drdmedsearch.com€¦ · Web viewGENERAL INSTRUCTIONS: The attachment is a compilation made for Medical Billing & Coding, and for students use as a Review Symposium for any of the

GENERAL INSTRUCTIONS:

1. The attachment is a compilation made for Medical Billing & Coding, and for students use as a Review Symposium for any of the current National Board Examinations.

2. You should attempt to complete all examination samples prior to consulting the attachment answer keys. You should also give yourself at least a 2-3 week period of study and review prior to sitting for your Boards.

3. It is requested that no further copies of this attachment be made for any distribution, without the express permission of the institution, herein.

MEDICAL BILLING REVIEW PACKET

NATIONAL BOARDREVIEW PACKET

A COMPREHENSIVE & INTENSIVE REVIEW FOR YOUR M.B. BOARDS WITH OVER 1000 QUESTIONS AND

ANNOTATED ANSWER KEYS !

Dr. J. Domenech

TABLE OF CONTENTSPage

MEDICAL BILLING REVIEW PACKETSTUDENT REVIEW SHEET (PART I)………………………………………………………………………………………………………..3

STUDENT REVIEW SHEET (PART II)………………………………………………………………………………………………….……5

SECTION I, EXAMINATION I, CUMULATIVE 142 QUESTIONS……………………………………………………………………..…..8INCLUDES SECTIONS ON: HEALTH CARE REIMBURSEMENT, MEDICAL CODING -1,CLAIMS MANAGEMENT, ADVANCED CODING WITH REPORTS, CLAIMS PROCESSING

SECTION II, EXAMINATION I, CUMULATIVE 76 QUESTIONS…………………………………………………………….…………..20INCLUDES SECTIONS ON: HEALTH CARE REIMBURSEMENT, CLAIMS MANAGEMENT

SECTION II, EXAMINATION II, CUMULATIVE WORTH 15 QUESTIONS {CASE SUMMARY }…………………….………………25INCLUDES SECTIONS ON: ADVANCED CODING, CLAIMS MANAGEMENT

SECTION III, EXAMINATION I, CUMULATIVE 72 QUESTIONS……………………………………………………….…………….…30INCLUDES SECTIONS ON: HEALTH CARE REIMBURSEMENT, MEDICAL CODING -1,CLAIMS MANAGEMENT, CLAIMS PROCESSING

SECTION III, EXAMINATION II, CUMULATIVE 100 QUESTIONS……………………………………………………….…………….34INCLUDES SECTIONS ON: HEALTH CARE REIMBURSEMENT, MEDICAL CODING -1,CLAIMS MANAGEMENT, CLAIMS PROCESSING, ADVANCED CODING

SECTION IV, EXAMINATION I, CUMULATIVE 62 QUESTIONS……………………………………………………….………………39INCLUDES SECTIONS ON: HEALTH CARE REIMBURSEMENT, MEDICAL CODING -1,CLAIMS MANAGEMENT, CLAIMS PROCESSING, ADVANCED CODING

SECTION IV, EXAMINATION II, CUMULATIVE 70 QUESTIONS………………………………………………………………………43INCLUDES SECTIONS ON: HEALTH CARE REIMBURSEMENT, MEDICAL CODING -1,CLAIMS MANAGEMENT, CLAIMS PROCESSING, ADVANCED CODING

SECTION V, EXAMINATION I, CUMULATIVE 84 QUESTIONS………………………………………………………………………..47INCLUDES SECTIONS ON: OFFICE ADMINISTRATION, BILLING MANAGEMENT, ACCOUNTS RECEIVABLE, INSURANCE POLICIES, LEDGER CARDS, PURCHASE ORDERS, RECEIPTS, ALPHANUMERIC FILING, INSURANCE FORMS [CMS1500], MEDISOFT.

SECTION V, EXAMINATION II, CUMULATIVE 165 QUESTIONS……………………………………………………………………..52INCLUDES SECTIONS ON: HEALTH CARE REIMBURSEMENT, MEDICAL CODING -1,CLAIMS MANAGEMENT, CLAIMS PROCESSING, ADVANCED CODING

SECTION VI, EXAMINATION I, CUMULATIVE 25 QUESTIONS……………………………………………………………………....56SAMPLE NHA EXAMINATION

SECTION VI, EXAMINATION II, CUMULATIVE 150 QUESTIONS…………………………………………………………………..60INCLUDES SECTIONS ON: HEALTH CARE REIMBURSEMENT, MEDICAL CODING -1,CLAIMS MANAGEMENT, CLAIMS PROCESSING, ADVANCED CODING

COMMON CODES YOU SHOULD KNOW………………………………………………………………………64

STUDENT REVIEW SHEET (PARTVII)…………………………………………………………………………………………………..67SAMPLE PRACTICE CLAIMS AND CODING

KNOW ALL COMPONENTS OF A CMS 1500…………………………………………………………………..73

ANNOTATED ANSWER KEY SECTION………………………………………………………………………..74MEDICAL BILLING REVIEW PACKET

STUDENT REVIEW SHEET (PART I)

2

DEFINE THE FOLLOWING TERMS:FIRST GROUP:

1. COMPREHENSIVE CODE = A single code that describes or covers two or more component codes that are bundled together as one unit.

2. UNBUNDLING = coding and billing numerous CPT codes to identify procedures that usually are described by a single code.

3. MODIFIER = permits the physician to indicate circumstances in which a procedure as performed differs in some way from that described by its usual code.

4. . = this is the code sign for “a new or revised text”.

5. = this is the code sign for a “new code”.

6. = this code sign implies “service includes surgical procedure only”.

7. ⊘ = this is the code sign for a modifier which generally has a negative sign with two digit number.

8. = this is the code sign for an “add on code”.

9. = this code sign indicates “ a revised code”.

10. CUSTOMARY FEE = this fee is in the range of the fees charged by providers of similar training and experience in a given geographic area.

11. REASONABLE FEE = this fee meets the criteria of the usual fee and is in the opinion of the medical review committee, justifiable, considering the special circumstances of the patient and case.

12. INCOMPLETE CLAIM = this can be any medicare claim missing required information. It is generally identified to the provider so that it can be resubmitted.

13. DINGY CLAIM = this claim happens when the medicare contractor cannot process a claim for a particular service or bill type.

14. DIRTY CLAIM = this is a claim submitted with errors or one requiring manual processing for resolving problems or one rejected for payment. Pending or suspense claims are placed in this category because something is holding the claim back from payment (review)

15. INVALID CLAIM = this is any medicare claim that contains complete, necessary information but is illogical or incorrect.16. CLEAN CLAIM = this means that the claim was submitted within the program or policy time limit and contains all the necessary information so it can be processed and paid promptly.17. PIN NUMBER = this is a carrier assigned number that every physician uses to render services to patients when submitting claim forms for insurance purposes.18. NPI NUMBER = this is a medicare lifetime 10 digit number issued to providers. When adopted it will be recognized by Medicaid, medicare, tricare and CHAMPVA programs and eventually will be used by private insurance carriers.19. UPIN NUMBER = this is a number issued by the medicare fiscal intermediary to each physician who renders medical service to medicare recipients used for identification purposes on CMA 1500 claim forms.20. PPIN NUMBER = this is a performance number that each physician or provider gets for each group office or clinic in which he or she practices. In medicare each member has an eight character PPIN which collaborates to that groups location in addition to the group number.

DEFINE THE FOLLOWING TERMS:SECOND GROUP:

1. DME NUMBER = this is given to medicare providers who charge patients a fee for supplies and equipment such as crutches, urinary catheters, ostomy supplies, surgical dressings and so forth which must be billed through medicare using this number.

2. DIGITAL CLAIM = this is a claim sent to the insurance carrier as a paper claim via fax but never printed to paper at the receiving end.3. EIN NUMBER = this is an individual’s (provider) federal tax identification number which is issued by the Internal Revenue Service for income tax purposes.4. FACILITY NUMBER = this is an institutional number serving as a provider such as hospitals, labs, nursing, etc which is used to bill services or used by performing physicians to report services done at that location.5. GROUP PROVIDER NUMBER = this is a number assigned to a number of physicians submitting insurance claim forms under one name and reporting income under one name. It is used instead of the individual PIN number for the performing provider.6. ELECTRONIC CLAIM = this claim is submitted to an insurance carrier via a central processing unit (CPU), tape diskette, direct data entry, direct wire, dial in telephone or personal computer via modem and are never printed on paper.7. OCR = a device that can read typed characters at a very high speed and then converts them to digitized computer characters within files to be saved on disk.

8. REJECTED CLAIM = this is an insurance claim submitted to an insurance carrier that is discarded by the system because of a technical error (omission or erroneous information) or because it does not follow medicare instructions. It is usually returned to the provider for corrections or changes so that it may be processed properly for payment.9. OTHER CLAIMS = this is the name given to all medicare claims not considered ‘clean’. They are claims that require investigation or development on a pre-payment basis to determine if medicare is the primary or secondary carrier.10. PAPER CLAIM = this is an insurance claim submitted on paper including those optically scanned and converted to an electronic format by the insurance carrier.11. PENDING CLAIM = this is an insurance claim held in suspense because of review or other reasons. These claims may be cleared for payment or denied.12. PHYSICALLY CLEAN CLAIM = these are insurance claims with no staples or highlighted areas and with non-deformed bar codes.13. CLEAN CLAIM = this means that the claim was submitted within the program or policy time limit and contains all the necessary information so it can be processed and paid promptly.14. CMS 1500 = this is the universal insurance claim form developed and approved the American Medical Assoc as well as centers for for medicare and Medicaid services. It is used by physicians and other professionals to bill output services and supplies for tricare, medicare & some Medicaid programs as well as private insurance carriers and managed care plans.15. STATE LICENSE NUMBER = this is a license issued to a physician who has passed the state medical examinations and indicates his/her right to practice medicine in the state where issued.

MAQ AND FILL-IN QUESTIONS:

3

21. List the four major reasons for the development and use of diagnostic codes:a. Tracking of disease processes.b. Classification of causes of mortalityc. Medical researchd. Evaluation of hospital service utilization

22. Name the codes that are a supplementary classification of coding in which you look for the external causes of injury rather than disease. They are found in Volume I, Tabular List, explain the mechanism of injury and are not used by physicians offices on claims?[ E codes ]

23. Which system of codes are a supplementary classification of coding used for example when a person who is not currently sick encounters health services for some specific purpose such as to act as a donor of an organ or tissue or receive a vaccination. They are found in Volume I, Tabular List, and alphabetic index of volume II, and may also be used when a circumstance influences health status?[ V codes ]

16. An insurance claim form may require three different provider identification numbers. Name the three different types of physicians whose identification numbers may be requested ?

a). Referring physician b). Ordering physician c). Performing physician

17. What is the basic format for CPT codes ? [ formula = 5 + 2 ] [ codes + modifiers ]

18. Private insurance companies and federal and state programs adopt different methods for basing their payments on outpatient claims. Name the three basic and universally accepted methods ?

a) fee schedules b). usual, customary and reasonable c). relative value scales or schedules

19. Some insurance policies pay for only one consultation per year and may require a written report for any additional consultations. Name the four basic types of consultations for which CPT codes exist ?

a). Office or other outpatient consultations b). Initial inpatient consultations b). Follow-up inpatient consultationsc). Confirmatory consultations

1. MODIFIER = permits the physician to indicate circumstances in which a procedure as performed differs in some way from that described by the usual five digit code.

2. ADJUCT CODES = they are referred to in the Medicine Section of the CPT codes as Special Services and Reports and fall under the category of Miscellaneous Services.

3. UPCODING = this term is used to describe the deliberate manipulation of CPT codes for increased payments.

4. DOWNCODING = a term used to describe when the coding system used on a claim submitted to an insurance carrier does not match the coding system used by the company receiving the claim.

5. BUNDLING = when related to insurance claims, this term means to group codes together that are related to a procedure.

6. UNBUNDLING = coding and billing numerous CPT codes to identify procedures that usually are described by a single code.

7. [ -26 ] = when added to a CPT code, this modifier will a ‘Professional Component.

8. [ -25 ] = when added to a CPT code, this modifier will code for a ‘Significant, Separately Identifiable Evaluation and Management Service by the Same Physician on the Day of a Procedure or Other Service.

9. [ -50 ] = when added to a CPT code, this modifier will code for a ‘Bilateral Procedure’.

10. [ -51 ] = when added to a CPT code, this modifier will code for ‘Multiple Procedures.

11. ACTUAL FEE = this is the amount that a physician bills a patient for a particular medical procedure or service.

12. PREVAILING FEE = this is the charge or fee that falls within the range of charges most frequently used in a locality for a particular medical service or procedure.

13. [ -TC ] = when added to a CPT code, this modifier will code for the use of equipment such as a radiograph.

14. CUSTOMARY FEE = this fee is in the range of the fees charged by providers of similar training and experience in a given geographic area.15. REASONABLE FEE = this fee meets the criteria of the usual fee and is in the opinion of the medical review committee, justifiable, considering the special circumstances of the patient and case.

16. Name the two components that are always included in a “Surgical Package” ?a). The Operationb). Local Infiltration such as topical anesthesia

17. The E/M Section of CPT has categories and subcategories that have from three to five levels for reporting purposes. These levels are based on three factors or components. Name them:

a). Key Componentsb). Contributory Factorsc). Face-to-Face Time with the patient or family.

STUDENT REVIEW SHEET (PART II)

4

DEFINE THE FOLLOWING HEALTH CARE PLANS:5

1. COMPETITIVE MEDICAL PLAN2. HEALTH MAINT ORGANIZATION4. EXCLUSIVE PROVIDER ORG5. FOUNDATION FOR MED. CARE6. INDEPENDENT (INDIVIDUAL) PRACTICE ASSOCIATION7. MATERNAL & CHILD HLTH PGM8. MEDICAID9. MEDICARE

10. MEDICARE/MEDICAID11. POINT OF SERVICE PLAN12. PREFERRED PROVIDER ORG. 13. TRICARE14. UNEMPLOYMENT COMP. DIS15. CHAMPVA16. WORKER'S COMP. INS

1. COMPETITIVE MEDICAL PLAN = medical plan created by the 1982 Tax Equity and Fiscal Responsibility Act that allows for enrollment of medicare patients into managed care plans.

2. DISABILITY INCOME INSURANCE = form of health insurance that provides payments to replace income if the insured is unable to work because of illness, injury or disease

3. EXCLUSIVE PROVIDER ORGANIZATION = type of managed care plan in which the subscriber members are eligible for benefits only when they use the services of a limited network of providers.

4. FOUNDATION FOR MEDICAL CARE = Organization of physicians, sponsored by a state or local medical association, concerned with the development and delivery of medical services and the cost of health care.

5. INDEPENDENT (INDIVIDUAL) PRACTICE ASSOCIATION = This type of plan contracts with a number of physicians who agree to provide treatment in their own offices or clinics for a fixed capitation payment per month.

6. MATERNAL AND CHILD HEALTH PROGRAM = A state and federal program for children under 21 years with special health care needs.

7. MEDICAID = A state, federal and local program that provides health care benefits to indigent persons on welfare (public assistance), the elderly who meet who meet certain financial requirements, and the disabled.

8. MEDICARE = a three part program that is hospital insurance, supplemental medical insurance or a plus choice program for people 65 years of age and created by the 1965 Social Security Act.

9. MEDICARE/MEDICAID = In some regions, this program is referred to as the Medi-Medi Program.

10. POINT OF SERVICE PLAN = a managed care plan consisting of a network of physicians and hospitals that provides an insurance company or employer with discounts on its services.

11. PREFERRED PROVIDER ORGANIZATION = This is a form of contract medicine by which a large employer or any other organization that can produce a large number of patients contracts with a hospital or group of physicians to offer medical care at a reduced rate.

12. TRICARE = a government sponsored program that provides non-military hospital and medical services for dependents and spouses of active service personnel, the retired and their dependents, as well as dependents of the deceased from active duty.

13. UNEMPLOYMENT COMPENSATION DISABILITY = a state program that is essentially insurance that covers off-the-job injury or sickness and is paid for by deductions from a person’s paycheck.

14. WORKER’S COMPENSATION INSURANCE = this is a non-state program that insures a person against on-the-job injury or illness.

15. CHAMPVA = an insurance for veterans that shares the medical bills of spouses and children of veterans with the total, permanent and service connected disabilities and also covering dependents of deceased veterans.

ANSWER THE FOLLOWING QUESTIONS:

17. Name the health insurance plans in which there is "no assignment" in regards to benefit payments? ANSWER: MEDICAID / MEDICARE and WORKMEN’S COMPENSATION

18. What is the general definition of "assignment" of benefits? ANSWER: “The transfer, after an event insured against, of an individual’s legal right to collect an amount payable

under an insurance contract”.

19. What is the general definition of "accepting assignment of benefits" for Tricare ?

6

ANSWER: The physician (center) agrees to accept the allowable charge as the full fee and cannot charge the patient the difference”.

20. What is the general definition of "accepting assignment of benefits" for Private Carriers ? ANSWER: The insurance check will be directed to the provider’s office instead of to the patient.

21. Describe the Medicaid Program? ANSWER: A federal and state funded program providing health care benefits to the indigent [poor] and those on

welfare (public assistance).

22. What is the percentage formula for Medicare payments ? ANSWER: 20 / 80 %

23. What is the general definition of a Premium in health insurance and policy terms ? ANSWER: The monthly, quarterly or annual fee that must be paid to keep the insurance in force.

24. What is the general definition of a deductible in health insurance and policy terms ? ANSWER: A specific amount of money paid each year before the policy begins.

DEFINE THE FOLLOWING TERMS:

1. HALITOSIS 2. HEMATOMA 3. THROMBUS 4. DYSPNEA 5. TACHYPNEA 6. ORTHOPNEA 7. HERPES SIMPLEX 8. OTORRHEA 9. CARDIOMEGALY

10. VERTIGO 11. SYNCOPE 12. DIPLOPIA 13. RUBELLA 14. ENURESIS 16. PRURITIS 17. MYOPIA 15. CEPHALALGIA 18. HYPEROPIA

19. EPISTAXIS 20. PYURIA 21. HERPES ZOSTER 22. STRABISMUS 23. HORDEOLUM 24. DYSPHAGIA 25. PERTUSSIS

7

SHORT FORM DEFINITIONS:

1. HALITOSIS = bad breath2. HEMATOMA = blood blister3. THROMBUS = abnormal stationary blood clot

4. DYSPNEA = difficulty breathing [SOB = shortness breath]

5. TACHYPNEA = rapid breathing[hyperventilation]

6. ORTHOPNEA = positional difficulty breathing[difficult breathing in upright position]

7. HERPES SIMPLEX = cold sore, fever blister 8. OTORRHEA = ear discharge9. CARDIOMEGALY = enlarged heart10. VERTIGO = dizziness

11. SYNCOPE = fainting12. DIPLOPIA = blurred vision [double vision] 13. RUBELLA = German Measles

14. ENURESIS = Bedwetting [incontinence of urine]15. PRURITIS = itching16. MYOPIA = nearsightedness 17. CEPHALALGIA = headache18. HYPEROPIA = farsightedness19. EPISTAXIS = nosebleed20. PYURIA = pus in urine21. HERPES ZOSTER = Shingles22. STRABISMUS = squint23. HORDEOLUM = Stye24. DYSPHAGIA = difficulty swallowing25. PERTUSSIS = whooping cough

ANSWER THE FOLLOWING QUESTIONS:

1. Name three alternate names for a tickler file? ANSWER: suspense, follow-up, reminder file.

2. What is the difference between an electronic signature and a digital signature ? ANSWER: An electronic has the signer authenticate the document by key entry or with a pen pad; while in the digital the signer’s name, date and time appear.

3. Name the five minimum information requirements needed by third party payers for completion of insurance claim forms: ANSWER: (a) what was done (CPT’s); (b) why was it done (ICD’s) (c) when was it performed (DOS); (d) where was it received (POS); (e) who did it (provider)

4. What should you do using an insurance claim with no printed assignment.......? ANSWER: place SOF on CMS 1500 and attach a copy of any signed form on file.

5. What is the standard insurance claim form used by private insurance companies ? ANSWER: CMS 1500

6. Give an alternate name for the ledger card ? ANSWER: Financial Accounting Record

7. The superbill is a component of what form ? ANSWER: Encounter Form

8. Name the five situations in which the confidentiality between physician and patient may be automatically waived (breach of confidential communication): ANSWER: (a) Managed Care Organization [MCO]; (b) Patient Suing; (c) Records Subpoenaed; (d) 3rd Party Payer; (e) Other [child / elder abuse, gunshot wounds, infectious diseases]

9. Name at least three reasons for documentation in the medical record process? ANSWER: (a) Avoidance of denied or delayed payments; (b) Enforcement of medical record rules; (c) Subpoena; (d) Liability

10. Name the four basic pre-approval requirements that many private insurance carriers and pre-paid health plans have and which must be met before they approve hospital admissions, surgeries or elective procedures:

ANSWER: (a) Eligibility (b) Pre-certification (c) Pre-authorization (d) Pre-determination

11. There are only three basic ways in which a person can obtain health insurance. Name them: ANSWER: (a) individual plan (b) group plan (c) prepaid plan

12. Give an alternate name for an Encounter Form ? ANSWER: (a) charge slip (b) communicator (c) fee ticket (d) multipurpose billing form (e) patient service slip

(f) routing form (g) superbill (h) transaction slip

9

SECTION I, EXAMINATION I, CUMULATIVE 142 QUESTIONSINCLUDES SECTIONS ON: HEALTH CARE REIMBURSEMENT, MEDICAL CODING -1, CLAIMS MANAGEMENT, ADVANCED CODING WITH REPORTS, CLAIMS PROCESSING

* FINAL EXAMINATION *( SAMPLE)

SECTION I: MATCHING DIRECTIONS: { HEALTH CARE REIMBURSEMENT }: Match the following terms or phrases on the left hand column with their equivalent definitions found on the right hand column. In the `space' provided place ònly' letters!

1. COMPETITIVE MEDICAL PLAN______A). an insurance for veterans that shares the medical bills of spouses and children of veterans with the total, permanent and service connected disabilities and also covering dependents of deceased veterans.

2. HEALTH MAINT ORGANIZATION____B). In some regions, this program is referred to as the Medi-Medi Program.

3. DISABILITY INCOME INS. __________C). a government sponsored program that provides non-military hospital & medical services for dependents and spouses of active service personnel, the retired & their dependents, and the dependents of deceased from active duty.

4. EXCLUSIVE PROVIDER ORG._______D). form of health insurance that provides payments to replace income if the insured is unable to work because of illness, injury or disease

5. FOUNDATION FOR MED. CARE_____E). type of managed care plan in which the subscriber members are eligible for benefits only when they use the services of a limited network of providers.

6. INDEPENDENT (INDIVIDUAL) PRACTICE ASSOCIATION_________ F. This type of plan contracts with a number of physicians who agree to provide treatment in their own offices or clinics for a fixed capitation payment per month.

7. MATERNAL & CHILD HLTH PGM____G). This is a form of contract medicine by which a large employer or any other organization that can produce a large number of patients contracts with a hospital or group of physicians to offer medical care at a reduced rate.

8. MEDICAID_______________________H). . this is a non-state program that insures a person against on-the-job injury or illness.9. MEDICARE_______________________I). . a three part program that is hospital insurance, supplemental medical insurance or a plus choice program for people 65 years of age and created by the 1965 Social Security Act.

10. MEDICARE/MEDICAID____________J). Organization of physicians, sponsored by a state or local medical association, concerned with the development and delivery of medical services and the cost of health care.

11. POINT OF SERVICE PLAN ________K). a managed care plan consisting of a network of physicians and hospitals that provides an insurance company or employer with discounts on its services.

12. PREFERRED PROVIDER ORG. _____L). A state and federal program for children under 21 years with special health care needs.13. TRICARE_______________________M). a state program that is essentially insurance that covers off-the-job injury or sickness and is paid for by deductions from a person's paycheck.

14. UNEMPLOYMENT COMP. DIS._____N). A state, federal and local program that provides health care benefits to indigent persons on welfare (public assistance), the elderly who meet who meet certain financial requirements, and the disabled.

15. CHAMPVA _____________________O). . medical plan created by the 1982 Tax Equity and Fiscal Responsibility Act that allows for enrollment of medicare patients into managed care plans.

16. WORKER'S COMP. INS. __________P). organization that provides a wide range of comprehensive health care services for a specified group at a fixed periodic payment. The emphasis is on preventive care. Physicians are reimbursed by capitation. An HMO may be sponsored by a wide variety of organizations.

SECTION II: DIRECTIONS: MULTIPLE ANSWER QUESTION (MAQ) { HEALTH CARE REIMBURSEMENT }: Place a circle around the `letter' containing the `best' and most applicable answer. One answer only !

10

17. In which of the following health insurance plans is there specifically "no assignment" in regards to benefit payments? a). Private Carriers e). Worker's Compensation b). Managed Care f). Tricare c). Medicaid g). Only answers "c" and "e" are correct d). Medicare h). Only answers "d" and "f" are correct

18. Which of the following is the general definition of "assignment" of benefits? a). the provider agrees to accept the allowable charge as the full fee and cannot charge the patient the difference between the providers charge and the allowable charge. b). the insurance check will be directed to the provider's office instead of to the patient address. c). the transfer, after an event insured against, of an individual's legal right to collect an amount payable under an insurance contract. d). Only answers "a" and "c" are correct e). All of the above are correct.

19. Which of the following is the definition of "accepting assignment of benefits" for Tricare ? a). the provider agrees to accept the allowable charge as the full fee and cannot charge the patient the difference between the providers charge and the allowable charge.

b). the insurance check will be directed to the provider's office instead of to the patient address. c). the transfer, after an event insured against, of an individual's legal right to collect an amount payable under an insurance contract. d). Only answers "a" and "c" are correct e). All of the above are correct.

