Question 1

For reporting purposes, CPT considers a patient "new" if the patient has not received professional services within the past ____ year(s).

Accepted Answer

CPT considers a patient "new" if they have not received professional services from the physician or another physician of the same specialty in the same group practice within the past three years.

Question 2

To ensure reimbursement at the highest allowed level, CPT codes must ____.

Accepted Answer

CPT codes should accurately reflect the services performed and any applicable modifiers to ensure reimbursement at the highest allowed level. Including unbundled procedures or reflecting a procedure or service higher or lower than what was actually performed would be considered fraudulent coding. To ensure reimbursement at the highest allowed level, CPT codes must include codes and modifiers that accurately reflect the services performed. Including only modifiers, all unbundled procedures, or reflecting a procedure or service higher or lower than what was actually performed can result in incorrect reimbursement and potential legal issues.

Question 3

Medical offices usually have a(n) ____ to help minimize the risk of fraud by discovering and correcting coding and billing problems.

Accepted Answer

A compliance plan is specifically designed to identify and prevent fraud and ensure that a medical office is following all relevant laws and regulations related to billing and coding. It includes procedures for regular audits, staff training on billing practices, and measures for addressing any identified issues to prevent future problems. A quality assurance program may also be implemented in medical offices but its primary purpose is to ensure the quality of patient care rather than financial management. Billing software and financial management plans are tools used in medical offices, but they do not necessarily focus on fraud prevention. An external auditor is not typically a regular part of a medical office's operations, but may be brought in for occasional audits or evaluations. A compliance plan is specifically designed to detect and correct coding and billing errors, as well as prevent fraud and abuse in medical offices. It includes policies and procedures related to coding, billing, documentation, and other areas that affect reimbursement. A quality assurance program may overlap with a compliance plan but is focused on improving overall quality of care rather than detecting and preventing fraud. Billing software, financial management plans, and external auditors may be useful but are not specific to detecting and correcting coding and billing errors.

Question 4

When unbundling is done intentionally to receive more payment than is allowed, the claim is likely to be considered ____.

Accepted Answer

Unbundling is the practice of charging separately for a group of services that should be billed together. Intentional unbundling to receive higher payment than allowed is considered fraudulent and illegal. Unbundling intentionally to receive more payment than allowed is considered fraudulent behavior. This involves the deliberate separation of a bundled service or procedure into component parts with the intention of receiving a higher payment rate for each component separately.

Question 5

A healthcare provider who practices under false qualifications or credentials is guilty of ____.

Accepted Answer

A healthcare provider who practices under false qualifications or credentials is guilty of fraud, as they are intentionally deceiving patients and employers by pretending to have required qualifications or credentials. Slander, defamation, assault, and libel all involve making false or harmful statements, but do not specifically relate to impersonating a healthcare provider. Practicing under false qualifications or credentials is considered fraud, as it involves intentionally misleading patients and misrepresenting one's skills and experience. Slander, defamation, assault, and libel are all forms of intentional harm or injury, but they do not refer specifically to the act of practicing medicine with false qualifications.

Question 6

An act of deception used to take advantage of another person or entity is called ____.

Accepted Answer

Fraud is an act of deception that is used to take advantage of another person or entity. It involves deliberate lying or misrepresentation of facts, and is often carried out in order to gain financial or other benefits. Liabilities are legal responsibilities or obligations, coercion involves using threats or force to compel someone to do something, slander refers to defamatory speech, and defamation can include both slander and libel (defamatory statements made in writing). None of these concepts directly involve an act of deception for personal gain. Fraud involves intentionally deceiving another person or entity for personal gain or to cause harm. It may involve false information or withholding important information that would affect a decision. Liability refers to legal responsibility, coercion refers to using threats or force to make someone do something, slander refers to making false and damaging statements about someone, and defamation is a broader term that includes both slander and libel (damaging statements made in writing or other permanent media).

Question 7

When a patient has no symptoms of a disease and the provider performs the tests for that disease at the patient's request, the provider has committed which of these fraudulent coding and billing practices?

Accepted Answer

This scenario describes performing a procedure that is not medically necessary or related to the patient's condition, which is considered fraudulent by the healthcare system. It is important for providers to only perform tests and procedures that are medically necessary for the patient and not solely for financial gain. Performing procedures that are not medically necessary or related to the patient's condition is considered fraudulent coding and billing practices. Testing for a disease when there are no symptoms and no medical justification for the testing is unnecessary and potentially harmful to the patient, as well as a waste of resources.

Question 8

If a laboratory bills for a general health panel but fails to perform one of the tests, it is guilty of which of these fraudulent coding and billing practices?

Accepted Answer

Reporting services that were not performed is known as unbundling which is a fraudulent coding and billing practice. If the laboratory bills for a general health panel but fails to perform one of the tests, it is considered unbundling.

Question 9

Analysis of the connection between the diagnostic and procedural information on a claim is called ____.

