Insurance Claims Management

Question 1

Co-payment

Answer 1

Refers to making a small amount at the time of visit.

Question 2

Premium

Answer 2

Is a monthly payment to keep a policy in force.

Question 3

Exclusion

Answer 3

Is a peril that is not covered by the policy.

Question 4

Capitation

Answer 4

A fixed, prepaid fee per person enrolled in a managed cafe program.

Question 5

Maternity Leave

Answer 5

Can qualify as FMLA or short term disability.

Question 6

Beneficiary

Answer 6

The person or party designated by the policyholder to receive the value of a policy.

Question 7

Preadimission Certification

Answer 7

Determining medical necessity before a hospital admission is approved.

Question 8

Preauthorization

Answer 8

Determines whether a service will reimbursed before its delivery.

Question 9

Concurrent Review

Answer 9

Determines medical necessity before hospital admission.

Question 10

Discharging Planning

Answer 10

Refers to arranging appropriate following patient release.

Question 11

Medicare

Answer 11

Is title 18 of the Social Security Act.

Question 12

Medicare Part B covers

Answer 12

Out-patient care.

Question 13

Insurance Claims Management

Answer 13

A medical coding system enables the translation of verbal description of diseases, injuries, illness, and procedures into numerical.

Question 13

CPT coding conventions, terms after a semicolon (;)

Answer 13

Is to clarify a main term.

Question 14

Tracking

Answer 14

Systematic method of monitoring progress of disease condition.

Question 15

Classification

Answer 15

Allows for grouping related diagnosis and procedures.

Question 16

Research

Answer 16

Provides comparable data for compiling research information.

Question 17

Evaluation

Answer 17

Permits analysis of medical utilization.

Question 18

Standardization

Answer 18

Simplifies reimbursement functions.

Question 19

Types of coding systems

Answer 19

ICD-9-CM: International Classification of Diseases 9th Edition
CPT: Current Procedural Terminology
HCCPCS: Healthcare Common Procedural Coding System
RBRVS: Resource-Base Relative Value System
DRG: Diagnosis Related Group
MS-DRG: Medical Severity
RVS: Relative Value Study

Question 20

ICD-9-CM

Answer 20

International Classification of Diseases 9th Revision, Clinical Modification

 - Used to code diagnosis or disease condition.
 - Assigns numeric codes to diseases, illnesses, injuries and health-related conditions.

Question 21

CPT

Answer 21

Current Procedural Terminology

- Used to code medical services and procedures provided by physician.

Question 22

HCCPCS

Answer 22

Healthcare Common Procedural Coding System

- A national coding system for reporting medical services to the Medicare program.

Question 23

RBRVS

Answer 23

Resource-Based Relative Value System

- Medical Fee Schedule (MFS) for services based on the level or resources needed to provide a service.

Question 24

DRG

Answer 24

Diagnosis Related Group
- A prospective fixed Medicare fee structure for hospital billing of inpatient services based on principle diagnosis.

Question 25

RVS

Answer 25

Relative Value Study
- A point value is assigned to the service performed based on the time, knowledge, and skilled required of the provider. This point value is multiplied by a standard dollar factor to arrive at a final fee amount.

Question 26

MS-DRG

Answer 26

Medical Severity

- Weighted by the severity of diagnosis, paying more for sicker patients.

Question 27

ICD-9-CM coding system organized in three volumes

Answer 27

• Volume I (Tabular List of Diseases): numerical arrangement of conditions:
• Volume II (Alphabetical Index of Diseases): diseases and conditions arranged alphabetically.
• Volume III (Tabular List and Alphabetical Index of Procedures): medical procedures arranged both numerically and
  alphabetically. Commonly used by hospitals to code inpatient procedures.

Question 28

ICD-9 Volume I

Answer 28

Numerical arrangement

- 001 to 799: codes referring to specific health conditions by body systems.

Question 29

ICD-9 Volume II

Answer 29

Numerical arrangement

- 800 to 959, 990 to 999: codes referring to injuries.

Question 30

ICD-9 Volume III

Answer 30

Numerical arrangements

- 960 to 989: codes referring to poisoning.

Question 31

ICD-9 V Codes (V01 to V89)

Answer 31

Codes referring to factors that influence health status. A definitive diagnosis can’t be stated; however, there’s a valid reason for seeking medical care.

 - Preoperative evaluation 
 - Annual physical exams
 - Well-baby check

Question 32

ICD-9 E Codes

Answer 32

External causes of injuries and poisoning (associated with 800 + level codes.)

Question 33

ICD-9 M Codes

Answer 33

• On Appendix A.

- Morphology of neoplasms.

Question 34

ICD-9 Glossary of Mental Disorders

Answer 34

• Appendix B.
• Alphabetical list of terms and definitions associated with mental disorders.
• Code 290 to 319

Question 35

ICD-9 Classification of Drugs by (AHFS) American Hospital Formulary Services

Answer 35

• Appendix C.

- Organizes in AHFS numerical order along with its ICD-9-CM equivalent.

Question 36

ICD-9 Classification of Industrial Accident According to Agency

Answer 36

Appendix D

Question 37

ICD-9 List of Three-Digit Categories

Answer 37

• Appendix E

- Identifies the three-digit category codes organized by section headings.

Question 38

ICD-9 Volume II- Three-part index to Volume I

Section 1

Answer 38

1. Alphabetical index of diseases and injuries.
2. Hypertension chart
3. Neoplasm chart

Question 39

ICD-9 Volume II Section 2

Answer 39

Table of Adverse Effect to Drugs and Chemicals.

 - Accidental poisoning 
 - Assault 
 - Misadventure in therapeutic use
 - Suicide attempts 
 - Undetermined

Question 40

ICD-9 Section 3

Answer 40

• The Index to External Causes (E codes).

- Codes the circumstances surrounding an accident or act of violence that resulted in an injury.

Question 41

ICD-9 Coding conventions Volume I

Answer 41

• Colon :
• Brace }
• Section mark §
• Excludes (enclosed with a rectangle)
• Includes

Question 42

ICD-9 Coding conventions Volume I

Colon :

Answer 42

Each modifier after the colon completes the main statement before the colon.