20. List the five (5) types of presenting problems from the most risk and least recovery to the least risk and most recovery:a). ______________ b). ______________ c) ______________ d) ______________ e) ______________

21. List the four (4) types of medical decision making, in order of complexity from most to least complex:a). ______________ b). ______________ c. ______________ d) ______________

22. Diagnosis codes are entered in ____?

11

a. Block 24b. Block 33

c. Block 21d. None of the above

23. The maximum number of ICD-9-CM codes that may appear on a single claim is ____?

a. Fourb. Six

c. Twod. None of the above

24. The first code reported on a claim should be the _______?

a. Qualified diagnosisb. Possible diagnosis

c. Primary diagnosisd. None of the above

25. If a diagnosis is not treated or addressed during an encounter and is stated on a patient’s record, you should ____?

a. Not list the diagnosisb. List the diagnosis as secondary

c. List the diagnosis as probabled. None of the above

26. Until a definitive diagnosis is determined, which of the following diagnoses should be used ?

a. Rule outb. Suspicious for

c. Possibled. None of the above

27. Some claims require attachments such as _____?

a. Clinic notesb. Operative reports

c. Discharge summariesd. All of the above

SECTION III: FILL-IN BLANK DIRECTIONS: { MEDICAL CODING -1 } Fill-in the blank spaces with the most appropriate words or phrases that best completes the sentences. (Claims Management )

28. Describe how the name on the claim should be typed for the following patients:

a. The name on the ID card reads: James M. Apple, II ANS:____________________________________b. The name on the ID card reads: Charles T. Treebark, Jr. ANS:____________________________________c. The name on the ID card reads: David J. Hurts, III ANS:____________________________________d. The name on the ID card reads: Jake R. Elbow, Sr. ANS:____________________________________

29. What are three questions that must be asked to code surgeries properly?

a. __________________________________________________________________________b. __________________________________________________________________________c. ___________________________________________________________________________

30. CPT divides surgical procedures into which two main groups ?

a). __________________________________ b). ___________________________________

31. List three services/procedures included in a surgical package

a). ____________________ b). ___________________ c). ___________________

32. On what basis are minor surgical procedures to be billed? __________________________________

33. Briefly describe “Unbundling” _____________________________________________________________________________ _____________________________________________________________________________

34. Define the following:

A) Skin Lesion- ___________________________________________________________________________B) Excision of a Lesion- _____________________________________________________________________C) Destruction of a Lesion- __________________________________________________________________

35. List five things you must know when reporting the excision or destruction of lesions

1) __________________________________________________________ 2) __________________________________________________________ 3) __________________________________________________________ 4) ___________________________________________________________ 5) ___________________________________________________________

36. Layered closure requires the use of 2 codes. One is for the ________________________ and one for the _______________________________________

37. If a physician reports the size of a lesion in inches, what must the coder do? _______________________________________38. When converting the size of a lesion, one inch = _____________________________________________________________39. When there are multiple lacerations, which repair should be listed first? ____________________________________________SECTION IV: FILL-IN BLANK DIRECTIONS: { MEDICAL CODING -1 }: Fill-in the blank spaces with the most appropriate words or phrases that best completes the sentences. DIRECTIONS: MULTIPLE ANSWER QUESTION (MAQ): Place a circle around the `letter' containing the `best' and most applicable answer. One answer only !

40. Define the term “Balance Billing ? ______________________________________________________________________________________________________________________________________________________________________

41. What is the purpose of obtaining an ABN ? __________________________________________________________

42. List three forms of MSP Medicare beneficiaries often purchase to cover the Medicare deductible and coinsurance requirements:a). ______________________________________________________________________b). ______________________________________________________________________c). ______________________________________________________________________

43. List five advantages of joining a Medicare HMO ?

a). ______________________________________________________________________b). ______________________________________________________________________c). ______________________________________________________________________d). ______________________________________________________________________e). ______________________________________________________________________

44. For HMO authorized fee-for-service specialty care, the claim is sent directly to ?

a. The patientb. Medicarec. The HMO

d. Only a and b are correcte. All of the above are correctf. None of the above are correct

45. What is the deadline for filing Medicare HMO claims ?

a. 90 daysb. 60 daysc. 45 days

d. one yeare. All of the above are correctf. None of the above are correct

SECTION V: ADVANCED CODING: DIRECTIONS: Using the ICD or CPT, assign codes to the following:

46. Removal of foreign body in tendon sheath, simple. Code(s): ___________47. Puncture aspiration of cyst of breast. Code(s): ___________48. Incision and drainage of thyroid gland cyst. Code(s): ___________49. Abrasion, single lesion. Code(s): ___________50. Destruction of four flat warts. Code(s): ___________51. Incision and drainage of ankle abscess. Code(s): ___________52. Incision and drainage of wrist hematoma. Code(s): ___________53. Aspiration thyroid cyst. Code(s): ___________54. Laparoscopy with bilateral total pelvic lymphadenectomy and periaortic lymph node biopsy. Code(s): ___________55. Acute prostatitis due to streptococcus. Code(1): ___________ Code(2): ____________56. Gangrene, left great toe, due to Diabetes Mellitus type I. Code(1): ___________ Code(2): ____________57. Vitamin D-resistant Rickets. Code(s): ___________58. Newborn female delivered in the hospital by cesarean delivery with evidence of cleft palate and cleft lip. Code(1): ___________ Code(2): ____________59. Flaccid hemiplegia affecting the dominant side due to cerebrovascular accident 4 months ago.

Residual and cause are flaccid hemiplegia, dominant side, CVA. Code(s): ___________60. Tumor abdomen, uncertain behavior. Code(1): ___________ M-Code(2): ___________61. Hepatocellular adenoma. Code(1): ___________ M-Code(2): ___________62. A 62 year – old male admitted to the hospital with acute subendocardial myocardial infarction. Code(s): ___________63. A 24 year – old woman at 28 weeks’ gestation has hypothyroidism. Code(1): ___________ Code(2): ____________64. Cellulitis left foot and ankle due to staphylococcus. Code(1): ___________ Code(2): ____________ Code(3): ____________65. Newborn female delivered in the hospital by cesarean delivery with evidence of cleft palate and cleft lip. Code(1): _________ Code(2): ________66. A patient develops gastrointestinal bleeding while taking Motrin as prescribed for abdominal cramping (Hint: Generic Motrin). Code(1): _________ Code(2): ________67. Acute renal failure develops in a patient following a cardiac catheterization and the patient is admitted for dialysis. Code(1): _________ Code(2): ________

SECTION VI: ADVANCED CODING: REPORTS / DIRECTIONS: Interpret and assign codes to the following report (you may use the ICD or CPT Code books):

INDICATION: Prolonged fetal heart rate deceleration.

PROCEDURE: Vacuum assisted vaginal delivery.

COMPLICATIONS: Shoulder dystocia, relieved with McRobert’s maneuver.

PREAMBLE: The patient is a 33 year old gravida 3, para 2, 38 week, 3 days gestation, admitted for induction secondary to pelvic pain. The patient received Pitocin and had artificial rupture of membranes and with this was able to progress to complete dilation. She then began pushing and some prolonged fetal heart rate deceleration down to about 90 beats per minute were noted. Because of this, a decision was made to proceed with vacuum extraction to assist in expediting delivery.

PROCEDURE NOTE: Maternal bladder was emptied using straight catheter. Pelvic examination was carried out and the cervix was confirmed to be fully dilated. Fetal vertex was present at +1 station. The small kiwi cup vacuum was then applied to the fetal vertex. On the second pull, there was one pop off but this was after good descent of the fetal head had been achieved. Baby then delivered and was a live-born male infant. There was some moderate shoulder dystocia present and this was relieved with McRobert’s maneuver. The baby was handed off to the NICU team and is currently in the NICU for further observation. Apgar’s are not available at this time. Cord blood gas is also pending.

There was a small second degree peritoneal tear. This was repaired using 3-0 chromic in the usual manner. The patient tolerated this procedure well. Estimated blood loss during delivery was 200 cc.

68. Code(1): ___________ Code(2): ____________ Code(3): ____________

Code(4): ___________ Code(5): ____________ Code(6): ____________

SECTION VII: MATCHING DIRECTIONS: { CLAIMS PROCESSING }: Match the following terms or phrases on the left hand column with their equivalent definitions found on the right hand column. In the `space' provided place ònly' letters!

69. COMPREHENSIVE CODE____________ A). this is a performance number that each physician or provider gets for each group office or clinic in which he or she practices. In medicare each member has an eight character PPIN which collaborates to that groups location in addition to the group number.70. UNBUNDLING ____________________ B). this is a medicare lifetime 10 digit number issued to providers. When adopted it is recognized by

Medicaid, Medicare, Tricare & CHAMPVA programs and eventually will be used by private insurance carriers.71. MODIFIER _______________________ C). this is any medicare claim that contains complete, necessary information but is illogical or incorrect.72. _______________________ D). this means that the claim was submitted within the program or policy time limit and contains all the necessary information so it can be processed and paid promptly.73. ____________________________ E). this is a carrier assigned number that every physician uses to render services to patients when submitting claim forms for insurance purposes.74. __________________________ F). A single code that describes or covers two or more component codes that are bundled together as one unit.

75. ⊘ ___________________________ G). permits the physician to indicate circumstances in which a procedure as performed differs in some way from that described by its usual code.

76. ___________________________ H). this fee meets the criteria of the usual fee and is in the opinion of the medical review committee, justifiable, considering the special circumstances of the patient and case.

77. ___________________________ I). this claim happens when the medicare contractor cannot process a claim for a particular service or bill type.78. CUSTOMARY FEE ________________ J). this is a claim submitted with errors or one requiring manual processing for resolving problems or one rejected for payment. Pending or suspense claims are placed in this category because something is holding the claim back from payment (review)79. REASONABLE FEE ______________ K). this is the code sign for an “add on code”.80. INCOMPLETE CLAIM _____________ L). this is a number issued by the medicare fiscal intermediary to each physician who renders medical service to medicare recipients used for identification purposes on CMA 1500 claim forms.81. DINGY CLAIM ____________________ M). this code sign indicates “ a revised code”.82. DIRTY CLAIM ____________________ N). this fee is in the range of the fees charged by providers of similar training and experience in a given geographic area.83. INVALID CLAIM ___________________ O). this is the code sign for a modifier which generally has a negative sign with two digit number.84. CLEAN CLAIM ____________________ P). this is the code sign for “a new or revised text”.85. PIN NUMBER ____________________ Q). this is the code sign for a “new code”.86. NPI NUMBER _____________________ R). term used to define coding and billing numerous CPT codes to identify procedures that usually are described by a single code.87. UPIN NUMBER ___________________ S). this can be any medicare claim missing required information. It is generally identified to the provider so that it can be resubmitted.88. PPIN NUMBER ____________________ T). this code sign implies “service includes surgical procedure only”.

SECTION VIII: MATCHING DIRECTIONS: { CLAIMS PROCESSING }: Match the following terms or phrases on the left hand column with their equivalent definitions found on the right hand column. In the `space' provided place ònly' letters!

89. DME NUMBER _____________ A). this is an insurance claim submitted to an insurance carrier that is discarded by the system because of a technical error (omission or erroneous information) or because it does not follow medicare instructions. It is usually returned to the provider for corrections or changes so that it may be processed properly for payment.90. DIGITAL CLAIM _____________B). a device that can read typed characters at a very high speed and then converts them to digitized computer characters within files to be saved on disk.91. EIN NUMBER _______________C). this means that the claim was submitted within the program or policy time limit and contains all the necessary information so it can be processed and paid promptly.

92. FACILITY NUMBER___________D). this is the universal insurance claim form developed and approved the American Medical Assoc as well as centers for medicare and Medicaid services. It is used by physicians and other professionals to bill output services and supplies for tricare, medicare & some Medicaid programs as well as private insurance carriers and managed care plans.

93. GROUP PROVIDER NUMBER___E). these are insurance claims with no staples or highlighted areas and with non-deformed bar codes.94. ELECTRONIC CLAIM__________F). this is a license issued to a physician who has passed the state medical examinations and indicates his/her right to practice medicine in the state where issued.95. OCR ________________________G). this is a claim sent to the insurance carrier as a paper claim by fax & never printed to paper at receiving end.96. REJECTED CLAIM ____________H). this is given to medicare providers who charge patients a fee for supplies and equipment such as crutches, urinary catheters, ostomy supplies, surgical dressings and so forth which must be billed through medicare using this number.97. OTHER CLAIMS ______________I)). this is an insurance claim held in suspense because of review or other reasons. These claims may be cleared for payment or denied.98. PAPER CLAIM_______________ J). this claim is submitted to an insurance carrier via a central processing unit (CPU), tape diskette, direct data entry, direct wire, dial in telephone or personal computer via modem and are never printed on paper.99. PENDING CLAIM_____________ K). this is the name given to all medicare claims not considered ‘clean’. They are claims that require investigation or development on a pre-payment basis to determine if medicare is the primary or secondary carrier.100. PHYSICALLY CLEAN CLAIM____L). this is a number assigned to a number of physicians submitting insurance claim forms under one name and reporting income under one name. It is used instead of the individual PIN number for the performing provider.101. CLEAN CLAIM________________M). this is an individual’s (provider) federal tax identification number which is issued by the Internal Revenue Service for income tax purposes.102. CMS 1500____________________N). this is an institutional number serving as a provider such as hospitals, labs, nursing, etc which is used to bill services or used by performing physicians to report services done at that location.103. STATE LICENSE NUMBER______O). this is an insurance claim submitted on paper including those optically scanned and converted to an electronic

format by the insurance carrier.

SECTION IX: CASE STUDY: { ADVANCED CODING }: ( 7 PTS): DIRECTIONS:

* Using the case presentation attached, you are TO ACCOMPLISH ONLY #2 / ANYTHING ELSE IS COUNTED AS EXTRA CREDIT !! **1. Define the patient record abbreviations (below) indicated as well as the additional coding in section II.2. Using the Patient Record No. 13-5, on a separate blank sheet of paper make an outline of all the charges to be made for this patient in the format of Date,

Charge Explanation, Code number and Amount Charged and turn this in with your work.3. Complete an CMS 1500 claim form for this TRICARE case posting all relevant data.4. Complete a Financial Accounting Record with posted transactions.

SPECIFIC INDICATIONS:

1. After completion of your manual format for the case history along with charges and codes found as well as abbreviations, complete the CMS 1500 using OCR guidelines for this TRICARE case. Direct the claim to the Tricare Fiscal Intermediary, 100 North Philadelphia Avenue, Omaha Nebraska 10567. This assignment may or may not require more than one CMS 1500 claim form for completion. Hand in both when done. Refer to the attachment listing of amount charges for procedures to be used on the ledger and claim form. Date the claim Feb 3. Dr. Ulibarri is accepting assignment in this case. The patient met her deductible last November when seen by a previous physician.

2. Use your CPT and ICD-9 code books to look up all code numbers needed in this case. Record all transactions on the financial record and indicate when you have billed the primary insurance carrier.

3. On Jan 24th the patient made an advanced payment of $575 (check #387) on this claim. Indicate this amount on your forms with appropriate justifications and balances. Post this payment on the financial accounting record and indicate the balance that will be billed to Tricare on the following day. The explanation of benefits from this case is to be sent to Tricare with a completed CMS1500 claim form. Also post a 15 % Courtesy Adjustment for this claim. The Tricare formula for this claim is 30/70 %.

4. Pertinent Fee Schedules:

FEE SCHEDULES

NEW PATIENTS 99201 OV#1 Level 1 $33.2599202 OV#2 Level 2 $51.9199203 OV#3 Level 3 $70.9299204 OV#4 Level 4 $106.1199204 OV#5 Level 5 $132.28

OLD PATIENTS (Established)99211 OV#1 Level 1 $16.0799212 OV#2 Level 2 $28.5599213 OV#3 Level 3 $40.2099214 OV#4 Level 4 $61.5199215 OV#5 Level 5 $96.97

HOSPITAL (Observation Svcs / New or Established)99217 Discharge $66.8899218 D hx/exam SF / LC MDM $74.2299219 C hx/exam MC / MDM $117.7599220 C hx/exam HC / MDM $147.48

EMERGENCY DEPARTMENT(New/Established Patient)99281 PF hx/exam SF MDM $24.3299282 EPF hx/exam LC MDM $37.0299283 EPF hx/exam MC MDM $66.2399284 D hx/exam MC MDM $100.7199285 C hx/exam HC MDM $158.86

Knee Surgery $650EKG $45OV#1 (99201) $75MEDS $35Abscess I & D $75Injection $35U / A $35CBC $25CBC+Diff $45X-rays $20Cholangiogram $90U/A + Culture $60Nitro Pads $55Diuretics $40MEDS (bactrim) $22.50Ventolin $11Double X-rays $40

Chest P&A $45Lat. X-Rays $45Digoxin Inj. $25B12 Inj. $40Nitro (meds) $40Bronchogram $150CXR(AP/Lat) $75OV HCN PF Hx /SF MDM $134.99[MEDICARE]ABG O2 $85PFT”s $125OV C hx/exam MC MDM $138.50IV MEDS $25OV PF

Hx /SF MDM $36.80[MEDICARE]Skene Excision $165MRI (s contrast) $175Suture 2-5 cms Laceratiion $125ER and/or Physician Consult $85Cauterization $65Suture Removal Kit $45Septoplasy $653Professional Courtesy (-$55)C x R (2views) $65Elect Panel SMAC12 $45CT Thorax/Contrast $125IM Inj. Drug $25C & S Test $45Culture Transport $35

FINAL (SAMPLE)

PATIENT MEDICAL RECORD:

21

22

FINAL (SAMPLE)

MANUAL RECORDING OF CHARGES: [ GRADED COMPONENT ]

TOTALS = 142

23

DATE: CHARGE EXPLANATION: CODE #: AMOUNT CHARGED:

STATEMENT [ FINANCIAL ACCOUNT ] ( GRADED COMPONENT )

24

HEALTH INSURANCE CLAIM FORM (CMS-1500)( GRADED COMPONENT )

25

NAME:__________________ ___________ INSTRUCTOR:__________JD___ EXAM#:_________________ EXAMINATION DATE:_____________________ * ANSWER SHEET *

1.-__________ 26.-__________ 51.-__________ 76.-__________101.-__________

2.-__________ 27.-__________ 52.-__________ 77.-__________102.-__________

3.-__________ 28.-__________ 53.-__________ 78.-__________103.-__________

4.-__________ 29.-__________ 54.-__________ 79.-__________104.-__________

5.-__________ 30.-__________ 55.-__________ 80.-__________105.-__________

6.-__________ 31.-__________ 56.-__________ 81.-__________106.-__________

7.-__________ 32.-__________ 57.-__________ 82.-__________107.-__________

8.-__________ 33.-__________ 58.-__________ 83.-__________108.-__________

9.-__________ 34.-__________ 59.-__________ 84.-__________109.-__________

10.-__________ 35.-__________ 60.-__________ 85.-__________110.-__________

11.-__________ 36.-__________ 61.-__________ 86.-__________111.-__________

12.-__________ 37.-__________ 62.-__________ 87.-__________112.-__________

13.-__________ 38.-__________ 63.-__________ 88.-__________113.-__________

14.-__________ 39.-__________ 64.-__________ 89.-__________114.-__________

15.-__________ 40.-__________ 65.-__________ 90.-__________115.-__________

16.-__________ 41.-__________ 66.-__________ 91.-__________116.-__________

17.-__________ 42.-__________ 67.-__________ 92.-__________117.-__________

18.-__________ 43.-__________ 68.-__________ 93.-__________118.-__________

19.-__________ 44.-__________ 69.-__________ 94.-__________119.-__________

20.-__________ 45.-__________ 70.-__________ 95.-__________120.-__________

21.-__________ 46.-__________ 71.-__________ 96.-__________121.-__________

22.-__________ 47.-__________ 72.-__________ 97.-__________122.-__________

23.-__________ 48.-__________ 73.-__________ 98.-__________123.-__________

24.-__________ 49.-__________ 74.-__________ 99.-__________124.-__________

25.-__________ 50.-__________ 75.-__________100.-__________125.-__________

26

SECTION II, EXAMINATION I, CUMULATIVE 76 QUESTIONSINCLUDES SECTIONS ON: HEALTH CARE REIMBURSEMENT, CLAIMS MANAGEMENT

MATCHING DIRECTIONS: Match the following terms or phrases on the left hand column with their equivalent definitions found on the right hand column. In the `space' provided place ònly' letters!

1. COMPETITIVE MEDICAL PLAN______A). an insurance for veterans that shares the medical bills of spouses and children of veterans with the total, permanent and service connected disabilities and also covering dependents of deceased veterans.

2. HEALTH MAINT ORGANIZATION____B). In some regions, this program is referred to as the Medi-Medi Program.

3. DISABILITY INCOME INS. __________C). a government sponsored program that provides non-military hospital & medical services for dependents and spouses of active service personnel, the retired & their dependents, and the dependents of deceased from active duty.

4. EXCLUSIVE PROVIDER ORG._______D). form of health insurance that provides payments to replace income if the insured is unable to work because of illness, injury or disease

5. FOUNDATION FOR MED. CARE_____E). type of managed care plan in which the subscriber members are eligible for benefits only when they use the services of a limited network of providers.

6. INDEPENDENT (INDIVIDUAL) PRACTICE ASSOCIATION_________ F. This type of plan contracts with a number of physicians who agree to provide treatment in their own offices or clinics for a fixed capitation payment per month.

7. MATERNAL & CHILD HLTH PGM____G). This is a form of contract medicine by which a large employer or any other organization that can produce a large number of patients contracts with a hospital or group of physicians to offer medical care at a reduced rate.8. MEDICAID_______________________H). . this is a non-state program that insures a person against on-the-job injury or illness.9. MEDICARE_______________________I). . a three part program that is hospital insurance, supplemental medical insurance or a plus choice program for people 65 years of age and created by the 1965 Social Security Act.10. MEDICARE/MEDICAID____________J). Organization of physicians, sponsored by a state or local medical association, concerned with the development and delivery of medical services and the cost of health care.

11. POINT OF SERVICE PLAN ________K). a managed care plan consisting of a network of physicians and hospitals that provides an insurance company or employer with discounts on its services.

12. PREFERRED PROVIDER ORG. _____L). A state and federal program for children under 21 years with special health care needs.13. TRICARE_______________________M). a state program that is essentially insurance that covers off-the-job injury or sickness and is paid for by deductions from a person's paycheck.

14. UNEMPLOYMENT COMP. DIS._____N). A state, federal and local program that provides health care benefits to indigent persons on welfare (public assistance), the elderly who meet who meet certain financial requirements, and the disabled.

15. CHAMPVA _____________________O). . medical plan created by the 1982 Tax Equity and Fiscal Responsibility Act that allows for enrollment of medicare patients into managed care plans.

16. WORKER'S COMP. INS. __________P). organization that provides a wide range of comprehensive health care services for a specified group at a fixed periodic payment. The emphasis is on preventive care. Physicians are reimbursed by capitation. An HMO may be sponsored by a wide variety of organizations.

17. In which of the following health insurance plans is there specifically "no assignment" in regards to benefit payments? a). Private Carriers e). Worker's Compensation b). Managed Care f). Tricare c). Medicaid g). Only answers "c" and "e" are correct

27

d). Medicare h). Only answers "d" and "f" are correct

18. Which of the following is the general definition of "assignment" of benefits? a). the provider agrees to accept the allowable charge as the full fee and cannot charge the patient the difference between the providers charge and the allowable charge. b). the insurance check will be directed to the provider's office instead of to the patrient address. c). the transfer, after an event insured against, of an individual's legal right to collect an amount payable under an insurance contract. d). Only answers "a" and "c" are correct e). All of the above are correct.

19. Which of the following is the definition of "accepting assignment of benefits" for Tricare ? a). the provider agrees to accept the allowable charge as the full fee and cannot charge the patient the difference between the providers charge and the allowable charge.

b). the insurance check will be directed to the provider's office instead of to the patient address. c). the transfer, after an event insured against, of an individual's legal right to collect an amount payable under an insurance contract. d). Only answers "a" and "c" are correct e). All of the above are correct.

20. Which of the following is the definition of "accepting assignment of benefits" for Private Carriers ? a). the provider agrees to accept the allowable charge as the full fee and cannot charge the patient the difference between the providers charge and the allowable charge. b). the insurance check will be directed to the provider's office instead of to the patient address. c). the transfer, after an event insured against, of an individual's legal right to collect an amount payable under an insurance contract. d). Only answers "a" and "c" are correct e). All of the above are correct.

21. Which of the following best describes the Medicaid Program? a). Federal Supported Program e). Only answers "a" and "b" are correct b). State Program part of the public-assistance system f). Only answers "b" and "c" are correct c). Individual health Policy g). None of the above d). Group Policy

22. Medicare pays for what percentage of the bill? a). 20% b). 70% c). 80% d). 115% e). 100%

23. Which of the following is the definition of a Premium in health insurance and policy terms ? a). a monthly, quarterly or annual fee that must be paid by the insured in order to keep the policy in force. b). a specific amount of money that must be paid each year before the policy benefits begin. c). a cost sharing fee paid by the insured generated as a percentage of the total. d). Only answers "a" and "b" are correct e). All of the above

24. Which of the following is the definition of a deductible in health insurance and policy terms ? a). a monthly, quarterly or annual fee that must be paid by the insured in order to keep the policy in force. b). a specific amount of money that must be paid each year before the policy benefits begin. c). a cost sharing fee paid by the insured generated as a percentage of the total. d). Only answers "a" and "b" are correct e). All of the above

TOTALS = 24

28

PART II: MATCHING DIRECTIONS: Match the following terms or phrases on the left hand column with their equivalent definitions found on the right hand column. In the `space' provided place ònly' letters!

