coding and billing

Question 1

payment of medical benefits directly to the provider rather than the member/subscriber, requires written release

Answer 1

assignment of benefits

Question 2

gatekeeper/primary care provider approval for hospitalization or care

Answer 2

authorization

Question 3

he administrative practice of holding the patient financially responsible for the remainder of medical service charges, beyond the insurer’s allowed amount.

when does it not apply?

Answer 3

Balance billing

“Hold harmless” clause

Question 4

Patient responsible for portion of total charge. what is this method used for?

Answer 4

Cost sharing

to reduce utilization.

Question 5

Refusal by insurer to reimburse services that have been rendered.

Answer 5

denial

Question 6

insurer-provided description of provider services and explanation of those covered and denied

Answer 6

Explanation of benefits (EOB)

Question 7

purchaser of an insurance policy; in group health insurance, this is usually the employer who purchases policy coverage for its employees

Answer 7

Policy holder.

Question 8

insurance company review of care before delivery to establish appropriateness of payment.

Answer 8

pre-authorization

Question 9

Physical or mental condition of patient occurring before start of insurance coverage

Answer 9

Pre-existing condition

Question 10

data collection by insurers on billing and utilization by providers

Answer 10

profiling

Question 11

What is PT’s relationship with payers?

Answer 11

cultivate rep for quality of care, appropriate documentation.

Question 12

Office staff relationship with payers?

Answer 12

phone
competence
reliability.

Question 13

What is the admission process for clients?

Answer 13

Medical records
Business account
authorizations.

Question 14

Pt signs agreement of insurance to pay provider for service?

what is alternative

Answer 14

assignment of benefits.

patient pays and is reimbursed by insurance.

Question 15

What is more defensible? a single fee schedule with discounts based on policy or multiple fee schedules?

Answer 15

single.

Question 16

A claim must verify

Answer 16

patient info
person responsible for bill
insurance info
coordination of benefits.

Question 17

Term for situations where patient may have coverage under more than 1 insurance plane?

Answer 17

coordination of benefits

Question 18

primary payor to be decided by liability?

example?

Answer 18

health vs. liability insurer

worker’s comp or auto.

Question 19

Type of supplemental coverage medicare patients have?

Answer 19

medicaid or private medigap.

Question 20

If both spouses have coverage then what?

Answer 20

the others is the secondary and their self is primary.

Question 21

Process of coordination of benefits?

Answer 21

primary pays first and secondary pays liability or remaining costs.

Question 22

whats reasoning for copay?

Answer 22

reduce utilizations.

Question 23

For medicare providers, if service is known to be non-covered the provider may have the patient sign what?

Answer 23

advanced beneficiary notice.

Question 24

a 10 digit numeric identifier that must be used on claim forms submitted to payers by individual and organization HCP who mean definition of covered entity under HIPPA

Answer 24

the national provider identifier (NPI)

Question 25

What is the intent of the NPI?

Answer 25

National provider identifier

to streamline electronic claims already in place.

Question 26

What is the out of network model?

The insurance contracts are ___

Answer 26

collecting payment from pt and provide bill to give to insurance or just do it for the patient .

limited.

Question 27

Opt out of all private insurance contracts?

are PTs aloud to opt-out of medicare covered services?

Answer 27

cash practice.

payer takes responsibility.

naw.

Question 28

When billing for services provided by PT, must specify

Answer 28

medical Diagnosis (ICD-10)

Interventions: (CPT-4)

Question 29

official system of assigning codes to Dx associated with hospital utilization in the US

Answer 29

ICD-9 (14k Dx)

10-CM (69k Dx)

Question 30

ICD-9 has how many characters?

how about 10?

Answer 30

no more than 5

3,4,5,6,7

Question 31

Listing of descriptive terms and identifying for reportage medical services

Answer 31

common procedural terminology

CPT 1966

Question 32

What is CPT used for?

where is it mandated?

Answer 32

payment
outcome assessment
Data collection

medicare B

Question 33

payment policy for coding dependent on

Answer 33

payers and their policies.

Question 34

When did legal requirement to use CPT come into play?

Answer 34

1996

final rule in 2000

Question 35

What is CPT owned by?

Answer 35

AMA

Question 36

Most common codes used by PTS are

Answer 36

Category 1 codes.

Question 37

do supervised modalities require one-on-one contact by provider?

what does require it?

Answer 37

naw..

contant attendance.

Question 38

minutes for 1 unit

2???

Answer 38

1: 8-23 mins
2: 23-38

keep adding 15

Question 39

to be used when care is provided to more than one person during the same time interval?

Answer 39

group therapy code 97150

Question 40

modifiers increase specificity of

Answer 40

CPT codes.

Question 41

CMS policy implemented to promote correct coding by providers to ensure appropriate payment

Answer 41

correct coding initiative. CCI

Question 42

What is the purpose of CCI?

Answer 42

to curtail improper unbundling of services for medicare part B claims.