Billing & Insurance, Coding Chap 4,5,6

Alphabetic Index and Tabular List
What are the two main organization components
One difference between ICD-9 and ICD-10 is that ICD-10 describes a patient’s disease or condition with much greater specificity.
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ICD-10 CM must be used for diagnostic coding in the United States starting October 1, 2014
In diagnostic coding, the coexisting conditions are coded first; followed by any other conditions that are being treated in that encounter.
primary diagnosis
This is the main reason a patient is presenting to the doctor and provides the main term to be coded first.
In the term, “Complete paralysis”, what is the main term
The first Coding Step says to Review Complete Medical Documentation. This is where you will find the primary diagnosis.
According to the Steps of Diagnosis Coding, you should verify the code in the Tabular List and then check it in the Alphabetic Index.
Check compliance with any applicable Official Guidelines and list codes in appropriate order
The very last step before submitting a diagnosis code is to
ICD-10 is the _____ version of the diagnostic code set.
determine the procedures and services to report, identify the correct codes and determine the need for modifiers
Which is the correct process for selecting CPT codes
medical decision making
Upon selecting an Evaluation and Management code, three components are considered: the type of history, the physical examination and the
In CPT, E/M is the abbreviation for Evaluation and
the physician to whom the patient is referred
Under CPT’s definition, after a referral, who takes responsibility for the patient’s care
preoperative evaluation and planning
care during the procedure
routine postoperative care
“All of the above”
Codes in CPT’s anesthesia section generally cover
Which section of CPT codes is the physical status modifier, such as P1 for normal, healthy patient, exclusively used with
during the global period
Under CPT guidelines, all services related to a surgical procedure are not additionally reimbursed
What was set up to give healthcare providers a coding system that describes specific products, supplies, and services that patients receive
HCPCS codes
Durable medical equipment (DME) such as wheelchairs covered by the Medicare program are reported using?
services to track performance measurement
In CPT, what do Category II codes report
emerging technology, services and procedures
In CPT, what do Category III codes report
add-on code
In CPT, a plus sign (+) next to code indicates a
new code
In CPT, a bullet (a solid circle) next to a code indicates a
The division of CPT, such as anesthesia and radiology are referred to as
code pending FDA approval
In CPT, a lightning bolt symbol next to a code indicates a
revised code descriptor
In CPT, a triangle next to a code indicates a
new/revised test other than a code descriptor
in CPT, what do facing triangles that appear in front of a code indicate
add-on code
In CPT, what type of code is described by the following entry? + each additional 24 hours (list separately in addition to code for primary procedure)
is the most resource-intensive
The CPT code that is listed first for an encounter is the procedure that
reading the radiological examination and writing a report of interpretation
What is required of the physician in order to report the professional component of a CPT code from the Radiology section
In CPT, some codes have both a technical component and another component representing the physician’s skill, time and expertise. What is the name of this other component
In CPT, a single code grouping laboratory tests is called a
The use of CPT Category II codes does not affect reimbursement and is
American Medical Association
CPT is a publication of the
anatomical site of the procedure
“None of the above”
Which of the following is not a main term in the CPT index
both “see” and “see also” are seen
Which of the following is a cross-reference that might be seen in CPT
CPT was first published in what year
joint effort of CMS and AMA
The E/M coding method came from
determine the need for modifiers
The last step in the coding process is
How many key components are there when evaluating an E/M code
Which is not a key component in E/M coding
history of present illness
What is the abbreviation HPI used for
review of systems
ROS is the abbreviation for
In CPT, the term_____ describes services that a provider performs at the request of another provider after which the patient is returned to the requesting provider’s care
body system
Most of the surgery section is organized by
Which member of the medical practice is ultimately responsible for proper documentation and correct coding
denied claims and reduced payments
prison sentences
“All of the above”
Some possible consequences of inaccurate coding and incorrect billing in a medical practice are
The Correct Coding Initiative (CCI) is a program of
downcode the reported procedure code
If a payer judges that too high a code level has been assigned by a practice for a reported service, the usual action is to
truncated coding
What type of coding uses diagnoses that are not as specific as possible
What type of coding uses a procedure code that provides a higher reimbursement rate than the correct code
What type of coding uses a lower level code
discounted charges made for other providers and their families
Professional courtesy refers to
Routinely waiving deductibles and copayments is
prospective audit
What type of audit is performed internally before claims are reported
retrospective audit
What type of audit is performed internally after claims are submitted
What type of external audit is performed by payers before claims are processed
What type of audit do payers routinely conduct to ensure that claims are compliant
Evaluation and Management codes
The CMS/AMA Documentation Guidelines set up the rules for the selection of
usual fees
What type of fees are defined as those that physicians charge to most of their patients most of the time under typical conditions?
the provider’s work, practice cost, and malpractice insurance costs
Under RBRVs, the nationally uniform relative value is based on
allowed charges, contracted fee schedule, and capitation
What are the main methods payers use to pay providers
capitation rate
What is the fixed prepayment for each plan member in a capitation contract called
submitting claims that are correct and compliant
Medical insurance specialists help ensure maximum appropriate reimbursement for services by
advisory opinions
When regulations seem contradictory or unclear, the OIG issues
Correct Coding Initiative
CCI is an abbreviation for
OIG Work Plan
The _______ lists the types of medical billing and reporting practices that the Office of Inspector General intends to investigate in the coming year
the relationship between the diagnosis and the treatment provided
Medical necessity is based on
Cosmetic nasal surgery
Which of the following is NOT a medically necessary procedure
That the medical coder coded and reported services that were not documented in the patient’s medical record
What does the term “assumption coding” mean
Using a non-specific diagnosis code
Which of the following is not fraudulent
________ refers to a coding method in which lower-level codes are selected to avoid government investigation
____________ refers to a coding problem in which a procedure code is used that provides a higher reimbursement than the correct code
are supported by the documentation
Only the codes that ______ should be reported
10 days
Global periods for a minor procedure have which of the following postoperative periods
90 days
Global periods for a major procedure have which of the following postoperative periods
benchmarking practices’ E/M codes with national averages
What is a way that upcoding is being monitored by payers
Which of the following is considered a formal examination
professional courtesy
Which of the following means that a physician has chosen to waive the charges for services to other physicians
every claim
a sample
10% of the claim
“All of the above”
An audit involves reviewing
RACs requests for information must be answered in _____ days
an error is declared and penalties may result
If a RAC’s request is not answered in the appropriate amount of time, which of the following might occur
“None of the above”
Which of the following is not an element of HPI
usual fee
_________ is a normal fee charged by a provider
slightly above those paid by the highest reimbursing plan
Most practices set their fees

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