Deck 11: Physician Medical Billing

Question 1

The majority of income in a physician's office comes from:

A)bank loans.
B)payments from insurance companies.
C)payments from patients.
D)private donations.

Answer 1

payments from insurance companies.

Question 2

An advantage of filing claims electronically is:

A)lower administrative costs.
B)fewer claim rejections.
C)faster payment.
D)all of the above.

Answer 2

all of the above.

Question 3

A claim can only be submitted to an insurance carrier on the patient's behalf if the patient has signed a(n):

A)assignment of benefits form.
B)explanation of benefits form.
C)patient information form.
D)release of information form.

Answer 3

release of information form.

Question 4

Most providers submit medical claims:

A)using paper forms and optical scanners.
B)by mailing paper forms.
C)electronically.
D)by faxing paper forms.

Question 5

A company that receives claims from providers, audits them, and forwards them on to insurance carriers is a(n):

A)billing service.
B)independent auditing firm.
C)clearinghouse.
D)third-party administrator.

Question 6

The individual who purchases an insurance policy is known as the:

A)employee.
B)guarantor.
C)patient.
D)policyholder.

Question 7

The person who is ultimately responsible for payment to the medical office is called the:

A)guarantor.
B)patient.
C)guardian.
D)insured.

Question 8

A company that provides data processing and claims processing services to medical practices is a(n):

A)billing service.
B)independent auditing firm.
C)clearinghouse.
D)third-party administrator.

Question 9

A UB-04 claim form is used by:

A)physician offices.
B)hospitals.
C)surgeons.
D)therapists.

Question 10

A patient information form typically includes:

A)demographic information.
B)employment information.
C)insurance information.
D)all of the above.

Question 11

Clearinghouses charge providers based on which type of
payment system?

A)A percentage of each claim's dollar value
B)A flat fee per claim
C)Per diem
D)Per membership per month

Question 12

If a patient wishes insurance payments to be made directly to the provider, the patient must sign which type of form?

A)Assignment of benefits form
B)Explanation of benefits form
C)Patient information form
D)Release of information form

Question 13

A disadvantage of filing electronic claims is:

A)increased claim rejections.
B)increased administrative costs.
C)inability to create an electronic attachment.
D)inability to audit claims.

Question 14

An audit/edit report from a clearinghouse will show all of the following EXCEPT:

A)claims that need corrections.
B)claims that are missing information.
C)claims forwarded to the insurance carrier.
D)paid claims.

Question 15

If an insured patient signs an Assignment of Benefits form, the insurance carrier will send payment directly to the:

A)bank.
B)guarantor.
C)patient.
D)physician.

Question 16

Electronic claims can be submitted:

A)directly to the carrier.
B)through a clearinghouse.
C)through a billing service.
D)all of the above.

Question 17

The form used by the provider to document ICD-9-CM and CPT codes for routine services is referred to as a(n):

A)encounter form.
B)charge slip.
C)superbill.
D)all of the above.

Question 18

Most physicians bill insurance carriers by completing paper or electronic versions of which form?

A)Verification of benefits form
B)CMS-1500 claim form
C)UB-04 claim form
D)Superbill

Question 19

The policy in most medical offices is to request that the patient sign and update a release of information form:

A)at every visit.
B)once per year.
C)every 2 years.
D)every 3 years.

Question 20

Confirmation of a patient's insurance coverage is usually done online, but when it is done by phone, the medical office specialist can record answers to questions on a worksheet called a(n):

A)assignment of benefits form.
B)patient information form.
C)release of information form.
D)verification of benefits form.

Question 21

The use of the CMS-1500 claim form is:

A)mandatory for all physician office claims.
B)mandatory for all Medicare claims but optional for private insurance carriers.
C)optional for all Medicare claims but mandatory for private insurance carriers.
D)optional for all physician office claims.

Question 22

To submit claims to an insurance carrier, a billing service requires:

A)the patient's personal and insurance information.
B)a copy of the patient's insurance card.
C)the encounter form documenting the diagnosis and services provided.
D)all of the above.

Question 23

According to HIPAA, covered entities for compliance issues include:

A)clearinghouses and billing services only.
B)health plans and providers only.
C)health plans, clearinghouses, billing services, and providers.
D)health plans and clearinghouses only.

Question 24

The subsection of HIPAA that regulates electronic billing is known as the:

A)Electronic Data Interchange.
B)Administrative Simplification.
C)Privacy and Security Standard.
D)False Claims Section.