1. HALITOSIS_____________ a). dizziness 2. HEMATOMA_____________ b). double vision 3. THROMBUS_____________ c). ear discharge 4. DYSPNEA______________ d). squint 5. TACHYPNEA ___________ e). german measles 6. ORTHOPNEA ___________ f). a blood blister 7. HERPES SIMPLEX_______ g). difficult breathing in upright position 8. OTORRHEA ____________ h). fainting 9. CARDIOMEGALY_________ i). headache 10. VERTIGO_____________ j). Stye 11. SYNCOPE ____________ k). difficult breathing 12. DIPLOPIA____________ l). whooping cough 13. RUBELLA ____________ m). bad breath 14. ENURESIS ___________ n). incontinence of urine 15. PRURITIS ___________ o). shingles 16. MYOPIA _____________ p). farsightedness 17. CEPHALALGIA_________ q). cold sore, fever blisters on lips 18. HYPEROPIA __________ r). hyperventilation 19. EPISTAXIS __________ s). enlarged heart 20. PYURIA __________ t). nearsightedness 21. HERPES ZOSTER_______ u). difficulty swallowing 22. STRABISMUS__________ v). itching 23. HORDEOLUM __________ w). a blood clot 24. DYSPHAGIA __________ x). nosebleed 25. PERTUSSIS __________ y). pus in the urine

26. Which of the following may be considered an alternate name for a tickler file? a). suspense file b). follow-up file c). reminder file d). All of the above e). Only answers "a" and "d" are correct f). None of the above

27. What is the difference between an electronic signature and a digital signature ?

a). an electronic signature looks like the signers handwritten signature which requires key entry authentication. b). a digital signature is lines of text with the signers name, date, time and attached statement of signature. c). a digital signature looks like the signers handwritten signature which requires key entry authentication. d). an electronic signature is lines of text with the signers name, date, time and attached statement of signature. e). Only answers "a" and "b" are correct f). Only answers "c" and "d" are correct g). None of the above

28. Name the five minimum information requirements needed by third party payers for completion of insurance claim forms:

a). _________________ b). __________________ c). ___________________ d). _________________ e). __________________

TOTALS = 32

PART III

1. When using an insurance claim with no printed assignment.......?

29

a). attach a letter of request (LOR) to the form and mail. b). make two copies of the assignment form (one for the insurance company and one for the patients file). c). attach a signed patient authorization form with SOF typed in the appropriate place. d). Only answers "a" and "b" are correct e). All of the above are correct

2. Which of the following is the standard insurance claim form used by private insurance companies ?

a). CMS-1800 b). CMS-1500 c). CMS-1400 d). CMS-2100 e). CMS-1200

3. An alternate name for the ledger card is which of the following?

a). the daysheet d). the daily post record b). the financial accounting record e). Only answers "a" and "b" are correct c). the running balance record f). All of the above are correct 4. Generally speaking the superbill is a component of which of the following?

a). encounter form c). ledger card b). annual alpha file d). daily post record

5. Name the five situations in which the confidentiality between physician and patient may be automatically waived (breach of confidential communication):

a). _________________ b). __________________ c). ___________________ d). _________________ e). __________________

6. Name at least three reasons for documentation in the medical record process?

a). _________________ b). __________________ c). ___________________


a). ______________ b). ______________ c). ______________ d). ______________

8. There are only three basic ways in which a person can obtain health insurance. Name them:

a). ______________ b). ______________ c). ______________

9. Which of the following is an alternate name for an Encounter Form ?

a). charge slip b). communicator c). fee ticket d). superbill

e). All of the above f). Only answers "a" and "d" are correct

TOTALS = 20

30


1.-__________ 26.-__________ 51.-__________ 76.-__________101.-__________

2.-__________ 27.-__________ 52.-__________ 77.-__________102.-__________

3.-__________ 28.-__________ 53.-__________ 78.-__________103.-__________

4.-__________ 29.-__________ 54.-__________ 79.-__________104.-__________

5.-__________ 30.-__________ 55.-__________ 80.-__________105.-__________

6.-__________ 31.-__________ 56.-__________ 81.-__________106.-__________

7.-__________ 32.-__________ 57.-__________ 82.-__________107.-__________

8.-__________ 33.-__________ 58.-__________ 83.-__________108.-__________

9.-__________ 34.-__________ 59.-__________ 84.-__________109.-__________

10.-__________ 35.-__________ 60.-__________ 85.-__________110.-__________

11.-__________ 36.-__________ 61.-__________ 86.-__________111.-__________

12.-__________ 37.-__________ 62.-__________ 87.-__________112.-__________

13.-__________ 38.-__________ 63.-__________ 88.-__________113.-__________

14.-__________ 39.-__________ 64.-__________ 89.-__________114.-__________

15.-__________ 40.-__________ 65.-__________ 90.-__________115.-__________

16.-__________ 41.-__________ 66.-__________ 91.-__________116.-__________

17.-__________ 42.-__________ 67.-__________ 92.-__________117.-__________

18.-__________ 43.-__________ 68.-__________ 93.-__________118.-__________

19.-__________ 44.-__________ 69.-__________ 94.-__________119.-__________

20.-__________ 45.-__________ 70.-__________ 95.-__________120.-__________

21.-__________ 46.-__________ 71.-__________ 96.-__________121.-__________

22.-__________ 47.-__________ 72.-__________ 97.-__________122.-__________

23.-__________ 48.-__________ 73.-__________ 98.-__________123.-__________

24.-__________ 49.-__________ 74.-__________ 99.-__________124.-__________

25.-__________ 50.-__________ 75.-__________100.-__________125.-__________

31

SECTION II, EXAMINATION II, CUMULATIVE WORTH 15 QUESTIONS {CASE SUMMARY }INCLUDES SECTIONS ON: ADVANCED CODING, CLAIMS MANAGEMENT

DIRECTIONS:

Using the case presentation attached, you are to do the following:5. Define the patient record abbreviations indicated6. Using the Patient Record No. 11-6, on a separate blank sheet of paper

make an outline of all the charges to be made for this patient in the format of Date, Charge Explanation, Code number and Amount Charged and turn this in with your work.

7. Complete an CMS 1500 claim form for this MSP case posting all relevant data

8. Complete a Financial Accounting Record with posted transactions


After completion of your manual format for the case history along with charges and codes found as well as abbreviations, complete the CMS 1500 using OCR guidelines for this MSP case. Direct the claim to the primary insurance carrier. This assignment may require more than one CMS 1500 claim form for completion. Hand in both when done. Refer to the attachment listing of amount charges for procedures to be used on the ledger and claim form. Date the claim May 14. Dr. Antrum is not accepting assignment in this case.

Use your CPT and ICD-9 code books to look up all code numbers needed in this case. Record all transactions on the financial record and indicate when you have billed the primary insurance carrier.

On June 5, Coastal Health Insurance Company paid $800 (check #45632) on this claim. Indicate this amount on your forms with appropriate justifications and balances. Post this payment on the financial accounting record and indicate the balance that will be billed to Medicare on the following day. The explanation of benefits from Coastal Health would be sent to Medicare with a completed CMS-1500 Claim Form.

ABBREVIATIONS

ER ______________________p.m. _____________________EPF______________________hx________________________exam______________________&_________________________adm_______________________MC________________________Imp________________________PF_________________________LC_________________________

MDM_______________________est_________________________pts_________________________cm_________________________consult______________________c____________________________C____________________________M____________________________MRI__________________________Px____________________________SF____________________________

hosp__________________________RTO__________________________OV____________________________Surg.__________________________Sched.________________________D_____________________________Ofc____________________________Postop_________________________Wk____________________________

32


33

FEE SCHEDULES





Knee Surgery $650EKG $45OV#1 (99201) $75MEDS $35Abscess I & D $75Injection $35U / A $35CBC $25CBC+Diff $45

X-rays $20Cholangiogram $90U/A + Culture $60Nitro Pads $55Diuretics $40MEDS (bactrim) $22.50Ventolin $11Double X-rays $40

Chest P&A $45Lat. X-Rays $45Digoxin Inj. $25B12 Inj. $40Nitro (meds) $40Bronchogram $150CXR(AP/Lat) $75OV HCN PF

Hx /SF MDM $134.99[MEDICARE]ABG O2 $85PFT”s $125OV C hx/exam MC MDM $138.50IV MEDS $25OV PF

Hx /SF MDM $36.80[MEDICARE]Skene Excision $165MRI (s contrast) $175Suture 2-5 cms Laceratiion $125ER and/or Physician Consult $85Cauterization $65Suture Removal Kit $45Septoplasy $653Professional Courtesy (-$55)C x R (2views) $65Elect Panel SMAC12 $45CT Thorax/Contrast $125IM Inj. Drug $25C & S Test $45Culture Transport $35


36



HEALTH INSURANCE CLAIM FORM (CMS-1500)

37

( GRADED COMPONENT )

38

SECTION III, EXAMINATION I, CUMULATIVE 72 QUESTIONSINCLUDES SECTIONS ON: HEALTH CARE REIMBURSEMENT, MEDICAL CODING -1, CLAIMS MANAGEMENT, CLAIMS PROCESSINGPART I: MATCHING DIRECTIONS: Match the following terms or phrases on the left hand column with their equivalent definitions found on the right hand column. In the `space' provided place ònly' letters!

1. COMPREHENSIVE CODE____________ A). this is a performance number that each physician or provider gets for each group office or clinic in which he or she practices. In medicare each member has an eight character PPIN which collaborates to that groups location in addition to the group number.2. UNBUNDLING _____________________ B). this is a medicare lifetime 10 digit number issued to providers. When adopted it is recognized by Medicaid, Medicare, Tricare & CHAMPVA programs and eventually will be used by private insurance carriers.3. MODIFIER ________________________ C). this is any medicare claim that contains complete, necessary information but is illogical or incorrect.4. ________________________ D). this means that the claim was submitted within the program or policy time limit and contains all the necessary information so it can be processed and paid promptly.5. _____________________________ E). this is a carrier assigned number that every physician uses to render services to patients when submitting claim forms for insurance purposes.6. __________________________ F). A single code that describes or covers two or more component codes that are bundled together as one unit.

7 ⊘ ___________________________ G). permits the physician to indicate circumstances in which a procedure as performed differs in some way from that described by its usual code.

8. ___________________________ H). this fee meets the criteria of the usual fee and is in the opinion of the medical review committee, justifiable, considering the special circumstances of the patient and case.

9. ___________________________ I). this claim happens when the medicare contractor cannot process a claim for a particular service or bill type.10. CUSTOMARY FEE ________________ J). this is a claim submitted with errors or one requiring manual processing for resolving problems or one rejected for payment. Pending or suspense claims are placed in this category because something is holding the claim back from payment (review)11. REASONABLE FEE ______________ K). this is the code sign for an “add on code”.12. INCOMPLETE CLAIM _____________ L). this is a number issued by the medicare fiscal intermediary to each physician who renders medical service to medicare recipients used for identification purposes on CMA 1500 claim forms.13. DINGY CLAIM ____________________ M). this code sign indicates “ a revised code”.14. DIRTY CLAIM ____________________ N). this fee is in the range of the fees charged by providers of similar training and experience in a given geographic area.15. INVALID CLAIM ___________________ O). this is the code sign for a modifier which generally has a negative sign with two digit number.16. CLEAN CLAIM ____________________ P). this is the code sign for “a new or revised text”.17. PIN NUMBER ____________________ Q). this is the code sign for a “new code”.18. NPI NUMBER _____________________ R). term used to define coding and billing numerous CPT codes to identify procedures that usually are described by a single code.19. UPIN NUMBER ___________________ S). this can be any medicare claim missing required information. It is generally identified to the provider so that it can be resubmitted.20. PPIN NUMBER ____________________ T). this code sign implies “service includes surgical procedure only”.

21. List the four major reasons for the development and use of diagnostic codes: a). ______________ b). ______________ c). ______________ d). ______________

22. Which of the following are a supplementary classification of coding in which you look for the external causes of injury rather than disease. They are found in Volume I, Tabular List, explain the mechanism of injury and are not used by physicians offices on claims? a). V codes b). E codes c). X codes d). none of the above e). only answers ‘a’ and ‘b’ are correct

23. Which of the following are a supplementary classification of coding used for example when a person who is not currently sick encounters health services for some specific purpose such as to act as a donor of an organ or tissue or receive a vaccination. They are found in Volume I, Tabular List, and alphabetic index of volume II, and may also be used when a circumstance influences health status? a). V codes b). E codes c). X codes d). none of the above e). only answers ‘a’ and ‘b’ are correct

TOTALS = 26

39

PART II: MATCHING DIRECTIONS: Match the following terms or phrases on the left hand column with their equivalent definitions found on the right hand column. In the `space' provided place ònly' letters!

1. DME NUMBER _____________ A). this is an insurance claim submitted to an insurance carrier that is discarded by the system because of a technical error (omission or erroneous information) or because it does not follow medicare instructions. It is usually returned to the provider for corrections or changes so that it may be processed properly for payment.2. DIGITAL CLAIM _____________B). a device that can read typed characters at a very high speed and then converts them to digitized computer characters within files to be saved on disk.3. EIN NUMBER _______________C). this means that the claim was submitted within the program or policy time limit and contains all the necessary information so it can be processed and paid promptly.

4. FACILITY NUMBER___________D). this is the universal insurance claim form developed and approved the American Medical Assoc as well as centers for for medicare and Medicaid services. It is used by physicians and other professionals to bill output services and supplies for tricare, medicare & some Medicaid programs as well as private insurance carriers and managed care plans.

5. GROUP PROVIDER NUMBER___E). these are insurance claims with no staples or highlighted areas and with non-deformed bar codes.6. ELECTRONIC CLAIM__________F). this is a license issued to a physician who has passed the state medical examinations and indicates his/her right to practice medicine in the state where issued.7. OCR ________________________G). this is a claim sent to the insurance carrier as a paper claim by fax & never printed to paper at receiving end.8. REJECTED CLAIM ____________H). this is given to medicare providers who charge patients a fee for supplies and equipment such as crutches, urinary catheters, ostomy supplies, surgical dressings and so forth which must be billed through medicare using this number.9. OTHER CLAIMS ______________I)). this is an insurance claim held in suspense because of review or other reasons. These claims may be cleared for payment or denied.10. PAPER CLAIM_______________J). this claim is submitted to an insurance carrier via a central processing unit (CPU), tape diskette, direct data entry, direct wire, dial in telephone or personal computer via modem and are never printed on paper.11. PENDING CLAIM_____________K). this is the name given to all medicare claims not considered ‘clean’. They are claims that require investigation or development on a pre-payment basis to determine if medicare is the primary or secondary carrier.12. PHYSICALLY CLEAN CLAIM____L). this is a number assigned to a number of physicians submitting insurance claim forms under one name and reporting income under one name. It is used instead of the individual PIN number for the performing provider.13. CLEAN CLAIM________________M). this is an individual’s (provider) federal tax identification number which is issued by the Internal Revenue Service for income tax purposes.14. CMS 1500____________________N). this is an institutional number serving as a provider such as hospitals, labs, nursing, etc which is used to bill services or used by performing physicians to report services done at that location.15. STATE LICENSE NUMBER______O). this is an insurance claim submitted on paper including those optically scanned and converted to an electronic format by the insurance carrier.

16. An insurance claim form may require three different provider identification numbers. Name the three different types of physicians whose identification numbers may be requested ? a). ______________________ b). ________________________ c). _______________________

17. Which of the following represents the basic format for CPT codes ? a). a basic five digit system for coding physician services and two digit add on modifiers for special circumstances. b). a basic six digit system for coding physician services and three digit add on modifiers for special circumstances. c). a basic seven digit system for coding physician services and two digit add on modifiers for special circumstances. d). Only answers "a" and "c" are correct e). None of the above are correct.

18. Private insurance companies and federal and state programs adopt different methods for basing their payments on outpatient claims. Name the three basic and universally accepted methods ? a). ______________________ b). ________________________ c). _______________________

19. Some insurance policies pay for only one consultation per year and may require a written report for any additional consultations. Name the four basic types of consultations for which CPT codes exist ? a). ______________ b). ______________ c). ______________ d). ______________

TOTALS = 26

PART III: MATCHING DIRECTIONS: Match the following terms or phrases on the left hand column with their equivalent definitions found on the right hand column. In the `space' provided place ònly' letters!

40

1. MODIFIER __________________ (A). when added to a CPT code, this modifier will code for a ‘Professional Component.

2. ADJUCT CODES _____________ (B). this fee meets the criteria of the usual fee and is in the opinion of the medical review committee, justifiable, considering the special circumstances of the patient and case.

3. UPCODING _________________(C). when added to a CPT code, this modifier will code for ‘Multiple Procedures.

4. DOWNCODING ______________(D). when added to a CPT code, this modifier will code for a ‘Bilateral Procedure’.

5. BUNDLING __________________(E). this is the charge or fee that falls within the range of charges most frequently used in a locality for a particular medical service or procedure.

6. UNBUNDLING _______________(F). when added to a CPT code, this modifier will code for the use of equipment such as a radiograph.

7. [ -26 ] ______________________(G). permits the physician to indicate circumstances in which a procedure as performed differs in some way from that described by the usual five digit code.

8. [ -25 ] _______________________(H). this fee is in the range of the fees charged by providers of similar training and experience in a given geographic area.

9. [ -50 ] _______________________(I). a term used to describe when the coding system used on a claim submitted to an insurance carrier does not match the coding system used by the company receiving the claim.

10. [ -51 ] _____________________(J). this is the amount that a physician bills a patient for a particular medical procedure or service.

11. ACTUAL FEE ______________(K). when added to a CPT code, this modifier will code for a ‘Significant, Separately Identifiable Evaluation and Management Service by the Same Physician on the Day of a Procedure or Other Service.

12. PREVAILING FEE ___________(L). when related to insurance claims, this term means to group codes together that are related to a procedure.

13. [ -TC ] _____________________(M). coding and billing numerous CPT codes to identify procedures that usually are described by a single code.

14. CUSTOMARY FEE____________(N). this term is used to describe the deliberate manipulation of CPT codes for increased payments.

15. REASONABLE FEE ___________(O). they are referred to in the Medicine Section of the CPT codes as Special Services and Reports and fall under the category of Miscellaneous Services.

16. Name the two components that are always included in a “Surgical Package” ?

a). ______________________ b). ________________________


a). ______________________ b). ________________________ c). _______________________

TOTALS = 20

41


1.-__________ 26.-__________ 51.-__________ 76.-__________101.-__________

2.-__________ 27.-__________ 52.-__________ 77.-__________102.-__________

3.-__________ 28.-__________ 53.-__________ 78.-__________103.-__________

4.-__________ 29.-__________ 54.-__________ 79.-__________104.-__________

5.-__________ 30.-__________ 55.-__________ 80.-__________105.-__________

6.-__________ 31.-__________ 56.-__________ 81.-__________106.-__________

7.-__________ 32.-__________ 57.-__________ 82.-__________107.-__________

8.-__________ 33.-__________ 58.-__________ 83.-__________108.-__________

9.-__________ 34.-__________ 59.-__________ 84.-__________109.-__________

10.-__________ 35.-__________ 60.-__________ 85.-__________110.-__________

11.-__________ 36.-__________ 61.-__________ 86.-__________111.-__________

12.-__________ 37.-__________ 62.-__________ 87.-__________112.-__________

13.-__________ 38.-__________ 63.-__________ 88.-__________113.-__________

14.-__________ 39.-__________ 64.-__________ 89.-__________114.-__________

15.-__________ 40.-__________ 65.-__________ 90.-__________115.-__________

16.-__________ 41.-__________ 66.-__________ 91.-__________116.-__________

17.-__________ 42.-__________ 67.-__________ 92.-__________117.-__________

18.-__________ 43.-__________ 68.-__________ 93.-__________118.-__________

19.-__________ 44.-__________ 69.-__________ 94.-__________119.-__________

20.-__________ 45.-__________ 70.-__________ 95.-__________120.-__________

21.-__________ 46.-__________ 71.-__________ 96.-__________121.-__________

22.-__________ 47.-__________ 72.-__________ 97.-__________122.-__________

23.-__________ 48.-__________ 73.-__________ 98.-__________123.-__________

24.-__________ 49.-__________ 74.-__________ 99.-__________124.-__________

25.-__________ 50.-__________ 75.-__________100.-__________125.-__________

42

SECTION III, EXAMINATION II, CUMULATIVE 100 QUESTIONSINCLUDES SECTIONS ON: HEALTH CARE REIMBURSEMENT, MEDICAL CODING -1, CLAIMS MANAGEMENT, CLAIMS PROCESSING, ADVANCED CODING

PART #1: FILL-IN BLANK DIRECTIONS: Fill-in the blank spaces with the most appropriate words or phrases that best completes the sentences. (Evaluation and Management { E / M } Section )

1. List the five (5) types of presenting problems from the most risk and least recovery to the least risk and most recovery:

a). ______________ b). ______________ c) ______________ d) ______________ e) ______________

2. List the four (4) types of medical decision making, in order of complexity from most to least complex:

a). ______________ b). ______________ c. ______________ d) ______________

3. Counseling and coordination of care are what kind of factors in most cases? ANS: ________________________

4. Time that is used as a guide for out-patient services is what kind of time? ANS: ________________________

5. Inpatient time spent at the bedside or nursing station during or after the visit is what kind of time? ANS: _________________

6. The patient’s ____________________________ _________________________will reflect the number of systems examined by a brief statement of the findings.

7. The history is the ______________________information the patient tells the physician.

8. A discussion with a patient and/or family concerning one or more of the following areas: diagnostic results, impressions and/or recommended diagnostic studies; prognosis, risks, and benefits of treatment; instructions for treatment; importance of compliance with treatment; risk factor reduction; and patient and family education is ________________________________.


1. CONSULTATION__________________ A) A face-to-face encounter in an office between the physician and patient..

2. ADMISSION______________________ B) One who has not received services from the physician or another physician in the same group within the last three years

3. OFFICE VISIT. ___________________ C) Advice or opinion from one physician to another physician

4. NEWBORN CARE_________________ D) One who has been formally admitted to an acute health care facility.

5. ESTABLISHED PATIENT___________ E) One who has received services from the physician or another physician in the same group within the last three years..

6. INPATIENT______________________ F) Attention to an acute illness or injury that results in hospitalization.

7. NEW PATIENT ___________________ G). Evaluation and determination of care for a newborn infant

8. OUT PATIENT ___________________ H). One who has not been formally admitted to a health care facility

PART #2: FILL-IN BLANK DIRECTIONS: Fill-in the blank spaces with the most appropriate words or phrases that best completes the sentences. (Anesthesia Section and Modifiers)

43

1. What two words describe a decreased level of consciousness that does not put patients completely to sleep and that allows the patients to breathe on their own during a surgical procedure ? ANS: ___________________ _________________________.

2. What do the initials CRNA stand for? ANS: ____________________________________________________________.

3. What appendix in the CPT manual contains a complete list of all modifiers? ANS: ________________________________.

4. What is the word that means assigning multiple codes when one code would do? ANS: ____________________________.

5. What is the term that describes the services provided to a patient by the physician before surgery? ANS: __________________.

6. What is another term for the time after the surgery that the physician provides services to the patient? ANS: _______________.

7. Do all third party payers recognize all modifiers as listed in the CPT manual? ANS: _____________________.

8. What is the term that describes two physicians working together in the completion of a procedure when each has the same level of responsibility? ANS: _________________________________________.

PART #3: MATCHING DIRECTIONS: Match the following terms or phrases on the left hand column with their equivalent definitions found on the right hand column. In the `space' provided place ònly' letters! (Cardiovascular System )

1. PERICARDIUM. ________ A) Forcing of fluid into a vessel or cavity2. CARDIOPULMONARY____ B) Blood bypasses the heart through a heart lung machine during open heart surgery.3. BYPASS_______________ C) Lead attached to a generator that carries the electrical current from the generator to the

atria or ventricles.4. PACEMAKER__________ D) Vessel that carries unoxygenated blood to the heart from the body tissues5. SINGLE-CHAMBER _____E). Blood Clot. PACEMAKER

6. DUAL-CHAMBER ______F). Abnormal opening from one area to other area or to outside of the body.. PACEMAKER 7. ELECTRODE __________G). To go around..8. VENTRICLE____________H). Surgically placed device that directs an electrical current shock to the heart to restore rhythm..9. ATRIUM _______________I). Blockage of a blood vessel by a blood clot or other matter that has moved from another area of

the body through the circulatory system

10. CARDIOVERTER-______J). Direct communication (passage) between an artery and vein DEFIBRILLATOR11. ARTERY______________K). Tube placed into the body to put fluid in or take fluid out..12. VEIN_________________L). Surgical or percutaneous procedure on a vessel to dilate the vessel opening, used in the

treatment of atherosclerotic disease..13. ANEURYSM___________M). Electrode of the pacemaker is placed only in the atrium or only in the ventricle, but not in both places...

14. EMBOLISM____________N). Membranous sac enclosing the heart and ends of the great vessels.15. THROMBOSIS__________O). Vessel that carries oxygenated blood 16. ENDARTERECTOMY_____P). A sac of clotted blood of fluid formed in the circulatory system (e.g. vein or artery)..17. ANGIOPLASTY_________Q). Incision into an artery to remove the inner lining to remove disease or blockage.18. INJECTION____________R). Divert or make an artificial passage..19. CATHETER____________S). Refers to the heart and lungs.20. ARTERIOVENOUS_______T). Electrodes of the pacemaker are placed in both the atrium and the ventricle of the heart.. FISTULA21. ANOMALY______________U). Deficient blood supply caused by obstruction of the circulatory system.22. ISCHEMIA _____________V). Chamber in the upper part of the heart..23. CARDIOPULMONARY____W). Electrical device that controls the beating of the heart by electrical impulses. BYPASS24. FISTULA ______________X). Chamber in the lower part of the heart..25. SHUNT________________Y). Abnormality.

44

PART #4: MATCHING DIRECTIONS: Match the following terms or phrases on the left hand column with their equivalent definitions found on the right hand column. In the `space' provided place ònly' letters! (Radiology Section ).

