NAME:_____________________ INSTITUTE HEALTH ED [IHE ...



* FINAL EXAMINATION * [Version #1]

Medical Billing & Coding

SECTION 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 `only' 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 physi-

cians 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 require-

ments, 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): Place a circle around the `letter' containing the `best' and most applicable answer. One answer only !

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 ____?

a. Block 24

b. Block 33

c. Block 21

d. None of the above

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

a. Four

b. Six

c. Two

d. None of the above

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

a. Qualified diagnosis

b. Possible diagnosis

c. Primary diagnosis

d. 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 diagnosis

b. List the diagnosis as secondary

c. List the diagnosis as probable

d. None of the above

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

a. Rule out

b. Suspicious for

c. Possible

d. None of the above

27. Some claims require attachments such as _____?

a. Clinic notes

b. Operative reports

c. Discharge summaries

d. All of the above

SECTION III: FILL-IN BLANK DIRECTIONS: 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: ADVANCED CODING: DIRECTIONS: Assign codes to the following:

40. Removal of foreign body in tendon sheath, simple. Code(s): ___________

41. Puncture aspiration of cyst of breast. Code(s): ___________

42. Incision and drainage of thyroid gland cyst. Code(s): ___________

43. Abrasion, single lesion. Code(s): ___________

44. Destruction of four flat warts. Code(s): ___________

45. Incision and drainage of ankle abscess. Code(s): ___________

46. Incision and drainage of wrist hematoma. Code(s): ___________

47. Aspiration thyroid cyst. Code(s): ___________

48. Laparoscopy with bilateral total pelvic lymphadenectomy and

periaortic lymph node biopsy. Code(s): ___________

49. Acute prostatitis due to streptococcus. Code(s): ___________ _____________

50. Gangrene, left great toe, due to Diabetes Mellitus type I. Code(s): ___________ _____________

51. Vitamin D-resistant Rickets. Code(s): ___________

52. Newborn female delivered in the hospital by cesarean delivery

with evidence of cleft palate and cleft lip. Code(s): ___________ _____________

SECTION V: FILL-IN BLANK DIRECTIONS: 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 !

53. Define the term “Balance Billing ? ______________________________________________________________________

________________________________________________________________________________________________

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

________________________________________________________________________________________________

55. List three forms of MSP Medicare beneficiaries often purchase to cover the Medicare deductible and coinsurance

requirements:

a). ______________________________________________________________________

b). ______________________________________________________________________

c). ______________________________________________________________________

56. List five advantages of joining a Medicare HMO ?

a). ______________________________________________________________________

b). ______________________________________________________________________

c). ______________________________________________________________________

d). ______________________________________________________________________

e). ______________________________________________________________________

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

a. The patient

b. Medicare

c. The HMO

d. Only a and b are correct

e. All of the above are correct

f. None of the above are correct

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

a. 90 days

b. 60 days

c. 45 days

d. one year

e. All of the above are correct

f. None of the above are correct

SECTION VI: 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 `only' letters!

59. 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 collabor-

ates to that groups location in addition to the group number.

60. 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.

61. MODIFIER _______________________ C). this is any medicare claim that contains complete, necessary information but is illogical or incorrect.

62. (( _______________________ 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.

63. [pic] ____________________________ E). this is a carrier assigned number that every physician uses to render services to patients when

submitting claim forms for insurance purposes.

64. ( __________________________ F). A single code that describes or covers two or more component codes that are bundled together as

one unit.

65. ⊘ ___________________________ G). permits the physician to indicate circumstances in which a procedure as performed differs in some

way from that described by its usual code.

66. ( ___________________________ 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.

67. ( ___________________________ I). this claim happens when the medicare contractor cannot process a claim for a particular service or

bill type.

68. 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)

69. REASONABLE FEE ______________ K). this is the code sign for an “add on code”.

70. 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.

71. DINGY CLAIM ____________________ M). this code sign indicates “ a revised code”.

72. 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.

