Deck 6: Visit Charges and Compliant Billing

Question 1

If balance billing is allowed, the provider

A) writes off the entire patient bill.
B) bills the patient for the total amount of the bill.
C) bills the patient for the difference between a higher usual fee and a lower allowed amount.
D) writes off the difference between a higher usual fee and a lower allowed amount.

Answer 1

bills the patient for the difference between a higher usual fee and a lower allowed amount.

Question 2

EMRs have which of the following to assist physicians with their documentation process?

A) automatic Code Linkage Tool
B) documentation templates
C) billing programs
D) voice recognition software

Answer 2

documentation templates

Question 3

Medical insurance specialists rely on which of the following to stay up to date with payers billing rules?

A) websites
B) regular communications
C) bulletins
D) all of these are correct.

Answer 3

all of these are correct.

Question 4

What is the fixed prepayment for each plan member in a capitation contract called?

A) provider withhold
B) capitation rate
C) allowed amount
D) usual fee

Question 5

______________ refers to a coding problem in which a procedure code is used that provides a higher reimbursement than the correct code.

A) Assumption coding
B) Downcoding
C) Upcoding
D) Truncated coding

Question 6

When regulations seem contradictory or unclear, the OIG issues

A) advisory opinions.
B) legal advice.
C) bulletins.
D) professional polls.

Question 7

Which of the following is not fraudulent?

A) using a non-specific diagnosis code
B) altering documentation after services are reported
C) reporting services provided by unlicensed personnel
D) coding without proper documentation

Question 8

In an allowed charges payment method, if the provider's charge is lower than the allowed amount, the reimbursement is based on

A) the amount billed.
B) the co-insurance.
C) the deductible.
D) the amount allowed.

Question 9

Maximum charge a plan pays for a service or procedure may be referred to as

A) allowed charge.
B) allowed amount.
C) maximum allowable fee.
D) all of these are correct.

Question 10

The Medicare allowed charge for a procedure is $150, and a PAR provider's usual charge is $200. What amount must the provider write off?

A) $100
B) $150
C) $30
D) $50

Question 11

Only the codes that ___________ should be reported.

A) are supported by the documentation
B) the coder thinks will get paid
C) the nurse tells the coder to assign
D) are circled by the physician superbill

Question 12

What is the purpose of X modifiers?

A) Describe unlisted HCPCS codes.
B) Report bilateral codes.
C) Report subsets of E/M codes.
D) Define subsets of modifier 59.

Question 13

Which is not a characteristic of correctly linked codes?

A) The procedures are provided at an appropriate level.
B) The procedures are not elective, experimental, or nonessential.
C) The procedure codes are truncated.
D) The procedure codes match the diagnosis codes.

Question 14

The conversion factor is a(n) __________.

A) unit.
B) time allowance.
C) number.
D) dollar amount.

Question 15

______________ refers to a coding problem in which the age of the patient and the selected code do not match.

A) Incorrect coding
B) Assumption coding
C) Downcoding
D) Upcoding

Question 16

What is another term for contractual adjustment?

A) write off
B) co-payment
C) co-insurance
D) deductions

Question 17

The ___________ lists the types of medical billing and reporting practices that the Office of Inspector General intends to investigate in the coming year.

A) CMS Website
B) OIG Website
C) OIG Advisory Opinions
D) OIG Work Plan

Question 18

What type of coding uses a procedure code that provides a higher reimbursement rate than the correct code?

A) downcoding
B) assumption coding
C) upcoding
D) truncated coding

Question 19

To calculate RBRVS fees, multiply each RVU by its __________, add the three adjusted totals, and multiply the sum by the conversion factor.

A) time allowance
B) GPCI
C) conversion factor
D) UCR

Question 20

Most practices set their fees

A) slightly above those paid by the lowest reimbursing plan.
B) slightly below those paid by the lowest reimbursing plan.
C) slightly above those paid by the highest reimbursing plan.
D) slightly below those paid by the highest reimbursing plan.

Question 21

Under RBRVS, the nationally uniform relative value is based on

A) the provider's work, practice cost, and malpractice insurance costs.
B) the geographic adjustment factor.
C) the UCR, practice cost, and malpractice insurance costs.
D) the uniform conversion factor.

Question 22

The standard conversion factor for any year is __________.

A) 1.54
B) 1.0
C) 1.19
D) varied

Question 23

Using a job reference aid may lead to

A) an easy way to find the linked diagnosis and procedure codes.
B) the way to look up codes since offices don't have coding manuals.
C) questions about compliance.
D) Correct E/M codes

Question 24

The cost of a practice depends on all of the following except

A) office rental prices.
B) malpractice insurance.
C) local taxes.
D) all of these are determinants.

Question 25

What are the main methods payers use to pay providers?

A) capitation and retrospective payments
B) contracted fee schedule and capitation
C) allowed charges
D) allowed charges, contracted fee schedule, and capitation

Question 26

In the CCI, which type of codes cannot both be billed for a patient on the same day of service?