SECTION (A): Match the following terms to the correct definitions:

1. ANTERIOR (VENTRAL) _________ A). Toward the midline of the body2. POSTERIOR (DORSAL__________ B). Toward the head or the upper part of the body; also known as cephalad or cephalic3. SUPERIOR____________________ C). In front of4. INFERIOR____________________ D). Away from the midline of the body (to the side)5. MEDIAL______________________ E). In back of6. LATERAL_____________________ F). Away from the head or the lower part of the body; also known as caudad or caudal

SECTION (B): Match the following radiographic procedures to the correct structures imaged:

7. FLOUROSCOPY _________________ A). Radiographic contrast medium8. MAGNETIC RESONANCE B). Procedure for viewing the interior of the body using x-rays and projecting the image onto IMAGING (MRI) ________________ a television screen

9. TOMOGRAPHY __________________ C). Photoelectric process of radiographs10. XERORADIOGRAPHY ____________ D). Application of a statistical method to a biological fact11. BARIUM_______________________ E). Procedure that uses monionizing radiation to view the body in a cross-sectional view12. BIOMETRY_____________________ F). Procedure that allows viewing of a single plane of the body by blurring out all but that particular level

SECTION (C): Match the following radiographic procedures to the correct structures imaged:

13. ARTHROGRAPHY__________ A). Uterine cavity and Fallopian Tubes 14. CHOLANGIOGRAPHY __________ B). Intervertebral joint15. CYSTOGRAPHY ___________________ C). Kidneys, renal pelvis, ureters, and bladder16. DISKOGRAPHY ____________________ D). Bile Ducts17. EPIDIDYMOGRAPHY _______________ E). Joint18. HYSTEROSALPINGOGRAPHY__________ F). Veins and tributaries19. LYMPHANGIOGRAPHY __________ G). Subarachnoid space of the spine20. MYELOGRAPHY __________ H). Epididymis21. UROGRAPHY __________ I). Urinary bladder22. VENOGRAPHY ____________________ J). Lymphatic vessels and nodes

SECTION (D): Without the use of reference material, answer the following:

23. E codes are located in Section: a). 3 b).2 c).1 d). 0

24. Benign, malignant, and carcinoma in situ are examples of types of:

A). Secondary sites B) Neoplasm behavior C) Borderline malignancy D) Primary sites

SECTION (E): Match the abbreviations, punctuations, symbols, words, or typeface to the correct descriptions:

45

25. ________ [ ] A). Incomplete term that needs one of the modifiers to make a code assignable26 ________ NOS B) Used in Volume 2 to enclose the disease and procedure codes that are recorded with 27. ________ : the code they are listed with28 ________ § C) Typeface used for all codes and titles in Volume 129 _______ Italics D) Information is not available to code to a more specific category30. _______ Excludes E) Encloses a series of terms that are modified by the statement to the right31. _______ Includes F). Encloses synonyms, alternative words, or explanatory phrases32 _______ } G) Equals unspecified33 _______ NEC H) Typeface used for all exclusion notes34. _______ ( ) I) Footnote or section mark35. _______ [ ] J) Appears under a 3digit code title to further define or explain category content36. _______ BOLD TYPE K) Encloses supplementary words and does not affect the code L) Indicates terms that are to be coded elsewhere

SECTION (F): Match the convention to the definition:

37. _________ See Category A) Indented under main term and are essential to code selection38. _________ Modifiers B) Terms in parentheses that are nonessential39. __________ See C) Explicit direction to look elsewhere40. _________ Notes D) Follows terms to define and give instructions41. __________ Subterms E) Directs coder to look under another term since all information is not under the first42. __________ See also term43. _________ Eponym F) Directs coder Volume 1 G) Disease/ syndrome named for a person

46


1.-__________ 26.-__________ 51.-__________ 76.-__________101.-__________

2.-__________ 27.-__________ 52.-__________ 77.-__________102.-__________

3.-__________ 28.-__________ 53.-__________ 78.-__________103.-__________

4.-__________ 29.-__________ 54.-__________ 79.-__________104.-__________

5.-__________ 30.-__________ 55.-__________ 80.-__________105.-__________

6.-__________ 31.-__________ 56.-__________ 81.-__________106.-__________

7.-__________ 32.-__________ 57.-__________ 82.-__________107.-__________

8.-__________ 33.-__________ 58.-__________ 83.-__________108.-__________

9.-__________ 34.-__________ 59.-__________ 84.-__________109.-__________

10.-__________ 35.-__________ 60.-__________ 85.-__________110.-__________

11.-__________ 36.-__________ 61.-__________ 86.-__________111.-__________

12.-__________ 37.-__________ 62.-__________ 87.-__________112.-__________

13.-__________ 38.-__________ 63.-__________ 88.-__________113.-__________

14.-__________ 39.-__________ 64.-__________ 89.-__________114.-__________

15.-__________ 40.-__________ 65.-__________ 90.-__________115.-__________

16.-__________ 41.-__________ 66.-__________ 91.-__________116.-__________

17.-__________ 42.-__________ 67.-__________ 92.-__________117.-__________

18.-__________ 43.-__________ 68.-__________ 93.-__________118.-__________

19.-__________ 44.-__________ 69.-__________ 94.-__________119.-__________

20.-__________ 45.-__________ 70.-__________ 95.-__________120.-__________

21.-__________ 46.-__________ 71.-__________ 96.-__________121.-__________

22.-__________ 47.-__________ 72.-__________ 97.-__________122.-__________

23.-__________ 48.-__________ 73.-__________ 98.-__________123.-__________

24.-__________ 49.-__________ 74.-__________ 99.-__________124.-__________

25.-__________ 50.-__________ 75.-__________100.-__________125.-__________

47

SECTION IV, EXAMINATION I, CUMULATIVE 62 QUESTIONSINCLUDES SECTIONS ON: HEALTH CARE REIMBURSEMENT, MEDICAL CODING -1, CLAIMS MANAGEMENT, CLAIMS PROCESSING, ADVANCED CODING

PART I: DIRECTIONS: MULTIPLE ANSWER QUESTION (MAQ): Place a circle around the `letter' containing the `best' and most applicable answer. One answer only !

1. Diagnosis codes are entered in ____?

e. Block 24f. Block 33

g. Block 21h. None of the above

2. The maximum number of ICD-9-CM codes that may appear on a single claim is ____?

e. Fourf. Six

g. Twoh. None of the above

3. The first code reported on a claim should be the _______?

e. Qualified diagnosisf. Possible diagnosis

g. Primary diagnosish. None of the above

4. If a diagnosis is not treated or addressed during an encounter and is stated on a patient’s record, you should ____?

e. Not list the diagnosisf. List the diagnosis as secondary

g. List the diagnosis as probableh. None of the above

5. Until a definitive diagnosis is determined, which of the following diagnoses should be used ?

e. Rule outf. Suspicious for

g. Possibleh. None of the above

6. Some claims require attachments such as _____?

a. Clinic notesb. Operative reports

c. Discharge summariesd. All of the above

48

FILL-IN BLANK DIRECTIONS : Fill-in the blank spaces with the most appropriate words or phrases that best completes the sentences. (Claims Management )


e. The name on the ID card reads: James M. Apple, II ANS:____________________________________f. The name on the ID card reads: Charles T. Treebark, Jr. ANS:____________________________________g. The name on the ID card reads: David J. Hurts, III ANS:____________________________________h. The name on the ID card reads: Jake R. Elbow, Sr. ANS:____________________________________

8. The surgery section is organized by ___________________ ______________________


a. __________________________________________________________________________b. __________________________________________________________________________c. ___________________________________________________________________________

TOTALS = 15PART II: FILL-IN BLANK DIRECTIONS: Fill-in the blank spaces with the most appropriate words or phrases that best completes the sentences. (Claims Management )


a). __________________________________ b). ___________________________________


a). ____________________ b). ___________________ c). ___________________

12. On what basis are minor surgical procedures to be billed? __________________________________

13. Briefly describe “Unbundling” _____________________________________________________________________________ _____________________________________________________________________________


A) Skin Lesion- ___________________________________________________________________________B) Excision of a Lesion- _____________________________________________________________________C) Destruction of a Lesion- __________________________________________________________________


1) __________________________________________________________ 2) __________________________________________________________ 3) __________________________________________________________ 4) ___________________________________________________________ 5) ___________________________________________________________

16. Layered closure requires the use of 2 codes. One is for the ________________________ and one for the _______________________________________

17. If a physician reports the size of a lesion in inches, what must the coder do? _________________________________

18. When converting the size of a lesion, one inch = ___________________________________

19. When there are multiple lacerations, which repair should be listed first? ____________________________________________

Assign codes to the folllowing:

A) Removal of foreign body in tendon sheath, simple _________B) Puncture aspiration of cyst of breast ____________________C) Incision and drainage of thyroid gland cyst _______________

D) Abrasion, single lesion ______________________________E) Destruction of four flat warts __________________________F) Incision and drainage of ankle abscess _________________G) Incision and drainage of wrist hematoma ________________H) Aspiration thyroid cyst ____________________________I) Laparoscopy with bilateral total pelvic lymphadenectomy and

periaortic lymph node biopsy ________________________

TOTALS = 29

PART III: Match the following terms:

1) Medicare Part A- __________ A) Used only once during Patient’s lifetime2) Hospice care- ___________ B) The temporary hospitalization of a hospice patient3) ESRD- _____________ C) Covers institutional care4) Lifetime Reserve Days- _______ D) All terminally ill patients qualify5) Home health Svcs.- _____________ E) Available to patients confined to the home6) Respite care- ____________ F) Available to patients in need of renal dialysis or transplant

G) Disease/ syndrome named for a person

7). The development of an insurance claim begins when the _____?

a. Patient presents to the medical facilityb. Patient schedules an appointment

c. Services are delivered to the patientd. All of the above

8). Inpatient medical cases are billed on ______?

a. A fee-for-service basisb. A global fee basisc. An additional procedure basis

d. Only “b” and “c” are correcte. None of the above are correctf. All of the above are correct

9). Inpatient or outpatient major surgery cases are billed on _____?


d. Only “a and “c” are correcte. None of the above are correctf. All of the above are correct

10). Postoperative complications requiring a return to the operating room for surgery related to the original procedure are billed on____ ?



11). Minor surgery cases are billed on _____?



12). List four (4) circumstances in which a letter should be used ?

a). __________________ b). ___________________

c). ___________________d). ___________________

13). List five (5) key strokes that can be substituted by a space when completing a claim:

1) __________________________________________________________

2) __________________________________________________________ 3) __________________________________________________________ 4) ___________________________________________________________ 5) ___________________________________________________________

TOTALS = 18


1.-__________ 26.-__________ 51.-__________ 76.-__________101.-__________

2.-__________ 27.-__________ 52.-__________ 77.-__________102.-__________

3.-__________ 28.-__________ 53.-__________ 78.-__________103.-__________

4.-__________ 29.-__________ 54.-__________ 79.-__________104.-__________

5.-__________ 30.-__________ 55.-__________ 80.-__________105.-__________

6.-__________ 31.-__________ 56.-__________ 81.-__________106.-__________

7.-__________ 32.-__________ 57.-__________ 82.-__________107.-__________

8.-__________ 33.-__________ 58.-__________ 83.-__________108.-__________

9.-__________ 34.-__________ 59.-__________ 84.-__________109.-__________

10.-__________ 35.-__________ 60.-__________ 85.-__________110.-__________

11.-__________ 36.-__________ 61.-__________ 86.-__________111.-__________

12.-__________ 37.-__________ 62.-__________ 87.-__________112.-__________

13.-__________ 38.-__________ 63.-__________ 88.-__________113.-__________

14.-__________ 39.-__________ 64.-__________ 89.-__________114.-__________

15.-__________ 40.-__________ 65.-__________ 90.-__________115.-__________

16.-__________ 41.-__________ 66.-__________ 91.-__________116.-__________

17.-__________ 42.-__________ 67.-__________ 92.-__________117.-__________

18.-__________ 43.-__________ 68.-__________ 93.-__________118.-__________

19.-__________ 44.-__________ 69.-__________ 94.-__________119.-__________

20.-__________ 45.-__________ 70.-__________ 95.-__________120.-__________

21.-__________ 46.-__________ 71.-__________ 96.-__________121.-__________

22.-__________ 47.-__________ 72.-__________ 97.-__________122.-__________

23.-__________ 48.-__________ 73.-__________ 98.-__________123.-__________

24.-__________ 49.-__________ 74.-__________ 99.-__________124.-__________

25.-__________ 50.-__________ 75.-__________100.-__________125.-__________

SECTION IV, EXAMINATION II, CUMULATIVE 70 QUESTIONSINCLUDES SECTIONS ON: HEALTH CARE REIMBURSEMENT, MEDICAL CODING -1, CLAIMS MANAGEMENT, CLAIMS PROCESSING, ADVANCED CODING

PART I: DIRECTIONS: MULTIPLE ANSWER QUESTION (MAQ): Place a circle around the `letter' containing the `best' and most applicable answer. One answer only ! FILL-IN BLANK DIRECTIONS: Fill-in the blank spaces with the most appropriate words or phrases that best completes the sentences.

1. At what age can individuals who do not qualify for social security benefits “buy in” to Medicare Part A ?

a. 62 yearsb. 65 years

c. 64 yearsd. 63 years

e. None of the above

2. What is the percentage of allowed charges that the coinsurance for outpatient mental health treatments pay for ?

a. 20 %b. 75 %

c. 50 %d. 85 %

e. None of the above

3. Describe the possible consequences for providers who are in violation of Medicare regulations by routinely refraining from collecting the patient’s deductible and coinsurance ? ________________________________________________________________________________________________

________________________________________________________________________________________________

4. Federal law requires that all providers submit claims to Medicare if they provide a Medicare-covered service to a patient enrolled in Medicare Part B. This regulation does not apply if ?

a. The patient disenrolled before the service was furnishedb. The patient is not enrolled in Part Bc. The patient or the patient’s legal representative refuses to sign an authorization for release of medical

information.d. All of the abovee. None of the above

5. Define the term “Balance Billing ? ______________________________________________________________________________________________________________________________________________________

6. What is the purpose of obtaining an ABN ? ______________________________________________________________________________________________________________________________________________________

7. List three forms of MSP Medicare beneficiaries often purchase to cover the Medicare deductible and coinsurance requirements:a). ______________________________________________________________________b). ______________________________________________________________________c). ______________________________________________________________________

8. List five advantages of joining a Medicare HMO ?a). ______________________________________________________________________b). ______________________________________________________________________c). ______________________________________________________________________d). ______________________________________________________________________e). ______________________________________________________________________

9. List three disadvantages of joining a Medicare HMO ?a). ______________________________________________________________________b). ______________________________________________________________________c). ______________________________________________________________________

10. For HMO authorized fee-for-service specialty care, the claim is sent directly to ?

a. The patientb. Medicarec. The HMO

d. Only a and b are correcte. All of the above are correctf. None of the above are correct

11. What is the deadline for filing Medicare HMO claims ?

a. 90 daysb. 60 daysc. 45 days

d. one yeare. All of the above are correctf. None of the above are correct

12. Explain how the regional carrier for traditional Medicare claims is selected by CMS ?________________________________________________________________________________________________

13. Coal miner’s claims are sent to the ? ANS: ___________________________________

14. What is the name of the claim form that must be completed for all paper claims ? ________________________________________________________________________________________________

15. When Medicare is the secondary payer, the ___________________________________________must be attached to the Medicare claim.

PART II: Match the following terms:

1. Axillary nodes ________________ a. Incision into a lymphatic vessel 2. Splenectomy__________________ b. Station along the lymphatic system 3. Splenoportography____________ c. Grafting of tissue from one source to another 4. Allogenic_____________________ d. Congenital deformity of benign tumor of the lymphatic system 5. Autologous, autogenous________ e. Of the same species, but genetically different 6. Aspiration____________________ 7. Stem cell_____________________ f. Localization of pus 8. Transplantation_______________ g. Behind the sac holding the abdominal organs and viscera (peritoneum) 9. Lymph node__________________ h. Use of a needle and syringe to withdraw fluid 10. Lymphadenitis________________ i. Excision of the spleen 11. Lymphangiotomy______________ j. Excision of a lymph mode (or nodes) 12. Thoracic duct_________________ k. Lymph located next to the large vein in the neck 13. Lymphadenectomy____________ l. Term that refers to the groin and thigh 14. Retroperitoneal_______________ m. Collection and distribution point for lymph and the largest lymph 15. Jugular nodes________________ vessel located in the chest 16. Cystic hygroma_______________ 17. Cloquet’s node_______________ n. Lymph nodes located in the armpit 18. Inguinofemora________________ o. Insertion of a tube into a duct or cavity 19. Cannulation__________________ p. From oneself 20. Abscess_____________________ q. Immature blood cells r. Also called a gland; it is the highest of the deep groin lymph nodes s. Inflammation of a lymph node t. Radiographic procedure to allow visualization of the splenic and portal veins of the spleen


1. Keratoplasty_________________________ a. Opaque covering on or in the lens 2. Evisceration_________________________ b. Prefix meaning pertaining to the lacrimal sac 3. Enucleation__________________________ c. Vascular tissue of the choroids, ciliary body and iris 4. Pelvic exenteration____________________ d. Condition in which the refractive surfaces of the eyes are unequal 5. Cataract_____________________________ e. Prefix meaning tear / tear duct 6. Sclera_______________________________ f. Prefix meaning ciliary body or eye muscle 7. Conjunctiva__________________________ g. Surgical repair of the cornea 8. Uveal________________________________ h. Prefix meaning eyelid 9. Tarsorrhaphy_________________________ i. Removal of an eye 10. Ocular adnexa________________________ j. Prefix meaning cornea 11. Anterior segment______________________ k. Those parts of the eye behind the lens 12. Posterior segment_____________________ l. Extra ocular muscle deviation resulting in unequal visual axes 13. Blephar/o_____________________________ m. Prefix meaning eye 14. Cor/o_________________________________ n. Suturing together of the eyelids 15. Cyclo/o_______________________________ o. Lining of the eyelids and covering of the sclera 16. Dacry/o_______________________________ p. Those parts of the eye in the front of and including the lens, orbit,17. Kerat/o_______________________________ extra ocular muscles and eyelid

57

18. Ocul/o_______________________________ q. Removal of contents of a body cavity 19. Dacryocyst/o__________________________ r. Prefix meaning pupil 20. Vitre/o________________________________ s. White outer portion of the eyeball 21. Astigmatism__________________________ t. Prefix meaning pertaining to the vitreous body of the eye 22. Strabismus___________________________ u. Orbit, extra ocular muscles and eyelid v. Pulling the viscera outside the body through an incision

23. What do the following medical abbreviations or acronyms mean:

ABN ______________________________________________________________________________________________________

CLIA ______________________________________________________________________________________________________

ESRD______________________________________________________________________________________________________

PPO________________________________________________________________________________________________________

SLMB______________________________________________________________________________________________________

TOTALS = 70

58


1.-__________ 26.-__________ 51.-__________ 76.-__________101.-__________

2.-__________ 27.-__________ 52.-__________ 77.-__________102.-__________

3.-__________ 28.-__________ 53.-__________ 78.-__________103.-__________

4.-__________ 29.-__________ 54.-__________ 79.-__________104.-__________

5.-__________ 30.-__________ 55.-__________ 80.-__________105.-__________

6.-__________ 31.-__________ 56.-__________ 81.-__________106.-__________

7.-__________ 32.-__________ 57.-__________ 82.-__________107.-__________

8.-__________ 33.-__________ 58.-__________ 83.-__________108.-__________

9.-__________ 34.-__________ 59.-__________ 84.-__________109.-__________

10.-__________ 35.-__________ 60.-__________ 85.-__________110.-__________

11.-__________ 36.-__________ 61.-__________ 86.-__________111.-__________

12.-__________ 37.-__________ 62.-__________ 87.-__________112.-__________

13.-__________ 38.-__________ 63.-__________ 88.-__________113.-__________

14.-__________ 39.-__________ 64.-__________ 89.-__________114.-__________

15.-__________ 40.-__________ 65.-__________ 90.-__________115.-__________

16.-__________ 41.-__________ 66.-__________ 91.-__________116.-__________

17.-__________ 42.-__________ 67.-__________ 92.-__________117.-__________

18.-__________ 43.-__________ 68.-__________ 93.-__________118.-__________

19.-__________ 44.-__________ 69.-__________ 94.-__________119.-__________

20.-__________ 45.-__________ 70.-__________ 95.-__________120.-__________

21.-__________ 46.-__________ 71.-__________ 96.-__________121.-__________

22.-__________ 47.-__________ 72.-__________ 97.-__________122.-__________

23.-__________ 48.-__________ 73.-__________ 98.-__________123.-__________

24.-__________ 49.-__________ 74.-__________ 99.-__________124.-__________

25.-__________ 50.-__________ 75.-__________100.-__________125.-__________

59

SECTION V, EXAMINATION I, CUMULATIVE 84 QUESTIONSINCLUDES SECTIONS ON: OFFICE ADMINISTRATION, BILLING MANAGEMENT, ACCOUNTS RECEIVABLE, INSURANCE POLICIES, LEDGER CARDS, PURCHASE ORDERS, RECEIPTS, ALPHANUMERIC FILING, INSURANCE FORMS [CMS1500], MEDISOFT.

Medical Office Administration

Multiple Choice:

1. Which of the following is not the correct procedure when making collection calls ?a. Stating your business to the person who answers the

telephoneb. Speaking on the patient’s level

c. Allowing the patient to talkd. Recording the results of the call

2. Health Maintenance Organizations?a. Are different from health insurance companiesb. Are the same as health insurance companies

c. Are always non-profit organizationsd. Always use salaried physicians in a clinic setting

3. Medicaid was developed by ?a. The federal government

b. The individual states c. A group of Insurance Co’s, HMO’s & PPO’s d. The federal government and the states

4. Blue Shield pays for?a. Physician’s services

b. Hospital services c. All patient services d. All services that the patient requests

5. In a cross-posting report, a computer system can:a. Proof the posting for the dayb. Proof the posting for the month

c. Determine the amount spent from petty cashd. Track the application of fees to individual doctors in a group practice

6. Patients pay:a. Most of the cost of their physician’s feesb. A small portion of their physician’s fees

c. None of their physician’s feesd. All of their physician’s fees

7. HMO’s can afford to guarantee no unexpected costs because their physicians are less likely to duplicate laboratory tests and because?a. HMO’s do not earn a profitb. HMO’s obtain some of their funding from charity

organizations

c. Paperwork expenses for HMO’s are less than for private

d. HMO’s accept no emergency patients

8. Preferred Provider Organizations (PPO’s) offer medical services through:a. Groups of Physicians, hospitals and an insurerb. Services to private patients

c. Groups of Physicians who serve only one company’s employees

d. None of the above

9. In the typical PPO, the insurer pays the entire bill or all but a small deductible, as long as:a. The patient refers a required number of friends to the PPO each yearb. The physician is willing to see a patient

c. The medical problem is not an emergencyd. The patient uses only the preferred providers

10. Medicare provides health care for?a. Americans age 65 and over and disabled Americans

under the age of 65b. The poor

c. Older people and illegitimate childrend. All of the above

11. Which of the following is not a component of the pegboard accounting system ?a. The daily logb. The Ledger card

c. The medical recordd. The superbill

12. The cost of Worker’s Compensation insurance is paid by ?a. Employeesb. Employers

c. The public through taxesd. All of the above

13. Pegboard accounting refers to a simple method of record keeping that requires only:

60

a. Proofreadingb. Posting an entry once

c. Posting an entry three timesd. None of the above

14. Hospital visits may be recorded in all but which of the following ways ?

a. Dailyb. At discharge with a superbill

c. At discharge with no superbilld. At the hospital and given to the patient

15. Which of the following is not a legitimate reason for leasing instead of purchasing a computer ?a. The practice can maintain state of the art equipment and software without incurring exorbitant costsb. There is the risk of losing money when a software company goes out of businessc. There is more risk because the computer company may ask for the computer to be returnedd. Leases cover routine maintenance, insurance and an option to purchase at the end of the period

16. Proof of posting refers to:a. The physicians review of the day’s postingb. Another medical assistant’s review of the day’s posting

c. Cross checking columns to show matching totalsd. All of the above

17. Insurance designed to help offset huge medical expenses for lengthy illness or serious accident is called?a. Comprehensive coverageb. Basic coverage

c. Major medical coveraged. Total coverage

18. The Truth-in-Lending Act ?a. Requires physicians who provide installment credit to state the charges and interest in writing to the patientb. Allows physicians to charge only for fees and to charge no interestc. Requires physicians who provide installment credit to state the charges and interest orally to the patientd. None of the above

19. The term “accounts receivable” refers to the amount of money:a. Owed by the patientb. Owed by the medical practice

c. Received from patients in one dayd. Spent by the practice in one day

20. The check register is a record of?a. Checks received in one dayb. Checks written personally by the doctor

c. Checks issued by the practiced. None of the above

21. Insurance that pays physicians fees, hospital expenses up to a maximum, and certain surgical fees is called:a. Comprehensive coverageb. Basic coverage

c. Major medical coveraged. Total Coverage

22. CPT-4 stands for:a. Current Patient Terminology, fourth edition c. Capital Payment Taxes, fourth editionb. Current Procedural Terminology, fourth edition d. None of the above

23. DRGs were developed as an answer to escalating charges experienced by:a. Medicare patients c. Private physiciansb. Insurance companies d. All patients

24. Blue Cross pays for:a. The physician’s services c. All patient servicesb. Hospital services d. Services that the patient requests

25. After a patient’s name and other information are written on a superbill, the superbill is:a. Given to the patient c. Clipped to the medical recordb. Given to the doctor d. Kept at the receptionist’s desk

26. ICD-9 stands for:a. Intentional Classification of Diseases, ninth edition c. International Certification of Diseases, ninth editionb. International Classification of Diseases, ninth edition d. Intentional Certification of Diseases, ninth edition

61

27. In an assignment of payment, a physician:a. Agrees to accept an amount predetermined by a third-party carrier c. Signs a form outlining payment proceduresb. Charges a usual and customary fee d. None of the above

28. When cycle billing is used, accounts are:a. Divided into groups and billed according to a schedule c. Billed by a different employee each monthb. Billed every other month d. None of the above

29. The ledger card is a: a. Summary of the day’s activity c. Summary of one type of treatment b. Summary of one family’s account d. None of the above

30. Mr. Larry Ditta came to the office today for the first time. He is a new patient and will need a Ledger Card, Receipt and an insurance form for the following treatments: Comprehensive History and Physical, EKG, PA and Left Lateral x-rays of the chest and Hemoccult slides.

He paid the doctor IN FULL and would like a receipt and insurance form. His ledger card information is as follows: Mr. Larry J. Ditta Telephone # 201-779-1234 7 Delwick Lane He is married Short Hills, N.J. 07078 His occupation is Lawyer He has BC/BS and the # is: DOB is 4-6-30 152-05-9462 BCI He was referred by Mrs. Duffy.

The doctor's name and address is: Dr. Fx Claps, 70 East 73rd St, NYC 10021 Note: Unfortunately Mr. Ditta suffered a heart attack and died shortly after leaving the doctor's office. P/E = $ 25.00 (DCM# 91125) XRAYS = $ 20.00 (DCM# 46238) EKG = $ 45.00 (DCM# 90132) SLIDES = $ 15.00 (DCM# 35625)

31. What do the following Medical / Medical Billing Abbreviations mean ? ( 1 pt ea)

a). q.i.d. = ________ b). B/F = ________ c). p.p.a. = ________ d). a.c. = ________ e). d = ________ f). c/a * = ________

g). s.o.s. = ________ h). p.r.n. = ________ i). q.o.d. = ________ j). D. = ________ k). H.S.(hs) = ________ l). ck * = ________

m). ad lib = ________ n). OS = ________ o). def * = _______ p). cr * = _______ q). adj = _______

DIRECTIONS QUESTIONS #32-35: After each group of names, indicate the order in which they would be arranged in an alphabetical file. The second line of the example shows the patients' names as they would appear on file labels. EXAMPLE: (a) J. T. Jefferson; (b) John Thompson; (c) Mrs. T.J. Brown (Marsha) ANS:___CAB_____

32. (a) Hugh M. MacAdoo; (b) Bruce T.McCall; (c) Robert A. Macall _______

33. (a) J.W. Winn, M.D., 1404 Rosealea Rd., Cleveland, Ohio: (b) James W. Winn, 1203 Venetta Drive, Cleveland, Ohio; (c) J.W. Winn, IV, 18 Maple St., Cleveland, Ohio ________

34. (a) Mary Sue Shelton; (b) Marth Lee Shelton-Alston; (c) Sheila-Lynn Alston (Mrs. Shelton A.) ________

35. (a) Jas. E.McBean; (b) J.L. MacBeen; (c) Jason McBean ________ 36. (a) W. L. Arther-Davis; (b) Carolyn Archer (Mrs. David): (c) Sister Aeletta-Marie _________ 37. (a) Mrs. Loretta Maggio; (b) Nokker T. Magallon, Sr.; (c) B.L. Magill, Rev. __________

38. What four steps would you take when a patient chart cannot be located? a. _____________________________ c. _____________________________ b. _____________________________ d. _____________________________

39. Write a LEDGER CARD for the following data provided (3 points): DATA: Today Mrs. Duffy came into the office and had an OV- (Office Visit) and an electrocardiogram. She paid the doctor IN FULL and would like a receipt and an insurance form. Her diagnosis is the same as her last visit (Rheumatic Heart Disease, Mitral Stenosis, and Paroxysmal Atrial Fibrillation). STAT DATA: Address: Mrs. R. Duffy, 545 E. Main St., Dearborne, MI. 90602; DOB: 7/2/46, EKG = $ 45.00 (DCM #90132). The doctor's name & address is: Dr. F.X. Claps, 70 E. 73rd St., NYC, NY 10021

40. The following PURCHASE ORDERS for supplies are requested by Dr. Langford:

1.-(1000) blank sheets of standard style history forms at $ 0.35 each. 2.-Four pcs. swivel chairs at $ 75.80 each (Style is bone white). 3.-Gauze standard 500 per pack; current request is 15 pks. at $ 1.79/pk. 4.-Curite Bandaid at 350 per box; current request is 23 boxes at $ 1.83/bx

5.-Autolet finger puncture stylets at 125/pk., requesting 4 pks. $ 2.15/pk 6.-Patient Exam. Gowns at 50 per pack; current request is for 350 of them costing $ 85.65 per pack. Style is standard white.

