2024 AAPC CPB Practice Exam 460 questions and answers new exam update | Exams Nursing | Docsity (2024)

Download 2024 AAPC CPB Practice Exam 460 questions and answers new exam update and more Exams Nursing in PDF only on Docsity! 2024 AAPC CPB Practice Exam 460 questions and answers new exam update Joe and Mary are a married couple and both carry insurance from their employers. Joe was born on February 23, 1977 and Mary was born on April 4, 1974. Using the birthday rule, who carries the primary insurance for their children for billing? A. Joe, because he is the male head of the household. B. Mary, because her date of birth is the 4th and Joe's date of birth is the 23rd. C. Mary, because her birth year is before Joe's birth year. D. Joe, because his birth month and day are before Mary's birth month and day. - answer is D. Joe, because his birth month and day are before Mary's birth month and day. Which type of managed care insurance allows patients to self-refer to out-of-network providers and pay a higher co-insurance/copay amount? I. HMO II. PPO III. EPO IV. POS V. Capitation A. II B. IV C. II and IV D. II, III, and V - answer is C. II and IV A patient covered by a PPO is scheduled for knee replacement surgery. The biller contacts the insurance carrier to verify benefits and preauthorize the procedure. The carrier verifies the patient has a $500 deductible which must be met. After the deductible, the PPO will pay 80% of the claim. The contracted rate for the procedure is $2,500. What is the patient's responsibility? A. $400 B. $500 C. $900 D. $1,600 - answer is C. $900 When a nonparticipating provider files a claim for a patient to BC/BS, how is the payment processed? A. The payment is sent to the patient and the patient must pay the provider. B. The payment is sent to the provider if the provider agrees to accept assignment. C. The payment is sent to the provider regardless if he accepts assignment. D. The claim is not paid because the provider is not participating in the plan. - answer is A. The payment is sent to the patient and the patient must pay the provider. Which of the following TRICARE options is/are available to active duty service members? A. TRICARE Select B. TRICARE Prime C. TRICARE For Life D. TRICARE Young Adult - answer is B. TRICARE Prime A female patient who was involved in an auto accident presents to the emergency department (ED) for evaluation. She does not have any complaints. The provider evaluates her and determines there are no injuries. The provider informs the patient to come back to the ED or see her primary care physician if she develops any symptoms. How is the claim processed for this encounter? A. The medical insurance is billed primary and the auto insurance is billed secondary. B. The auto insurance is billed primary and the medical insurance is billed secondary. C. Bill the medical insurance first to receive a denial and then submit with the remittance advice to the auto insurance. D. Bill only the medical insurance because the auto insurance only covers damage to the vehicle, not medical expenses. - answer is B. The auto insurance is billed primary and the medical insurance is billed secondary. What forms need to be submitted when billing for a work-related injury? A. Progress reports, and WC-1500 claim form B. UB-04 C. First Report of Injury form and an itemized statement D. First Report of Injury form, progress reports, and CMS-1500 claim form - answer is D. First Report of Injury form, progress reports, and CMS-1500 claim form A document provided to Medicare patients explaining their financial responsibility if Medicare denies a service is a(n): A. Notice of Financial Liability B. Advance Beneficiary Notice C. Insurance waiver D. Explanation of Benefits - answer is B. Advance Beneficiary Notice What is an Accountable Care Organization (ACO)? A. Groups of doctors, hospitals, and other health care providers who coordinate high quality care to Medicare patients. B. An insurance carrier that provides a set fee based on the diagnosis of the patient. C. A group of providers who contract with a third party administrator to pay fee for service for services. D. Hospitals who see a subset of patients for cost efficiency. - answer is A. Groups of doctors, hospitals, and other health care providers who coordinate high quality care to Medicare patients. A new patient presents for her annual exam and has no complaints. She is scheduled to see the physician assistant (PA). How should services be billed ? A. Bill under the PA. B. A new patient can be billed incident to the physician. C. The PA cannot see new patients. D. Reschedule the patient with the physician - answer is A. Bill under the PA. CPT® codes 12032 and 12001 were reported together for a 2.6 cm intermediate repair of a laceration to the right arm and a 2.5 cm simple repair of a laceration to the left arm. 12001 was denied as a bundled service. What action should be taken by the biller (following the CPT® guidelines)? A. Write-off the charge for 12001 as it is a bundled procedure. B. Resubmit a corrected claim as 12032, 12001-59. C. Transfer the charge to patient responsibility. D. Resubmit a corrected claim as 12032, 12001-51. - answer is B. Resubmit a corrected claim as 12032, 12001-59. According to CMS, which of the following services are included in the global package for surgical procedures? I. Surgical procedure performed II. E/M visits unrelated to the diagnosis for which the surgical procedure is performed III. Local infiltration, digital block, or topical anesthesia IV. Treatment for postoperative complication which requires a return trip to the operating room (OR)V. Writing Orders VI. Postoperative infection treated in the office A. I, III, V, VI B. I, IV, V C. I, II, III, V D. I-VI - answer is A. I, III, V, VI Which CPT® code below can be reported with modifier 51? A. 17004 B. 17312 C. 19101 D. 19126 - answer is C. 19101 A HCPCS/CPT® code is assigned "1" in the MUE file. What does this indicate? A. Code pairs cannot be reported together. B. Codes can be reported together if documented. Append modifier 59. B. The rule is fraudulent because the office is billing for services not performed and services that are a result of provider error. C. The rule would be legal if changed to only bill for two blood draws on the patients the MA misses on the first stick. D. The rule is only legal if the clinic is in a hospital-based office. - answer is B. The rule is fraudulent because the office is billing for services not performed and services that are a result of provider error. An example of an overpayment that must be refunded is _____________? A. Payment based on a reasonable charge. B. An unprocessed voided claim. C. Incorrect posting of an EOB. D. Duplicate processing of a claim - answer is D. Duplicate processing of a claim Which of the following is true regarding provider credentialing? A. A provider can complete an application with CAQH which handles credentialing for many payers. B. A provider is required to complete the credentialing process with private payers before an NPI application can be submitted. C. A provider can complete an application with NCQA to credential with private payers and obtain an NPI. D. Approval of the NPI number is all the provider needs to be credentialed with all payers. - answer is A. A provider can complete an application with CAQH which handles credentialing for many payers. Which Act protects information collected by consumer reporting agencies? A. Equal Credit Opportunity Act B. Fair Credit Reporting Act C. Fair Debt Collection Practices Act D. Truth in Lending Act - answer is B. Fair Credit Reporting Act There is a written office policy to write off patients co-insurance and copayment amounts as a professional courtesy. Is this appropriate? A. Yes, if it is a policy in writing it must be followed. B. Yes, if it is a written policy and everyone in the office adheres to it. C. No, it is considered fraud to write off the patients' responsibility for all patients. D. No, it is a violation of Stark law to write off patients' responsibility. - answer is C. No, it is considered fraud to write off the patients' responsibility for all patients. Which statement is TRUE regarding the Fair Debt Collection Practices Act (FDCPA)? A. Collectors are allowed to threaten legal action even if it will not be pursued. B. The FDPCA does not apply to medical practices. C. Collectors are allowed to contact debtors repeatedly. D. Collectors are not allowed to contact debtors at odd hours. - answer is D. Collectors are not allowed to contact debtors at odd hours. Which of the following is an allowed collection policy after a patient files for bankruptcy? A. Unpaid insurance claims for dates of service occurring after the date of the bankruptcy can be collected. B. Any co-payments or deductibles that are