Deck 6: Financial Management: Insurance and Billing Functions

Question 1

Of the following, which is not a reason that the United States did not implement ICD-10 at the time other countries did?

A) costly to convert from one coding system to the other
B) decision whether ICD-10 or CPT would be used to code diagnoses
C) increased training needs
D) unknown whether ICD-10 would meet the needs of the United States

Answer 1

decision whether ICD-10 or CPT would be used to code diagnoses

Question 2

Nick Malone underwent an appendectomy by Dr. Lopez on September 5. Dr. Lopez documented appendicitis as Mr. Malone's diagnosis. The diagnosis was documented

A) to show medical necessity.
B) to determine how much the procedure will cost.
C) to prove why Mr. Malone missed work.
D) to prove what procedure was done.

Answer 2

to show medical necessity.

Question 3

Converting narrative diagnoses and procedures into numeric form is known as

A) conversion.
B) coding.
C) statistics.
D) reporting.

Answer 3

coding.

Question 4

In many managed care plans, patients are responsible for paying a portion of the charges (fixed amount) at the time services are rendered. This is known as the

A) deductible.
B) coinsurance.
C) co-pay.
D) balance.

Question 5

Groups of doctors and other healthcare providers and facilities who voluntarily form a partnership that results in high-quality, coordinated healthcare is known as a/an

A) traditional insurance plan.
B) Managed care plan.
C) Fee-for-service plan.
D) Accountable Care Organization.

Question 6

The amount charged for each service provided in a medical practice is known as a

A) chargemaster.
B) fee schedule.
C) ledger.
D) day sheet.

Question 7

The actual claim process begins when the patient

A) is discharged.
B) makes the appointment.
C) is seen by the care provider.
D) pays the bill.

Question 8

Which is true of ACOs?

A) There are currently two models: Medicare Shared Savings and Advance Payment Model.
B) Sharing of patient information through an EHR is necessary.
C) Data can be in structured or unstructured form.
D) Participation in an ACO is voluntary.

Question 9

The type of insurance plan that promotes quality, cost-effective healthcare by monitoring patients, encouraging preventive care, and requiring performance measures of physicians is known as

A) Medicare Part
B) managed care.
C) fee-for-service.
D) consumer driven.

Question 10

The term used to describe the relationship between ICD-10 and CPT codes, demonstrating medical necessity, is

A) code verification.
B) billing processes.
C) code linkage.
D) medical necessity application.

Question 11

Which of the following is a true statement about ICD-10-CM/PCS?

A) It will only be used in physicians' office settings.
B) Current coders will need to relearn how to code.
C) Healthcare facilities will have the choice to either continue to use ICD-9-CM or convert to ICD-10-PCS.
D) The adoption of ICD-10-CM/PCS was endorsed by the American Medical Association in 1990.

Question 12

ICD-10-CM/PCS was implemented because

A) the American Medical Association has requested it.
B) ICD-9-CM no longer meets the needs of healthcare organizations.
C) it is already in use in Canada.
D) ICD-9-CM is out of print.

Question 13

Knowingly billing for services that are not medically necessary or that did not happen at all is

A) unintentional.
B) commonplace.
C) fraud.
D) abuse.

Question 14

The coding system used in illustrating the tangible items such as supplies is

A) ICD-9-CM.
B) HCPCS level 2.
C) CPT.
D) ICD-10-CM/PCS.

Question 15

Which of the following is a true statement about using practice management (PM) software for an office's claims management process?

A) It prevents automated functions.
B) Insurance verification is completed automatically.
C) It is required by Medicare.
D) It allows for more efficient tracking and reporting of daily transactions.

Question 16

The source document for completing the actual insurance claim form is the

A) medical record.
B) CMS-1500.
C) UB-04.
D) encounter form.

Question 17

As a result of which piece of legislation are hospitals and providers reimbursed based on proof that they are rendering high-quality, coordinated care to their patients?

A) Health Information Technology for Economic and Clinical Health Act (HITECH)
B) Health Insurance Portability and Accountability Act (HIPAA)
C) Affordable Care Act (ACA)
D) Amendment to the Social Security Act

Question 18

In a physician's office, procedures and services are converted into numeric form using which coding system?

A) ICD-9-CM
B) HCPCS
C) CPT
D) ICD-10-CM/PCS

Question 19

As of October 1, 2015, the coding system used to code diagnoses in any healthcare setting is

A) ICD-9-CM.
B) HCPCS level 2.
C) CPT.
D) ICD-10-CM.

Question 20

Which of the following is not part of a paper encounter form (Superbill)?

A) name of the medical practice
B) CPT codes for procedures
C) the medical history
D) ICD-10-CM diagnosis codes

Question 21

The primary person covered by an insurance plan is the

A) patient.
B) prescriber.
C) subscriber.
D) provider.

Question 22

An insurance company submits payment to a medical practice, along with a document that details the patients and accounts for which payment is made. This document is called the

A) Superbill.
B) encounter form.
C) remittance advice.
D) subscriber benefits notice.

Question 23

The last step in the revenue cycle is

A) review coding compliance.
B) pre-register patients.
C) follow up payments and collections.
D) establish financial responsibility.

