals Hypertension classifications: - correct answer Maligant- an accelerated, severe form of hypertension with vascular damage and a diastolic pressure of 130mmHg or greater. Benign- Mild or controlled hypertension and no damage to the vascular system or organs. Unspecified- not specified as bengin or malignant in the diagnosis or medical record. malignant neoplasm - correct answer further classified as to primary , secondary, or cacinoma in situ primary malignancy - correct answer original cancer site. Malignant tumors are considered primary unless documented as secondary or metastatic carcinoma in situ - correct answer cancer that is localized and has not spread to adjacent tissue or distant parts of the body secondary malignacy - correct answer cancer that has metasized (spread) to a secondary site either adjacent or remote region of the body 3 sections of Alphabetic index - correct answer Section 1: Index to Diseases: each term is followed by the code or codes that apply to that term Section 2: Table of Drugs and Chemiclas: contains list of drugs and chemicals with corresponding poisoning codes and E codes. Current Procedural Terminology (CPT) - correct answer Codes used to report services and procedures by physicians. Published and updated anually by the American Medical Association (AMA) with a new one coming out each November and becoming effective on January 1st of the following calendar year. Category I codes - correct answer respresent services and procedures widely used by many health care professional in clinical practice in multiple locations and have been approved by the FDA Category II codes - correct answer supplemental codes used for performance measurements. Category III codes - correct answer temporary codes for emerging technology, services and procedures. If a Category III code is available, it is reported instead of a Category I unlisted code. stand-alone code - correct answer contain the full description of the procedure for the code indented codes - correct answer codes are listed under associated stand-alone codes. To complete the description for indeneted codes, one must refer to the portion of the stand alone code description before the semi-colon add-on codes - correct answer used for procedures that is always performed during the same operative session as another surgery in addition to the primary service/procedure and is never performed separatley. Never stand alone, they are always reported in addition to a primary procedure code. Modifier -51 (multiple procedures) exempt modifiers - correct answer provide the means by which the reporting physician can indicate that a service or procedurethat has been performed has been altered by some specific circimstance but not change in its definition or code. A triangle - correct answer symbol in the CPT manual that represents a change in the code description since the last edition. The change may be minor or significant and it could be and addition, deletion or revision. Two trianguar symbols - correct answer represents changes in the text or definition between the triangles bullet - correct answer a new procedure or service code added since the previous edition of the manual a plus sign - correct answer indicates a add-on codes circle with a line through it - correct answer Exemption from the use of modifier -51 CPT Modifiers - correct answer two-digit add- on codes attached to regular codes to tell third party payers of circumstances in which the serices procedures were altered. Listed in Appendix A -24 - correct answer Unrelated E/M Services by the Same Physician During a Postoperative Period -26 - correct answer Professional Component -32 - correct answer Mandated Services -50 - correct answer Bilateral Procedure -51 - correct answer Multiple Procedures -58 - correct answer Staged or Related Procedure or Service by the same Physician during the Postoperative Period -78 - correct answer Return to Operating Room for a Related Procedure during the Postoperative Period -79 - correct answer Unrelated Procedure by the Same Physician During the Postoperative Period -90 - correct answer Reference (Outside) Laboratory -99 - correct answer Multiple Modifiers Unlisted Procedures - correct answer considered experimental, newly approved, or seldom used may not be listed in the CPT Manual. Key components of E/M are - correct answer History, Chief Complaint (CC), History of present illness,(HPI), Review of systems (ROS), Past,family and social history (PFSH), physical examination, Medical decision making complexity surgical surgery (global package) - correct answer Surgical procedure performed, local infiltration, mateacarpal/metatarsal/digital block, or topical anesthesia,preoperative E/M services: on day immediately prior to or on the day of procedure, Normal, uncomplicated postoperative care policyholder - correct answer one who purchases a health insurance contract insurance carrier - correct answer one who proovides the benefit plan or a government program developed to reimbures the policyholder of all or most medical expense 3 ways to obtain heath insurance - correct answer Group, personal, per-paid health plan group insurance - correct answer when a group of employees and their dependents are insured under (1) group policy issued to the employer personal insurance - correct answer an insurance plan issured to an individual pre-paid health plan - correct answer pre- determined set of benifits covered under one set annual fee. Usual, Customary, and Reasonable fee schedule - correct answer 1. the physician's most frequen charge for a given service (the usual) 2. the average charge o all providers of similar training and experience in a given geographical area ( the customary) 3. the actual charge submitied on a claim (must be reasonable to the provider) Relative Value Payment Schedules Method (RVPM) - correct answer involves the use of relative value scales which assign a relative weight to individual services according to the basis for the scale. Medicare's Resource Based Relative Value Scale (RBRVS) Payment Schedule - correct answer under this schedule, a procedure's value is the sum total of three elements:Work, overhead, malpractice convesion factor (multipliers) - correct answer conversion factors are determined annaully by the CMS in cooperation with Congress. Factors varies according to the type varies according to the type of service provided such as medical, surgical, non-surgical medicare pays - correct answer 80% of covered services benificiary pays - correct answer deductible, premiums, 20% coinsurance, non-covered services Relative Value for Physicians (RVP) - correct answer has no geographic adjustment factor or individual RVU component to calculate. However, for each category of procedures, a separate conversion factor must be developed contracted rates with MCO's - correct answer physicians agree to provide sevices at a discount of their usual fee in return for a pool of existing patients capitated rates - correct answer the physician provides a full range of contracted sevice to covered patients for a FIXED amount on a periodic basis/monthly medicare - correct answer the federal government's health insurance program created by the Social Security Act 1965 titled " Health Insurance for the Aged and Disabled". It is an entitlement program administered by the Centers for Medicare