Question 25

A limited insurance policy purchased to cover part of the patient's expenses, such as coinsurance, for which the patient would otherwise be responsible, is:

A)secondary insurance.
B)supplemental insurance.
C)additional insurance.
D)optional insurance.

Question 26

Components of the Administration Simplification subsection of HIPAA include all of the following EXCEPT:

A)transaction and code sets.
B)compliance and auditing guidelines.
C)uniform identifiers.
D)privacy and security rules.

Question 27

If needed information is missing from a claim when it is submitted to an insurance carrier, it is referred to as a(n):

A)clean claim.
B)dirty claim.
C)erroneous claim.
D)incomplete claim.

Question 28

If a patient has more than one insurance plan, the determination of how much will be paid by each is known as:

A)assignment of benefits.
B)the birthday rule.
C)coordination of benefits.
D)verification of benefits.

Question 29

As it pertains to the CMS-1500 form, the acronym OCR refers to:

A)the Office of Civil Rights.
B)optical character recognition.
C)optional code references.
D)optical CPT recognition.

Question 30

If an individual is covered under Plan A through her employment and is covered under Plan B through her spouse's employment:

A)Plan A is primary, and Plan B is secondary.
B)Plan B is primary, and Plan A is secondary.
C)only Plan A will pay for her benefits.
D)Plan B will pay all of the benefits.

Question 31

The CMS-1500 claim form used by physician offices was developed by:

A)the American Medical Association (AMA).
B)the Blue Cross/Blue Shield Association.
C)the Centers for Medicare and Medicaid Services (CMS).
D)representatives from all insurance carriers.

Question 32

The employer identification number (EIN) or federal tax ID number is issued by:

A)the Centers for Medicare and Medicaid Services (CMS).
B)the Internal Revenue Service (IRS).
C)the Health Insurance Portability and Accountability Act (HIPAA).
D)insurance carriers.

Question 33

The identification number issued to physicians who are authorized to practice medicine in a given state is the:

A)Social Security number.
B)Federal Tax Identification number.
C)state license number.
D)Employer Identification Number.

Question 34

The CMS-1500 claim form includes the following number of locators (fields):

A)13
B)33
C)52
D)70

Question 35

All of the following statements are true about optical character recognition (OCR) devices EXCEPT that they:

A)are used in processing electronic claims.
B)improve accuracy.
C)enable faster claims processing.
D)reduce the cost of data entry.

Question 36

When a patient has more than one insurance policy, one policy is considered the primary coverage and the additional policy is:

A)secondary insurance.
B)supplementary insurance.
C)additional insurance.
D)individual insurance.

Question 37

Scrambling electronic information during transmission to prevent it from being intercepted or read by unauthorized users is a process known as:

A)electronic data transmission.
B)encryption.
C)optical character recognition (OCR).
D)transcription.

Question 38

If a patient is the primary policyholder on two insurance plans, the primary plan is considered:

A)the plan with the highest level of benefits.
B)the plan in effect for the longest period of time.
C)the plan that has the highest premium.
D)the plan in effect for the shortest period of time.

Question 39

According to the birthday rule, if both parents cover dependent children under their insurance policies, the primary insurance is the policy:

A)that has been in force the longest.
B)of the older parent.
C)of the parent whose date of birth occurs earliest in the year.
D)that has the highest level of benefits.

Question 40

When health claims information is exchanged electronically, both the sender and the receiver must follow what HIPAA transaction standard?

A)5010
B)CMS-1500
C)OCR
D)EMC

Question 41

If more than one physician is involved in a case, what priority order is used to determine the physician listed in form locator 17?

A)Ordering Provider, Referring Provider, Supervising Provider
B)Referring Provider, Supervising Provider, Ordering Provider
C)Supervising Provider, Ordering Provider, Referring Provider
D)Referring Provider, Ordering Provider, Supervising Provider

Question 42

On universal claim forms for physician or hospital services, a form locator is a number printed on the form that serves as a unique identifier.

Question 43

On the CMS-1500 claim form, the abbreviation MM indicates that:

A)more than one area of malignancy was located.
B)multiple tests were performed.
C)the month should be entered as two digits.
D)more information is needed before a diagnosis can be determined.

Question 44

The person who is ultimately responsible to pay the physician is known as the policyholder.

Question 45

The majority of income received by a medical facility comes from patients.

Question 46

Examples of standard code sets recognized under HIPAA include:

A)CPT codes.
B)HCPCS codes.
C)ICD-9(10)-CM codes.
D)all of the above.

