Medical Billing and Coding Certificate exam
Chief Complaint (element 1 of history) - Answer- History of present illness,
Review symptom,
Past, Family, and Social history
History Levels (Element 2 of history) and Examination Levels (Element 3 of History) - Answer-
Problem focused,
expanded problem focused,
detailed,
Comprehensive
Medical Decision Making Complexity Levels (element 4 of history) - Answer- Straightforward,
Low,
Moderate,
High
straightforward - Answer- Minimal diagnosis
Minimal risk
Minimal complexity of data
Low - Answer- Limited diagnosis
Limited/low risk to patient
Limited data
Moderate - Answer- Multiple diagnosis
Moderate risk to patient
Moderate amount and complexity of data
high - Answer- Extensive diagnosis
high risk to patient
extensive amount and complexity of data
truncated coding (error in coding) - Answer- using diagnosis codes that are not as specific as
possible
assumption coding (fraudulent coding) - Answer- reporting items of services that are not actually
documented
errors of the coding process - Answer- -altering documentation after services are reported
-coding without documentation
-reporting services provided by unlicensed or unqualified clinical personnel
-coding a unilateral service twice instead of choosing the bilateral
-not satisfying the condition of coverage for a particular service
-codes that report more than one diagnosis with one code is a combination code
Unbundling codes - Answer- when multiple codes are used to code a procedure when a single
code should be used
, Upcoding - Answer- using a procedural code that provides a higher reimbursement rate than the
correct code
Downcoding - Answer- the document does not justify the level of service
Most common billing errors - Answer- Billing non-covered services
Billing over limit services
Upcoding
Downcoding
Billing without signatures
Using outdated codes
External Audits
Internal Audits
Retrospective audits - Answer- Types of Audits done to avoid billing and coding errors
External Audits - Answer- a private payer or government investigator's review of selected records
of a practice for compliance
Internal Audits - Answer- self-audit conducted by a staff member or consultant
Retrospective Audits - Answer- conducted after the claim has been send the remittance advice
has been received
Adjustments - Answer- amounts added to or taken away from the balance of an account
Two methods to determine rates to be paid to providers - Answer- Charge; Resource
Charge - Answer- based fees are established using the fees of providers providing similar services
resource - Answer- -how difficult is it for the provider to do the procedure
-how much office overhead is involved
-the relative risk the procedure presents to the patient and the provider
Clearing Houses - Answer- Edits and transmits batches of claims to insurance companies
Fee schedule - Answer- Payment is predetermined according to a table of diagnoses and their
eligible fees
usual - Answer- fee normally charged for a given service
Customary fee - Answer- fee in the range of usual fees charged by physicians of similar training
experience for the same service within the same specific and limited socioeconomic are
resonable fee - Answer- fee that meets both usual or customary fees or is considered justifiable by
responsible medical opinion considering special circumstances of the particular case in question
relative value studies (rvs) - Answer- a list of 5 digit procedure codes for services with unit values
that indicate the value for each procedure
Chief Complaint (element 1 of history) - Answer- History of present illness,
Review symptom,
Past, Family, and Social history
History Levels (Element 2 of history) and Examination Levels (Element 3 of History) - Answer-
Problem focused,
expanded problem focused,
detailed,
Comprehensive
Medical Decision Making Complexity Levels (element 4 of history) - Answer- Straightforward,
Low,
Moderate,
High
straightforward - Answer- Minimal diagnosis
Minimal risk
Minimal complexity of data
Low - Answer- Limited diagnosis
Limited/low risk to patient
Limited data
Moderate - Answer- Multiple diagnosis
Moderate risk to patient
Moderate amount and complexity of data
high - Answer- Extensive diagnosis
high risk to patient
extensive amount and complexity of data
truncated coding (error in coding) - Answer- using diagnosis codes that are not as specific as
possible
assumption coding (fraudulent coding) - Answer- reporting items of services that are not actually
documented
errors of the coding process - Answer- -altering documentation after services are reported
-coding without documentation
-reporting services provided by unlicensed or unqualified clinical personnel
-coding a unilateral service twice instead of choosing the bilateral
-not satisfying the condition of coverage for a particular service
-codes that report more than one diagnosis with one code is a combination code
Unbundling codes - Answer- when multiple codes are used to code a procedure when a single
code should be used
, Upcoding - Answer- using a procedural code that provides a higher reimbursement rate than the
correct code
Downcoding - Answer- the document does not justify the level of service
Most common billing errors - Answer- Billing non-covered services
Billing over limit services
Upcoding
Downcoding
Billing without signatures
Using outdated codes
External Audits
Internal Audits
Retrospective audits - Answer- Types of Audits done to avoid billing and coding errors
External Audits - Answer- a private payer or government investigator's review of selected records
of a practice for compliance
Internal Audits - Answer- self-audit conducted by a staff member or consultant
Retrospective Audits - Answer- conducted after the claim has been send the remittance advice
has been received
Adjustments - Answer- amounts added to or taken away from the balance of an account
Two methods to determine rates to be paid to providers - Answer- Charge; Resource
Charge - Answer- based fees are established using the fees of providers providing similar services
resource - Answer- -how difficult is it for the provider to do the procedure
-how much office overhead is involved
-the relative risk the procedure presents to the patient and the provider
Clearing Houses - Answer- Edits and transmits batches of claims to insurance companies
Fee schedule - Answer- Payment is predetermined according to a table of diagnoses and their
eligible fees
usual - Answer- fee normally charged for a given service
Customary fee - Answer- fee in the range of usual fees charged by physicians of similar training
experience for the same service within the same specific and limited socioeconomic are
resonable fee - Answer- fee that meets both usual or customary fees or is considered justifiable by
responsible medical opinion considering special circumstances of the particular case in question
relative value studies (rvs) - Answer- a list of 5 digit procedure codes for services with unit values
that indicate the value for each procedure
