Ch 6

Question 0

The connection between a service in a patient’s condition or illness.

Answer 0

Code linkage

Question 1

What is the importance of code linkage on healthcare claims?

Answer 1

Diagnoses and procedures must be correctly linked on healthcare claims so payers can analyze the connection and determine the medical necessity of charges.

Question 2

Computerized Medicare system that prevents overpayment.

Answer 2

Correct coding initiative (CCI)

Question 3

Code combinations used by computers in the Medicare system to check claims.

Answer 3

CCI edits

Question 4

Medicare code edit where CPT codes in column 2 will not be paid if reported in the same way as the column one code.

Answer 4

CCI column 1/ column 2 code pair edit

Question 5

Both services represented by MEC codes that could not have been done during one encounter.

Answer 5

CCI mutually exclusive code (MEC)

Question 6

Number showing if the use of a modifier can bypass a CCI edit.

Answer 6

CCI modifier indicator

Question 7

Units of service edits used to the lower the Medicare fee-for-service paid claims error rate.

Answer 7

Medically unlikely edits (MUEs)

Question 8

OIG’s annual list of planned projects

Answer 8

OIG workplan

Question 9

Opinion issued by CMS or the OIG that becomes legal advice.

Answer 9

Advisory opinion

Question 10

Individuals or companies not permitted to participate in federal healthcare programs.

Answer 10

Excluded parties

Question 11

Claims are rejected or downcoded because? (3)

Answer 11

• Medical necessity errors
• Coding error
• Errors related to billing

Question 12

Diagnoses not coded at the highest level of specificity.

Answer 12

Truncated coding

Question 13

Reporting undocumented services, the coder assumes have been approved due to the nature of the case or condition.

Answer 13

Assumption coding

Question 14

Use of a procedure code that provides a higher payment.

Answer 14

Upcoding

Question 15

Payers review and reduction of a procedure code.

Answer 15

Downcoding

Question 16

What major strategies ensure compliance billing?

Answer 16

Carefully define bundled codes and know global periods, benchmark the practices E/M codes with national averages, use modifiers appropriately, be clear on professional courtesy and discounts to uninsured/low income patients, maintain compliant job reference aids documentation templates.

Question 17

Providing free services to other physicians.

Answer 17

Professional courtesy

Question 18

List of practices frequently reported procedures and diagnoses.

Answer 18

Job reference aid

Question 19

Allows a software program to assist in the assigning codes.

Answer 19

Computer-assisted coding (CAC)

Question 20

Form used to prompt a physician to document a complete review of systems ROS and a treatments medical necessity.

Answer 20

Documentation template

Question 21

A formal examination or review.

Answer 21

Audit

Question 22

Program designed to audit Medicare claims.

Answer 22

Recovery audit contractor (RAC)

Question 23

Audit conducted by an outside organization.

Answer 23

External audit

Question 24

Self-audit conducted by a staff member or consultant.

Answer 24

Internal audit

Question 25

Internal audit of claims conducted before transmission.

Answer 25

Prospective audit

Question 26

Internal audit conducted after claims are processed and RA’s have been received.

Answer 26

Retrospective audit

Question 27

How do physicians set their fee schedules?

Answer 27

Physicians set their fee schedules in relation to this fees that other providers charge for similar services.

Question 28

Normal fee charged by a provider.

Answer 28

usual fee

Question 29

Fees based on typically charged amounts.

Answer 29

Charge-based fee structure

Question 30

What structure is built by comparing three factors? What are the three factors?

Answer 30

Resource-based fee structure

1. How difficult it is for the provider to do the procedure
2. How much office overhead the procedure involves
3. The relative risk that the procedure presents to the patient and to the provider

Question 31

Setting fees by comparing usual fees, customary fees, and reasonable fees.

Answer 31

Usual, customary, and reasonable (UCR)

Question 32

System of assigning unit values to medical services based on their required time and skill.

Answer 32

Relative value scale (RVS)

Question 33

Factor assigned to a medical service based on the relative scale and required time.

Answer 33

Relative value units (RVU)

Question 34

Amount used to multiply a relative value unit to arrive at a change.

Answer 34

Conversion factor

Question 35

Relative value scale for establishing Medicare charges.

Answer 35

Resource-based relative value scale (RBRVS)

Question 36

Medicare factor used to adjust providers fees any particular geographic area.

Answer 36

Geographic practice cost index (GPCI)

Question 37

The RBRVS-based allowed fees.

Answer 37

Medicare physician fee schedule (MPFS)

Question 38

What are the following steps used to calculate the RBRVS payments under the MPFS?

Answer 38

Determine the procedure code for the service, use the MPF to find three RVUs-work, practice expense, and malpractice-for the procedure, use the Medicare GPC I list to find the three geographic practice cost in disses, multiply each RV you abides GP CI to calculate the adjusted value, add the three adjusted totals, and multiplied somebody in a conversion factor to determine the payment.

Question 39

What are the three main methods to pay providers?

Answer 39

Allowed charges
Contracted fee schedule
Capitation

Question 40

Maximum charge a plan pays for a service or procedure.

Answer 40

Allowed charge

Question 41

Collecting the difference between a providers usual fee and a payers lower allowed charge.

Answer 41

Balance billing

Question 42

To deduct an amount from a patients account.

Answer 42

Write off

Question 43

The periodic prepayment to a provider for specified services to each plan member.

Answer 43

Capitation rate

Question 44

Amount withheld from a providers payment by an MCO.

Answer 44

Provider withhold

Question 45

Changes to a patients account.

Answer 45

Adjustments

Question 46

Types of payment methods

Answer 46

Cash, check, credit or debit card.

Question 47

What is a walkout receipt? How can it be used?

Answer 47

A walkout receipt summaries services and charges as well as any payments made.

A patient can use a walkout reciept to report charges to their insurance company.