past due and owed by the patient can be collected. C. Unpaid claims for dates of service occurring before the date of the bankruptcy and any co-pays or deductibles adjudicated on that same claim. D. Discuss a payment arrangement with the patient to settle the past due account. - answer is A. Unpaid insurance claims for dates of service occurring after the date of the bankruptcy can be collected. A patient with an acute myocardial infarction is brought by ambulance to the emergency department. The patient is taken into the cardiac catheterization lab. Angioplasty and a stent was placed in the LAD. The patient's insurance requires preauthorization for all surgical procedures. Which of the following statements is true for most payers? A. If the biller did not obtain authorization prior to the procedure being performed, the surgical services will not be paid. B. Because this was an emergency, it is acceptable to obtain authorization following the surgery. C. Because this was an emergency, a preauthorization is not required. D. If the biller did not obtain authorization prior to the procedure being performed, the entire claim will not be paid. - answer is B. Because this was an emergency, it is acceptable to obtain authorization following the surgery. Which of the following steps should be completed when filling an appeal? I. Submit in the format required by the payer. II. Review the reason for the denial and determine if the payer made an error. III. Provide supporting documentation from an official source to support your reason for appeal. IV. Keep a copy of the information submitted to the payer for the appeal. V. Appeal the claim as soon as a denial is received. VI. Appeal the claim as soon as you are certain the payer denied in error and the claim cannot be reprocessed. A. I, II, and V B. I, IV, V and VI When you respond to a patient with "How may I help you, Mrs. Jones?", the use of the patient's name: A. Is too familiar B. Violates HIPAA C. Indicates to the caller you are interested and listening D. Is too formal for an existing patient - answer is C. Indicates to the caller you are interested and listening A dermatologist performed an excision of a squamous cell carcinoma from the patients forehead with a 1.2 cm excised diameter. The excision site required an intermediate wound closure measuring 1.8 cm. What is/are the correct code(s)? A. 11642 B. 11442 C. 11642, 12051-51 D. 11442, 12051-51 - answer is C. 11642, 12051-51 55-year-old female presents to the office with ongoing history of type I diabetes which has been controlled with insulin. During the exam the physician notes that gangrene has set in due to the diabetic peripheral angiopathy on her left great toe. Patient is recommended to see a general surgeon for treatment of the gangrene on her left great toe. A. I96, E10.9, Z79.4 B. E11.52, I96, Z79.4 C. E10.52 D. I96, E11.52 - answer is C. E10.52 What is the correct HCPCS Level II code for Depo-Provera (medroxyprogesterone acetate) injection of 100 mg? A. J1050 B. J1050 x 100 C. J1020 x 5 D. J1030 x 3 - answer is B. J1050 x 100 The provider performs an office visit with an expanded problem focused history, expanded problem focused exam and low MDM to manage the patient's hypertension. The provider also destroys two plantar warts. How is this reported? A. 99213-25, 17110 B. 99213-25, 17110-59 C. 99213, 17110-25 D. 99213, 17110-59 - answer is A. 99213-25, 17110 HMO plans require the enrollee to: - answer is To have referrals to see a specialist that is generated by the patient's PCP What are PPOs (preferred provider organizations)? - answer is Organizations in which medical professionals and facilities provide services to subscribed clients at reduced rates. What is a covered entity? - answer is Health plans, clearinghouses, and any entity transmitting health information is considered to be as is stated by the Privacy Rule. What are the three steps to be taken when there is a breach of contract between a covered entity and a business associate? - answer is 1. Take steps to correct or end the violation 2. Terminate the contract 3. Report the breach to HHS A request for medical records is received for a specific date of service from patient's insurance company with regards to a submitted claim. No authorization or release of information is provided. What action should be taken? - answer is Release the requested records to the insurance company. Can you release PHI without authorization from a patient if it is for a workers' compensation claim? - answer is Yes, Workers compensation information is not protected under HIPAA HIPAA mandated what entity to adopt national standards for electronic transactions and code sets? - answer is HHS What is the standard time frame established for record retention? - answer is There is no single standard record retention time frame. It varies by state and federal regulation. CMS defines ______ as billing for a lower level of care than is supported in documentation, making false statements to obtain undeserved benefits or payment from a federal healthcare program, or billing for services that were not performed. - answer is Fraud A claim is submitted for a patient on medicare with a higher fee schedule that a patient on Insurance ABC. What is this considered under CMS? - answer is Abuse A person that files a claim for a Medicare beneficiary knowing that the service is not correctly reported is in violation of what statue? - answer is FCA (False claims act) What act is "upcoding or unbundling services" considered under? - answer is The false claims act Entities that have been identified as having improper billing practices are defined by CMS as a violation of what standard? - answer is Abuse What penalties can be imposed for Fraud and / or abuse related to the US code? - answer is Monetary penalties ranging from $10k to $50k (before inflation) for each item or service, imprisonment, and exclusion from federal healthcare programs. How long after being identified should a practice return medicare over payments? (days) - answer is 60 days A private practice hires a consultant to come in and audit some medical records. Under the Privacy Rule, what is this consultant considered? - answer is A covered entity According to the privacy rule, what health information *may not* be de-identified? - answer is The physician provider number A hospital records transporter is moving medical records from the hospital to an off-site building. During the transport, a chart falls from the box on the street. It is discovered when the transporter arrives at the off-site building and the number of charts is not correct. What type of violation is this? - answer is A breach A practice allows patients to pay large balances over a six month time period with a finance charge applied. The patient receives a statement every month that only shows the unpaid balance. What does this violate? - answer is TILA When a practice sends an electronic claim to a commercial health plan for payment, what is this considered? - answer is A transaction While working in a large practice, medicare over-payments are found in several patient accounts. The manager states that the practice will keep the money until medicare asks for it back. What does this action constitute? - answer is Fraud What were the eight standard EDI transactions adopted under? - answer is HIPAA A practice agrees to pay $250k to settle a lawsuit alleging that the practice used x-rays of one patient to justify services on multiple other patient's claims. That manager of the office brought the civil suit. What type of case is this? - answer is Qui Tam A health plan sends a request for medical records in order to adjudicate a claim. Does the office have to notify the patient or have them sign a release to send the information? - answer is No, since the information is used for payment activities it is not necessary to notify or obtain authorization (reference: TPO) Fraud or Abuse: A clinic fails to maintain adequate medical records - answer is Abuse Fraud or Abuse: A clinic bills every new patient at the highest level E/M visit no matter what - answer is Fraud Fraud or Abuse: A clinic is found to be falsifying documentation to support a service that was billed to receive payment - answer is Fraud Fraud or Abuse: Reporting a diagnosis code that the patient does not have, but is payable by medicare. - answer is Fraud According to the privacy rule, what must a business associate and covered entity have in order to do business? - answer is A contract If a provider is excluded from federal health plans, what does that mean? - answer is They many not participate in Medicare, Medicaid, VA programs, or Tricare and They cannot bill for services or provide services, order services, or prescribe medication to any beneficiary of a federal plan. What is the purpose of