If the tax rate is 8 ¼ % with a 25% Discount when purchased as well as a $45 delivery charge, then (2 pts ea / MUST SHOW MATH !): a). What is the total Purchase Price ? ANS: ______ b). What is the total Purchase Price Plus Tax ? ANS: _______

62

c). What is the Discounted Purchase Price Plus Tax ? ANS: ___ d). What is the Final Purchase Price with Delivery ? ANS: _____

41. Write Keys you will use to:

1. Print a File_______________2. Spelling check______________3. Slide Show_________________4. Duplicate Slides_____________

5. Save a File_________________6. Cut the Text________________7. Copy the Text_______________8. Delete Text__________________

9. Open a File__________________10. Exit Word or Excel___________

1. In the ‘transactions’ section of medisoft, which of the following must be entered in order to complete the transactions for a patient ?a). All of the chargesb). All of the payments, adjustments and/or commentsc). The CPT codesd). The amounts charged for each procedure

e). Only ‘a’ and ‘b’ are correctf). Only ‘c’ and ‘d’ are correctg). All of the above are correcth). None of the above are correct

2. What three basic things must be added to CPT in medisoft in order to process your transactions ?a). A Commentb). INSPAYc). COPAYd). Assigned Providere). Referred Provider

f). ICD-9 (Dx)g). Only ‘a, b,’ and ‘c’ are correcth). Only ‘c, d,’ and ‘e’ are correcti). All of the above are correctj). None of the above are correct

3. While doing the ‘transactions’ section of medisoft, if you obtained charges of $105, with payments of $ 165 and a balance of [ - $ 55 ], what does this balance obtained mean ?a). An error made by the person entering datab). A wrong amount entered for the COPAYc). An amount that must be returned to the patientd). A wrong amount entered in the ‘applications’ (apply)

e). Only ‘a’ and ‘b’ are correctf). Only ‘a’ and ‘d’ are correctg). All of the above are correcth). None of the above are correct

4. Which of the following represents the information that must be entered in medisoft in order to complete processing of the transactions section ?

a). The Practice Information b). Patient information with Casesc). The CPT Codesd). Assigned Providere). ICD-9 (Dx)

f). Insurance Carriersg). Only ‘a, b, c’ and ‘e’ are correcth). Only ‘a, b, c’ and ‘f’ are correcti). Only ‘a, b, c’ and ‘d’ are correctj). All of the above are correctk). None of the above are correct

5. What does the amount placed on INSPAY in medisoft represent ?a). All CPT’s performedb). A justification of charges in transactionsc). The total charges for all proceduresd). Only ‘a’ and ‘b’ are correct

e). Only ‘b’ and ‘c’ are correctf). All of the above are correctg). None of the above are correct

6. When entering information on the “Patient Screen” segment of medisoft, which of the following must be entered in order to complete this screen ?

63

a). New Case g). Only ‘b’ and ‘c’ are correctb). Diagnoses h). Only ‘c’ and ‘d’ are correctc). Assigned Provider i). All of the above are correctd). CPT Codes j). None of the above are correcte). Signature on File (SOF)f). Only ‘a’ and ‘b’ are correct

TOTALS = 84


1.-__________ 26.-__________ 51.-__________ 76.-__________101.-__________

2.-__________ 27.-__________ 52.-__________ 77.-__________102.-__________

3.-__________ 28.-__________ 53.-__________ 78.-__________103.-__________

4.-__________ 29.-__________ 54.-__________ 79.-__________104.-__________

5.-__________ 30.-__________ 55.-__________ 80.-__________105.-__________

6.-__________ 31.-__________ 56.-__________ 81.-__________106.-__________

7.-__________ 32.-__________ 57.-__________ 82.-__________107.-__________

8.-__________ 33.-__________ 58.-__________ 83.-__________108.-__________

9.-__________ 34.-__________ 59.-__________ 84.-__________109.-__________

10.-__________ 35.-__________ 60.-__________ 85.-__________110.-__________

11.-__________ 36.-__________ 61.-__________ 86.-__________111.-__________

12.-__________ 37.-__________ 62.-__________ 87.-__________112.-__________

13.-__________ 38.-__________ 63.-__________ 88.-__________113.-__________

14.-__________ 39.-__________ 64.-__________ 89.-__________114.-__________

15.-__________ 40.-__________ 65.-__________ 90.-__________115.-__________

16.-__________ 41.-__________ 66.-__________ 91.-__________116.-__________

17.-__________ 42.-__________ 67.-__________ 92.-__________117.-__________

18.-__________ 43.-__________ 68.-__________ 93.-__________118.-__________

19.-__________ 44.-__________ 69.-__________ 94.-__________119.-__________

20.-__________ 45.-__________ 70.-__________ 95.-__________120.-__________

21.-__________ 46.-__________ 71.-__________ 96.-__________121.-__________

22.-__________ 47.-__________ 72.-__________ 97.-__________122.-__________

23.-__________ 48.-__________ 73.-__________ 98.-__________123.-__________

24.-__________ 49.-__________ 74.-__________ 99.-__________124.-__________

25.-__________ 50.-__________ 75.-__________100.-__________125.-__________

SECTION V, EXAMINATION II, CUMULATIVE 165 QUESTIONSINCLUDES SECTIONS ON: HEALTH CARE REIMBURSEMENT, MEDICAL CODING -1, CLAIMS MANAGEMENT, CLAIMS PROCESSING, ADVANCED CODING

PART (A): Multiple Choice (Choose the best answer): Answer in letter only. Choose the answer that best describes the question. Fill-n Blanks = Fill-in the most appropriate response to question.

1. When a person misuses his or her Medicaid card, they are put on a A) Limited Time Basis B) Blacklist C) Restricted Recipient Program D) Recall-Card List E) Partial Payment Plan Choose either A,B,C,D,E _______________

2. When a person has medical bills above what their surplus income is for the month, even when their yearly income is above the Medicaid level, they can still receive Medicaid help. Answer True or False ________________

3. Medicaid is a A) Federal Supported Program B) State Program part of the public-assistance system C) Individual health Policy D) Group Polic Choose either A,B,C,D _________________

4. To whom do we send Workmens Compensation copies to?

_______________________ _________________________ _______________________ ______________________

5. What does the acronym CHAMPUS stand for? ________________________ 6. Medicare pays for what percentage of the bill? __________________

7. If a medicare patient wants extra coverage for what medicare does NOT pay, what type of insurance can be obtained? _________________________________________________________________

8. What is the name for the date on which insurance coverage begins? _____________________________________

9. Name one (1) thing which Blue Shield does not pay? _____________________________________

10. Medicare is insurance which covers people who are ?............... _______________________________

11. Give an example of a provider __________________________________12. Give an example of a carrier __________________________________

13. Give an a synonym for the word subscriber ______________________

14. What does it mean if the doctor “accepts assignment”? ___________________________________

15. What is the pt.'s medicare number? ______________________________

PART (B): MATCHING DIRECTIONS: Match the following terms or phrases on the left hand column with their equivalent definitions found on the right hand column. In the `space' provided place ònly' letters!

1. JURISPRUDENCE ______ a). A Lawsuit. b). A `twist of the law' which may be a pri- 2. RES IPSA LOQUITUR _____ vate or civil wrong or injury. c). Literally means `let the master answer'. 3. LIBEL _______ A Labor Doctrine making the employer res- posible for the acts of his employees. 4. BURDEN OF PROOF ______ d). The party who complains or sues in a lawsuit. A complaint of an offense. 5. NONFEASANCE ________ e). "The thing speaks for itself" f). "The Philosophy of Law" 6. RES JUDICATA ________ g). Defamatory words either in print or oral which injure the character or reputation 7. PLAINTIFF ________ of another either through ridicule, con- tempt or disgrace. 8. RESPONDEAT SUPERIOR _____ h). An offense of injuring another's reputation by false and malicious statements.

9. LITIGATION ______ i). A form of Medical Negligent Liability im- plying `the failure to do something that10. DEFENDENT ______ should have been done'. j). "Something for Something"11. TORT _______ k). The party against whom a complaint is made in a lawsuit.12. QUID PRO QUO _____ l). A law whose intention is the prevention of liability for civil damages as a re-13. NON CAMPOS MENTIS _____ sult of rendering emergency care. m). The necessity or duty of proving the14. DEFAMATION ______ fact(s) in dispute, beyond any doubt and and between parties in a cause.15. GOOD SAMARITAN ACT ____ n). Mentally incapable of rendering judgement o). A thing or matter settled by judgement.16. BATTERY ____________ p). Intentional & unlawful attempt to do harm to another person. q). A statement spoken in presence of others17. SLANDER ____________ that demands a person's reputation or sub- jects a person to riducule.18. ASSAULT ____________ r). A deliberate physical attack upon a person

19. Name the four " D's " of NEGLIGENCE:

a). ___________ b). _____________ c). _____________ d). _____________

20. What is the MEDICAL ABBREVIATION for the following:

1) four times a day:_____________ 2) three times a day:____________ 3) before meals:_________________ 4) after meals:__________________ 5) nothing by mouth:_____________ 6) once if necessary:____________ 7) as often as necessary:________ 8) every other day:______________ 9) two drops:____________________ 10) at bedtime:___________________ 11) BMR :______________________ 12) D :________________________ 13) con :_______________________

14) CAT :_________________________ 15) Bx :_________________________ 16) cr* :_______________________ 17) CVA :______________________ 18) AGIT :______________________ 19) as desired:__________________ 20) p.o. :_______________________ 21) def*: _______________________ 22) Adj :_______________________ 23) C & R :______________________ 24) C & S :______________________ 25) Tx :_______________________

26) ASHD :______________________ 27) b.i.d. :_____________________ 28) p.p.a. :_____________________ 29) D. :_______________________ 30) CPX :_______________________ 31) d :_________________________ 32) ca :________________________ 33) ck* : _____________________ 34) B/F : ______________________ 35) c/a* :_______________________ 36) CBS :_______________________

DIRECTIONS: FILL-IN THE BLANKS WITH THE MOST APPROPRIATE WORDS:

21. List at least SIX (6) WORDS that can DEFINE the term "CODE OF ETHICS": a). ______________________ d). ________________________ b). ______________________ e). ________________________ c). ______________________ f). ________________________

22. Name FOUR ESSENTIAL ELEMENTS that an ÌNFORMED CONSENT' must contain in order for this consent to be considered LEGALLY BINDING: a). ______________________ c). ________________________ b). ______________________ d). ________________________

23. The SETTLEMENT OF A DISPUTE by a third party or parties is called ___________________. If this dispute is brought to court for JUDICIAL SETTLEMENT it is then called a ________________ .

24. The LABEL ON ALL MEDICATIONS should always be read at least `FOUR' times prior to and after patient administration ! Name these: a). ______________________ c). ________________________ b). ______________________ d). ________________________

25. Except for emergency circumstances and as a general rule, MINORS CANNOT CONSENT to medical treatment. Name THREE EXCEPTIONS to this rule: a). _________________ b). _________________ c). _____________________

PART (C): DEFINE THE FOLLOWING TERMS:

1. HALITOSIS_____________ 2. HEMATOMA_____________ 3. THROMBUS_____________ 4. DYSPNEA______________ 5. TACHYPNEA ___________ 6. ORTHOPNEA ___________ 7. HERPES SIMPLEX_______ 8. OTORRHEA ____________ 9. CARDIOMEGALY_________

10. VERTIGO_____________ 11. SYNCOPE ____________ 12. DIPLOPIA____________ 13. RUBELLA ____________ 14. ENURESIS ___________ 16. PRURITIS ___________ 17. MYOPIA _____________ 15. CEPHALALGIA_________ 18. HYPEROPIA __________

19. EPISTAXIS __________ 20. PYURIA __________ 21. HERPES ZOSTER_______ 22. STRABISMUS__________ 23. HORDEOLUM __________ 24. DYSPHAGIA __________ 25. PERTUSSIS __________

PART (D): FILL-IN THE BLANKS WITH THE MOST APPROPRIATE WORDS:


a). _________________ b). __________________ c). ___________________ d). _________________ e). __________________

2. Name at least three reasons for documentation in the medical record process? a). _________________ b). __________________ c). ___________________

3. Name the four basic pre-approval requirements that many private insurance carriers and pre-paid health plans have and which must be met before they approve hospital admissions, surgeries or elective procedures: a). ______________ b). ______________ c). ______________ d). ______________

4. There are only three basic ways in which a person can obtain health insurance. Name them: a). ______________ b). ______________ c). ______________

28. Name the five minimum information requirements needed by third party payers for completion of insurance claim forms: a). _________________ b). __________________ c). ___________________ d). _________________ e). __________________

PART (E): MATCHING DIRECTIONS: Match the following terms or phrases on the left hand column with their equivalent definitions found on the right hand column. In the `space' provided place ònly' letters!

1. Arbitration ___________ a. Act of releasing or freeing.

2. Privilege Communication ____________ b. Statement given concerning scientific matter by an expert.

3. Tort ____________ c. Confidential information exchanged between a professional and patient. 4. Assumption of Risk ____________ d. Resolve any controversy that occurs before an impartial panel.

5. Negligence ____________ e. Private (civil) wrong or injury to a person. 6. Statute of Limitations ____________ f. Physician liable for wrongful acts of his employees.

7. Emancipation ____________ g. Impartial panel to investigate complaints of medical care or fees.

8. Litigation ____________ h. Failure to do something a reasonable person would or would not do under ordinary circumstances. 9. Respondeat Superior ____________ i. Knowing consent to treatment based on full understanding of all risk.

10. Deposition ____________ j. Failure to act in a prudent and reasonable manner.11. Libel ____________ k. Statute that enforces private rights.

12. Slander ____________ l. A Lawsuit.13. Burden of Proof ____________ m. Statement spoken that damages a persons reputation.

14. Judgement ____________ n. Time limit for filing a lawsuit.

15. Subpoena ____________ o. Final decision of a court.

16. Defendant ____________ p. The plaintiff is required to prove that the physician was negligent.17. Grievance Committee ___________ q. A person sued.

18. Suspend ___________ r. An attack on a person's reputation written or spoken.19. Civil Law __________ s. Testimony written down before trial.

20. Plaintiff ___________ t. Written or graphic statement that damages the reputation of another.21. Expert Testimony __________ u. One who institutes a lawsuit.

22. Ethics __________ v. To interrupt or discontinue.23. Defamation __________ w. Latin meaning for Ùnder Penalty'.

24. Breach of Confidential Communication________ x. Moral principles and standards.

25. Contributory Negligence __________ y. Unauthorized release of information.

26. An insurance that compensates the injured party without regard to fault is known as _________________

27. Define the term Expressed Consent _____________________________________

28. When rendering first aid in a life or death situation, is the physician held liable for any future outcome or care he has rendered ? Why? ________________________________________________________________

- GOOD LUCK -

70

NAME:__________________ ___________ INSTRUCTOR:__________JD___EXAM#:_________________ EXAMINATION DATE:_____________________ * ANSWER SHEET *

1.-__________ 26.-__________ 51.-__________ 76.-__________101.-__________

2.-__________ 27.-__________ 52.-__________ 77.-__________102.-__________

3.-__________ 28.-__________ 53.-__________ 78.-__________103.-__________

4.-__________ 29.-__________ 54.-__________ 79.-__________104.-__________

5.-__________ 30.-__________ 55.-__________ 80.-__________105.-__________

6.-__________ 31.-__________ 56.-__________ 81.-__________106.-__________

7.-__________ 32.-__________ 57.-__________ 82.-__________107.-__________

8.-__________ 33.-__________ 58.-__________ 83.-__________108.-__________

9.-__________ 34.-__________ 59.-__________ 84.-__________109.-__________

10.-__________ 35.-__________ 60.-__________ 85.-__________110.-__________

11.-__________ 36.-__________ 61.-__________ 86.-__________111.-__________

12.-__________ 37.-__________ 62.-__________ 87.-__________112.-__________

13.-__________ 38.-__________ 63.-__________ 88.-__________113.-__________

14.-__________ 39.-__________ 64.-__________ 89.-__________114.-__________

15.-__________ 40.-__________ 65.-__________ 90.-__________115.-__________

16.-__________ 41.-__________ 66.-__________ 91.-__________116.-__________

17.-__________ 42.-__________ 67.-__________ 92.-__________117.-__________

18.-__________ 43.-__________ 68.-__________ 93.-__________118.-__________

19.-__________ 44.-__________ 69.-__________ 94.-__________119.-__________

20.-__________ 45.-__________ 70.-__________ 95.-__________120.-__________

21.-__________ 46.-__________ 71.-__________ 96.-__________121.-__________

22.-__________ 47.-__________ 72.-__________ 97.-__________122.-__________

23.-__________ 48.-__________ 73.-__________ 98.-__________123.-__________

24.-__________ 49.-__________ 74.-__________ 99.-__________124.-__________

25.-__________ 50.-__________ 75.-__________100.-__________125.-__________

71

SECTION VI, EXAMINATION I, CUMULATIVE 25 QUESTIONSSAMPLE NHA EXAMINATION

DIRECTIONS: Multiple Choice (Choose the best answer): Answer in letter only. Choose the answer that best describes the question.

1. All of the following are correct regarding add-on codes except:

a. They can be reported as stand alone codes.b. They are exempted from modifier-51 (multiple procedures).c. They are performed in addition to a primary procedure.d. The add-on procedure must be performed by the same physician.

2. What is a pre-existing condition ?

a. An illness or condition present before insurance coverage begins.b. A hereditary illness or condition.c. An illness or condition present after insurance coverage begins.d. A recurring condition.

3. Which insurance policy is never primary when the insured has more than one policy ?

a. Blue Cross / Blue Shieldb. Medicarec. Medicaid

d. Any insurance can be considered as primary

4. A triangle in front of a code in the updated CPT Manual means:

a. It is a new procedureb. It is a minor procedure

c. The description for the code has been changed

d. The code has been deleted

5. The CPT coding system is:

a. Chief complaint basedb. Cost based

c. Diagnosis basedd. Service & procedure based

6. A respirator used by a Medicare patient is an example of:

a. Expendable Medical Equipmentb. Non-billable item

c. Non-reusable medical equipmentd. Durable medical equipment

7. Medical ethics are:

a. Laws which govern hospital protocol

b. Standards of conduct

c. For physicians onlyd. Traditions passed through

generations

8. The way to correct an error on a patient’s medical record is:

a. To use white-out and enter the correct data using a blue pen.b. To erase the error and enter the correct data and write over the incorrect

information.c. To cross out the incorrect data with a single line and write in the correct

information followed by initials and date.d. To place self-adhesive paper over the incorrect data.

72

9 - A patient was diagnosed with cardiomegaly. This means the patient has:

a. Inflammation of the heart. c. A heart attack.b. Bacterial infection of the heart. d. Enlargement of the heart.

10- Which of the following is an ICD-9-CM subclasification ?

a. 045b. 255.0

c. 282.60d. V15.4

11 – Mrs. Ann Smith had a biopsy taken from a lump found in her left breast. Three days after the procedure, she was informed that the biopsy is positive for carcinoma. Five days later, Mrs. Smith undergoes a radical mastectomy. Which of the following modifiers will be attached to the mastectomy procedure ?

a. - 24 (Unrelated Evaluation and Management Service by the same physician During a Postoperative period).

b. - 58 (Staged or Related Procedure or Service by the Same Physician During a Postoperative period).

c. - 78 (Return to the Operating Room for a related Procedure During a Postoperative period).

d. - 79 (Unrelated Procedure or Service by the same physician During a Postoperative period).

12 – A document that contains dates of service, list of detailed charges, co- payments and deductibles paid, date insurance was filed, adjustments and account balances is called:

a. An inventory list.b. An Encounter Form.

c. A Superbilld. An itemized statement

13 – Those who qualify for Medicaid include all of the following, except:

a. Low income families with childrenb. Persons over 65 who are blind or have a permanent disability.c. Persons who earn enough money to pay basic living expenses, but cannot

afford high medical bills.d. High income earners

14 – ICD – 9 – CM is the:

a. Hierarchal listing of codes describing psychological conditions.b. International Classification of Diseases, 9th Revision, Clinical

Modification.c. Procedural Terminologyd. List of Fees for services

15 – An established patient is defined as one who has received professional services from the physician or another physician of the same specialty in the same group within the past how many years ?

a. 1 yearb. 2 year

c. 3 yeard. 4 year

16- Patient is diagnosed with metastatic bone neoplasm. The neoplasm will be coded as ?

a. Primary malignantb. Secondary malignant

c. Carcinoma in situd. Benign

73

17- Under the RBRVS method of reimbursement, “Conversion factor” is:

a. A dollar amount b. A way to find alternative codes.

c. Converts a consultation into an office visit.

d. Cost of living adjustment.

18- An organization that initiated the development of ICD codes is ?

a. WHOb. HCFA

c. NCHSd. AMA

19- The patient’s birth date on the CMS-1500 form is entered in which of these formats ?

a. MM/DD/YYb. DD/MM/YY

c. MM/DD/CCYYd. DD/MM/YYYY

20- A patient has contracture of the right hand due to a third degree burn suffered a year ago. Code for the third degree burn suffered a year ago will be referenced from the Alphabetic Index under which main term and subterm ?

a. History, personalb. History, family

c. Late, effects of burnd. Burn, third degree

21- The term used to describe the five long bones of the midfoot is:

a. Maxillary bonesb. Metacarpal bones

c. Lacrimal bonesd. Metatarsal bones

22- A service that is rarely provided, unusual, variable, or new may require a (n) ____________________in determining medical appropriateness of the service.

a. Modifierb. Add-on code

c. Special Reportd. Unlisted procedure

23- A new patient is:

a. One who has not visited the physician in more than 6 months.b. One who has not visited the physician in more than 3 years.c. Determined by the physician and staff.d. Determined by a third party payer.

24- Which statement sent by the payer to the covered individual contains reimbursement amounts and an explanation in an easy-to-read format ?

a. Remittance Adviceb. UB-04

c. CMS-1500d. Explanation of Benefits

25- What are the three key components of an E & M Code ?

a. Examination, coordination of care, medical decision making.b. History, Examination, medical decision making.c. History, nature of presenting problem, coordination of care.d. nature of presenting problem, Examination, coordination of care

74


1.-__________ 26.-__________ 51.-__________ 76.-__________101.-__________

2.-__________ 27.-__________ 52.-__________ 77.-__________102.-__________

3.-__________ 28.-__________ 53.-__________ 78.-__________103.-__________

4.-__________ 29.-__________ 54.-__________ 79.-__________104.-__________

5.-__________ 30.-__________ 55.-__________ 80.-__________105.-__________

6.-__________ 31.-__________ 56.-__________ 81.-__________106.-__________

7.-__________ 32.-__________ 57.-__________ 82.-__________107.-__________

8.-__________ 33.-__________ 58.-__________ 83.-__________108.-__________

9.-__________ 34.-__________ 59.-__________ 84.-__________109.-__________

10.-__________ 35.-__________ 60.-__________ 85.-__________110.-__________

11.-__________ 36.-__________ 61.-__________ 86.-__________111.-__________

12.-__________ 37.-__________ 62.-__________ 87.-__________112.-__________

13.-__________ 38.-__________ 63.-__________ 88.-__________113.-__________

14.-__________ 39.-__________ 64.-__________ 89.-__________114.-__________

15.-__________ 40.-__________ 65.-__________ 90.-__________115.-__________

16.-__________ 41.-__________ 66.-__________ 91.-__________116.-__________

17.-__________ 42.-__________ 67.-__________ 92.-__________117.-__________

18.-__________ 43.-__________ 68.-__________ 93.-__________118.-__________

19.-__________ 44.-__________ 69.-__________ 94.-__________119.-__________

20.-__________ 45.-__________ 70.-__________ 95.-__________120.-__________

21.-__________ 46.-__________ 71.-__________ 96.-__________121.-__________

22.-__________ 47.-__________ 72.-__________ 97.-__________122.-__________

23.-__________ 48.-__________ 73.-__________ 98.-__________123.-__________

24.-__________ 49.-__________ 74.-__________ 99.-__________124.-__________

25.-__________ 50.-__________ 75.-__________100.-__________125.-__________

SECTION VI, EXAMINATION II, CUMULATIVE QUESTIONSINCLUDES SECTIONS ON: HEALTH CARE REIMBURSEMENT, MEDICAL CODING -1, CLAIMS MANAGEMENT, CLAIMS PROCESSING, ADVANCED CODING

PART I: ADVANCED CODING: CASE SUMMARIES / DIRECTIONS: Interpret and assign codes to the following case historiest (you may use the ICD or CPT Code books):

1. The initial consultation physician subsequently sees a 55 year old patient injured at work when he fell from a house roof and struck his head. The patient had a right frontal parietal craniotomy 6 days previously and is recovering rapidly. The initial consultation was requested regarding a drug reaction that produced a rash on the upper torso. The consultant recommended a medication change, but after 48 hours the patient had no improvement. The physician reevaluates for other possible causes of the rash. An expanded problem-focused interval history and a physical examination were performed. The MDM complexity was moderate. Code(s): ______________________

2. A 44 year old patient, with chronic mastoiditis, was seen in consultation by the ENT specialist in the office. Her physician was inquiring as to the advantages of surgery versus continued antibiotic treatment when an acute flare comes on. The ENT specialist recommends surgery because of the increasing severity with each acute flare. She is fearful of the surgery because of the need to go under general anesthetic and a fear of general hearing loss. The physician performs an expanded problem focused history to include the duration of this problem and how many acute flares a year the patient experiences. An expanded problem focused examination and straightforward decision making is completed. It is determined that with the number of acute flares a year and the increasing severity of each case that surgery is recommended. The patient’s fears are laid to rest and the patient decides to go ahead with the surgery. Code(s): ______________________

3. An established patient is seen in the office for a new problem that requires a comprehensive history and examination. The MDM complexity is high, and the physician spends 40 minutes with the patient. However, the patient has numerous concerns, and the physician spends an additional hour and 50 minutes in prolonged direct patient contact.