Question 47

The patient information form is standardized and used by all physicians' offices.

Question 48

On the CMS-1500 claim form, the abbreviation EIN refers to:

A)Employer Identification Number.
B)Employer Identifier for National Coverage.
C)Estimated Insurance Number for payment.
D)Examination Indicates Nothing.

Question 49

On the CMS-1500 claim form, the abbreviation EMG indicates that:

A)an employer identifier number must be entered.
B)it must be noted if emergency services were provided.
C)it must be noted if preauthorization was obtained.
D)it must be noted if the service is considered emerging or experimental.

Question 50

Electronic claims are entered into a computer system and then printed out to be filed in the patient's medical record.

Question 51

The source document used by a medical office specialist to enter patient encounter data into a computerized accounting system is the superbill.

Question 52

On the CMS-1500 claim form, the abbreviation DD indicates that:

A)up to two diagnosis codes can be entered.
B)a doctor of dentistry performed the service.
C)the day of the month should be entered as two digits.
D)durable medical equipment (DME) was ordered.

Question 53

The Health Insurance Portability and Accountability Act (HIPAA) regulates protected health information while allowing appropriate use by all of the following entities EXCEPT:

A)providers.
B)health plans.
C)clearinghouses.
D)employers.

Question 54

Place of service codes used in form locator 24B include all of the following EXCEPT:

A)private residence.
B)urgent care facility.
C)operating room.
D)independent laboratory.

Question 55

The CMS-1500 claim form is mandatory for all Medicare claims.

Question 56

The options provided in locator 1 on the CMS-1500 claim form include:

A)five government plans, group health plan, and other.
B)five government plans, group health plan, and individual plan.
C)four government plans and three private plans.
D)eight health plan options.

Question 57

Most providers submit healthcare claims electronically.

Question 58

On the CMS-1500 claim form, the abbreviation NPI indicates that:

A)a condition was Not Present or Indicated upon examination.
B)the National Health Plan Identifier must be entered.
C)the National Provider Identifier must be entered.
D)the National Preferred Identifier for clearinghouses must be entered.

Question 59

The diagnosis code required in form locator 24E is the:

A)ICD-9-CM code describing the patient condition.
B)number of the diagnosis code listed in form locator 21 that points to the related service.
C)number of diagnostic tests performed to justify the physician's diagnosis.
D)diagnostic modifier, if applicable.

Question 60

Optical character recognition (OCR) guidelines require adherence to specific standards for the size and alignment of printed characters.

Question 61

The form a new patient completes when registering in a physician's office is known as a(n) __________ form.

Question 62

The place of service code is mandatory for all claims submitted to Medicare.

Question 63

The scrambling of information during electronic claims submission to prevent it from being read by unauthorized individuals is known as __________ .

Question 64

According to HIPAA, covered entities include health plans, clearinghouses, and healthcare providers.

Question 65

If form locator 20 is marked Yes because the physician referred the patient to an outside lab for some type of lab work, form locator 32 must also be completed.

Question 66

The person who purchases an insurance policy is known as the __________ .

Question 67

Most claims to secondary insurance carriers are submitted electronically.

Question 68

ICD-9 codes in form locator 21 should be listed in order of precedence with number 1 being the primary diagnosis.

Question 69

A company that receives claims from providers, audits them to check for errors, and forwards them to insurance carriers for payment is a(n) __________ .

Question 70

A physician's Social Security number is always used on the CMS-1500 claim form.

Question 71

The person who is ultimately responsible for paying for medical services is known as the __________ .

Question 72

The form that allows an insurance company to make payments directly to a physician on behalf of the patient is the __________ form.

Question 73

A signature stamp should never be used in place of the physician's original signature on a claim form.

Question 74

If a patient has signed a consent document authorizing release of medical information to the insurance carrier, the notation "Signature on File" or "SOF" may be entered in form locator 12.

Question 75

Physicians bill insurance carriers using a universal form, the __________ claim form.

Question 76

Form locator 17, Name of Referring Physician or Other Source, can include the name of a relative or friend who referred the patient to the physician's office.

Question 77

If a patient is covered by more than one health plan, form locator 11d is answered Yes and form locators 9a-d must be completed.

Question 78

The form that specifies which information from the medical chart may be released and to whom is a(n) __________ form.

Question 79

If required information is missing from a claim form, the medical office specialist will have to correct the claim and resend it for payment.

Question 80

A claim that is missing information or contains incorrect information is referred to as a(n) __________ claim.