the privacy rule? - answer is To protect patient privacy A records request is received from a health plan for three dates of service in a chart months apart. What should the biller do? - answer is Copy each date of service individually and send to the health plan. Is a healthcare consulting firm considered a covered entity? - answer is No A new radiology company opens in town. The manager calls your practice and offers to pay $20 for every medicare patient you send them for radiology services. What does this offer violate? - answer is The Anti-kickback law How many national priority purposes are under the Privacy rule to disclose PHI without an individuals authorization? - answer is 12 What are the 12 national priority purposes under the privacy rule? - answer is 1. Required by law 2. Public health activities 3. Victims of abuse / neglect/ domestic violence 4. Health oversight activities 5. Judicial and administrative proceedings 6. Law enforcement purposes 7. decedents 8. cadaver organ / eye / tissue donation 9. Research 10. Serious threat to health or safety 11. Essential government functions 12. Workers comp. -verify the provider is listed as a creditor -stop all collection efforts for balances filed under the bankruptcy What is the number one thing you should obtain from an insurance call? - answer is The call reference number When given a denial, what should be done? - answer is Review the denial to determine if additional information is needed, if errors need to be corrected, or if the denial should be appealed When should patient invoices be sent to the patient? - answer is As soon as the RA is posted and the balance has been transferred to the patient account. May small balances for which processing costs exceed potential collections be automatically written off? - answer is Yes, as long as it is allowed according to the financial policy of the practice. What documents are needed for a successful appeal? - answer is -Copy of the RA -Copy of the medical record -Copy of the original claim - A letter detailing why the claim should be paid A biller received a request for medical records for Patient A for DOS 05/15/20XX. Patient A's entire medical record (multiple dates of service) was copied and sent to the insurance carrier. What is this a violation of? - answer is HIPAA Once a credit balance for an insurance carrier has been identified, what action should the biller take? - answer is Research to determine if it is a true overpayment, the submit a refund to the insurance carrier for the overpayment. What a patient files for Chapter 7 under the U.S. bankruptcy code, what happens to the debt? - answer is Most medical debt is discharged, the provider will write-off amounts owed. Which chapter of U.S. Bankruptcy combines the debt of the debtor and reduces the monthly payments allowing the provider to potentially receive a portion of what is owed? - answer is Chapter 13 According to the Prompt Pay Act, who must pay bills within 30 days? - answer is Federal Agencies What is a prior authorization? - answer is A requirement that your physician receives approval form your heath insurance plan to approve payment for a specific service for you What is a pre-determination? - answer is A request from a healthcare facility to get an idea whether or not a service may be covered. This is not a guarantee of payment and is not required. The provider, hospital, or entity that agrees to provide healthcare services to an insurance plans enrolees is a: - answer is Participating provider What is the process of determining which of two or more insurance policies will have the primary responsibility of processing a claim? - answer is Coordination of benefits Balance billing by participating providers is: - answer is Not allowed under participating providers contract Claim rejections are due to what? - answer is Claims that do not contain necessary information for adjudication What information can be found on the BCBS insurance identification card? - answer is -Type of plan -ID number -Group number -phone number for member services/benefits questions -mailing address of the BCBS office According to aetna's published guidelines what is the time frame for filing a reconsideration? - answer is Within 180 calendar days of the initial claim decision A BCBS insurance plan that allows members to choose any provider but offers higher levels of coverage when members obtain services from network providers would be an example of: - answer is PPO If a claim is denied, investigated, or found to be denied in error what should a biller do? - answer is Appeal that claim Carl has enrolled in a healthcare insurance plan that allows him to choose to have services provided within the BCBS network or outside of the network what type of plan best describes Carl's coverage - answer is POS What is the limit called what payrs allow to submit a claim or appeal? - answer is Timely filing Jerod is employed with the US IRS and has enrolled in the BCBS healthcare insurance offered through his employer, what is the name of the BCBS insurance program offered by the federal government? - answer is FEP(Federal Employee Program) What may be appealed? - answer is A denied claim A savings account that allows individuals to save pre tax dollars to reimburse for healthcare expenses is known as an: - answer is FSA and HSA The liaison between BCBS and the contracted provider community is known as what? - answer is The insurance representative. Also known as the provider representative or the provider network consultant. In what box on the CMS-1500 form does a PA number get placed? - answer is Box 23 A health insurance plan that reimburses for healthcare services provided to members based on providers bills submitted after the services are rendered is known as: - answer is Traditional insurance. Also known as Fee-for-service, or an indemnity plan. What is the difference between non-covered services and not medically necessary services? - answer is Non-covered services are pre-determined to not be re-reimbursable by the insurance while not- medically necessary services have been found to not be necessary for the evaluation and treatment of an individuals disease, condition, illness, or injury. When a patient presents for their appointment, insurance coverage should be verified and: - answer is A copy should be made of both the front and back of the member's insurance card. For which denial is it acceptable to balance bill the patient? - answer is Non-covered service BCBS offers which type of Medicare plan? - answer is A medicare advantage plan (part C) A participating provider of BCBS sees a patient in the ER. The charges equal $500. The patient has a $1000 deductible of which none has been met, and a $75 ER copay, How much should be collected from the patient for this service? - answer is $75 What is a copay? - answer is A fixed amount of money that you will pay for an office visit *same day*. What is a deductable? - answer is The amount of money you need to pay for services before insurance will pay anything. What is Co-insurance? - answer is The amount of money you will pay for services after the deductible is met but *before* you have reached your maximum out of pocket amount. What is Out-of-pocket? - answer is The amount of money you need to pay out of pocket *before* insurance will pay at 100%. What are the 4 parts of Medicare? - answer is A,B,C,D What does Medicare A cover? - answer is Hospital services What does Medicare B cover? - answer is Out-patient services What is Medicare C? - answer is This is a Medicare replacement plan for A+B offered by private companies that are contracted with Medicare. AKA a medicare advantage plan. What is Medicare D? - answer is Coverage for prescription medicine A patient receiving inpatient care in a critical access hospital would be covered under which part of Medicare? - answer is Part A For services such as screening for depression, bone mass measurements, and glaucoma screenings, what does Medicate consider these services to be? - answer is Preventative To determine the Medicare coverage and payment policy for a service or procedure, which resources will indicate if a service or procedure is payable, non-covered, or bundled into another service? - answer is Status codes Medigap policies must conform to minimum standards identified as federal and state laws and clearly be identified as: - answer is Medicare supplemental insurance Allen who is a non-par provide who doesn't accept assignment performs an appendectomy on a 67 year old Medicare patient. The physician's UCR for the surgery is $1500. Medicare's approved fee for this procedure is $1100. What is the charge that this non-par provider can charge to this Medicare patient? - answer is $1201.75 A Medicare patient is seen by a participating provider. A claim is sent for $123 