Code(s): __________________Code(s): ________________ Code(s): ___________________

4. Rita, an established patient, has a 16.2 cm simple repair of the cheek. A surgical tray is used.

Code(s): __________________Code(s): ________________

4. Rita, an established patient, has a percutaneous needle core biopsy with image guidance for a left breast mass. A surgical tray is used. Code(s): __________________Code(s): ________________

5. Laser destruction of multiple malignant lesions, as follow: 3.4 cm on the right hand, 2.1 cm on the left hand, 5.2 cm on the right hand, 4.3 cm on the left hand, 0.3 cm on the right eyelid, and 0.5 cm on the left eyelid.

Code(s): __________________Code(s): ________________ Code(s): ___________________

7. Replantation of the index finger, including sublimes tendon insertion, following a complete traumatic amputation. Code only the replantation service. Code(s): __________________Code(s): ________________

8. Arthroscopic chondroplasty of the knee with minimal debridement. Code(s): ______________________

9. Extensive bilateral removal of nasal polyps, performed in the hospital outpatient department. Code(s): __________________

10. Surgical thoracoscopy, with wedge resection of the lung. Code(s): ______________________

11. Valvuloplasty of the aortic valve using transventricular dilation with vardiopulmonary bypass. Code(s): ______________

PART II: FEMALE GENITAL TERMINOLOGY: MATCHING DIRECTIONS: Match the following terms or phrases on the left hand column with their equivalent definitions found on the right hand column. In the `space' provided place ònly' letters!

1. Vulva ______________ a. Herniation of the bladder into the vagina.

76

2. Perineum____________ b. Rounded, cone-shaped neck of the uterus, part of it protruding into the vagina.3. Introitus_____________ c. Prefix meaning ovary.

4. Vagina______________ d. External female genitalia, including labia majora, labia minora, clitoris, and vaginal opening5. Cervix uteri__________ e. Uterus6. Corpus uteri_________ f. Herniation of the rectal wall through the posterior wall of the vagina.

7. Oviduct_____________ g. Prefix meaning tube.8. Salpingo-___________ h. Opening or entrance to the vagina from the uterus.9. Oophor-____________ i. Scraping of a cavity using a spoon-shaped instrument.

10. Curretage__________ j. Expansion11. Dilation____________ k. Area between the vulva and anus; also known as the pelvic floor.12. Cystocele__________ l. Canal from the external female genitalia to the uterus.

13. Rectocele__________ m. Fallopian tube.

PART III: MATERNITY CARE AND DELIVERY: MATCHING DIRECTIONS: Match the following terms or phrases on the left hand column with their equivalent definitions found on the right hand column. In the `space' provided place ònly' letters!

14. Anteparum_________ a. Turning of the fetus from a presentation other than cephalic (head down) to cephalic for ease of birth.

15. Postpartum_________ b. Termination of pregnancy.

16. Abortion___________ c. Surgical opening through abdominal wall for delivery.

17. Delivery___________ d. Before Childbirth.

18. Cesarean__________ e. After Childbirth. 19. Ectopic____________ f. Pregnancy outside the uterus (e.g. in the fallopian tube)

20. Version____________ g. Childbirth

21. Amniocentesis______ h. Incision into the uterus.

22. Cordocentesis______ i. Surgical removal of the uterus.

23. Chorionic villus Sampling (CVS)____ j. Percutaneous aspiration of amniotic fluid.

24. Hysterotomy_________________ k. Surgical removal of ovary.

25. Salpingectomy_______________ l. Biopsy of the outermost part of the placenta.

26. Oophorectomy_______________ m. Suturing of the uterus.

27. Hysterectomy_______________ n. Repression of uterine contractions

28. Hysterorrhaphy ______________ o. Surgical removal of a fallopian tube.

29. Tocolysis___________________ p. Vaginal delivery after previous cesarean delivery

30. VBAC_____________________ q. Procedure to obtain a fetal blood sample, also called a percutaneous umbilical blood sampling.

77

78


1.-__________ 26.-__________ 51.-__________ 76.-__________101.-__________

2.-__________ 27.-__________ 52.-__________ 77.-__________102.-__________

3.-__________ 28.-__________ 53.-__________ 78.-__________103.-__________

4.-__________ 29.-__________ 54.-__________ 79.-__________104.-__________

5.-__________ 30.-__________ 55.-__________ 80.-__________105.-__________

6.-__________ 31.-__________ 56.-__________ 81.-__________106.-__________

7.-__________ 32.-__________ 57.-__________ 82.-__________107.-__________

8.-__________ 33.-__________ 58.-__________ 83.-__________108.-__________

9.-__________ 34.-__________ 59.-__________ 84.-__________109.-__________

10.-__________ 35.-__________ 60.-__________ 85.-__________110.-__________

11.-__________ 36.-__________ 61.-__________ 86.-__________111.-__________

12.-__________ 37.-__________ 62.-__________ 87.-__________112.-__________

13.-__________ 38.-__________ 63.-__________ 88.-__________113.-__________

14.-__________ 39.-__________ 64.-__________ 89.-__________114.-__________

15.-__________ 40.-__________ 65.-__________ 90.-__________115.-__________

16.-__________ 41.-__________ 66.-__________ 91.-__________116.-__________

17.-__________ 42.-__________ 67.-__________ 92.-__________117.-__________

18.-__________ 43.-__________ 68.-__________ 93.-__________118.-__________

19.-__________ 44.-__________ 69.-__________ 94.-__________119.-__________

20.-__________ 45.-__________ 70.-__________ 95.-__________120.-__________

21.-__________ 46.-__________ 71.-__________ 96.-__________121.-__________

22.-__________ 47.-__________ 72.-__________ 97.-__________122.-__________

23.-__________ 48.-__________ 73.-__________ 98.-__________123.-__________

24.-__________ 49.-__________ 74.-__________ 99.-__________124.-__________

25.-__________ 50.-__________ 75.-__________100.-__________125.-__________

79

COMMON CODES YOU SHOULD KNOW

New Patient - Minor 99201 _____ Established Patient - Minimal 99211 _____ NP - Limited 99202 _____ EP - Limited 99212 _____ NP - Detailed 99203 _____ EP - Expanded 99213 _____ NP - Comprehensive 99204 _____ EP - Detailed 99214 _____ NP - Complex Comprehensive 99205 _____ EP - Comprehensive 99215 _____ Physical Age _____ ______ _____ House Call New Pt 99342 Est Pt 99352 ___ __

Allergy 96115 Multiple #____ 95117 ____ DPT 90701 TD Adult 90718 _____ Venipuncture - Under 3 yrs 36400 _____ DT Child 90702 MMR 90707_____ Venipuncture 36415 _____ OPV 90712 Rubella 90706_____ Stool Occult 82270 _____ HIB 90737 Hep-B (NB-11) 90744_____ Urinalysis 81002 _____ Flu 90724 Hep-B (1)-19) 90745_____ Strept. Test 86403 _____ Pneumovax 90732 Hep-B (20 + ) 90746_____ Pregnancy Test (Urine) 81025 _____ Tetanus 90703 P.P.D. 80580_____ Medical Supplies 99070 _____ Acellular 90700 T.B. Tine 86585_____ Splint A4570 _____ Tetra 90720 Chicken Pox 90716_____ ____________________ ______ _____ Decadron LA 8 mg J1096_____Decadron J1100 _____ Sub Epl. _____ J0170 _____

Unasyn 1.5 gm J0295 _____ Vistorl 25 mg J3410 _____ Cortisone 50 mg J0810 _____ Rocepin 250 mg J0696 _____ Epogen 1000 unit 00136 _____ B-12 J3420 _____ Nupogen 1.0 J1440 _____ I.M. Inj. Antibiotic _________ 90788 _____ Toradol 15 mg J1886 _____ Joint & Steroid ____________ 20610 _____ Tigan 200 mg J3260 _____ Unlisted Immun ____________ 90749 _____ Kenalog 10 mg J3301 _____ Unlisted Injection___________ 90799 _____ Ancel 500 mg J0690 _____ ______________ ____________ _____ _____

Abdominal Pain 789.0_ Eczema 692.6 Obesity 278.00 Abortion Threatened 640.03 Edema 782.3 Onychomycosis 110 Acne 706.1 Electrolyte Imbal. 276.9 Otitis Externa 380.11 Adenopathy 785.6 Empyema 510.9 Otitis Media 382.00 Allergic Rhinitis 477__ Endometritis 615.9 Palpitations 766.1 Allergy 996.3 Epipidymitis Unspec. 604.90 Pancreatitis 677.0 Amenorrhea 626.0 Epistaxis 784.7 Pap Smear Abnormal 795.0 Anemia ? Iron Def. 280.9 Eustachian tube Dysf. 381.81 Parkinson?s Disease 332.0 Anemia Pernicious 281.0 Fatigue 780.7 Peripheral Vas. Dis. 443.9 Angina Pectoris 413.9 Fibrocystic Breast Dysf. 610.1 Pharyngitis-Acute 462 Angina Unstable 411.1 Fungal Infection 117.8 Pharyngitis-Chronic 472.1 Anxiety 300.02 Furuncle 680.9 Physical-Required V70 Aortic Disease 424.1 Ganglion Tendon 727.42 PID 614.9 Appendicitis 640.0 Gastritis 535.5 Pinworms 127.4 Arthralgia 719.49 Gastroenteritis 558.9 Pityriasis Rosea 696.3 Arthritis Gouty 274.0 G.E Reflux 530.11 Plantar Fasciatis 728.71 Arth-Osteo 715.09 G.I Bleeding 578.0 Pleurisy 511.0 Arthritis-Rheum. 714.0 G.I. Bleeding, lower 578.1 Pneumonia 486 Asthma 493.90 Glaucoma 365.9 Positive Stool 792.1 Atrial Fib. 427.31 Headache Migraine 346.10 Pregnancy V22.2 Back Pain-Lumbar 724.02 Headache-Tension 307.81 Premenstrual Syn. 626.4 BPH 600 Hearing Loss 389.18 Proctitis 569.49 Breast Mass 611.72 Heart Murmur- Innoc. 765.2 Prostatitis, Acute 601.0 Bronchiolitis 466.11 Hematuria 599.70 Psoriasis 696.1 Bronchitis Acute 466.0 Hemochromatosis 275.0 Pulmonary Edema 614

80

A. OFFICE SERVICES CPT FEE

____________________________________________________________________________________________________________________________________________________________________________________DATE REFERENCE COPAY CREDITS CURRENT BALANCE PREVIOUS BALANCE NAME

C. IN-HOUSE LAB. B. INJECTIONS/IMMUNIZATIONS

C. INJECTIONS/IMMUNIZATIONS (CON’D)

DIAGNOSIS ICD-9 DIAGNOSIS DIAGNOSISICD-9 ICD-9

CPT FEE

CPT FEE

DIAGNOSIS ICD-9 DIAGNOSIS DIAGNOSISICD-9 ICD-9

Burns 653 Hemorrhoids 455.6 Pyelonephritis 590.80 Bursitis 432.1 Hepatitis ________ Rash 782.1 Cardiomyopathy 425.4 Hepatitis-B, Acute 070.30 Rectal Bleeding 569.3 Carpal Tunnel Syndrome 354.0 Hernia-Hiatal 553.3 Rectal Fissure 565.0 Cellulitis 682.9 Hernia-Inguinal 550.9 Scabies 133.0 Cerebrovascular Dis. 437.0 Hernia-Umbilical 553.1 Scarlet Fever 034.1 Cerumen Impacted 380.4 Herniated Cerv. Disc 722.0 Sebaceous Cyst 706.2 Cervicitis 616.0 Herniated Lum. Disc 722.10 Seborrhea 706.3 Chest Pain 786.59 Herpes Genital 054 Seborrheic Keratosis 702.11 CHF 428.0 Herpes-Simplex 054.9 Seizure Disorder 780.3 Cholecystitis Acute 575.0 Senile Dementia 290.0 Cholelithiasis 574.0 Herpes-Zoster 053 Serous Otitis Media 381.01 Cirrhosis 571.5 Hyperlipidemia 272.4 Sciatica 724.3 Colitis 566.6 Hypertension 401.1 Sinusitis-Acute 461 Concussion 850.9 Hyperthyroidism 242.90 Sinusitis-Chronic 473 Conjunctivitis 372.03 Hypoglycemia 251.2 Skin Cancer 173 Constipation 564.0 Hypokalemia 276.8 Stasis Dermatitis 454.1 Contact Dermatitis 692.9 Hypotension 458.9 Stomatitis 528.00 Contraception Adv. V25.01 Hypothyroidism 244.9 Strep Throat 041.01 COPD 495 Impetigo 684 Stress Incontinence 626.6 Corneal Abrasion 918.1 Influenza 487.1 Suture Removal V58.32 Corneal For.Body 930.0 Ingrown toe nail 703.0 Syncope 780.2 Coronary Art. Dis. 414.01 Insomnia 780.52 Tendonitis 726 Costochondritis 733.6 Intertrigo 695.89 Thrombophlebitis 451.9 Coxsacchie Virus 079.2 Irritable Bowel Syn. 654.1 Thrombosis L.E. 461.11 C.P.E. V70.0 Jaundice 782.4 Thyroid Disorder 246..9 Croup 464.4 Jaundice Newborn 774.6 TIA 436.9 CVA 436 Labyrinthitis 386.3 Tinea Pedis 110.4 CVA, old V12.5 Tinea Versicolor 111.0 Depression Mod. 296.22 Laryngitis-Acute 464.20 Tinnitus 388.3 Dermatitis 691 Lymes Disease 088.81 TMJ 624.60 Diabetes Mellitus Ins Dep 250.1 Lymphadenitis 289.3 Tonsillitis 463 Diabetes Mellitus Non-Ins Dep 250.2 Low Back Syndrome 724.2 Ulcer Duodenal 632.30 Diaper Rash 691.0 Medication Problem 995.2 Ulcer-Peptic 633.30 Diarrhea Bact. 008.43 Menopausal Symp. 627.2 Ulcer-Skin 707.0 Diarrhea Viral 008.62 Menstrual Disorder 626.9 Ulcer-Stomach 631.30 Diverticular Dis. 562.10 Mental Retardation 318.1 Urethritis 697.8 Diverticulitis 562.11 URI 466.9 Dysf. Somatic - Cervical 739.1 Mitral Valve Prolapse 424.0 Urticaria 708.0 Dysf. Somatic - Lumbar 739.3 Mononucleosis 075 UTI 699.0 Dysf. Somatic - Sacroiliac 739.4 Multiple Sclerosis 340 Vaginal Discharge 623.6

Dysf. Somatic - Thoracic 739.2 Myocardial Infarction 410 Vaginal Candidal 112.1 Dysf. Uterine Bleeding 626.8 Myolasitis/Myositis 729.1 Vaginitis Senile 627.3 Dysmenorrhea 625.3 Nausea-Vomiting 787.01 Vaginitis Trich 131.01 Dyspnea 786.09 Neuritis 729.2 Varicose Veins 454.1 Dysuria 788.1 Neuropathy 355.9 Vertigo 780.4 Yearly Pelvic & Pap Test V72.3 Nevus 216.0 Viral Syndrome 079.0 Well Child Care V20.2 Weight Loss 783.2 Wart, Unspec. 078.10

STUDENT REVIEW SHEET (PARTVII)SAMPLE PRACTICE CLAIMS AND CODING

DIRECTIONS:

Using the case presentation attached, you are to do the following:

81

9. Define the patient record abbreviations (below) indicated as well as the additional coding in section II.10. Using the Patient Record No. 13-5, on a separate blank sheet of paper make an outline of all the charges to be made for this patient

in the format of Date, Charge Explanation, Code number and Amount Charged and turn this in with your work.11. Complete an CMS 1500 claim form for this TRICARE case posting all relevant data.12. Complete a Financial Accounting Record with posted transactions.


c. After completion of your manual format for the case history along with charges and codes found as well as abbreviations, complete the CMS 1500 using OCR guidelines for this TRICARE case. Direct the claim to the Tricare Fiscal Intermediary, 100 North Philadelphia Avenue, Omaha Nebraska 10567. This assignment may or may not require more than one CMS 1500 claim form for completion. Hand in both when done. Refer to the attachment listing of amount charges for procedures to be used on the ledger and claim form. Date the claim Feb 3. Dr. Ulibarri (Tax ID #C658764) is accepting assignment in this case. The patient met her deductible last November when seen by a previous physician.

d. Use your CPT and ICD-9 code books to look up all code numbers needed in this case. Record all transactions on the financial record and indicate when you have billed the primary insurance carrier.

e. On Jan 24th the patient made an advanced payment of $575 (check #387) on this claim. Indicate this amount on your forms with appropriate justifications and balances. Post this payment on the financial accounting record and indicate the balance that will be billed to Tricare on the following day. The explanation of benefits from this case is to be sent to Tricare with a completed CMS1500 claim form. Also post a 15 % Courtesy Adjustment for this claim. The Tricare formula for this claim is 30/70 %.

f. Abbreviations pertinent to this patient’s record: [ Graded Component ]

82

a. Pt_ ____________________b. D______________________c. PX_____________________d. HX_____________________e. UA_____________________f. WBC___________________g. LC_____________________h. MDM___________________i. PF_____________________j. rec_____________________k. SF_____________________l. C______________________

m. RBC____________________n. cc______________________o. lab_____________________p. Rx_____________________q. caps____________________r. t.i.d.____________________s. Rem____________________t. Dx_____________________u. M_____________________v. surg___________________w. ofc____________________x. PO____________________

y. OV____________________z. rtn_____________________aa. PRN____________________bb. sched.__________________cc. EPF____________________dd. MC_____________________ee. FBS____________________ff. CBC____________________

83


FEE SCHEDULES





84

Knee Surgery $650EKG $45OV#1 (99201) $75MEDS $35I & D Skene Glnd $75Injection $35U / A $35CBC $25CBC+Diff $45X-rays $20Cholangiogram $90U/A + Culture $60Nitro Pads $55Diuretics $40MEDS (bactrim) $22.50Ventolin $11Double X-rays $40

Chest P&A $45Lat. X-Rays $45Digoxin Inj. $25B12 Inj. $40Nitro (meds) $40Bronchogram $150CXR(AP/Lat) $75OV HCN PF Hx /SF MDM $134.99[MEDICARE]ABG O2 $85PFT”s $125OV C hx/exam MC MDM $138.50IV MEDS $25OV PF Hx /SF MDM $36.80

Cult Abscess (Skene) $45MRI (s contrast) $175Suture 2-5 cms Laceratiion $125ER and/or Physician Consult $85Cauterization $65Suture Removal Kit $45Septoplasy $653Professional Courtesy (-$55)C x R (2views) $65Elect Panel SMAC12 $45CT Thorax/Contrast $125IM Inj. Drug $25C & S Test $45Excision Skene $165U/A Non-Auto Micro $55MEDS (Terramycin) $22.50Handling/Transport $35

g. Section II: Additional Coding and Fee Calculations: [ Graded Component ]

(1).- Refer to Ms. Drew’s medical record, abstract information, and code procedures that would be billed by outside providers.

Site Description Code

a. Drainage Skene’s Gland _______________________ _________________

b. Handling/Transport Culture _______________________ _________________

c. Excision Skene’s Gland _______________________ _________________

d. Abscess Drainage _______________________ _________________

(2).- Use your diagnostic code book and code the symptoms that the patient presented with in the clinic.

Symptom Code

a. _______________________________ __________________

b. _______________________________ __________________

c. _______________________________ __________________

(3).- On the surgery of Jan 24, 20xx), assume that Tricare Fiscal Intermediary paid $658.45:

a. What would be posted in the financial statement ? ________________________________________.

b. What would the patient responsibility be ? __________________________________________.

c. What would the Courtesy Adjustment be at 15 % ? ______________________________________.

PATIENT MEDICAL RECORD:


87

HEALTH INSURANCE CLAIM FORM (CMS-1500)( GRADED COMPONENT )

88


89


KNOW ALL COMPONENTS OF A CMS 1500

90

ANNOTATED ANSWER KEY SECTION

SECTION I, EXAMINATION I, CUMULATIVE 142 QUESTIONSINCLUDES SECTIONS ON: HEALTH CARE REIMBURSEMENT, MEDICAL CODING -1, CLAIMS MANAGEMENT, ADVANCED CODING WITH REPORTS, CLAIMS PROCESSING

ANSWER KEY

MATCHING:

1. COMPETITIVE MEDICAL PLAN (O) 9. MEDICARE (I) 2. HEALTH MAINT ORGANIZATION (P) 10. MEDICARE/MEDICAID (B) 3. DISABILITY INCOME INS (D) 11. POINT OF SERVICE PLAN (K)4. EXCLUSIVE PROVIDER ORG (E) 12. PREFERRED PROVIDER ORG. (G) 5. FOUNDATION FOR MED. CARE (J) 13. TRICARE (C) 6. INDEPENDENT (INDIVIDUAL) (F) 14. UNEMPLOYMENT COMP. DIS (M) PRACTICE ASSOCIATION 15. CHAMPVA (A) 7. MATERNAL & CHILD HLTH PGM (L) 16. WORKER'S COMP. INS (H) 8. MEDICAID (N)

17. (g). Only answers "c" and "e" are correct (Medicaid & Workers Comp)

18. (c). the transfer, after an event insured against, of an individual's legal right to collect an amount payable under an insurance contract.

19. (a). the provider agrees to accept the allowable charge as the full fee and cannot charge the patient the difference between the providers charge and the allowable charge.

20. List the five (5) types of presenting problems from the most risk and least recovery to the least risk and most recovery:a. Minimalb. Self-limitedc. Low Security

d. Moderate Severitye. High Severity


a. Highb. Medium

c. Lowd. Straightforward

22. (C )23. (A)

24. (C )25. (A)

26. (A)27. (D)

91


a. Apple II, James M.b. Treebark Jr., Charles T.

c. Hurts II, David J.d. Elbow Sr., Jake R.


a. What body system was involved.b. What anatomic site was involved.c. What type of procedure was performed.


a). Minor Surgery b). Major Surgery


a). Surgical Procedure b). Local infiltration c). Normal uncomplicated follow-up calls

32. On what basis are minor surgical procedures to be billed? Fee-for-service

33. Briefly describe “Unbundling” Assigning multiple codes when only one is necessary; the procedure is illegal


A) Skin Lesion = Any alteration of the skinB) Excision of a Lesion = Requires cutting through the dermal layersC) Destruction of a Lesion = An alternate to cutting of tissues; involves complete tissue destruction (coagulation, burning)


1) Site 2) Size of the lesion measured before excision 3) Number lesions removed

4) Benign or Malignant status 5) Method used for the removal

36. Layered closure requires the use of 2 codes. One is for the Excision and one for the Intermediate repair

37. If a physician reports the size of a lesion in inches, what must the coder do? ANS: Convert the inches to centimeters

38. When converting the size of a lesion, one inch = 2.54 cms

39. When there are multiple lacerations, which repair should be listed first? The most complicated repair

40. THE ACT OF BILLING THE PATIENT FOR THE DIFFERENCE BETWEEN THE MEDICARE CHARGES AND ACTUAL CHARGES

41. IT IS A WRITTEN DOCUMENT PROVIDED TO THE MEDICARE BENEFICIARY BY A SUPPLIER

42. a. ORIGINAL MEDICARE PLANb. MEDICARE MANAGED CARE PLAN WHICH ARE AVAILABLE IN MANY AREASc. PRIVATE FEE FOR SERVICE PLAN

43. a. ADDITIONAL BENEFITSb. LOWER COSTc. LESS PAPERWORKd. NO ACCEPTING ASSIGNMENT PROBLEMe. PREVENTATIVE CARE

44. ( C )45. ( C )

SECTION V: ADVANCED CODING: DIRECTIONS: Using the ICD or CPT, assign codes to the following:

46. Code(s): 2052047. Code(s): 19000 48. Code(s): 6000049. Code(s): 1578650. Code(s): 1711051. Code(s): 2760352. Code(s): 2502853. Code(s): 6030054. Code(s): 3857255. Code(1): 601.0 Code(2): 041.0056. Code(1): 785.4 Code(2): 250.7

57. Code(s): 275.358. Code(1): 749.2 Code(2): V30.0159. Code(s): 438.2160. Code(1): 238.1 M-Code(2): M8000/161. Code(1): 211.5 M-Code(2): M8170/062. Code(s): 410.763. Code(1): 648.1 Code(2): V23.064. Code(1): 682.6 Code(2): 682.7 Code(3): 041.1065. Code(1): 749.2 Code(2): V30.01 66. Code(1): 578.9 Code(2): E935.667. Code(1): 584.9 Code(2): V45.11

68. Code (1): 659.71 Delivery, complicated by fetal heart rate or rhythmCode (2): 660.41 Delivery, complicated by dystocia, shoulder girdleCode (3): 664.11 Delivery, complicated by laceration, perineum, second degreeCode (4): 72.79 Delivery, vacuum extractionCode (5): 73.09 Rupture, membrane, artificialCode (6): 75.69 Repair, perineum, laceration, obstetric, current

SECTION VII: MATCHING:

69. COMPREHENSIVE CODE (F)70. UNBUNDLING (R)71. MODIFIER (G) 72. (P)73. (Q)74. (T)

75. ⊘ (O) 76. (K)77. (M)78. CUSTOMARY FEE (N)79. REASONABLE FEE (H)80. INCOMPLETE CLAIM (S)81. DINGY CLAIM ( I )

82. DIRTY CLAIM (J)83. INVALID CLAIM (C)84. CLEAN CLAIM (D)85. PIN NUMBER (E)86. NPI NUMBER (B)87. UPIN NUMBER (L)88. PPIN NUMBER (A)

SECTION VIII: MATCHING

89. DME NUMBER (H)90. DIGITAL CLAIM (G)91. EIN NUMBER (M)92. FACILITY NUMBER (N)93. GROUP PROVIDER NUMBER (L)94. ELECTRONIC CLAIM (J)95. OCR (B)96. REJECTED CLAIM (A)

97. OTHER CLAIMS (K)98. PAPER CLAIM (O)99. PENDING CLAIM ( I )100. PHYSICALLY CLEAN CLAIM (E)101. CLEAN CLAIM (C)102. CMS 1500 = (D) 103. STATE LICENSE NUMBER (F)

SECTION IX: CASE STUDY: { ADVANCED CODING }: MANUAL RECORDING OF CHARGES: [ GRADED COMPONENT ]

TOTALS = 142

SECTION II, EXAMINATION I, CUMULATIVE 76 QUESTIONS


1/13 NP OV D (hx/px) LC MDM 99218 $ 74.22

U / A (non-automated) w/ microscopy 81000 $ 35.00

I & D Abscess (Skenes) 53040 $ 75.00

Culture/Transport (Handling) 99000 $ 35.00

Terramycin 0005F/4120F $22.50

1/18 OV PF (hx/px) SF MDM 99281 $ 24.32

Culture / Sensitivity Test 87070 $ 45.00

Abscess Drainage 26990 $ 65. 00

1/24 OV C (hx/px) MC MDM 99219 $ 117.75

Excision Skene’s Gland 53270 $ 125.00

Terramycin 0005F/4120F $22.50

Discharge 99217 $ 66.88

1/18 OV PF (hx/px) SF MDM 99281 $ 24.32 _____________

$ 732.49

15 % Discount -109.87 ______________

$ 622.62

Advanced Payment - 575.00 ______________

Balance Account $ 47.62

Dx: Paraurethral Abscess 753.8

INCLUDES SECTIONS ON: HEALTH CARE REIMBURSEMENT, CLAIMS MANAGEMENT

ANSWER KEY

MATCHING:

1. COMPETITIVE MEDICAL PLAN (O) 9. MEDICARE (I) 2. HEALTH MAINT ORGANIZATION (P) 10. MEDICARE/MEDICAID (B) 3. DISABILITY INCOME INS (D) 11. POINT OF SERVICE PLAN (K)4. EXCLUSIVE PROVIDER ORG (E) 12. PREFERRED PROVIDER ORG. (G) 5. FOUNDATION FOR MED. CARE (J) 13. TRICARE (C) 6. INDEPENDENT (INDIVIDUAL) (F) 14. UNEMPLOYMENT COMP. DIS (M) PRACTICE ASSOCIATION 15. CHAMPVA (A) 7. MATERNAL & CHILD HLTH PGM (L) 16. WORKER'S COMP. INS (H) 8. MEDICAID (N)

17. (g). Only answers "c" and "e" are correct (Medicaid & Workers Comp)

18. (c). the transfer, after an event insured against, of an individual's legal right to collect an amount payable under an insurance contract.

