Chapt 1

Question 1

health insurance claim

Answer 1

claim is the documentation submitted to a third-party payer or government program requesting reimbursement for health care services provided

Question 2

hold harmless clause

Answer 2

(patient is not responsible for paying what the insurance plan denies) in the contract, the health care provider cannot collect the fees from the patient.

Question 3

health care provider

Answer 3

is a physician or other health care practitioner (e.g., nurse practitioner, physician’s assistant).

Question 4

Centers for Medicare and Medicaid Services (CMS)

Answer 4

which is the administrative agency within the federal Department of Health and Human Services (DHHS)

Question 5

Coding

Answer 5

is the process of assigning ICD-10-CM, ICD-10-PCS, CPT, and HCPCS level II codes, which contain alphanumeric and numeric characters (e.g., A01.1, 0DTJ0ZZ, 99201, K0003), to diagnoses, procedures, and services.

Question 6

International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM)

Answer 6

coding system used to report diseases, injuries, and other reasons for inpatient and outpatient encounters, such as an annual physical examination performed at a physician’s office

Question 7

International Classification of Diseases, 10th Revision, Procedural Coding System (ICD-10-PCS)

Answer 7

coding system used to report procedures and services on inpatient hospital claims coding system used to report procedures and services on inpatient hospital claims

Question 8

Current Procedural Terminology (CPT)

Answer 8

coding system published by the American Medical Association that is used to report procedures and services performed during outpatient and physician office encounters, and professional services provided to inpatients

Question 9

HCPCS level II codes (or national codes)

Answer 9

coding system published by CMS that is used to report procedures, services, and supplies not classified in CPT

Question 10

Medical necessity

Answer 10

involves linking every procedure or service code reported on the claim to a condition code (e.g., disease, injury, sign, symptom, other reason for encounter) that justifies the need to perform that procedure or service

Question 11

Health insurance specialists (or reimbursement specialists)

Answer 11

review health-related claims to match medical necessity to procedures or services performed before payment (reimbursement) is made to the provider.

Question 12

claims examiner

Answer 12

employed by a third-party payer reviews health-related claims to determine whether the charges are reasonable and for medical necessity.

Question 13

Medical necessity

Answer 13

involves linking every procedure or service code reported on the claim to a condition code (e.g., disease, injury, sign, symptom, other reason for encounter) that justifies the need to perform that procedure or service

Question 14

Claims review process requires verification of the claim

Answer 14

1. Authorize appropriate payment

2. Refer the claim to an investigator for a more thorough review

Question 15

medical assistant

Answer 15

is employed by a provider to perform administrative and clinical tasks that keep the office or clinic running smoothly

Question 16

internship

Answer 16

internship benefits students and facilities that accept students for placement. Students receive on-the-job experience prior to graduation, and the internship assists them in obtaining permanent employment.

Question 17

AAPC -

Answer 17

professional association, previously known as the American Academy of Professional Coders, established to provide a national certification and credentialing process, to support the national and local membership by providing educational products and opportunities to networks, and to increase and promote national recognition and awareness of professional coding.

Question 18

American Association of Medical Assistants (AAMA)

Answer 18

enables medical assisting professionals to enhance and demonstrate the knowledge, skills, and professionalism required by employers and patients; as well as protect medical assistants’ right to practice.

Question 19

American Health Information Management Association (AHIMA)

Answer 19

American Health Information Management Association (AHIMA) - founded in 1928 to improve the quality of medical records, and currently advances the health information management (HIM) profession toward an electronic and global environment, including implementation of ICD-10-CM and ICD-10-PCS in 2013.

Question 20

bonding insurance

Answer 20

• an insurance agreement that guarantees repayment for financial losses resulting from the act or failure to act of an employee. It protects the financial operations of the employer.

Question 21

business liability insurance -

Answer 21

an insurance agreement that guarantees repayment for financial losses resulting from the act or failure to act of an employee. It protects the financial operations of the employer.

Question 22

business liability insurance

Answer 22

• protects business assets and covers the cost of lawsuits resulting from bodily injury, personal injury, and false advertising.