and an EOMB is received that states the approved amount is $100. If the patient has met their deductible, what should the reimbursem*nt on this claim be from Medicare? - answer is $80 If a physician opts-out of Medicare and has a private contract with the medicare patient, at what percent of the Medicare fee schedule may they charge the patient for services rendered? - answer is They do not participate with Medicare therefore do not abide by their fee schedules. They may charge the whole amount of the service as long as they have the contract with the patient prior to services being rendered. Should an ABN be signed before or after services are performed on Medicare patients? - answer is Before EPSDT is a program associated with: - answer is Medicaid Medicaid's minimum eligibility is based on what criteria? - answer is The federal poverty level. A 21 year old patient presents for fillings for two of his teeth. Are these services covered under EPSDT? - answer is No, because the patient is not *under* the age of 21 The clinical prior authorization program assists in the monitoring of: - answer is Drugs not on medicaid's formulary What are two ways that non-covered service denials can be decreased in a practice - answer is -verify coverage before a major service -understand policies of largest payer contracts Metabolism - answer is the body ability to produce energy and burn fat through proper diet, exercise and hydration Inferior - answer is lower part of the body Efferent - answer is carrying away; carries nerves impulse away from the CNS Cicatrix - answer is A scar remaining after healing of a wound Neoplasm - answer is abnormal growth mass Malunion - answer is a fracture that healed in an abnormal position Parasympathetic - answer is part of the nervous system that control homeostasis and responsible for the body rest and digest function Meatus - answer is opening of the urethra where urine exit the body Hormone - answer is it regulated the body temperature, sleep cycle and mood of the body Nevus - answer is pigmented spot on the skin e.g. mole Bruit - answer is abnormal narrowing of the artery Interstitial - answer is relating to a space between or within a tissue or organ Perforation - answer is cut into the skin or a hole or break in the walls or membrane of organ or structure of the body Proliferative - answer is increasing in numbers of similar forms Transplanation - answer is transfer of living organs or tissue from one part of the body to another or from one individual to another Medicare statutorily excluded services are - answer is -non-covered items and services -not reimbursed by Medicare Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) is a program associated with - answer is medicaid The clinical Prior Authorization (PA) Program assists in the monitoring of - answer is drugs not on Medicaid's formulary Albert has purchased a Medigap policy to supplement his Medicare benefits, To which entity will Albert pay his monthly premium - answer is Medigap insurance company The total RVU is composed of which of the following components - answer is physician work, practice expense and malpractice insurance To determine the Medicare coverage and payment policy for a service or procedure, which of the following resources will indicate if a service or procedure is payable, noncovered, or bundled into another service - answer is status codes Medicare A Medicare B Medicare C Medicare D - answer is Inpatient hospital stays Outpatient hospital care Medicare Advantage Prescription drugs Medicare has four categories of items and services that are not covered under the program, they are: - answer is 1) Services and supplies that are not medically reasonable and necessary; 2) Non-covered items and services; 3) Services and supplies denied as bundled or included in the basic allowance of another service; and 4) Items and services reimbursable by other organizations or furnished without charge. Explain incident to services and who they are preformed by - answer is Once the initial physician relationship has been established, incident-to services can be billed even when there is not a physician in the room. He or she must only be on the premises and immediately available to assist the non-physician providers (nurse practitioners, physician assistants, certified nurse midwives and clinical nurse specialists) provider rendering the services An NPI doesn't ensure - answer is a provider is licensed or credentialed guarantee payment by a health plan enroll a provider in a health plan Medicare was passed into law under the title XVIII of what Act? - answer is Social Security Act Which of the following statements are true regarding healthcare regulations? - answer is Healthcare regulations may vary by state and by payer A physician office (covered entity) discovers that the billing company (business associate) is in breach of their contract. What is the first step to be taken? - answer is Take steps to correct the problem and end the violation OIG, CMS, and the Department of Justice are the government agencies enforcing ______? - answer is Federal fraud and abuse laws Fraud and Abuse penalties do NOT include: - answer is Ability to re-file claims in question A biller at a medical practice notices that all claims contain CPT code 81002. She questions the nurse who tells her that because they are an OB/GYN office they bill every patient for a urinalysis. What does this violate? - answer is False Claims Act Individuals have the right to review and obtain copies of the PHI. What is excluded from the right of access? - answer is Psychotherapy notes Medical Records are requested for a patient for a specific date of service. When records are copied, multiple dates of service are copied and sent in reply to the request. What standard does this violate? - answer is Minimum Necessary Patient has questions and concerns regarding the Privacy Practices in the clinic should be addressed by what party? - answer is Privacy Official What standard transactions are NOT included in EDI and adopted under HIPAA? - answer is Waiver of liability The Federal False Claim Act allows for claims to be reviewed for how many years after an incident? - answer is Seven years While working in a large practice, Medicare overpayments are found in several patient accounts. The manager states that the practice will keep the money until Medicare asks for it back. What is that action considered? - answer is Fraud What penalties can be imposed for Fraud and/or Abuse related to the United States Code? - answer is a. Monetary penalties ranging from $10,000 to $50,000 for each item or service b. Imprisonment c. Exclusion from Federal Healthcare Programs (d.) All of the above Medicare overpayments should be returned within ____ days after the overpayment has been identified? - answer is 60 days What entities are exempt from HIPAA and not considered to be covered entities? - answer is Workers Compensation A private practice hires a consultant to come in and audit some medical records. Under the Privacy Rule, what is this consultant considered? - answer is A business associate A hospital records transported is moving medical records from the hospital to an off-site building. During the transport, a chart falls from the box onto the street. It is discovered when the transporter arrives at the off-site building and the number of charts is not correct. What type of violation is this? - answer is A breach When a practice sends an electronic claim to a commercial health plan for payment, what is this considered? - answer is A transaction Which statement is true regarding the Prompt Pay Act? - answer is Federal agencies are required to pay all clean claims within 30 days of the receipt. Review the policy: Collections policy: Invoices not paid within 60 days begin our collection process. Invoices not paid within 120 days are subject to patient dismissal and submission to our collections agency and notification to your insurance plan. According to this policy, at what age is a balance owed by the patient considered bad debt and sent to the collection agency? - answer is 120 days When accepting debit cards in a medical practice, which act requires the office to disclose specific information before completing a transaction? - answer is Electronic Funds Transfer Act A claim has been denied as not medically necessary. The biller has checked the medical record and the medical policy and verified it is not covered according to the carrier's medical policy. What is the next action the biller should take? - answer is Check with the provider to appeal the claim and if necessary write off the balance. A provider removes a skin lesion in an ASC and receives a denial from the insurance company that states "lower level of care". What steps should the biller take? - answer is Check with