19. (a). the provider agrees to accept the allowable charge as the full fee and cannot charge the patient the difference between the providers charge and the allowable charge.

20. (b). the insurance check will be directed to the provider's office instead of to the patient address.

21. (e). Only answers "a" and "b" are correct (Federal & State)

22. (c). 80%

23. (a). a monthly, quarterly or annual fee that must be paid by the insured in order to keep the policy in force.

24. (b). a specific amount of money that must be paid each year before the policy benefits begin.

TOTALS = 24

PART II

MATCHING:

1. HALITOSIS (M) 10. VERTIGO (A) 19. EPISTAXIS (X) 2. HEMATOMA (F) 11. SYNCOPE (H) 20. PYURIA (Y) 3. THROMBUS (W) 12. DIPLOPIA (B) 21. HERPES ZOSTER(O) 4. DYSPNEA (K) 13. RUBELLA (E) 22. STRABISMUS (D) 5. TACHYPNEA (R) 14. ENURESIS (N) 23. HORDEOLUM (J) 6. ORTHOPNEA (G) 15. PRURITIS (V) 24. DYSPHAGIA (U) 7. HERPES SIMPLEX (Q) 16. MYOPIA (T) 25. PERTUSSIS (L) 8. OTORRHEA (C) 17. CEPHALALGIA (I) 9. CARDIOMEGALY (S) 18. HYPEROPIA (P)26. (d). All of the above 27. (e). Only answers "a" and "b" are correct

28. Name the five minimum information requirements needed by third

101

party payers for completion of insurance claim forms:

a). what was done (services/procedure codes) b). why was it done (diagnostic codes) c). when was it performed (date of service - DOS) d). where was it received (place of service - POS) e). who did it (provider name & ID)

TOTALS = 32

PART III

1. (c). attach a signed patient authorization form with SOF typed in the appropriate place.

2. (b). CMS-1500 3. (b). the financial accounting record 4. (a). encounter form


a). patient is a member of a managed care organizationb). physician examines a patient at the request of 3rd paying partyc). patient is suing someoned). patients records are subpoenaed or search warrante). other: state law, child/elder abuse, infections, gunshot wounds6. Name at least three reasons for documentation in the medical record process?

a). avoidance of denied or delayed payments by insurance carriersb). enforcement of medical record keeping rulesc). subpoena of medical records by state and courtd). defense of professional liability claim


(a) eligibility (b) pre-certification (c) pre-authorization (d) pre-determination


(a) Group Plan (b) Individual Plan (c) Pre-paid Health Plan

9. (e). All of the above

TOTALS = 20

SECTION II, EXAMINATION II, CUMULATIVE WORTH 15 QUESTIONS {CASE SUMMARY }INCLUDES SECTIONS ON: ADVANCED CODING, CLAIMS MANAGEMENT

102

SECTION II, EXAMINATION II, SAMPLE NHA EXAMINATION

Certified Billing And Coding Specialist Examination

1. Which of the following entities is responsible for implementing the various provisions of HIPAA in health care ?

a. Occupational safety and health administration (OSHA)b. Centers for Disease Control and Prevention (CDC)c. Food and drug administration (FDA)d. Centers for Medicare and Medicaid services (CMS)

2. Which of the following is not a key component in selecting a level of evaluation and management (E & M.) services ?

a. Historyb. Date

c. Examinationd. Medical decision-making

3. Which of the following is incorrect in reference to add on codes ?

a. They are exempt from modifier -51 (multiple procedures)b. They are performed in addition to a primary procedure.c. The add-on procedure must have been performed by the same physician.d. They may be reported as standalone codes.

4. A physician who specializes in the study of the nervous system is called a?

a. Neurologistb. Dermatologist

c. Psychologistd. Endocrinologist

5. While reviewing delinquent accounts, you come across one that has been previously billed but was never paid by the insurance company. Your next step is?

a. Call insurance company for statusb. Review the previous a patient for a rest and resubmit if necessary.c. Turn the account to a collection agency for further action.d. Wait one more month to see if payment comes in.

6. The suffix meaning “surgical repair” is?

a. -plastyb. -ectomy

c. -tomyd. -itis

7. A triangle placed in front of a code in the CPT manual means?

a. It is a code for a new procedure.b. The description for the code has changed.

103

c. It is a minor procedure.d. A secondary procedure only.

8. In which section of the CPT manual would you find the code for x-ray procedures?

a. Radiologyb. Pathology and laboratory

c. Medicined. Surgery

9. Medical ethics are?

a. Laws which govern hospital protocolb. Provisions passed through generations.c. Standards of conduct.d. Applicable to physicians only.

10. In a state that has workers compensation, a patient being treated by a physician for a work-related fracture is found to have on none work-related poison ivy rash. Which of the following is not an option for the physician ?

a. Treat the patient for poison ivy and Bill workers compensation carrier.b. Treat the rash free of charge, with documentation.c. Treat the poison ivy rash and Bill the patient group insurance.d. Refer the patient who was a family physician for treatment of the rash.

11. A number assigned for billing of supplies and equipment is?

a. Provider identification number.b. State license number.

c. Double medical equipment number.d. Employee identification number.

12. Which of the following is the correct format to enter a patient’s birthday on the CMS 1500 form?

a. MM/DD/YYYYb. MM/DD/CCYY

c. DD/MM/YYYYd. MM/DD/YY

13. The payment of the physician of a fixed sum per enrollee, per month, regardless of the services rendered, is described as?

a. Fee-for-service.b. Closed panel contract.

c. Salary method of payment.d. Capitation.

14. An Otorhinolaryngologist specializes in the diagnosis and treatment of ?

a. Disorders of the respiratory systemb. Disorders of the reproductive

system

c. Disorders of the eye.d. Disorders of the ear, nose and

throat.

15. Incorrect payments from an insurance company should be ?

104

a. Acceptedb. Forwarded to the patient.

c. Investigated and appealed.d. Sent to the collections lawyer.

16. A claim for services not medically necessary is an example of?

a. Downcoding.b. Upcoding

c. Abused. Hardship waiver

17. When a non-member physician treats an HMO patient, the service rendered is termed ?

a. Provisionalb. Within network

c. Improperd. Out of plan or out of network

18. Which CPT modifier would you attach to a consultation code when the service performed is required by a third party payer or governmental regulatory body?

a. -22 (unusual procedural services)b. -59 (distinct procedural services)

c. -26 (professional component)d. -32 (mandated services)

19. A patient developed rashes after taking a properly prescribed medication. The E-code to be used to indicate how the rashes happened is referenced from which “E” code column in the table of drugs and chemicals?

a. Accidentb. Undetermined

c. Therapeuticd. Suicide attempt

20. A 24-year-old man suffered multiple lacerations in different parts of the body due to a vehicular accident. The following are the codes and the procedures done to the patient. (Applicable modifiers are intentionally omitted.):

Code Procedure

12005 repair, simple, 15 CM, right thigh: $10012002 repair, simple, 7 CM, left forearm, $7512032 repair, intermediate, five CM, right arm: $15013132 repair, complex, three CM, right cheek: $175

Which of the following is the correct sequence of reporting the above repair procedures?

a. 12005, 12002, 12032, 13132b. 13132, 12032, 12002, 12005

c. 12002, 12005, 12132, 12032d. 13132, 12032,12005, 12002

21. Which of the following is a fixed amount patients pay each time they receive health care services?

a. Coinsuranceb. Deductible

c. Insurance d. Copayment

105

22. New codes in a CPT manual are represented by?

a. A plus signb. A triangle

c. A solid circled. Right and left triangles

23. Under the RBRVS method of reimbursement, a “conversion factor” is?

a. A dollar amount.b. A cost living adjustment.

c. A limiting charged. The practice expense.

24. Blocks 14 – 33 of the CMS 1500 form referred primarily to do?

a. Provider and servicesb. Third-party payer information

c. Secondary insurance pland. Patient demographics

25. Which of the following is not bundled into reimbursement for the surgical code ?

a. The surgical procedureb. Local anesthesia provided by the

physician

c. Post-operative servicesd. Post-operative visits for

complications

26. The medical program for dependence of active military personnel is called?

a. CHAMPVAb. TRICARE

c. Medicaidd. Blue Cross/Shield

27. An example of the federal tax identification number would be?

a. State license numberb. UPIN

c. NPId. E IN

28. What does the abbreviation EOB stand for?

a. Exemption of benefits.b. Examination of breasts.

c. Examination of bones.d. Explanation of benefits.

29. Administrative and/or monetary penalties for an established pattern of fraud and abuse are levied by the ?

a. Office of the district attorney.b. The fiscal office.

c. HCMS regulation officed. Office of the Inspector General

30. A patient underwent closed treatment of femoral shaft fracture, without manipulation. Using the “condition” location method, which of the following will be used to locate the code in the index of the CPT manual?

a. Femurb. Fracture

c. Treatmentd. Manipulation

106

31. Which of the following is a possible negative consequence of inaccurate coding and billing in a medical practice ?

a. Faster reimbursement.b. A clean claim.

c. Denied claims.d. 100% reimbursement of the claim

32. Block numbers 1 -13 on the CMS 1500 form are in reference to?

a. The patient.b. The provider.

c. The authorization to release information only.

d. The diagnosis.

33. A patient underwent a procedure for the removal of one kidney. Which of the following would it be?

a. Nephrectomyb. Lobectomy

c. Oophorectomyd. Gastrectomy

34. Which of the following describes any procedure or service reported on a claim that is not included on the third party payers benefit list?

a. Medically unnecessaryb. Pre-existing condition

c. Non-covered benefitd. Unauthorized service

35. Encrypted exchange of data in a standardized form through computer systems is called ?

a. Faxb. Relevant data cooperative

c. Electronic data interchanged. Information exchange services

36. The method used to establish a fee schedule in which three fees are considered in calculating payment is called ?

a. Capitationb. Contract services

c. Usual, customary, reasonabled. Averaged fee schedule

For the next question, use the following information:

Malignant

Neoplasm Primary Secondary Ca in Situ Benign Undetermined Unspecified Behavior

Bone 170.9 198.5 ----- 213.6 238 239.0(periosteum)

Prostate 185 198.82 233.4 236.5 222.2 239.5 (gland)

107

37. A 65-year-old male patient was diagnosed with bone metastases from the prostate. After verifying the codes in the tabular index, what are the correct codes and sequence to report in this case?

a. 170.9, 185b. 185, 198.5

c. 213.6, 236.5d. 182, 170.9

38. A patient has contractor of the right hand due to a third degree burn suffered a year ago. The code for the third degree burn will be referenced from the Alphabetic Index of the ICD-9 manual under which main term?

a. History (personal)b. Late (effects) burn

c. Contractord. Burn, third-degree

39. Which of the following is not a circumstance for the use of a “V” code?

a. A person who is not currently sick received health care services.b. To explain the mechanism for an injury.c. Indication of the “history of” an illness.d. To indicate the status of a newborn.

40. A three-month-old child is treated in the critical care unit. The service will be reported using codes from which age category?

a. Adult age groupb. Pediatric age groupc. Neonate group

d. There is no rule regarding age in critical care.

41. Mrs. Ann Smith had a biopsy taken from a mass found in her left breast. Three days after the procedure, she was informed that the biopsy is positive for cancer. Five days later, Mrs. Smith undergoes radical mastectomy. Which of the following modifiers will be attached to the mastectomy procedure code?

a. -78 (return to the operating room for a related procedure during a postoperative period).b. -79 (unrelated procedure or service by the same physician during the postoperative period)c. -58 (staged or related procedure or service by the same physician during the postoperative period)d. -24 (unrelated evaluation and management service by the same physician during the postoperative

period)

108

For items 42 and 43, use the following information:

Office Visit / Established Patient:

Key Components Medical Decision Code History Physical Exam Making Time

99211 ------ ------- ------- 5 min

99212 Problem Focused Problem Focused Straightforward 10 min

99213 Expanded problem Expanded problem Low Complexity 15 min Focused Focused 99214 Detailed Detailed Moderate Complexity 25 min

99215 Comprehensive Comprehensive High Complexity 40 min

42. An established patient came in with a chief complaint that required a detailed history, a detailed examination, and the medical decision-making of moderate complexity. However, the time spent face to face with the patient exceeded a straightforward exam by 20 minutes. How will you report the service?

a. 99214b. 99215

c. 99213d. 99216

43. A 12-year-old patient came to the authors clinic for removal of sutures in his arm. The nurse attended to the patient. Which code is appropriate for this service?

a. 99211b. 99212

c. 99214d. 99215

109

44. Of those listed below, which insurance policy is always the “payer of last resort”?

a. Blue Cross/Blue Shield PPOb. Group insurance

c. Medicaidd. Workers compensation

45. The insurance paper claim form used in all states for submitting Medicare/Medicaid claims is called?

a. CMS 1500b. EOB

c. EMRd. DEERS

46. Assignment of benefits from the patient means that the insurance company will?

a. Pay the patient directlyb. Reimbursed the patient for co-

insurance requirements.

c. Pay the physician directly.d. Not pay for medical services.

47. An insurance company that provides weekly or monthly cash benefits to employed policy holder, who becomes unable to work due to an accident or illness is called?

a. Special risk insuranceb. Loss of income protection

disability insurance.

c. Surgical insurance.d. Medical insurance.

48. In the “birthday rule” involving children beneficiaries, the primary insurance policy is the one held by the patient?

a. Who is older.b. With the birthday falling first in the

calendar year.

c. Who is the head of the family.d. Who pays a higher premium.

49. The code “11” for physician’s office is an example of a/an ?

a. POS codeb. TOS code

c. ICD coded. CPT code

50. Certain third party payers who meet the federal government guidelines covering Medicare deductibles and coinsurance as supplementary insurance. These third party payers are called?

a. Medigap/Medifillb. Copay collectors

c. Premium insurancesd. Government stop-gaps

51. Which of the following is the basis for Medicare’s allowed amounts ?

a. EOBb. UCR

c. RVUd. RBRVS

52. Medicare Part D is also known as?

a. Medicare prescription drug and other assistance programs.

110

b. Medicare advantage.c. Medicare hospital insurance.d. Medicare medical insurance.

111

53. A patient covered by Medicare part B, who is treated by a participating physician, is responsible for what percentage of Medicare’s amount allowed?

a. 100%b. 80%

c. 50%d. 20%

54. If a Medicaid patient requires emergency care while out of his/her home state, most states offer?

a. Social work servicesb. Transportation back to home state

c. Reciprocityd. Temporary release of benefits

55. Those who qualify for Medicaid include all of the following, except:

a. Low income families with children.b. High income earners.c. Persons over 65 who are blind or have a permanent disability.d. Persons who earn enough money to pay basic living expenses, but cannot afford high medical

bills.

56. A portable oxygen tank, used by a Medicare patient, is an example of which of the following?

a. Expendable medical equipment.b. Non-billable item.

c. Non-reusable medical equipment.d. Durable medical equipment

57. A physician who does not accept assignment under Medicare is called?

a. Group practice physicianb. A participating physician

c. A non- participating physiciand. Restrictive participating provider

58. Mr. John James came to the clinic with the chief complaint of muscle pains. The diagnosis will be?

a. Myastheniab. Myomalacia

c. Myalgiad. Myoma

59. A patient underwent a surgical procedure for colostomy. The part of the body involved is?

a. The liverb. The stomach

c. The small intestined. The large intestine

60. Which of the following is the best definition of “insurance fraud” ?

a. Correctly filing an insurance claimb. Paying annual premiums on timec. Mistakenly submitting an incorrect claimd. An intentional deception or misrepresentation made, knowing it to be false.

112

61. Which of the following is an example of an exemption from the “right of privacy” and must be reported to the proper authority / agency?

a. Child or spousal abuse records.b. Pregnancy test results for a 16-

year-old patient.

c. Past medical history regarding hip surgery.

d. Chemotherapy records for cancer patient.

62. This medical term describes a procedure performed on a joint?

a. Arthrotomyb. Orchiectomy

c. Tracheostomyd. Phlebotomy

63. The abbreviation H & P means?

a. Healthy and Productiveb. History and Physical

c. Hospital and Physiciand. History and Prognosis

64. The suffix meaning “forming a new opening” is?

a. -plastyb. -tomy

c. -stomyd. -rrhaphy

65. The suffix that means “inflammation” is?

a. -ectomyb. -rrhaphy

c. -algiad. -itis

66. External audits, ongoing training, and fraud advisories are all important parts of a commitment to keep both physicians and medical staff current with HIPAA. This is also known as?

a. Provider sponsored planb. Compliance plan

c. Dental insurance pland. An indemnity plan

67. This medical term contains the word root meaning “uterus” ?

a. Oophorectomyb. Salpingectomy

c. Hysterectomyd. Colporrhaphy

68. A report mentioning such terms as “Cranium”, “Maxilla”, and “Mandible” would refer to which part of the body?

a. Upper extremitiesb. Lower extremities

c. Headd. Trunk

69. The information that appears at the beginning of each of the major sections of the CPT is called the?

113

a. Appendixb. Guide lines

c. Notationsd. Preface

70. A document that contains dates of service, list of detailed charges, co payments/deductibles paid, date insurance was filed, adjustment and account balances is called?

a. An inventory listb. An itemized statement of ledger

c. A receiptd. A Superbill or encounter form

71. Claim form that has all required fields accurately filled out and has all necessary attachments required for processing is called?

a. A clean claimb. A dirty claim

c. A closed claimd. An invalid claim

72. Evaluation and Management codes in the CPT manual begin with?

a. 77b. 80

c. 99d. 10

73. There are many reasons for documentation. Which of the following is not a need for documentation?

a. For defense in case of a lawsuit.b. Documentation, even if fictitious, would allow for higher coding and billing.c. To support procedure and diagnostic codesd. To outline patient illnesses, treatments and plans.

74. An established patient is one who has received professional services from a physician of the same specialty in the same group, within the past how many years?

a. 1 yearb. 2 years

c. 3 yearsd. 4 years

75. The portion of a diagnostic statement used when finding a code in the Alphabetic Index (Volume 2) of the ICD –9– CM is called?

a. Primary diagnosisb. Main term

c. Primary physiciand. Table of contents

76. A Medicare beneficiary’s number is 123456789A. The suffix “A” means the holder of this card is?

a. The spouse of a qualified wage earner.

b. The qualified wage earner.

c. An underage dependent of a qualified wage earner.

d. Widow.

77. The medical term “symptomatic” means the patient has symptoms. When the prefix “a” is attached in front of “symptomatic”, the meaning becomes?

114

a. Painful symptomsb. Documented symptoms

c. Without symptomsd. First symptoms

78. A medical term that contains the combining form meaning “skin” is?

a. Oophorectomyb. Dermatology

c. Cryotherapyd. Arthroplasty

79. When professional services are rendered, the Medicaid identification card or electronic verification must show eligibility for?

a. Day of serviceb. Year of service

c. Month of serviced. Week of service

80. Northern medical center, a group practice, pays salaries to their physicians who provide care at the facility. Where within the CMS 1500 form will you indicate the name of the treating physician?

a. Block 21b. Block 24J

c. Block 19d. Block 14

81. A patient is diagnosed with metastatic adenocarcinoma of the liver from the pancreas. The liver cancer would be coded as?

a. Ca in situb. Primary malignant

c. Secondary malignantd. Benign neoplasm

82. This medical term contains the combining forms meaning “heart” ?

a. Choledocholithiasisb. Arteriosclerosis

c. Cardiomegalyd. Adenoma

83. A private medical insurance policy would cover expenses for all of the following accepted?

a. A physician’s fee for an operation.b. A work injury covered under

workers compensation.

c. Hospital room and board charges.d. Charges for cosmetic surgery

necessitated by an accident.

84. When physicians, hospitals, and other health providers contract with one or more HMOs or directly with employers to provide care, this is called?

a. A physician – hospital organizationb. A preferred provider plan

c. A health maintenance organizationd. A fee – for – service plan

85. Nutrient rich blood is returned back to the atrium through the?

a. Coronary arteriesb. Pulmonary arteries

c. Coronary sinusd. Pulmonary veins

115

86. Multi-gravida is a term associated with?

a. Bronchitisb. Pregnancy

c. Arthritisd. Glaucoma

87. Under this type of pain, a patient may see providers outside the plan, but the patient pays a higher portion of the fees?

a. Health maintenance planb. Independent practitioner plan

c. Preferred provider pland. Primary care plan

88. Licensure to practice medicine is done by?

a. Each individual stateb. The federal governmentc. Local and state governments

together

d. The federal government and the local government.

89. Physicians today practice primarily?

a. At the hospitalb. In sole proprietorships

c. In group practicesd. In large corporations

90. The patient care partnership (the patient Bill of Rights) is?

a. A state statute in all 50 statesb. A role in 30 of the 50 states

c. Not a state or federald. A federal law

91. The national provider (NPI), a standard unique identifier, is assigned by?

a. Plan IDb. CMS

c. WHOd. AMA

92. A patient with a diagnosis of COPD has problems with the____system of the body?

a. Urinaryb. Digestive

c. Reproductived. Respiratory

93. When the defendant alleges that he or she did no wrong, the defense is called?

a. Negligenceb. Contributory negligence

c. Deniald. Assumption of risk

94. Risk management is a process?

a. To assess liability insuranceb. To manage difficult patients

c. To minimize danger, hazard, and liability.

d. To minimize legal costs.

116

95. Medical malpractice insurance that covers the insured only for those claims made while the policy is in force is called ?

a. Prior acts coverage b. Self – insurance coverage

c. Claims – made coveraged. Occurrence coverage

96. A patient is checking the function of this gland when assessing a patient’s metanephrine (metabolite of epinephrine) levels ?

a. Adrenal glandb. Pituitary gland

c. Parathyroid glandd. Thymus gland

97. Interneurons connect sensory and motor neurons within the?

a. Brain and spinal cordb. Spinal cord and spinal nerves

c. Brain and cranial nervesd. Spinal roots and spinal nerves

98. The term metabolism refers to?

a. Anabolic reactionsb. Catabolic reactionsc. Oxidation

d. All of the chemical reactions of the body

99. Ethical guidelines for healthcare practitioners are meant to be used?

a. In courts of law as legal standards to which practitioners will be held.b. To guide healthcare practitioners and to encourage them to think about their individual actions

in certain situations.c. In situations where the healthcare practitioner may be held liable for their actions.d. In situations where the healthcare practitioner might offend a patient.

100.Which doctrine states that the physician is legally responsible for their own acts of negligence and for negligent acts of employees working within the scope of their employment?

a. Vicarious liabilityb. Respondeat superior

c. Strict liabilityd. Proximate cause

117

SECTION III, EXAMINATION I, CUMULATIVE 72 QUESTIONSINCLUDES SECTIONS ON: HEALTH CARE REIMBURSEMENT, MEDICAL CODING -1, CLAIMS MANAGEMENT, CLAIMS PROCESSING

ANSWER KEY

MATCHING:

1. COMPREHENSIVE CODE (F)2. UNBUNDLING (R)3. MODIFIER (G) 4. (P)5. (Q)6. (T)

7. ⊘ (O) 8. (K)9. (M)10. CUSTOMARY FEE (N)11. REASONABLE FEE (H)12. INCOMPLETE CLAIM (S)13. DINGY CLAIM ( I )

14. DIRTY CLAIM (J)15. INVALID CLAIM (C)16. CLEAN CLAIM (D)17. PIN NUMBER (E)18. NPI NUMBER (B)19. UPIN NUMBER (L)20. PPIN NUMBER (A)

21. List the four major reasons for the development and use of diagnostic codes:

e. Tracking of disease processes.f. Classification of causes of mortality

g. Medical researchh. Evaluation of hospital service utilization

22. (b). E codes 23. (a). V codes

TOTALS = 24

PART II

MATCHING

1. DME NUMBER (H)2. DIGITAL CLAIM (G)3. EIN NUMBER (M)4. FACILITY NUMBER (N)5. GROUP PROVIDER NUMBER (L)6. ELECTRONIC CLAIM (J)7. OCR (B)8. REJECTED CLAIM (A)

9. OTHER CLAIMS (K)10. PAPER CLAIM (O)11. PENDING CLAIM ( I )12. PHYSICALLY CLEAN CLAIM (E)13. CLEAN CLAIM (C)14. CMS 1500 = (D) 15. STATE LICENSE NUMBER (F)

16. An insurance claim form may require three different provider identification numbers. Name the three different types of physicians whose identification numbers may be requested ?

a). Referring physician b). Ordering physician c). Performing physician

17. (a). a basic five digit system for coding physician services and two digit add on modifiers for special circumstances.