Question 24

In the Superbill Summary shown, code 80053 is what type of code?

Question 25

Of the following, which would be included on a remittance advice or explanation of benefits?

A) total charges for a patient's account
B) subscriber's address
C) effective date of insurance
D) employer's information

Question 26

Which entity investigates suspected cases of fraud?

A) Office of Inspector General
B) Drug Enforcement Agency
C) Centers for Medicare and Medicaid Services
D) HIPAA Monitoring Agencies

Question 27

In the Superbill Summary shown, what type of visit did this patient have?

Question 28

Dr. Simmons' office has been notified that they are being audited due to a complaint that was filed by a Medicare patient regarding their billing practices. The audit will be conducted by the

A) Office of Civil Rights.
B) Centers for Medicare and Medicaid Services.
C) Internal Revenue Service.
D) Office of Inspector General.

Question 29

Describe accounts receivable.

Question 30

Roberta is going over the form with a patient; the form includes such information as the name of the patient, the provider's name and NPI number, the date of the visit, numeric codes corresponding to the patient's diagnoses and procedures performed that day. This form is called a Superbill and is otherwise known as what?

Question 31

What is the name of the document typically sent by insurance companies to a subscriber detailing the services and charges submitted for payment by the medical office, the allowed amount, the co-pay satisfied by the patient, any deductible due, the amount paid by the insurance company, and the amount owed by the subscriber?

Question 32

In the Superbill Summary, shown what were the charges for the 30-minute office visit?

Question 33

Coding practices that are inconsistent with typical practice are known as

A) fraud.
B) abuse.
C) illegal activity.
D) incorrect coding.

Question 34

Roberta is a billing coordinator at Greenway Medical Center. She is in the process of determining whether a patient is covered by insurance, whether a co-payment is due, and whether the patient has met his deductible. What function is Roberta performing?

Question 35

A formal, written document that describes how a hospital or physician practice ensures that rules, regulations, and standards are being adhered to is called a/an

A) OIG order.
B) OSHA plan.
C) compliance plan.
D) Qui Tam network.

Question 36

Philip James has been a patient at Greensburg Medical Center for three years. During that time, he has been seen twice for annual physical exams, three times for ear infections, and four times for follow-up of his hypertension. How many encounters does Mr. James have at Greensburg Medical Center?

Question 37

Dr. Markunas saw Drew Panek in his office today. Drew was diagnosed with strep pharyngitis. The diagnosis is otherwise known as which element of a SOAP note?

Question 38

____________________ CPT codes are used to capture the face-to-face time spent between a patient and the care provider.

A) Revenue
B) Diagnostic
C) Evaluation and management
D) Physical exam

Question 39

The coding system that is used to code services and procedures in a physician's office is _____________.

Question 40

An alphanumeric code that corresponds to each diagnosis made by the care provider, and is included on every claim form is known as what kind of code?

Question 41

Dr. Lewis's office collects patients' co-pays at the time of arrival; Dr. Mbadu's office collects the co-pay as the patient is leaving the visit. Is one method more advisable than the other? Explain your answer.

Question 42

An electronic claims process is more efficient than a manual process. Why?

Question 43

The out-of-pocket payment amount that a policyholder must meet before insurance coverage begins is called the

A) deductible.
B) coinsurance.
C) co-pay.
D) balance.

Question 44

Explain the factors that are taken into account when assigning an evaluation and management (E&M) code.

Question 45

Daniel Burke, a patient of Dr. Etherington, had a minor procedure performed in the office on May 5. His insurance paid a portion of Dr. Etherington's bill, but the insurance company denied payment for the procedure itself. Because of an administrative error, the office is not holding Mr. Burke responsible for the balance. Is it still necessary for that service to be included on the patient's account? Why or why not?

Question 46

Citing three examples, discuss how insurance plans differ.

Question 47

Explain the fee-for-service reimbursement system as it compares to the reimbursement model used as a result of the Affordable Care Act (ACA).

Question 48

The process of reviewing claims to determine payment is called

A) adjudication.
B) confirmation.
C) code linkage.
D) fraud check.

Question 49

All of the insurance companies and the individual plans of patients in a medical practice are included in what database of the practice's practice management software?

Question 50

Mrs. Lam was sent from her doctor's office to the outpatient laboratory for a urinalysis. Her insurance company denied the claim, stating that the procedure was not necessary. The healthcare professional reviewed the claim and saw that a urinalysis was ordered, and the diagnosis listed on the encounter form was upper respiratory infection. Why was this claim denied?

Question 51

Some insurance plans will pay for certain services and some will not. Explain this concept and give an example.

Question 52

A formal, written document that describes how a physician's practice or hospital ensures that rules, regulations, and standards are being adhered to is known as what kind of plan?

Question 53

Jeannie Lopez has never been seen in Greensburg Medical Center. The evaluation and management code assigned will be based on the fact that she is a/an ___________ patient.

Question 54

Explain why the health record is the source document for coding diagnoses and procedures.

Question 55

The charge for each service (by CPT code) provided in a medical practice is known as the fee ________________.

Question 56

Why was it necessary to convert from ICD-9 to ICD-10?