the provider and write an appeal explaining why the service required the ASC. A claim was resubmitted to Medicare through a clearinghouse 60 days after the date of service and the claim was denied. The biller checked the clearinghouse claim status system and determined Medicare did not receive the claim. What action should the biller take? - answer is Check the clearinghouse reports and appeal the denial with proof of the claims submission. What does a high number of days in A/R indicate for a medical practice? - answer is The practice potentially has a problem in the revenue cycle. What should be included in a financial policy? A. Convey that the patient balances are due at the time of service Review the following accounts receivable management policy: ... Insurance balances will be referred to internal follow-up staff for follow up at 45 days post initial claim and personal balances will be referred at the time the patient becomes responsible for all balances as soon as the charge is entered. Personal balances will be eligible for referral to an outside collection agency after 3 statements have been sent. Based on this policy, when does follow-up of insurance balances begin? When are patient balances eligible for an outside collection agency? - answer is 45 days post initial claim After 3 statements have been sent A patient receiving inpatient care in a critical access hospitable would be covered under which part of Medicare? - answer is Part A Which of the following services does Medicare consider preventative? - answer is Screening for depression Bone mass measurements Glaucoma screening *All of the above* Medicare statutorily excluded services are? - answer is Non-covered items and services Not reimbursed by Medicare *Both A and B* A Medicare patient has prescription drug coverage, but does not have Medicare Advantage. What Medicare coverage does the patient have for his medications? - answer is Part D Medigap policies must conform to minimum standards identified as federal and state laws clearly be identified as - answer is Medicare Supplemental Insurance Dr. Allen who is a non-PAR provider who doesn't accept assignment preforms an appendectomy on a 67 year old Medicare patient. The physician's UCR for the surgery is $1500.00. Medicare's approved fee for this procedure is $1100.00. What is the limiting charge that this non-PAR provider can charge to this Medicare patient? - answer is $1201.75 A Medicare patient is seen by a participating provider. A claim is sent for $123.00 and an EOMB is received that states the approved amount is $100.00. If the patient has met their deductible, what should the reimbursem*nt on this claim be from Medicare? - answer is $80.00 A Medicare patient is seen by her physician. The physician has opted out of the Medicare program. The patient and physician have a private contract. The charges for the service rendered are $300.00. Medicare's approved amount would be $200.00. What can the office charge this patient? - answer is $300.00 A Medicare patient presents for her pelvic, pap, and breast examination (PPB). The patient is not sure when she had her last PPB. As she is checking out, the front desk rep has her sign an ABN. The service is billed and denied for frequency. Can the patient be balance billed and why or why not? - answer is No. The ABN must be signed before the service is preformed. Medicare Advantage plans fall under which part of Medicare? - answer is Part C EPSDT is a program associated with: - answer is Medicaid Medicaid's minimum eligibility is based on which of the following criteria: - answer is Federal Poverty Level A 21 year-old patient presents for fillings for two of his teeth. Are these services covered under EPSDT? - answer is No, because the patient is not under the age of 21. Which of the following are mandatory benefits that must be provided by Medicaid programs in order to receive matching federal funding? - answer is a. Outpatient hospital services c. Home health services d. Federally qualified health center services e. Inpatient hospital services iii. a,c,d,e The Clinical Prior Authorization Program assists in the monitoring - answer is Drugs not on Medicaid's formulary Medicaid claims must be filed - answer is Based on the individual state's timely filing requirement Medicaid agencies are required to report EPSDT performance information - answer is Annually The term for a supplemental policy for Medicare is - answer is Medigap Medicare Supplemental Insurance policies or Medigap is sold by - answer is Private Insurance Companies Albert has purchased a Medigap policy to supplement his Medicare benefits. To which entity will Albert pay his monthly premium? - answer is Medigap Insurer Beth has purchased a Medigap policy to supplement Medicare coverage. She has authorized Medicare to send payments directly to the physician, and Medicare has transferred their claims information to the Medigap insurer. This transfer of information is known as: - answer is cross-over When processing Medigap claims, Item 9a of the CMS-1500 must have the policy and/or group number of the Medigap insured proceeded by: - answer is MEDIGAP What is the difference between a rejected claim and a denied claim? - answer is A rejection cannot be appealed A denial is received in the office from a patient's insurance company. It stated that the services billed are not covered due to exclusions under the patient's plan. What should be done at this point? - answer is The patient should be balance billed An RA is received that contains a denial for a coordination of benefits issue. What could this mean? - answer is b. Another insurer is primary c. The claim was submitted without the primary insurance RA *both b and c* According to the Patient Protection and Affordable Care Act, and insurance plan must offer? - answer is Internal and external review processes What type of denial indicates there may be an issue with the front desk registration/intake policies? - answer is Eligibility expired A denial is received for services bundled into the global period. The record is reviewed and it is found that the denial is for a staged service that fell within the global days of the initial service. There were no modifiers appended to the codes on the claim form. What should be done? - answer is A modifier should be attached to the claim to show staged procedure and the claim should be appealed. What is a timely filing requirement? - answer is The time frame a provider has to submit a claim. A _____ is a correspondence sent from the insurance payer to the patient after they receive healthcare services to explain the status of their claim. - answer is Explanation of Benefits Which one of the following is NOT a data entry denial? - answer is Coverage Terminated What does being a "participating provider" agrees to when signing a contract with an insurance payer? - answer is The provider wishes to participate with and agree to accept the fee schedules set by that specific insurance. Which of the following type of insurance that allows members to choose medical services as needed and can go in or out of network. - answer is POS Which of the following is an account that is usually funded by the employee only and reimburses employee for specified expenses as they are incurred? - answer is FSA What role does an Insurance Provider Representative play? - answer is Is the liaison between the insurance payer and the provider. The provider, hospital, or other entity that agrees to provide healthcare services to an insurance plan's enrollees is a: - answer is Participating provider Balance billing by participating providers is: - answer is Not allowed under a participating provider's contract What information can be found on a Blue Cross Blue Shield - answer is What information can be found on a Blue Cross Blue Shield insurance identification card? - answer is A type of plan C ID number D group number F phone number for member service/benefits questions G mailing address of BC/BS office *4 a,c,d,f,g* A BC/BS insurance plan that allows members to choose any provider, but offers higher level of coverage when members obtain services from network provider would be an example of: - answer is PPO Carl has enrolled in a healthcare insurance plan that allows him to choose to have services within the BC/BS network or outside of the network. What type of plan best describes Carl's insurance coverage? - answer is Point of Service Jared is employed with the United States Internal Revenue Service and has enrolled in the BC/BS healthcare insurance offered through his employer. What is the name of the BC/BS insurance program offered by the federal government? - answer is Federal Employee Program Tony's BC/BS healthcare insurance policy states that he must seek healthcare services only from providers that are part of a