Question 23

Embezzle

Answer 23

the illegal transfer of money or property as a fraudulent action; to steal money from an employer.

Question 24

errors and omissions insurance

Answer 24

see professional liability insurance.

Question 25

Ethics

Answer 25

principle of right or good conduct; rules that govern the conduct of members of a profession.

Question 26

nation of benefits (eob)

Answer 26

report that details the results of processing a claim (e.g., payer reimburses provider $80 on a submitted charge of $100).

Question 27

CPCS level ii codes

Answer 27

• national codes published by CMS, which include five-digit alphanumeric codes for procedures, services, and supplies not classified in CPT.

Question 28

health care provider

Answer 28

physician or other health care practitioner (e.g., physician’s assistant).

Question 29

health information technician

Answer 29

• professionals who manage patient health information and medical records, administer computer information systems, and code diagnoses and procedures for health care services provided to patients

Question 30

health insurance claim

Answer 30

documentation submitted to an insurance plan requesting reimbursement for health care services provided (e.g., CMS-1500 and UB-04 claims).

Question 31

health insurance specialist

Answer 31

person who reviews health-related claims to match medical necessity to procedures or services performed before payment (reimbursement) is made to the provider; see also reimbursement specialist

Question 32

Healthcare Common Procedure Coding System (HCPCS

Answer 32

coding system that consists of CPT, national codes (level II), and local codes (level III); local codes were discontinued in 2003; previously known as HCFA Common Procedure Coding System.

Question 33

hold harmless clause

Answer 33

policy that the patient is not responsible for paying what the insurance plan denies.

Question 34

independent contractor-

Answer 34

• defined by the ‘Lectric Law Library’s Lexicon as “a person who performs services for another under an express or implied agreement and who is not subject to the other’s control, or right to control, of the manner and means of performing the services. The organization that hires an independent contractor is not liable for the acts or omissions of the independent contractor.”

Question 35

International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM

Answer 35

coding system to be implemented on October 1, 2015, and used to report diseases, injuries, and other reasons for inpatient and outpatient encounters.

Question 36

International Classification of Diseases, 10th Revision, Procedural Coding System (ICD-10-PCS)
international classification -

Answer 36

coding system to be implemented on October 1, 2015 and used to report procedures and services on inpatient claims.

Question 37

medical malpractice insurance

Answer 37

• a type of liability insurance that covers physicians and other health care professionals for liability claims arising from patient treatment.

Question 38

medical necessity

Answer 38

• involves linking every procedure or service code reported on an insurance claim to a condition code (e.g., disease, injury, sign, symptom, other reason for encounter) that justifies the need to perform that procedure or service.

Question 39

national codes

Answer 39

commonly referred to as HCPCS level II codes; include five-digit alphanumeric codes for procedures, services, and supplies that are not classified in CPT (e.g., J-codes are used to assign drugs administered).

Question 40

professional liability insurance

Answer 40

• provides protection from liability as a result of errors and omissions when performing their professional services; also called errors and omissions insurance.

Question 41

Professionalism

Answer 41

conduct or qualities that characterize a professional person.

Question 42

property insurance

Answer 42

protects business contents (e.g., buildings and equipment) against fire, theft, and other risks.

Question 43

reimbursement specialist -

Answer 43

• see health insurance specialist.

Question 44

remittance advice (remit)

Answer 44

electronic or paper-based report of payment sent by the payer to the provider; includes patient name, patient health insurance claim (HIC) number, facility provider number/name, dates of service (from date/thru date), type of bill (TOB), charges, payment information, and reason and/or remark codes.

Question 45

respondeat superior

Answer 45

Latin for “let the master answer”; legal doctrine holding that the employer is liable for the actions and omissions of employees performed and committed within the scope of their employment.

Question 46

scope of practice

Answer 46

health care services, determined by the state, that an NP and PA can perform.

Question 47

workers’ compensation insurance -

Answer 47

workers’ compensation insurance - insurance program, mandated by federal and state governments, that requires employers to cover medical expenses and loss of wages for workers who are injured on the job or who have developed job-related disorders.