A) unbundled
B) mutually exclusive
C) black box
D) diagnostic

Question 27

Although anyone who comes into contact with a medical record is responsible for the accuracy of his or her own entry, who in the medical practice is ultimately responsible for proper documentation and correct coding?

A) registered nurse
B) payer representative
C) physician
D) medical coder

Question 28

All of the following are common billing errors except

A) billing with proper signatures on file.
B) upcoding.
C) unbundling.
D) billing noncovered services.

Question 29

The CMS/AMA Documentation Guidelines set up the rules for the selection of

A) Evaluation and Management codes.
B) Surgery codes.
C) Pathology and Laboratory codes.
D) Anesthesia codes.

Question 30

In an allowed charges payment method, if a provider's charge is higher than the allowed amount, the provider's reimbursement is based on

A) the amount billed.
B) the amount allowed.
C) the co-insurance.
D) the deductible.

Question 31

What type of external audit is performed by payers before claims are processed?

A) prepayment
B) prospective
C) retrospective
D) postpayment

Question 32

A conversion factor is multiplied by a _________ to arrive at a charge.

A) charge
B) relative value unit
C) time allowance
D) fee schedule

Question 33

Which of the following modifiers is important for compliant billing?

A) -59
B) -91
C) all of these are important
D) -25

Question 34

The _________ is the method used to set fees for Medicare.

A) RBRVS
B) UCR
C) RVU
D) GPCI

Question 35

If a practice accepts credit and debit cards, it must follow which standard?

A) FERPA
B) HIPAA
C) PCI DSS
D) HITECH

Question 36

The relative value unit is assigned to a service based on the

A) time and skill required to perform it.
B) extent of procedure and skill required to perform it.
C) amount of anesthesia and equipment needed to perform it.
D) time and equipment needed to perform it.

Question 37

RACs use a software program to analyze a practice's claims, looking for

A) excessive number of units billed.
B) medically unnecessary treatment.
C) obvious "black and white" coding errors.
D) all of these are analyzed.

Question 38

Which of the following means that a physician has chosen to waive the charges for services to other physicians?

A) adjustment
B) edits
C) audit
D) professional courtesy

Question 39

Which of the following three factors are built into the resource-based fee structure?

A) time of procedure, office overhead, risk of procedure
B) difficulty of procedure, anesthesia costs, risk of procedure
C) difficulty of procedure, office equipment, risk of procedure
D) difficulty of procedure, office overhead, risk of procedure

Question 40

What type of audit do payers routinely conduct to ensure that claims are compliant with the provisions of their contracts?

A) prospective
B) postpayment
C) retrospective
D) prepayment

Question 41

A charge that is written off is

A) balance billed to co-insurance.
B) just written off.
C) deducted from patient's account.
D) balance billed to the patient.

Question 42

If balance billing is permitted under a plan, the insured must

A) pay nothing since it is part of the contractual agreement.
B) pay for the entire provider's charge.
C) pay for the difference between the provider's charge and the allowed charge.
D) pay for only his/her deductible.

Question 43

Which of the following audits Medicare claims to determine if there is an opportunity to recover incorrect payments from previously paid services?

A) Recovery Audit Contractor
B) staff members
C) external consulting company
D) Compliance Officer

Question 44

Which of these payment methods is the basis for Medicare's fees?

A) RVS
B) GPCI
C) RBRVS
D) UCR

Question 45

PMP is the abbreviation for

A) practice management program.
B) physician medical program.
C) practice medical program.
D) physician management program.

Question 46

The Medicare allowed charge is $240 and the participating (PAR) provider's usual charge is $600. What amount does the patient pay, if the deductible has already been paid?

A) $192
B) $48
C) $480
D) $120

Question 47

Medical necessity is based on

A) number of diagnoses.
B) number of procedures.
C) the relationship between the diagnosis and the treatment provided.
D) extent of treatment.

Question 48

The unit of service (UOS) edits that CMS uses are called

A) geographic practice cost index (GPCI).
B) Recovery Audit Contractors (RACs).
C) medically unlikely edits (MUEs).
D) Correct Coding Initiative (CCIs).

Question 49

Which of the following is not a medically necessary procedure?

A) cosmetic nasal surgery
B) deviated septum surgery
C) nasal obstruction removal
D) acquired facial deformity surgery

Question 50

If a payer judges that a code level assigned by a practice is too high for a reported service, the usual action is to

A) upcode the reported procedure code.
B) add a modifier to the reported procedure code.
C) deny the claim.
D) downcode the reported procedure code.

Question 51

Medical insurance specialists help ensure maximum appropriate reimbursement for services by

A) submitting claims to get the maximum reimbursement.
B) submitting claims that are correct and compliant.
C) submitting claims after an approval from the third-party carrier.
D) submitting claims only if the doctor approved.