specific network. What type of BC/BS plan does Tony have? - answer is HMO BC/BS identifies the individual who pays for healthcare insurance coverage as the: - answer is Subscriber BC/BS identifies the individual who is eligible for covered services as the: - answer is Member Participating providers agree to: - answer is Accept the fee schedules determined by the insurance company. The best practice to prevent a non-covered service denial would be to: - answer is Determine if the procedure is covered prior to providing the service Obtaining approval from the insurance payer before a procedure is preformed is known as: - answer is Prior authorization Which type of denial is more likely to happen when the patient is insured through an HMO? - answer is No referral Which of the following defines point of service coverage? - answer is Coverage that allows members to choose medical services as needed within the BCBS network or seek medical care outside of the network Which of the following is NOT correct regarding timely filing? - answer is If the physician fails to send a claim during the timely filing limit, the balance can be sent to the patient. A 6 year-old is seen in the pediatrician office for the first time. He has insurance coverage through both his mother (DOB: 02/08/86 and his father (DOB: 05/15/85). Whose insurance is primary? A. Mother's insurance plan B. Father's insurance plan C. The policy that has the best benefits D. Either mother's or father's insurance plan depending who brings the child in for medical care. - answer is A. Mother's insurance plan Which managed care plan has the patient receiving care from participating providers (network provider) and the providers are only paid for services provided? A. Health Maintenance Organization (HMO) B. Point-of-Service Plan (POS) C. Exclusive Provider Organization (EPO) D. Integrated Delivery System (IDS) - answer is C. Exclusive Provider Organization (EPO) Which TRICARE plan is similar to an HMO plan? A. TRICARE For Life B. TRICARE Select C. TRICARE Prime D. TRICARE Young Adult - answer is C. TRICARE Prime Which of the services are covered by Medicare Part A? I. Skilled Nursing Facility Care II. Ambulatory Surgery III. Durable Medical Equipment IV. Hospice Care V. Home Health Services VI. Long Term Care VII. Outpatient prescription drugs A. I-VII B. II, III, VI C. I, II, IV, VII D. I, IV, V - answer is D. I, IV, V Which is a TRUE statement regarding Workers' Compensation? A. There is no copayment for the injured worker in workers' compensation cases. B. The filing deadline for a first report of injury form is one week from the date of the accident. C. Providers can balance bill a patient when compensation payment is not paid in full. D. There is a deductible for the injured worker in workers' compensation claims. - answer is A. There is no copayment for the injured worker in workers' compensation cases. Bob sees his family physician for seasonal allergies. Before leaving, Bob pays the charge for the office visit. As a courtesy, the physician's staff submits a claim to Bob's insurance company. If the service is covered by the insurance company, Bob can expect to be reimbursed for the office visit. This is which type of insurance model? A. Healthcare Anywhere B. Managed Care Plan C. Fee-for-service (traditional coverage) D. Health Maintenance Organization (HMO) - answer is C. Fee-for-service (traditional coverage) Which of the following benefits are NOT covered by all Medigap policies? I. Part A co-insurance and hospital costs II. Skilled nursing facility care co-insurance III. Parts A & B deductible IV. Part B excess charges V. Foreign travel exchange A. I, II, III B. I, III C. I, IV, V D. II, III, IV, V - answer is D. II, III, IV, V B. 11603 C. 12032 D. 11603, 12002-51 - answer is A. 11603, 12032-51 On the UB-04 claim form the type of bill (TOB) is reported with four digits. Which digit classifies the type of care provided? A. Digit 1 B. Digit 2 C. Digit 3 D. Digit 4 - answer is C. Digit 3 The CPT® or HCPCS Level II code reported on a UB-04 is translated to what type of code by Medicare to reimburse for outpatient facility services? A. Ambulatory Payment Classification (APC) B. National Drug Code (NDC) C. International Classification of Diseases, 10th Revision, Procedural Coding System (ICD-10-PCS) D. Both B and C - answer is A. Ambulatory Payment Classification (APC) Which of the following are common identifiers for protected health information (PHI) which can be used to identify an individual? I. Birth Date II. Past mental health condition III. Driving records IV. Mailing Address V. Medical record number A. I-V B. I, II, IV, V C. III, V D. I, IV - answer is B. I, II, IV, V Which of the following service type providers is required to accept assignment on Medicare claims? I. Clinical diagnostic laboratory services II. Specialized radiology services III. Services provided to Medicare/Medicaid patients IV. Simplified billing roster for influenza virus vaccine and pneumococcal vaccine V. Physical therapy services A. I, III, and IV B. I, II, and V C. III, IV, and V D. I, III, and V - answer is A. I, III, and IV A Medicare patient comes in for a consultation from the orthopedist. The patient was referred by her primary care provider due to right hip pain. The orthopedist documents a detailed history and an expanded problem focused exam. An X-Ray of the hip is ordered. The medical decision making was moderately complex. The orthopedist provides a report back to the primary care provider with recommendations for physical therapy and potential hip replacement. What codes are reported by the orthopedist? A. 99203, M79.651 B. 99242, M25.551 C. 99243, M79.651 D. 99202, M25.551 - answer is D. 99202, M25.551 Which of the following scenarios is the best example of fraud? A. Asking a patient presenting for their initial visit with the practice to pay their copayment prior to the visit. B. Submitting a claim for services prior to the physician performing the scheduled service. C. Providing a chest x-ray without prior authorization from Medicare. D. Requiring a patient to sign an ABN prior to providing a service that may be denied by Medicare. - answer is B. Submitting a claim for services prior to the physician performing the scheduled service. A medical practice assesses a finance charge for patient balances past 90 days. This practice has failed to disclose to patients the percentage rate that will be charged on past due balances. This is a violation of which federal law? A. Truth in Lending Act B. False Claims Act C. Anti-Kickback Statute D. Criminal Health Care Fraud Statute - answer is A. Truth in Lending Act A large group practice has implemented an electronic medical record system. They are setting up security groups and want to be sure access is correctly established to comply with HIPAA's minimum necessary requirements. Which of the following positions would generally not need to have access to the clinical notes of a patient's medical record? A. Pay the $10,000 it would have paid leaving the patient responsible for the balance B. Pay the $15,000 since it was reasonable for the patient to go to a superior facility C. Pay nothing as this provider was out-of-network D. Negotiate with the provider to accept the $10,000 as payment in full - answer is C. Pay nothing as this provider was out-of-network At the end of each day, daily deposits should be balanced. Which of the following items should the daily deposits be balanced against? I. Charges II. Personal payment receipts III. Mail receipts IV. Co-pays due V. Deductibles due A. IV and V B. II and III C. I, IV, and V D. I, II, and III - answer is B. II and III A 48-year-old female awakens in the middle of the night with severe abdominal pain and excessive vomiting. She calls for an ambulance, which takes her to the closest hospital. She had a ruptured appendix and underwent an emergency appendectomy. Neither the hospital nor physician was in the payer network for her HMO. In this situation, the payer will most likely pay the following: A. The hospital claim because it was reasonable to go to the closest hospital, but not the physician claim B. Both the hospital and physician claims for the emergency services C. The physician claim for the emergency services provided, but not the hospital claim D. Neither claim, as the member should have gone to an in-network facility since this was not a life threatening emergency. - answer is B. Both the hospital and physician claims for the emergency services Ms. Sally's provider does not accept the Medicare approved amount as full payment. Instead Ms. Sally has to pay her provider the limiting charge. The provider files a claim to Medicare. Medicare sends payment to the patient. This is what type of claim? A. Open B. Delinquent C. Unassigned D. Assigned - answer is C. Unassigned