73. INVALID CLAIM ___________________ O). this is the code sign for a modifier which generally has a negative sign with two digit number.

74. CLEAN CLAIM ____________________ P). this is the code sign for “a new or revised text”.

75. PIN NUMBER ____________________ Q). this is the code sign for a “new code”.

76. NPI NUMBER _____________________ R). term used to define coding and billing numerous CPT codes to identify procedures that usually are

described by a single code.

77. 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.

78. PPIN number ____________________ T). this code sign implies “service includes surgical procedure only”.

SECTION VII: 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 `only' letters!

79. DME Number _____________ A). this is an insurance claim submitted to an insurance carrier that is discarded by the system because of a techni-

cal 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.

80. 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.

81. EIN NUMBER _______________C). this means that the claim was submitted within the program or policy time limit and contains all the neces-

sary information so it can be processed and paid promptly.

82. 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.

83. GROUP PROVIDER NUMBER___E). these are insurance claims with no staples or highlighted areas and with non-deformed bar codes.

84. 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.

85. OCR ________________________G). this is a claim sent to the insurance carrier as a paper claim by fax & never printed to paper at receiving end.

86. 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.

87. 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.

88. 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.

89. 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.

90. 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.

91. 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.

92. 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.

93. 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 VIII: CASE STUDY: 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

Knee Surgery $650

EKG $45

OV#1 (99201) $75

MEDS $35

Abscess I & D $75

Injection $35

U / A $35

CBC $25

CBC+Diff $45

X-rays $20

Cholangiogram $90

U/A + Culture $60

Nitro Pads $55

Diuretics $40

MEDS (bactrim) $22.50

Ventolin $11

Double X-rays $40

Chest P&A $45

Lat. X-Rays $45

Digoxin Inj. $25

B12 Inj. $40

Nitro (meds) $40

Bronchogram $150

CXR(AP/Lat) $75

OV HCN PF

Hx /SF MDM $134.99

[MEDICARE]

ABG O2 $85

PFT”s $125

OV C hx/exam

MC MDM $138.50

IV MEDS $25

OV PF

Hx /SF MDM $36.80

[MEDICARE]

Skene Excision $165

MRI (s contrast) $175

Suture 2-5 cms Laceratiion $125

ER and/or Physician Consult $85

Cauterization $65

Suture Removal Kit $45

Septoplasy $653

Professional Courtesy (-$55)

C x R (2views) $65

Elect Panel SMAC12 $45

CT Thorax/Contrast $125

IM Inj. Drug $25

C & S Test $45

Culture Transport $35

PATIENT MEDICAL RECORD:

[pic]

MANUAL RECORDING OF CHARGES: [ GRADED COMPONENT ]

TOTALS = 117

-----------------------

OLD PATIENTS (Established)

99211 OV#1 Level 1 $16.07

99212 OV#2 Level 2 $28.55

99213 OV#3 Level 3 $40.20

99214 OV#4 Level 4 $61.51

99215 OV#5 Level 5 $96.97

NEW PATIENTS

99201 OV#1 Level 1 $33.25

99202 OV#2 Level 2 $51.91

99203 OV#3 Level 3 $70.92

99204 OV#4 Level 4 $106.11

99204 OV#5 Level 5 $132.28

EMERGENCY DEPARTMENT

(New/Established Patient)

99281 PF hx/exam SF MDM $24.32

99282 EPF hx/exam LC MDM $37.02

99283 EPF hx/exam MC MDM $66.23

99284 D hx/exam MC MDM $100.71

99285 C hx/exam HC MDM $158.86

HOSPITAL

(Observation Svcs / New or Established)

99217 Discharge $66.88

[?]"#*[pic]OJPJQJ\?hbEÓhjrHOJ99218 D hx/exam SF / LC MDM $74.22

99219 C hx/exam MC / MDM $117.75

99220 C hx/exam HC / MDM $147.48

DATE: CHARGE EXPLANATION: CODE #: AMOUNT CHARGED:

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