Question 52

A __________fee structure reflects the amounts that providers typically charge for services and procedures.

A) charge-based
B) resource-based
C) fee-based
D) time-based

Question 53

Medical practices use __________ to help them in the billing and coding process.

A) advisory opinions
B) job alerts
C) job reference aids
D) bulletins

Question 54

What type of audit is performed internally after claims are submitted?

A) prospective audit
B) accreditation audit
C) retrospective audit
D) routine payer audit

Question 55

A relative value scale assigns a higher relative value to a procedure that requires more

A) all of these.
B) effort.
C) skill.
D) time.

Question 56

The Correct Coding Initiative (CCI) is a program of

A) workers' compensation.
B) TRICARE.
C) Medicare.
D) CHAMPVA.

Question 57

If a nonparticipating provider's usual fee is $600, the allowed amount is $300, and balance billing is permitted, what amount is written off?

A) $0
B) $150
C) $480
D) $300

Question 58

The Medicare allowed charge for a procedure is $80. What amount does the participating provider receive from Medicare, and what amount from the patient, assuming the patient deductible has been met?

A) $40/$20
B) $64/$16
C) $80
D) $60/$20

Question 59

The amount withheld from a provider's payment by an MCO is called

A) allowed charge.
B) capitation rate.
C) provider withhold.
D) contractual discount.

Question 60

Correct claims report the connection between a billed service and a diagnosis. This is called

A) bundled payment.
B) code linkage.
C) balance billing.
D) downcoding.

Question 61

Many state and federal laws prohibit which of the following?

A) professional courtesy
B) edits
C) audits
D) adjustments

Question 62

In the CCI, which type of code cannot be billed together with a column 1 code for the same patient on the same day of service?

A) exclusive
B) column 2
C) diagnostic
D) edit

Question 63

Some possible consequences of inaccurate coding and incorrect billing in a medical practice are

A) all of these are correct.
B) denied claims and reduced payments.
C) prison sentences.
D) fines.

Question 64

A change to a patient's account is a(n)

A) contractual agreement.
B) deduction.
C) adjustment.
D) payment.

Question 65

The purpose of the GPCI is to account for

A) differences in relative work values.
B) regional differences in costs.
C) none of these are correct.
D) changes in the cost of living index.

Question 66

The "provider withhold" required by some managed care plans may

A) be repaid to the physician.
B) be repaid to the hospital.
C) be repaid to the patient.
D) be repaid to the managed care organization.

Question 67

One type of job reference aid is

A) a list of pre-linked diagnosis and procedure codes.
B) a list of the practice's frequently reported diagnosis and procedure codes.
C) a list of the practice's frequently reported diagnoses.
D) a list of the practice's frequently reported procedures.

Question 68

If a RAC's request is not answered within an appropriate amount of time, which of the following might occur?

A) None of these are correct.
B) An error is declared.
C) Penalties may result.
D) An error is declared and penalties may result.

Question 69

RVS is the abbreviation for

A) resource volume size.
B) resource value scale.
C) relative volume size.
D) relative value scale.

Question 70

Professional courtesy refers to providing free services to

A) poor patients.
B) other physicians and their families.
C) none of these are correct.
D) patients who pay on time.

Question 71

What type of coding uses diagnoses that are not as specific as possible?

A) assumption coding
B) upcoding
C) downcoding
D) truncated coding

Question 72

What type of audit is performed internally before claims are reported?

A) retrospective audit
B) accreditation audit
C) routine payer audit
D) prospective audit

Question 73

Recovery Audit Contractors' (RAC's) requests for information must be answered in __________ days.

A) 45
B) 30
C) 60
D) 90

Question 74

GPCI is the abbreviation for

A) geographic practice charges index.
B) geographically practicing cost indices.
C) geographic practice cost index.
D) geographically placing charges inline.

Question 75

Under a contracted fee schedule, the allowed amount and the provider's charge are

A) different.
B) the same for Medicare patients only.
C) the same.
D) the same for private pay patients only.

Question 76

The Medicare conversion factor is set

A) each decade.
B) annually.
C) semi-annually.
D) twice a year.

Question 77

How is upcoding being monitored by payers?

A) Benchmarking practice's E/M codes with local averages
B) collecting practice's contracts each year
C) collecting practice's profit and loss statement each year
D) Benchmarking practice's E/M codes with national averages

Question 78

The Medicare Physician Fee Schedule is based on

A) RBRVS fees.
B) provider fees.
C) UCR fees.
D) custom fees.

Question 79

The RBRVS fees are based on the __________analysis of what each service costs to provide.

A) federal government's
B) state government's
C) local government's
D) insurance's

Question 80

The three parts of an RBRVS fee are

A) None of these are correct.
B) uniform value, GPCI, and conversion factor.
C) usual, customary, and reasonable charges.
D) usual charges, GPCI, and conversion factor.