For claims assigned a "pending status" by the payer, the provider should: A. Write off the claim. B. Appeal the payer's decision and resubmit the claim for reconsideration attaching documentation to justify the service. C. Contact the insurance carrier to determine what additional information is needed and provide it to the insurance carrier. D. Bill the patient and then reimburse the patient when the payer pays the claim. - answer is C. Contact the insurance carrier to determine what additional information is needed and provide it to the insurance carrier. Ms. Robinson is seen by Dr. Judy on 4/13/17. The claim is sent to Medicare for payment on 4/12/18. Which of the following statements is correct? A. Medicare will deny the claim based on the timely filing statute. B. Medicare will reimburse the claim at 80% of the charges billed. C. Medicare will pass on the claim to the secondary insurance. D. Medicare will pay the claim for the services provided based on the timely filing statute - answer is D. Medicare will pay the claim for the services provided based on the timely filing statute Mr. Wilson was putting up a fence at his friend's house. In the process of nailing the fence to the posts, a nail was pushed through his thumb. His friend has homeowner's liability insurance and the patient has commercial coverage through his employer. Which of the following is correct? A. File the homeowner's liability as the primary payer and the commercial carrier as the secondary carrier if the primary denies the claim. B. File the homeowner's liability only C. File the commercial insurance only. D. File the commercial insurance carrier as the primary payer and the homeowner's carrier as the secondary carrier if the primary denies the claim - answer is A. File the homeowner's liability as the primary payer and the commercial carrier as the secondary carrier if the primary denies the claim. What resources could a biller use to determine whether a procedure is bundled with another procedure according to Medicare? I Star icon II. CPT® section guidelines III. Parenthetical instructions in the CPT® codebook IV. NCCI edits V. RVU file A. I, IV, and V B. II, III, and IV C. N18.5, I12.0 D. I12.0 - answer is A. I12.0, N18.5 A 54-year-old patient is brought to the ED by ambulance suffering from acute respiratory failure. The physician documents critical care services and also performs an endotracheal intubation. Physician services were provided for a total of 142 minutes. What are the correct CPT® codes to report? A. 99291, 99292-51 x 3 B. 99291, 99292 x 3, 31500-51 C. 99291, 99292 x 3, 31500 D. 99291, 99292 x 3 - answer is C. 99291, 99292 x 3, 31500 A patient undergoes a craniotomy to evacuate a hematoma. The anesthesiologist prepared the patient in the OR starting the anesthesia at 0300. Surgery started at 0320 and ended at 0505. The anesthesiologist stopped the anesthesia at 0515 and the patient was placed under postoperative supervision. The total anesthesia time the anesthesiologist should report on the claim form is: A. 2 hours and 15 minutes (135 minutes) B. 1 hour and 45 minutes (105 minutes) C. 2 hours and 5 minutes (125 minutes) D. 1 hour and 55 minutes (115 minutes) - answer is A. 2 hours and 15 minutes (135 minutes) Due to an extreme infection, the patient required an injection of amphotericin B of 50 mg. How should this be reported to the insurance company? A. J0285 B. J0289 x 5 C. J0287 x 5 D. J0285 x 5 - answer is A. J0285 The claims reviewer has received records indicating that a surgery was performed on the left anterior descending coronary artery. What modifier would be appropriate to describe the anatomical location? A. LD B. LT C. LC D. LM - answer is A. LD What is the term for the total amount of covered medical expenses a policyholder must pay each year out-of-pocket before the health insurance company begins to pay any benefits? A. Copayment B. Deductible C. Secondary Payment D. Coinsurance - answer is B. Deductible Which type of insurance covers physicians and other healthcare professionals for liability as to claims arising from patient treatment? A. Business liability B. Bonding C. Medical malpractice D. Workers' compensation - answer is C. Medical malpractice Which of the following does NOT fall under group policy insurance? I. The premium is paid for by the employee. II. The premium is paid for (or partially paid for) by an employer. III. The employer selects the plan(s) to offer to employees. IV. Physical exams and medical history questionnaires are a mandatory part of the application process. V. Employee can make changes to the policy. VI. The employee's spouse and children are not eligible for coverage. A. III, IV, and V B. II, III, and VI C. II, IV, and V D. I, IV, V, and VI - answer is D. I, IV, V, and VI Dr. Wallace is in a capitation contract with Belleview Managed Care Health Plan. He received $25,000 from the health plan to provide services for the 175 enrollees on the health plan. The services provided by Dr. Wallace to the enrollees cost $23,000. Based on the information, what must be done? A. Dr. Wallace can keep the $2,000 profit under the terms of the capitated plan. B. Dr. Wallace experienced a loss under the capitated plan and will need to pay $2,000 to the health plan. C. Dr. Wallace will need to payout the $2,000 to the 175 enrollees. D. Dr. Wallace is required to put the $2,000 in a mutual fund. - answer is A. Dr. Wallace can keep the $2,000 profit under the terms of the capitated plan. B. Code 11103 is reported twice C. Code 11103 is reported once with the number 2 in box 24G D. Code 11103 is reported twice with the number 2 in box 24G - answer is C. Code 11103 is reported once with the number 2 in box 24G Which set of documentation guidelines can be used for E/M services submitted to Medicare for a physician assistant (PA)? A. Physician assistants cannot report E/M services B. Only the 1995 CMS documentation guidelines C. Only the 1997 CMS documentation guidelines D. Either 1995 or 1997 CMS documentation guidelines - answer is D. Either 1995 or 1997 CMS documentation guidelines Select the scenario that meets the incident-to requirements. A. The physician is in the office suite actively treating a patient and the physician assistant in the next room is treating a new patient complaint. B. Care is delivered to an established patient by the physician assistant as part of the physician's treatment plan while the physician is seeing another patient in the same office suite in a different room. C. The physician assistant traveled for the physician to provide the service in the patient's New York City home and the physician is available by phone. D. The physician assistant provided a necessary part of the patient's medical treatment and the physician signed the chart when he returned to the office. - answer is B. Care is delivered to an established patient by the physician assistant as part of the physician's treatment plan while the physician is seeing another patient in the same office suite in a different room. Medicare beneficiary is having a screening colonoscopy performed. How is the service reported to Medicare? A. G0121 B. 45378 C. 45378, G0121 D. G0121, 45378 - answer is A. G0121 Which providers submit the CMS-1500 claim form? I. Independent diagnostic testing facilities (IDTFs) II. Emergency department physicians III. Hospice organizations IV. Ambulance companies submitting under their own Medicare number V. Physicians in a group practice VI. Ambulatory surgery centers A. III-VI B. IV and VI C. I, III, IV, and VI D. I, II, IV, V and VI - answer is D. I, II, IV, V and VI According to CPT® Radiology Guidelines, if a patient is given oral contrast for a CT scan of the abdomen which code is reported? A. 74150 Computed tomography, abdomen; without contrast material B. 74160 Computed tomography, abdomen; with contrast material(s) C. 74170 Computed tomography, abdomen; without contrast material, followed by contrast material(s) and further sections D. 74176 Computed tomography, abdomen and pelvis; with contrast material(s) - answer is A. 74150 Computed tomography, abdomen; without contrast material Which of the following is NOT in the HIPAA Privacy Rule? A. Physician must obtain a patient's written consent and authorization before using or disclosing PHI to carry out treatment. B. Implementing hardware, software, and/or procedural mechanisms to record and examine access and other activity in information systems that contains or use electronic PHI (e-PHI). C. Doctor's office leaving a message on the patient's answering machine to confirm an appointment time. D. Patient is given greater access to his own medical record(s) and control over how his PHI is used. - answer is B. Implementing hardware, software, and/or procedural mechanisms to record and examine access and other activity in