18. Private insurance companies and federal and state programs adopt different methods for basing their payments on outpatient claims. Name the three basic and universally accepted methods ?

b) fee schedules c) usual, customary and reasonable d) relative value scales or schedules

19. Some insurance policies pay for only one consultation per year and may require a written report for any additional consultations. Name the four basic types of consultations for which CPT codes exist ?

a). Office or other outpatient consultationsb). Initial inpatient consultations

b). Follow-up inpatient consultationsc). Confirmatory consultations

TOTALS = 26

PART III

MATCHING

1. MODIFIER (G)2. ADJUCT CODES (O)3. UPCODING (N)4. DOWNCODING ( I )5. BUNDLING (L )6. UNBUNDLING (M)7. [ -26 ] (A )8. [ -25 ] (K )

9. [ -50 ] (D)10. [ -51 ] ( C )11. ACTUAL FEE (J )12. PREVAILING FEE ( E)13. [ -TC ] ( F )14. CUSTOMARY FEE (H )15. REASONABLE FEE ( B )

16. Name the two components that are always included in a “Surgical Package” ?

a). The Operation b). Local Infiltration such as topical anesthesia


a). Key Componentsb). Contributory Factorsc). Face-to-Face Time with the patient or family.

TOTAL = 20

SECTION III, EXAMINATION II, CUMULATIVE 100 QUESTIONSINCLUDES SECTIONS ON: HEALTH CARE REIMBURSEMENT, MEDICAL CODING -1, CLAIMS MANAGEMENT, CLAIMS PROCESSING, ADVANCED CODING

ANSWER KEY

PART #1: FILL-IN BLANK DIRECTIONS: Fill-in the blank spaces with the most appropriate words or phrases that best completes the sentences. (Evaluation and Management { E / M } Section )

9. List the five (5) types of presenting problems from the most risk and least recovery to the least risk and most recovery:a. Minimalb. Self-limitedc. Low Security

d. Moderate Severitye. High Severity


a. Highb. Medium

c. Lowd. Straightforward

11. Counseling and coordination of care are what kind of factors in most cases? ANS: Contributory

12. Time that is used as a guide for out-patient services is what kind of time? ANS: Direct Face to Face

13. Inpatient time spent at the bedside or nursing station during or after the visit is what kind of time? ANS: Unit Floor Time

14. The patient’s MEDICAL RECORD will reflect the number of systems examined by a brief statement of the findings.

15. The history is the SUBJECTIVE information the patient tells the physician.

16. A discussion with a patient and/or family concerning one or more of the following areas: diagnostic results, impressions and/or recommended diagnostic studies; prognosis, risks, and benefits of treatment; instructions for treatment; importance of compliance with treatment; risk factor reduction; and patient and family education is REVIEW OF SYSTEMS (ROS)


1. C2. F3. A

4. G5. E6. D

7. B8. H

PART #2: FILL-IN BLANK DIRECTIONS: Fill-in the blank spaces with the most appropriate words or phrases that best completes the sentences. (Anesthesia Section and Modifiers

9. What two words describe a decreased level of consciousness that does not put patients completely to sleep and that allows the patients to breathe on their own during a surgical procedure ? ANS: MODERATE SEDATION

10. What do the initials CRNA stand for? ANS: CERTIFIED REGISTERED NURSE ANESTHESIOLOGIST (ANESTHECIST)

11. What appendix in the CPT manual contains a complete list of all modifiers? ANS: APPENDIX “A”

12. What is the word that means assigning multiple codes when one code would do? ANS: UNBUNDLING

13. What is the term that describes the services provided to a patient by the physician before surgery? ANS: PRE-OPERATIVE SVCS

14. What is another term for the time after the surgery that the physician provides services to the patient? ANS: POST-OPERATIVE SERVICES

15. Do all third party payers recognize all modifiers as listed in the CPT manual? ANS: NO

16. What is the term that describes two physicians working together in the completion of a procedure when each has the same level of responsibility? ANS: ASSISTANT PHYSICIAN

PART #3: MATCHING DIRECTIONS: Match the following terms or phrases on the left hand column with their equivalent definitions found on the right hand column. In the `space' provided place ònly' letters! (Cardiovascular System )

1. N2. S3. G4. W5. M6. T7. C8. X9. V

10. H11. O12. D13. P14. I15. E16. Q17. L18. A

19. K20. J21. Y22. U23. B24. F25. R

PART #4: MATCHING DIRECTIONS: Match the following terms or phrases on the left hand column with their equivalent definitions found on the right hand column. In the `space' provided place ònly' letters! (Radiology Section ).

SECTION (A): Match the following terms to the correct definitions:

1. C2. E

3. B4. F

5. A6. D

SECTION (B): Match the following radiographic procedures to the correct structures imaged:

7. B8. E

9. F10. C

11. A12. D

SECTION (C): Match the following radiographic procedures to the correct structures imaged:

13. E14. D15. I16. B

17. H18. A19. J20. G

21. C22. F

SECTION (D): Without the use of reference material, answer the following:

23. E codes are located in Section: ANS: (a) 24. Benign, malignant, and carcinoma in situ are examples of types of: ANS: (b)

SECTION (E): Match the abbreviations, punctuations, symbols, words, or typeface to the correct descriptions:

a. Fb. Gc. Ad. I

e. Hf. Lg. Jh. E

i. Dj. Kk. Bl. C

SECTION (F): Match the convention to the definition:

m. Fn. Bo. C

p. Dq. Ar. E

s. G

SECTION IV, EXAMINATION I, CUMULATIVE 62 QUESTIONSINCLUDES SECTIONS ON: HEALTH CARE REIMBURSEMENT, MEDICAL CODING -1, CLAIMS MANAGEMENT, CLAIMS PROCESSING, ADVANCED CODING

ANSWER KEY

PART I: DIRECTIONS: MULTIPLE ANSWER QUESTION (MAQ): Place a circle around the `letter' containing the `best' and most applicable answer. One answer only !

1. (C )2. (A)

3. (C )4. (A)

5. (A)6. (D)

FILL-IN BLANK DIRECTIONS : Fill-in the blank spaces with the most appropriate words or phrases that best completes the sentences. (Claims Management )

h. Describe how the name on the claim should be typed for the following patients:

e. Apple II, James M.f. Treebark Jr., Charles T.

g. Hurts II, David J.h. Elbow Sr., Jake R.

8. The surgery section is organized by BODY SYSTEM


a. What body system was involved.b. What anatomic site was involved.c. What type of procedure was performed.

TOTALS = 15

PART II: FILL-IN BLANK DIRECTIONS: Fill-in the blank spaces with the most appropriate words or phrases that best completes the sentences. (Claims Management )


a). Minor Surgery b). Major Surgery


a). Surgical Procedure b). Local infiltration c). Normal uncomplicated follow-up calls

12. On what basis are minor surgical procedures to be billed? Fee-for-service

13. Briefly describe “Unbundling” Assigning multiple codes when only one is necessary; the procedure is illegal


A) Skin Lesion = Any alteration of the skinB) Excision of a Lesion = Requires cutting through the dermal layersC) Destruction of a Lesion = An alternate to cutting of tissues; involves complete tissue destruction (coagulation, burning)


1) Site 2) Size of the lesion measured before excision 3) Number lesions removed

4) Benign or Malignant status 5) Method used for the removal

17. Layered closure requires the use of 2 codes. One is for the Excision and one for the Intermediate repair

17. If a physician reports the size of a lesion in inches, what must the coder do? ANS: Convert the inches to centimeters

18. When converting the size of a lesion, one inch = 2.54 cms

20. When there are multiple lacerations, which repair should be listed first? The most complicated repair

Assign codes to the folllowing:

J) Removal of foreign body in tendon sheath, simple _________20520K) Puncture aspiration of cyst of breast ____________________19000L) Incision and drainage of thyroid gland cyst _______________60000M) Abrasion, single lesion ______________________________15786N) Destruction of four flat warts __________________________17110

O) Incision and drainage of ankle abscess _________________27603P) Incision and drainage of wrist hematoma ________________25028Q) Aspiration thyroid cyst ______________________________60300R) Laparoscopy with bilateral total pelvic lymphadenectomy and

periaortic lymph node biopsy _________________________38572

TOTALS = 29


Match the following terms:

1) Medicare Part A- (C ) [ Covers institutional care ]2) Hospice care- (D ) [All terminally ill patients qualify ]3) ESRD (F) [Available to patients in need of renal dialysis or transplant]4) Lifetime Reserve Days (A) [Used only once during Patient’s lifetime]5) Home health Svcs (E) [Available to patients confined to the home]6) Respite care (B) [The temporary hospitalization of a hospice patient]

7). (B)8). (E)

9). (B)10). (C)

11). (A)

12). List four (4) circumstances in which a letter should be used ?

a. Surgery defined as an inpatient procedure that is performed.b. Surgery typically categorized as an office procedure but is performed ASC (ambulatory ER)c. A patient’s stay in the hospital is prolonged because of a medical or psychological reason.d. An outpatient office procedure is performed as an inpatient procedure because the patient is a high-risk case.

13). List five (5) key strokes that can be substituted by a space when completing a claim:

a. Dollar sign or decimal in all charges or totals.b. Decimal point in a diagnosis code number.c. Dash in front of a procedure code modifier.d. Parentheses surrounding the area code in a telephone number.e. Hyphens in social security numbers.

TOTALS = 18

SECTION IV, EXAMINATION II, CUMULATIVE 70 QUESTIONSINCLUDES SECTIONS ON: HEALTH CARE REIMBURSEMENT, MEDICAL CODING -1, CLAIMS MANAGEMENT, CLAIMS PROCESSING, ADVANCED CODING

ANSWER KEY

16. ( B )17. ( C )18. SUBJECT TO LARGE FINES AS WELL AS EXCLUSION FROM THE MEDICARE PROGRAM19. ( D )

20. THE ACT OF BILLING THE PATIENT FOR THE DIFFERENCE BETWEEN THE MEDICARE CHARGES AND ACTUAL CHARGES

21. IT IS A WRITTEN DOCUMENT PROVIDED TO THE MEDICARE BENEFICIARY BY A SUPPLIER

22. a. ORIGINAL MEDICARE PLANd. MEDICARE MANAGED CARE PLAN WHICH ARE AVAILABLE IN MANY AREASe. PRIVATE FEE FOR SERVICE PLAN

23. a. ADDITIONAL BENEFITSf. LOWER COSTg. LESS PAPERWORKh. NO ACCEPTING ASSIGNMENT PROBLEMi. PREVENTATIVE CARE

24. a. LACK OF FREEDOMb. PRIOR APPROVALc. DISENROLLMENT CAN BE LENGTHY

25. ( C )26. ( C )27. THROUGH A COMPETATIVE BIDDING PROCESS AND OBTAINING THE NAME AND MAILING ADDRESS OF THE CARRIER

FOR YOUR REGION28. FEDERAL BLACK LUNG PROGRAM29. CMS-150030. “ COPY OF THE PRIMARY CARRIER

PART II: Match the following terms:

1. Axillary nodes ____________N___ a. Incision into a lymphatic vessel 2. Splenectomy______________I___ b. Station along the lymphatic system 3. Splenoportography________T__ c. Grafting of tissue from one source to another 4. Allogenic_________________E___ d. Congenital deformity of benign tumor of the lymphatic system 5. Autologous, autogenous____P___ e. Of the same species, but genetically different 6. Aspiration________________H___ 7. Stem cell_________________Q___ f. Localization of pus 8. Transplantation____________C__ g. Behind the sac holding the abdominal organs and viscera (peritoneum) 9. Lymph node_______________B__ h. Use of a needle and syringe to withdraw fluid 10. Lymphadenitis____________S___ i. Excision of the spleen 11. Lymphangiotomy__________A___ j. Excision of a lymph mode (or nodes) 12. Thoracic duct_____________M___ k. Lymph located next to the large vein in the neck 13. Lymphadenectomy_________J__ l. Term that refers to the groin and thigh 14. Retroperitoneal____________G__ m. Collection and distribution point for lymph and the largest lymph 15. Jugular nodes_____________K__ vessel located in the chest 16. Cystic hygroma____________D__ 17. Cloquet’s node____________R__ n. Lymph nodes located in the armpit 18. Inguinofemora_____________L__ o. Insertion of a tube into a duct or cavity 19. Cannulation_______________O__ p. From oneself 20. Abscess_______________ _F__ q. Immature blood cells r. Also called a gland; it is the highest of the deep groin lymph nodes s. Inflammation of a lymph node t. Radiographic procedure to allow visualization of the splenic and portal veins of the spleen


1. Keratoplasty_________________G_______ a. Opaque covering on or in the lens 2. Evisceration_________________V_______ b. Prefix meaning pertaining to the lacrimal sac 3. Enucleation__________________i_______ c. Vascular tissue of the choroids, ciliary body and iris 4. Pelvic exenteration___________Q________ d. Condition in which the refractive surfaces of the eyes are unequal 5. Cataract____________________A________ e. Prefix meaning tear / tear duct 6. Sclera______________________S________ f. Prefix meaning ciliary body or eye muscle 7. Conjunctiva_________________O________ g. Surgical repair of the cornea 8. Uveal_______________________C________ h. Prefix meaning eyelid 9. Tarsorrhaphy________________N________ i. Removal of an eye

10. Ocular adnexa______________U_________ j. Prefix meaning cornea 11. Anterior segment____________P_________ k. Those parts of the eye behind the lens 12. Posterior segment___________K_________ l. Extra ocular muscle deviation resulting in unequal visual axes 13. Blephar/o__________________H__________ m. Prefix meaning eye 14. Cor/o______________________R__________ n. Suturing together of the eyelids 15. Cyclo/o____________________F__________ o. Lining of the eyelids and covering of the sclera 16. Dacry/o____________________E__________ p. Those parts of the eye in the front of and including the lens, orbit,17. Kerat/o____________________J__________ extra ocular muscles and eyelid 18. Ocul/o_____________________M_________ q. Removal of contents of a body cavity 19. Dacryocyst/o_______________B__________ r. Prefix meaning pupil 20. Vitre/o_____________________T__________ s. White outer portion of the eyeball 21. Astigmatism________________D_________ t. Prefix meaning pertaining to the vitreous body of the eye 22. Strabismus_________________L_________ u. Orbit, extra ocular muscles and eyelid v. Pulling the viscera outside the body through an incision

23. What do the following medical abbreviations or acronyms mean:

ABN = ADVANCE BENEFICIARY NOTICE

CLIA = CLINICAL LABORATORY IMPROVEMENT ACT

ESRD = END STAGE RENAL DISEASE

PPO = PREFERRED PROVIDER ORGANIZATION

SLMB = SPECIFIED LOW INCOME MEDICARE BENEFICIARY

TOTALS = 70

SECTION V, EXAMINATION I, CUMULATIVE 84 QUESTIONSINCLUDES SECTIONS ON: OFFICE ADMINISTRATION, BILLING MANAGEMENT, ACCOUNTS RECEIVABLE, INSURANCE POLICIES, LEDGER CARDS, PURCHASE ORDERS, RECEIPTS, ALPHANUMERIC FILING, INSURANCE FORMS [CMS1500], MEDISOFT.

ANSWER KEY

MULTIPLE CHOICE

1. (a)2. (a)3. (d)4. (b)5. (d)6. (b)7. (c)8. (a)9. (d)

10. (a)11. (c)12. (b)13. (b)14. (d)15. (c)16. (c)17. (c)18. (a)19. (a)

20. (c)21. (c)

22. (a)23. (b)24. (a)25. (a)26. (c)27. (b)28. (a)29. (a)

31. MUST PROVIDE LEDGER CARD, CASH RECEIPT AND CMS 1500 INSURANCE FORM FOR PATIENT LARRY DUFFY.

32. Medical / Medical Billing Abbreviations:

a). q.i.d. = four times a day b). B/F = Balance Forward c). p.p.a. = Shake the bottle first d). a.c. = Before meals e). d = diagnosis, detail, days f). c/a * = Cash on Account

g). s.o.s. = once if necedssary h). p.r.n. = as often as necessary i). q.o.d. = every other day j). D. = Doses k). H.S.(hs) = hour of sleep, bedtime

l). ck * = check

m). ad lib = as desired n). OS = left eye o). def * = charge deferred

p). cr * = credit q). adj = adjustment

DIRECTIONS QUESTIONS #32-35: FILING ORDER:

32. ACB

33. BAC

34. CBA

35. BAC

36. CBA

37. BAC

38. What four steps would you take when a patient chart cannot be located?

a. check listings on computer c. check transposition number b. check inactive files d. check filing order / correction of name

39. MUST PROVIDE LEDGER CARD, CASH RECEIPT AND CMS 1500 INSURANCE FORM FOR PATIENT MRS. DUFFY..

40. The following PURCHASE ORDERS for supplies are requested by Dr. Langford:

1.-(1000) blank sheets of standard style history forms at $ 0.35 each. 2.-Four pcs. swivel chairs at $ 75.80 each (Style is bone white). 3.-Gauze standard 500 per pack; current request is 15 pks. at $ 1.79/pk. 4.-Curite Bandaid at 350 per box; current request is 23 boxes at $ 1.83/bx

5.-Autolet finger puncture stylets at 125/pk., requesting 4 pks. $ 2.15/pk 6.-Patient Exam. Gowns at 50 per pack; current request is for 350 of them costing $ 85.65 per pack. Style is standard white.

If the tax rate is 8 ¼ % with a 25% Discount when purchased as well as a $45 delivery charge, then (2 pts ea / MUST SHOW MATH !): a). What is the total Purchase Price ? ANS: $ 1,330.29 b). What is the total Purchase Price Plus Tax ? ANS: $ 1,440.04

c). What is the Discounted Purchase Price Plus Tax ? ANS: $ 1,080.03 d). What is the Final Purchase Price with Delivery ? ANS: $1,125.03

a). What is the total Purchase Price ? ANS: $ 1,330.29

1. 1000 X $ 0.35 = $ 350.002. 4 X $75.80 = $ 303.203. 15 X $1.79 = $ 26.854. 23 X $1.83 = $ 42.095. 4 X $2.15 = $ 8.606. 350/50 = 7 X $85.65 = $ 599.55

====== $ 1,330.29

b). What is the total Purchase Price Plus Tax ? ANS: $ 1,440.04

8 ¼ % = 8.25 / 100 = 0.0825$ 1,330.29 X 0.0825 = $ 109.75$ 1,330.29 + $ 109.75 = $ 1,440.04

c). What is the Discounted Purchase Price Plus Tax ? ANS: $ 1,080.03

25 % = 25 / 100 = 0.25$ 1,440.04 X 0.25 = $ 360.01$ 1,440.04 - $ 360.01 = $ 1,080.03

d). What is the Final Purchase Price with Delivery ? ANS: $1,125.03

$ 1,080.03 + $45.00 = $1,125.03

41. WRITE KEYS YOU WILL USE TO:

1. CTRL - P2. F-73. F-54. CTRL – D

5. CTRL – S6. CTRL – X7. CTRL – C8. BACKSPACE

9. CTRL – O10. ALT – F, THEN X

17. Print a File_______________ CTRL-P18. Spelling check______________ F719. Slide Show_________________ F520. Duplicate Slides_____________ CTRL-D21. Save a File_________________ CTRL-S22. Cut the Text________________ CTRL-X

23. Copy the Text_______________CTRL-C24. Delete Text__________________BACKSP25. Open a File__________________CTRL-O26. Exit Word or Excel_________ __ALT-F, THEN X

42. (g) All of the above are correct43. (g) Only ‘a, b,’ and ‘c’ are correct

44. (c) An amount that must be returned to the patient45. (j) All of the above are correct

46. (f) All of the above are correct 47. (I) All of the above are correct

TOTALS = 84

SECTION V, EXAMINATION II, CUMULATIVE 165 QUESTIONSINCLUDES SECTIONS ON: HEALTH CARE REIMBURSEMENT, MEDICAL CODING -1, CLAIMS MANAGEMENT, CLAIMS PROCESSING, ADVANCED CODING

PART (A): Multiple Choice / Fill-n Blanks:

1. (C)

2. TRUE

3. A and B

4. Employer, Employee, Provider, Carrier

5. Civilian Health and Medical Program of the Uniformed Services (CHAMPUS)

6. 80 %

7. A “Supplemental” policy from another (approved) carrier.

8. PREMIUM DATE

9. COSMETIC SURGERY

10. 65 years and older.

11. Licensed practitioner certified by a carrier to provide care (physician, nurse, etc)

12. The name of an insurance company (BC/BS, AETNA, etc)

13. MEMBER, POLICY HOLDER, RECIPIENT, INSURED

14. PRIVATE CARRIERS = implies that the check will be sent to the provider’s office instead of the patient; TRICARE = the provider agrees to accept the allowable charge as the full fee and cannot charge the patient the difference; MANAGED CARE = assignment is automatic; MEDICAID/MEDICARE/WORKMEN’S COMP = There is no assignment.

15. Social Security Number

PART (B): MATCHING:

1.- F 2.- E 3.- G 4.- M 5.- I 6.- O

7.- D 8.- C 9.- A 10.- K 11.- B12.- J

13.- N14.- H15.- L16.- R17.- Q18.- P

19.- (a).-DUTY (c).-DIRECT CAUSE (b).-DERELICT (d).-DAMAGES

20. What is the MEDICAL ABBREVIATION for the following:

1) four times a day = qid / QID 2) three times a day = tid / TID 3) before meals = a.c. 4) after meals = p.c. 5) nothing by mouth = n.p.o. / NPO 6) once if necessary = s.o.s.

7) as often as necessary = p.r.n. 8) every other day = q.o.d. 9) two drops II gtt 10) at bedtime = h.s./ HS 11) BMR = basal metabolic rate 12) D = diopter (lens/eye)

13) con = consultation 14) CAT = computed axial tomography 15) Bx = biopsy 16) cr* = credit 17) CVA = cerebrovascular accident 18) AGIT = shake, stir 19) as desired = ad lib 20) p.o. = orally / by mouth 21) def* = charge deferred 22) Adj = adjustment 23) C & R = chest radiograph 24) C & S = culture & sensitivity

25) Tx = treatment 26) ASHD = arteriosclerotic heart disease 27) b.i.d. = twice a day 28) p.p.a. = shake the bottle first 29) D. - doses 30) CPX = complete physical exam 31) d = diagnosis, detailed, day(s) 32) ca = cancer, carcinoma 33) ck* = check 34) B/F = balance forward 35) c/a* = cash on account 36) CBS = chronic brain syndrome

DIRECTIONS: FILL-IN THE BLANKS WITH THE MOST APPROPRIATE WORDS:

21. AT LEAST 5 WORDS/EXAMPLES: HONESTY, RESPONSIBILITY, DUTY, COMPASSION, CONFI- DENTIALITY, COMPETENCY, RESPECT,DEDICATED

22.- (a).- What is to be done. (c).- Why it should be done. (b).- Risks involved. (d).- Alternate treatments (or alternate treatment risks)

23.- Arbitration, Litigation.

24.- (a).- When removing from storage. (c).- When returning to storage. (b).- Before preparing medication. (d).- After preparing medication.

25.- (a).- Married minors. (d).- Financially free minors. (b).- Minors in Armed Forces. (e).- Pregnant minors. (c).- Emancipated minors.

PART (C): DEFINE THE FOLLOWING TERMS:

1. HALITOSIS = bad breath2. HEMATOMA = blood blister3. THROMBUS = abnormal stationary blood clot 4. DYSPNEA = difficulty breathing

[SOB = shortness breath]5. TACHYPNEA = rapid breathing

[hyperventilation]6. ORTHOPNEA = positional difficulty breathing

[difficult breathing in upright position]7. HERPES SIMPLEX = cold sore, fever blister 8. OTORRHEA = ear discharge9. CARDIOMEGALY = enlarged heart10. VERTIGO = dizziness11. SYNCOPE = fainting12. DIPLOPIA = blurred vision [double vision]

13. RUBELLA = German Measles 14. ENURESIS = Bedwetting [incontinence of urine]15. PRURITIS = itching16. MYOPIA = nearsightedness 17. CEPHALALGIA = headache18. HYPEROPIA = farsightedness19. EPISTAXIS = nosebleed20. PYURIA = pus in urine21. HERPES ZOSTER = Shingles22. STRABISMUS = squint23. HORDEOLUM = Stye24. DYSPHAGIA = difficulty swallowing25. PERTUSSIS = whooping cough

PART (D): FILL-IN THE BLANKS WITH THE MOST APPROPRIATE WORDS:


a). patient is a member of a managed care organizationb). physician examines a patient at the request of 3rd paying partyc). patient is suing someoned). patients records are subpoenaed or search warrante). other: state law, child/elder abuse, infections, gunshot wounds

2. Name at least three reasons for documentation in the medical record process?

a). avoidance of denied or delayed payments by insurance carriersb). enforcement of medical record keeping rulesc). subpoena of medical records by state and courtd). defense of professional liability claim


(a) eligibility (b) pre-certification (c) pre-authorization (d) pre-determination


(a) Group Plan (b) Individual Plan (c) Pre-paid Health Plan

5. Name the five minimum information requirements needed by third party payers for completion of insurance claim forms:

a). what was done (services/procedure codes) b). why was it done (diagnostic codes) c). when was it performed (date of service - DOS) d). where was it received (place of service - POS) e). who did it (provider name & ID)

PART (E): MATCHING:

1. (D)2. (C) 3. (E)4. (I)5. (H)6. (N)7. (A)8. (L)9. (F)

10. (S)11. (R)12. (M)13. (P)14. (O)15. (W)16. (Q)17. (G)18. (V)

19. (K)20. (U)21. (B)22. (X)23. (T)24. (Y)25. (J)

26. NO FAULT INSURANCE

27. An Expressed Consent is a written formal document giving the physician (provider) permission to begin or continue with a treatment of procedure.

28. NO, He is covered by the “Good Samaritan Act”.

SECTION VI, EXAMINATION I, CUMULATIVE 25 QUESTIONSSAMPLE NHA EXAMINATION

1. (a)2. (a)3. (c)4. (c)5. (d)6. (d)7. (b)8. (c)9. (d)

10. (c)11. (b)12. (d)13. (d)14. (b)15. (c)16. (b)17. (a)18. (a)

19. (c)20. (c)21. (d)22. (c)23. (b)24. (d)25. (b)

SECTION II, EXAMINATION II, SAMPLE NHA EXAMINATION

Certified Billing And Coding Specialist Examination

ANSWER KEY

1. D2. B3. D4. A5. A6. A7. A8. A9. C10. A11. C12. D13. D14. D15. B16. C17. D18. D19. C20. B21. D22. D23. B *24. A25. D26. B27. D28. D29. B30. D31. C32. A33. A34. B

35. C36. D37. B *38. D39. B40. B41. A42. B *43. B44. B45. A46. C47. B48. B *49. A50. A51. A52. A53. D54. C55. B56. D57. C58. C59. D60. D61. B *62. A63. B64. C65. D66. B67. C68. C

69. B70. D71. A72. C73. B74. C75. B76. B *77. C78. B79. A80. B81. C82. C83. B *84. D85. D86. B87. C88. A89. C90. A91. B92. D93. D94. D95. C96. D97. A98. D99. B100. B

Documents

drdmedsearch.com€¦ · Web viewGENERAL INSTRUCTIONS: The attachment is a compilation made for Medical Billing & Coding, and for students use as a Review Symposium for any of the