Ch. 1 Q's and Acronyms Flashcards
A Medicare patient is receiving chemotherapy at her oncologist’s office. While the patient is receiving chemotherapy, the oncologist calls in a prescription for pain medication to a pharmacy in the same building. The pharmacy delivers the medication to the patient in the oncologist’s office for the patient to take home. What part of Medicare should be billed for the pain medication by the pharmacy?
A. Part A
B. Part B
C. Part C
D. Part D
D. Part D
RATIONALE: Medicare Part D is for prescription drug coverage. The patient’s prescription for the pain medication would be billed to Medicare Part D.
What is medical coding?
A. Reporting services on a CMS-1500
B. Translating medical documentation into codes
C. Programming an EHR
D. Creating a 5010 electronic file for transmission
B. Translating medical documentation into codes
RATIONALE: Coding is the process of translating written or dictated medical records into numeric or alpha-numeric codes.
Which one is NOT a covered entity of HIPAA?
A. Medicare
B. Workers’ compensation
C. Dentists
D. Pharmacies
B. Workers’ compensation
RATIONALE: A covered entity of HIPPA
I. A healthcare provider, such as:
- Doctors
- Clinics
- Psychologists
- Nursing Homes
- Pharmacies
II. A health plan, to include:
- Health Insurance Companies
- HMOs
- Company Health Plans
- Government programs that pay for healthcare, such as Medicare, Medicaid, and the military and veterans’ healthcare programs
- A healthcare clearinghouse
Which one falls under a commercial payer?
A. Medicare
B. Medicaid
C. Blue Cross Blue Shield
D. All the above are commercial payers
C. Blue Cross Blue Shield
RATIONALE: There are two primary types of insurers: commercial and government. Commercial payers are private payers that offer both group and individual plans. For example, Blue Cross Blue Shield organizations are private payers who usually operate in the state in which they are based.
When should an ABN be signed?
A. When a service is considered medically necessary by Medicare.
B. When a service is not expected to be covered by Medicare.
C. Routinely for any services given to a Medicare patient.
D. After a service is denied and the patient should be billed.
When a service is not expected to be covered by Medicare
RATIONALE: The Advance Beneficiary Notice (ABN) is a standardized form that explains to the patient why Medicare may deny the service or procedure. The ABN form should be completed for services potentially non-covered by Medicare to advise the patient of potential financial responsibility.
The amount on an ABN should be within how much of the cost to the patient?
A. $250 of cost
B. $100 or 25% of the cost
C. $10 or 10% of cost
D. $100 or 10% of cost
B. $100 or 25% of cost
RATIONALE: CMS instructions stipulate, “Notifiers must make a good faith effort to insert a reasonable estimate…the estimate should be within $100 or 25 percent of the actual costs, whichever is greater.”
An entity that processes nonstandard health information they receive from another entity into a standard format is considered what?
A. Billing Company
B. Electronic Health Record Vendor
C. Clearinghouse
D. Practice Management Vendor
C. Clearinghouse
RATIONALE: A Heathcare Clearinghouse is an entity that processes nonstandard health information they receive from another entity into a standard (such as standard electronic format, or data content), or vice versa.
What is PHI?
A. Personal History Information
B. Problem with History of Infection
C. Partial Health Interaction
D. Protected Health Information
D. Protected Health Information
RATIONALE: PHI is defined under HIPAA as Protected Health Information
Intentional billing of services not provided is considered ______________.
A. Deceptive Billing
B. Fraud
C. Abuse
D. Common practice
B. Fraud
RATIONALE: The definition of fraud is to purposely bill for services that were never given or to bill for a service that has a higher reimbursement than the service produced. Abuse consists of payment for items or services that are billed by providers in error that should not be paid for by Medicare.
What OIG document should a provider review for potential problem areas that will receive special scrutiny in the upcoming year?
A. Compliance Program Guidance
B. Safe Harbor Regulations
C. Red Flag Rules
D. OIG Work Plan
D. OIG Work Plan
RATIONALE: Each year in October, the OIG releases a Work Plan outlining its priorities for the fiscal year ahead.
ABN
Advance Beneficiary Notification
AMA
American Medical Association
APC
Ambulatory Payment Classification
ARRA
American Recovery and Reinvestment Act of 2009
ASC
Ambulatory Surgical Centers
CF
Conversion Factor
CMS
Centers for Medicare & Medicaid Services
CPC®
Certified Professional Coder
