Billing and Coding NHA Exam Questions with Correct Solutions Latest Version 2025 (Rated A+)
documentation - Answers record of clinical observations and care a pt receives at a health care facility
must be detailed, current and accurate
third party payers - Answers include insurance companies, Medicare and Medicaid
informed consent - Answers pcp explains medical or diagnostic procedures, surgical intervetions and the
benifits and risks involved, giving an oportunity for pts to ask questions before intervention is provided
implied consent - Answers pt presents for treatment, such as extending an arm to allow a blood draw
goes voluntarily
Protected Health Information (PHI) - Answers Any information about health status, provision of health
care, or payment for health care that can be linked to an individual. This is interpreted rather broadly
and includes any part of a patient's medical record or payment history.
clearinghouse - Answers agency that converts clains into a standardized electronic format, looks for
errors and formats them according to HIPAA and insurance standards
individiually identifiable - Answers documents that identify the person or provide enought info so that
the person coud be identified
consetn - Answers pts permission evidenced by signature
authorization - Answers permission granted by the pt or the pts representative to release information
for reasons other than treatment, pyment, or health care operations
reimbursement - Answers payment for services rendered by third party payer
auditing - Answers review of claims for accuract and completeness
fraud - Answers making falso statements of representations of material facts to obtain some benifit or
payment for which no entitlement would otherwise exist
upcoding - Answers assigning diagnosis/procedure code at a higher level than the documentation
supports
unbundling - Answers using multiplr codes that describe different components of a treatment instead of
using a single code that describes all the steps
abuse - Answers practices that directly or indirectly result in unnecessary costs to the medicare program
final rule - Answers business associates must ensure that PHI remains sucure, and they are expected to
report any breaches in security
, stark law - Answers pcps are not allowed to refer pts to a pcp with whom they have a financial
relationship with
CMS - Answers has oversight responsibilities to stark law
false claims act - Answers protects the government from being overcharges for services provider or sold,
or substandard goos or services
Office of the Inspector General (OIG) - Answers has the authority to exclude individuals and entities who
have engages in fraud and abuse from participating in Medicare, Medicaid, and other federal helath care
programs
claim - Answers complete recors of the servics provided by the health care professional, along with
appropriate insurance info
transmitting claims - Answers sending required info to third party payers for reimbursement
filing claims for medicare - Answers claims must be recieved within 1 calander year of the claim's date of
service
coordination of benifits - Answers determines which insurance plan is primary and which is secondary
conditional payment - Answers medicare payment that is recovered after primary insurance pays
crossover claim - Answers claim submitted by people covered by a primary and secondary insurance
plan
clean claim - Answers accurate and complete, have all info needed to submit a claim
dirty claim - Answers inaccurate, incomplete or contains errors
assignment of benefits - Answers contract in which a pcp directly bills the payr and accepts the
allowable charge
allowable charge - Answers amount an insurer will accept as full payment minus applicable cost sharing
Medicare Administrative Contractor (MAC) - Answers processes Medicare Parts A and B claims from
hospitals, and pcps
remittance advice (RA) - Answers report sent from the third party payer to the pcp that reflects any
changes made the the original billing
returning a claim - Answers must be resubmitted within 1 calander year
can be return because of clerical error
CMS-1500 Form - Answers used for medicare and medicaid
documentation - Answers record of clinical observations and care a pt receives at a health care facility
must be detailed, current and accurate
third party payers - Answers include insurance companies, Medicare and Medicaid
informed consent - Answers pcp explains medical or diagnostic procedures, surgical intervetions and the
benifits and risks involved, giving an oportunity for pts to ask questions before intervention is provided
implied consent - Answers pt presents for treatment, such as extending an arm to allow a blood draw
goes voluntarily
Protected Health Information (PHI) - Answers Any information about health status, provision of health
care, or payment for health care that can be linked to an individual. This is interpreted rather broadly
and includes any part of a patient's medical record or payment history.
clearinghouse - Answers agency that converts clains into a standardized electronic format, looks for
errors and formats them according to HIPAA and insurance standards
individiually identifiable - Answers documents that identify the person or provide enought info so that
the person coud be identified
consetn - Answers pts permission evidenced by signature
authorization - Answers permission granted by the pt or the pts representative to release information
for reasons other than treatment, pyment, or health care operations
reimbursement - Answers payment for services rendered by third party payer
auditing - Answers review of claims for accuract and completeness
fraud - Answers making falso statements of representations of material facts to obtain some benifit or
payment for which no entitlement would otherwise exist
upcoding - Answers assigning diagnosis/procedure code at a higher level than the documentation
supports
unbundling - Answers using multiplr codes that describe different components of a treatment instead of
using a single code that describes all the steps
abuse - Answers practices that directly or indirectly result in unnecessary costs to the medicare program
final rule - Answers business associates must ensure that PHI remains sucure, and they are expected to
report any breaches in security
, stark law - Answers pcps are not allowed to refer pts to a pcp with whom they have a financial
relationship with
CMS - Answers has oversight responsibilities to stark law
false claims act - Answers protects the government from being overcharges for services provider or sold,
or substandard goos or services
Office of the Inspector General (OIG) - Answers has the authority to exclude individuals and entities who
have engages in fraud and abuse from participating in Medicare, Medicaid, and other federal helath care
programs
claim - Answers complete recors of the servics provided by the health care professional, along with
appropriate insurance info
transmitting claims - Answers sending required info to third party payers for reimbursement
filing claims for medicare - Answers claims must be recieved within 1 calander year of the claim's date of
service
coordination of benifits - Answers determines which insurance plan is primary and which is secondary
conditional payment - Answers medicare payment that is recovered after primary insurance pays
crossover claim - Answers claim submitted by people covered by a primary and secondary insurance
plan
clean claim - Answers accurate and complete, have all info needed to submit a claim
dirty claim - Answers inaccurate, incomplete or contains errors
assignment of benefits - Answers contract in which a pcp directly bills the payr and accepts the
allowable charge
allowable charge - Answers amount an insurer will accept as full payment minus applicable cost sharing
Medicare Administrative Contractor (MAC) - Answers processes Medicare Parts A and B claims from
hospitals, and pcps
remittance advice (RA) - Answers report sent from the third party payer to the pcp that reflects any
changes made the the original billing
returning a claim - Answers must be resubmitted within 1 calander year
can be return because of clerical error
CMS-1500 Form - Answers used for medicare and medicaid
