MEDICAL BILLING REVIEW PACKET



MEDICAL BILLING REVIEW PACKET (FOR FIRST 3 EXAMS) FOR THE MEDICAL ASSISTANT

STUDENT REVIEW SHEET (PART I)

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. [pic] = 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:

21. List the four major reasons for the development and use of diagnostic codes:

a. Tracking of disease processes.

b. Classification of causes of mortality

c. Medical research

d. 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 consultations

c). 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 Operation

b). 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 Components

b). Contributory Factors

c). Face-to-Face Time with the patient or family.

STUDENT REVIEW SHEET (PART II)

DEFINE THE FOLLOWING HEALTH CARE PLANS:

1. COMPETITIVE MEDICAL PLAN

2. HEALTH MAINT ORGANIZATION

4. EXCLUSIVE PROVIDER ORG

5. FOUNDATION FOR MED. CARE

6. INDEPENDENT (INDIVIDUAL) PRACTICE ASSOCIATION

7. MATERNAL & CHILD HLTH PGM

8. MEDICAID

9. MEDICARE

10. MEDICARE/MEDICAID

11. POINT OF SERVICE PLAN

12. PREFERRED PROVIDER ORG.

13. TRICARE

14. UNEMPLOYMENT COMP. DIS

15. CHAMPVA

16. 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 ?

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

SHORT FORM DEFINITIONS:

1. HALITOSIS = bad breath

2. HEMATOMA = blood blister

3. 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 discharge

9. CARDIOMEGALY = enlarged heart

10. VERTIGO = dizziness

11. SYNCOPE = fainting

12. DIPLOPIA = blurred vision [double vision]

13. RUBELLA = German Measles

14. ENURESIS = Bedwetting [incontinence of urine]

15. PRURITIS = itching

16. MYOPIA = nearsightedness

17. CEPHALALGIA = headache

18. HYPEROPIA = farsightedness

19. EPISTAXIS = nosebleed

20. PYURIA = pus in urine

21. HERPES ZOSTER = Shingles

22. STRABISMUS = squint

23. HORDEOLUM = Stye

24. DYSPHAGIA = difficulty swallowing

25. 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

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