information systems that contains or use electronic PHI (e-PHI). When a physician intentionally bills procedures to Medicaid that he did not perform he is in violation of which Act? A. Truth in Lending Act B. Federal Claims Collection Act C. False Claims Act D. Health Insurance Portability and Accountability Act - answer is C. False Claims Act Cardiologist Dr. W has been consistently reporting a higher E/M level than what is documented to cover the revenue being lost in his practice. Is this considered fraud or abuse and why? A. Abuse; the provider's practice is common and therefore would not be considered fraudulent. the bill from the anesthesiologist, but he no longer has the money to pay it. The account becomes delinquent and is outsourced to a collection agency. The collection agency is unable to obtain any monies from Mr. Doyle. What is this is considered? A. Past-due account B. Open claim C. Pending account D. Bad debt - answer is D. Bad debt Mr. Jones is 67, retired, and has insurance coverage through Medicare and TRICARE. Mrs. Jones is 62 and still working for an employer that has 10 employees. Mr. and Mrs. Jones have health coverage through Mrs. Jones' employer's group health plan, United Plan. Mr. Jones is seen in a non-military hospital in the ED for a fractured wrist. Who gets billed first? A. Medicare B. Group health plan, United Plan C. TRICARE D. Medicare, the group health plan, and TRICARE will be billed at the same time. - answer is A. Medicare Relative Value Units (RVUs) are payment components consisting of: A. Actual time of the physician work; Place of service; Geographic adjustment B. Practice Expense; Diagnostic services; Payment Rate C. Physician work; Practice Expense; Professional liability/malpractice insurance D. Patient classification system; Geographic adjustment; Practice Expense - answer is C. Physician work; Practice Expense; Professional liability/malpractice insurance Which of the following falls under the Prompt Payment Act? A. Physician needs to refund overpayments within 30 days to the Medicare Administrative Contractor (MAC) from the date of receipt. B. Medicare and MACs have 60 days to pay or deny electronic clean claims. C. Clean claims must be paid or denied within 30 days from the date of receipt by MACs. D. Penalty fees will only be issued on clean claims if payments are 60 days overdue starting the day after the receipt date. - answer is C. Clean claims must be paid or denied within 30 days from the date of receipt by MACs. 25 year-old is 32 weeks pregnant. She was admitted to the labor and delivery unit because she was having severe pre-eclampsia and needed to have an emergency cesarean section. Reduced payment was sent to the obstetrician by the payer with a remittance advice stating that preauthorization for the cesarean section was not obtained. What does the biller do? A. Verify in the payer contract/policies that prior authorization is required for this procedure. If preauthorization was not obtained, bill the patient the rest of what is due to the obstetrician. B. Appeal the claim, explaining the reason for the emergency cesarean section C. Write off the claim because it was denied. D. Verify in the payer contract/policies that prior authorization is required for this procedure. If preauthorization was not obtained, bill the patient for the entire amount. - answer is B. Appeal the claim, explaining the reason for the emergency cesarean section When a provider chooses not to participate in the Medicare program and does not accept assignment on claims, the maximum amount the provider can charge is _______ percent of the approved fee schedule amount for non-participating providers. A. 115 B. 100 C. 50 D. 25 - answer is A. 115 Mr. Allen is scheduled for an appointment with his physician for follow-up of his rheumatoid arthritis and hypertension. The physician is called away for a personal emergency just after Mr. Allen arrives for his appointment and the patient is seen by the physician assistant, who orders labs and refills the patient's prescriptions. Mr. Allen is scheduled to return in one month. How should this patient's visit should be billed? A. Under the PA as the incident-to guidelines have not been met. B. As incident-to because labs were ordered and prescriptions refilled. C. As a new patient under the PA because the PA has not seen the patient before. D. As "no-charge" since the physician was unable to see the patient. - answer is A. Under the PA as the incident-to guidelines have not been met. Jill presents to Dr. Calvert for collagen injections to her upper lip for cosmetic reasons. She is informed by the office staff that cosmetic surgery may not be a benefit of her insurance plan in which case she would be responsible for the charges. Jill requests the claim to be submitted to her insurance. The claim is submitted to her insurance for payment. Dr. Calvert's office receives a remittance advice stating that the injections are considered cosmetic and are not a covered service. What is the appropriate next step for resolution? A. Change the diagnosis code to support medical necessity for the injections. B. Send an appeal to the payer demanding payment. C. Move charges to patient responsibility and send the patient a statement. D. Write off the charges. - answer is C. Move charges to patient responsibility and send the patient a statement. The financial policy for Midtown Physicians Group states that when all means for collecting payments have been exhausted and payment has not been received within 120 days, the account is turned over to a collection agency. When generating an accounts receivable aging report, you see an outstanding A. QX B. QZ C. QK D. QS - answer is B. QZ Patient presents to her physician 10 weeks following a true posterior wall myocardial infarction. The patient is still exhibiting symptoms of chronic ischemic heart disease. The physician reviews the current medications to confirm the patient is compliant and discusses a heart-healthy diet and exercise. What is the correct ICD-10-CM code for this condition? A. I25.9 B. I21.29 C. I21.21 D. I25.2 - answer is A. I25.9 10-year-old girl is scheduled for her yearly physical exam with her pediatrician .At the time of her visit, the patient complains of watery eyes, scratchy throat, and stuffy nose for the past two days. The physician first performs a complete physical. Then he also evaluates and treats the patient for a URI supported with separate documentation of an expanded problem focused exam and low medical decision making. What CPT® code(s) is/are reported for this visit? A. 99393, 99213-25 B. 99393 C. 99213 D. 99393-25, 99213 - answer is A. 99393, 99213-25 The patient is admitted for radiation therapy for metastatic bone cancer, unknown primary. What ICD-10-CM codes should be reported? A. C79.51, C80.1, Z51.0 B. C80.1, C79.51, Z51.0 C. Z51.0, C79.51, C80.1 D. Z51.0, C80.1, C79.51 - answer is C. Z51.0, C79.51, C80.1 60-year-old woman is seeking help to quit smoking. She makes an appointment to see Dr. Lung for an initial visit. The patient has a constant cough due to smoking and some shortness of breath. No night sweats, weight loss, night fever, CP, headache, or dizziness. She has tried patches and nicotine gum, which has not helped. Patient has been smoking for 40 years and smokes 2 packs per day. She has a family history of emphysema. A limited three system exam was performed. Dr. Lung discussed in detail the pros and cons of medications used to quit smoking. Counseling and education was done face to face for 20 minutes on smoking cessation of the 30 minute visit. Prescriptions for Chantix and Tetracycline were given. The patient to follow up in 1 month. A chest X-ray and cardiac work up was ordered. Select the appropriate CPT® code(s) for this visit: A. 99203, 99354 B. 99214, 99354 C. 99214 D. 99407 - answer is D. 99407 A 14-year-old male patient fell while skateboarding. He went to the emergency department at the local hospital. The diagnosis was a fracture of the upper right arm. The ICD-10-CM codes reported were S42.301A, V00.131A, and Y93.51.Is this correct? A. No; the codes reported should be S43.309B, V00.131B, Y93.51 B. No; the codes reported should be V00.131B, Y93.51, S42.309D C. No; the codes reported should be V00.131A, Y93.51, S42.301A D. Yes; the ICD-10-CM codes reported are correct - answer is D. Yes; the ICD-10-CM codes reported are correct Obstetrician A recommends a new type of cancer treatment for patient who has ovarian cancer. Before the patient's private insurance company approves the treatment, the insurer mandates Obstetrician B (in a different practice) to conduct a physical examination of the patient. What modifier should obstetrician B append to the E/M consultation code? A. Modifier 25 B. Modifier 24 C. Modifier 32 D. Modifier 59 - answer is C. Modifier 32