Accepted Answer

Code linkage refers to the analysis of the link between the diagnostic and procedural codes on a claim. It is important to ensure that the codes are appropriately linked and support each other, as this affects the reimbursement the provider receives. Code verification is the process of ensuring that the codes used are accurate and up-to-date, while code analysis is a broader term that may include both code linkage and verification. Claim processing refers to the overall process of submitting and adjudicating a claim, while claim association is not a commonly used term in the healthcare industry. Code linkage refers to the process of ensuring that the diagnosis codes reported on a claim match the procedures and services performed. It is important for accurate billing and reimbursement. Code verification and code analysis may be part of the overall code linkage process, but do not specifically refer to the connection between diagnostic and procedural information. Claim processing and claim association are broader terms that refer to the overall handling of a claim, including code linkage as one component.

Question 10

National codes issued by CMS that cover many supplies and durable medical equipment are ____.

Accepted Answer

National codes issued by CMS that cover many supplies and durable medical equipment are HCPCS Level II codes. National codes issued by CMS that cover many supplies and durable medical equipment are HCPCS Level II codes.

Question 11

Inaccuracy in linking diagnostic codes and procedural codes will result in all of the following except ____.

Accepted Answer

The answer of Inaccuracy in linking diagnostic codes and procedural...

Question 12

The Healthcare Common Procedure Coding System (HCPCS) was developed for use in coding services for ____.

Accepted Answer

HCPCS was developed primarily for coding services for Medicare patients, although it is also used for Medicaid and other health insurance programs.

Question 13

Having a medical practice compliance plan in place ____.

Accepted Answer

Having a medical practice compliance plan in place shows a "good-faith" effort to be compliant with coding regulations. It does not guarantee the elimination of audit risk or replace insurance company compliance checks, but it does help ensure adherence to state regulations and can simplify tasks for medical assistants. A medical practice compliance plan does not eliminate the risk of an audit, but it does show a "good-faith" effort to be compliant with coding regulations. It helps ensure adherence to state regulations and may simplify the tasks of the medical assistant, but it does not replace the insurance company's compliance checks.

Question 14

HCPCS Level I codes ____.

Accepted Answer

HCPCS Level I codes are also known as CPT codes, which are used for reporting medical procedures and services.

Question 15

Modifiers to CPT codes indicate ____.

Accepted Answer

Modifiers are added to CPT codes to indicate that some special circumstance applies to the service. They may identify, for example, that a service was bilateral or performed by a different provider. Modifiers are used to indicate that some special circumstance applies to the service described in the CPT code. Examples of these special circumstances include different anatomical sites, multiple procedures, and unusual circumstances or complications. Modifiers do not indicate the need for additional codes, synonyms, inclusions or exclusions.

Question 16

The most frequently used CPT codes are the ____.

Accepted Answer

Evaluation and management codes are used for a wide range of healthcare services and are commonly used for billing office visits, consultations, and hospital visits. They are used in a variety of specialties and settings, making them the most frequently used CPT codes. Evaluation and management codes are the most frequently used codes in medical billing as they cover a wide range of services including office visits, consultations, and hospital visits. The other options listed (anesthesiology, surgery, pathology and laboratory, and radiology codes) are more specific and apply to more specialized services.

Question 17

Billing for a moderate level evaluation and management service when only a simple BP check and injection were carried out is an example of ____.

Accepted Answer

Billing for a higher level of service than was actually provided is known as upcoding. In this case, a simple BP check and injection would not warrant a moderate level evaluation and management service, and therefore billing for it would be considered upcoding. Billing for a higher level service than was actually carried out is an example of upcoding, which is a type of fraud. It is important to accurately code and bill for the services provided to avoid ethical and legal issues.

Question 18

A plus sign (+) is used to indicate ____.

Accepted Answer

An plus sign (+) is used to indicate add-on codes, which can only be used in addition to another primary code to provide additional specificity to a procedure or service. A plus sign (+) is used to indicate add-on codes, which are used when a primary code is already present and additional procedures or services are performed.

Question 19

There is a question concerning a claim for a procedure submitted last year. Where will you look to double-check the codes in question?

Accepted Answer

Since the claim was submitted last year, the codes used would have been based on last year's CPT, so that is the best reference to double-check the codes. The question asks specifically where to look to double-check the codes in question for a claim submitted last year. It would be most appropriate to look at last year's version of the CPT codes to ensure accuracy in the codes used. Therefore, the best choice is option B, last year's CPT.

Question 20

A physician bills separately for a comprehensive metabolic panel and a quantitative glucose test, which is normally included in the metabolic panel. This is an example of which of the following fraudulent coding and billing practices?

Accepted Answer

Billing separately for services that are bundled in a single procedure code is known as unbundling, which is considered fraudulent coding and billing practice. In this case, the physician is billing separately for a test that is normally included in the comprehensive metabolic panel.

Quiz 19: Procedure Coding

For reporting purposes, CPT considers a patient "new" if the patient has not received professional services within the past ____ year(s) .