MED 227: HER and Reimbursement Mid-term Exam



Chapter 1Select the best answer.Health plans are often referred to as:PolicyholdersSubscribersProvidersPayersA managed care network of providers under contract to provide services at discounted fees.Health maintenance organization (HMO)Preferred provider organization (PPO)Point-of-service plan (POS)Open-access planA fixed prepayment made to a medical provider for all necessary, contracted services provided to each patient who is a plan member for a specific period.CapitationBenefitParticipationPayerAn amount that a health plan requires a beneficiary to pay at the time of service for each health care encounter.DeductibleCopaymentCoinsuranceFee-for-serviceA practice’s operating expenses.Cash flowPM/HERAccounts receivableAccounts payableChapter 2Define the following.HIPAA Privacy RuleHIPAA Security RuleMedical recordsProtected Health InformationMedical standards of careChapter 3Select the best answer.This patient has seen the provider (or another provider in the practice who has the same specialty) within the past three years.Established patientReferred patient New patientSurgical patientPatients who do not have insurance coverage are called:New patientsSelf-pay patientsEstablished patientsReturning patientsThe health insurance plan that pays first when more than one plan is in effect.Supplemental insuranceTertiary insuranceSecondary insurancePrimary insuranceThis form includes a patient’s personal, employment, and insurance company data.Encounter formAuthorization formClaim formPatient information formA form used to collect basic demographic information about the patient.Encounter formPatient information formCoordination of benefitsAuthorization formChapter 4Select the best answerA residual condition that remains after a patient’s acute illness or injury has ended.Late effectManifestationEtiologySymptoms A disease’s typical signs, symptoms, or secondary processes.Chronic symptomEtiologyManifestationLate effectAn abbreviation indicating the code to use when a disease or condition cannot be placed in any other categoryNITNECCMSNOS An abbreviation indicating the code to use when no information is available for assigning the disease or condition a more specific code.NECNOSCMSNICThe first-listed diagnosisEponymChief complaintEtiologyPrimary diagnosisChapter 5Select the best answer. These codes cover physicians’ services that are performed to determine the best course for patient careCategory I codesCategory II codesE/M codesAdd-on codes The period of time that is covered for follow-up careGlobal surgery ruleGlobal periodSection guidelinesKey componentThese codes have five digits (with no decimals) followed by a descriptor, which is a brief explanation of the procedureBundle codesCategory II codesCategory I codesCategory III codesTemporary codes for emerging technology, services, and proceduresCategory I codesAdd-on codesBundle codesCategory III codesA two-digit number that may be attached to five-digit procedure codes to indicate special circumstances when performing a procedureModifierPanelPhysical status modifierAdd-on codeChapter 6Select the best answerA private payer’s or government investigator’s review of selected records of a practice for compliance.Internal auditExternal AuditCompliance auditAuditThese audits are routine and are performed periodically without a reason to think that a compliance problem exists.Internal auditExternal auditCompliance auditAuditMedicare’s national policy on correct coding, which is an ongoing process to standardize bundled codes and control improper coding that would lead to inappropriate payment for Medicare claims for physician servicesOIG Fraud AlertCorrect Coding Initiative (CCI)OIG Work PlanRelative Value Scale (RVS)Using a procedure code that provides a higher reimbursement rate than the correct code.Assumptive codingDowncodingUpcodingTruncated codingUsing a lower level code that provides a lower reimbursement rate than the correct code.Assumptive codingDowncodingUpcodingTruncated codingChapter 7Select the best answer.The NPI is used to report the _______ on a claim.Provider identifierPatient identifierPayer identifierEmployer identifierOn HIPAA claims, a required data elementIs optionalMust be suppliedIs entered in capital lettersMust be entered in italicsThe HIPAA X12 276/277 Health Care Claim Status Inquiry/Response transaction is used toTransmit claimsTransmit claim attachmentsAsk about the status of claims that have been transmittedTransmit paper claimsHow many diagnosis code pointers can be assigned to a procedure code?OneTwoThreeFourThe number of the HIPAA Professional claim transaction isCMS-1500HCF-1500X12 837PX12 834Chapter 8Select the best answer.Which laws govern the portability of health insurance?ERISA and HIPAACOBRA and HIPAAPPO and HMOFEHB and ERISAProviders who participate in a PPO are paidA capitated rateA discounted fee-for-serviceAn episode-of-care paymentAccording to their usual physician fee scheduleWhat document is researched to uncover rules for private payers’ definitions of insurance-related terms?ERISAParticipation contractHIPAA Security RateRiderIn employer-sponsored health plans, employees may choose their plan during theCarve outOpen enrollment periodContract periodBirthday rule periodSelf-funded health plans are regulated byPHIPPOFEHBERISAChapter 9Select the best answer.Medicare part A coversPhysician servicesPrescription servicesHospital servicesMACsThe Original Medicare Plan requires a premium, a deductible, andMedigapSupplemental insuranceCoinsuranceHIPAA TCSUnder Medicare’s global surgical package regulations, a physician may bill a patient separately forSpplies used during the surgical procedureProcedures performed after the surgery to minimize painDiagnostic tests required to determine the need for surgeryThe removal of tubes, sutures, or cathetersOn Claims, CMS will NOT accept signatures thatAer handwrittenAre electronicUse facsimiles of original written/electronic signaturesUse signature stampsUnder the Medicare Part B traditional fee-for-services plan, Medicare pays _____percent of the allowed charges758090100Chapter 10Select the best answerUnder the Federal Medical Assistance Program, the federal government makes payment directly to healthcare coverage under a state ______ programTANFCategorically needyRestricted statusMedically needyUnder Medicaid, optional services commonly includeExperimental proceduresX-ray servicesFQHC, servicesProsthetic devicesThe Medicaid Alliance for Program SafegaurdsSpecifies civil and criminal penalties for fraudulent activitiesAudits state Medicaid payers on a regular basisIs a CMS program that came about as a result of the Welfare Reform ActOversees states’ fraud and abuse effortsIf services were provided in an emergency room, what place of service code is reported? (Hint: refer to Appendix C)24C1824I23To provide services to Medicaid recipients, physicians must sign a contract with the MIPHHSOIGCMS ................
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