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SEQUENCE 2 FINAL > INSURANCE CODING FINAL > Flashcards

INSURANCE CODING FINAL Flashcards

1
Q

ICD-9-CM is updated how often?

A

every year on October

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2
Q

Worker’s compensation cases are kept open for how long from the last date of service?

A

2 years from the last date of treatment

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3
Q

Is the data bank that lists all active and retired military service members called Manage Care? Why?

A

No, it is called DEERS ( defense enrollment eligibility reporting system)

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4
Q

When parents are divorced or separated, whose insurance is usually considered the primary plan?

A

Whoever has legal custody

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5
Q

An insurance card proves that a patient has insurance coverage?

A

No, eligibility need to be verified through the automated system using point of service or online in California

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6
Q

The statute of limitations for minors is extended until what age?

A

Legal age in all states

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7
Q

A V-code describes what?

A

A condition other than illness

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8
Q

An E-code is used to identify what?

A

Identifies an accident

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9
Q

What volume of ICD-9-CM would you use to code inpatient services?

A

Volume 3

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10
Q

Medicare Part A is for inpatient services, would the patient have to pay premiums for this coverage?

A

Usually they do not pay a premium

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11
Q

What is indemnity insurance? Can patients chose their own doctors?

A

A fee-for-service with annual deductible and copay; yes patients can choose their own doctor and pay portion of the fees

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12
Q

Where would you find the rules and regulations governing health insurance and coding?

A

Federal register

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13
Q

Which claim form would be submitted to the insurance company using ICD and CPT codes?

A

CMS 1500

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14
Q

What are the methods for sending electronic claim to the insurance company or clearinghouse?

A

Dial up modem, over the internet, and direct data entry

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15
Q

The Department of Veterans Affairs manages which healthcare program?

A

CHAMP VA

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16
Q

What is an explanation of benefits?

A

a statement receive from the insurance check and explained how payment was made

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17
Q

give four examples of Medical fraud

A

Dispensing generic drugs and billing for brand name drugs, bribery, false cost reports, and giving or accepting something in return for medical services (kickback)

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18
Q

list four services a state must provide to receive federal matching funds for Medicaid.

A

inpatient care, outpatient care, hospital care, and physical therapy

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19
Q

what is COBRA?

A

it provides possible continuation of health insurance coverage’s through a previous employer when a worker leaves a job

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20
Q

what is commercial insurance?

A

any kind of insurance not paid by the government

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21
Q

what is a waiver?

A

form that the doctor has the patient sign to acknowledge financial responsibility when the patient insist on receive treatment not covered by their insurance

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22
Q

what federal act protects civil rights of disabled individuals?

A

Federal act of 1990 of ADA

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23
Q

who issues a NPI number for physicians?

A

center of medicare and Medicaid (CMS)

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24
Q

which agency handles the claims and payments for self-funded insurance plans?

A

third party administrator

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25
Q

which volume of ICD-9-CM contains the alphabetic index?

A

volume 2

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26
Q

Medicaid is insurance that covers what category of patients?

A

Medically needy

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27
Q

what do the OCR guidelines consist of?

A

Month, day, year, upper case, no punctuation, cannot send a copy of the claim

28
Q

when using multiple modifiers in coding, which modifier would you use first?

A

-99

29
Q

Which HMO model allows patient’s to go outside and see any provider they choose?

A

point of service

30
Q

worker’s compensation benefits would include what type of coverage for patient’s?

A

Disability payments, medical cost, and vocational rehabilitation

31
Q

after finding a code in the alphabetic index of the ICD-9-CM, you should cross-reference the coding by checking what?

A

tabular list

32
Q

who pays the premiums for worker’s compensation?

A

the patients employer

33
Q

which insurance is more expensive, individual or group insurance?

A

individual

34
Q

can providers balance bill Medicaid patients for any cost of treatment after their insurance pays for services?

A

no

35
Q

what is one of the advantages of having group insurance through your employer, union, etc?

A

everyone is eligible for coverage no matter what their health status is

36
Q

does the date of service refer to the date the charges are posted to the patients account?

A

no the date of service is when the patient was provided the services

37
Q

are the usual, customary and reasonable fees of physician the same or different from the healthcare provider’ actual charges?

A

they may be different from the health care providers charges

38
Q

an allowable charge is the maximum that who will pay for the particular procedure or service?

A

third party payers

39
Q

what does ICD-9-CM stand for?

A

international classification of diseases, ninth revision, clinical modification

40
Q

what does HCPCS stand for?

A

health care common procedure coding system

41
Q

what does CPT stand for?

A

current procedural terminology

42
Q

how many sections are in the CPT?

A

6

43
Q

the codes most frequently used in the CPT manual are?

A

evaluation and management

44
Q

define outpatient:

A

not officially admitted, staying less than 24 hours

45
Q

do you only need to code from the alphabetic index in the ICD-9? Why?

A

no, confirm your code in the tabular list

46
Q

can V codes be used as the primary diagnosis?

A

yes

47
Q

can E codes be used as the primary diagnosis?

A

no

48
Q

how many digits are ICD-9 codes?

A

5th digit used whenever possible

49
Q

how many digits are CPT codes?

A

5

50
Q

when coding an unlisted procedure, what must be attached to the claim?

A

special report

51
Q

managed care insurance plans usually require what before a patient can be referred to a specialist?

A

referral report

52
Q

define deductible:

A

a specific amount of money that must be paid each year before the policy benefits begin

53
Q

define crossover claim:

A

claim that automatically forwards from one plan to another

54
Q

define an eligible patient:

A

a patient that has current coverage with an insurance claim

55
Q

define a dependent under an insurance plan:

A

person covered under the subscribers plan

56
Q

define pre-existing condition:

A

a condition test that existed and treated before the insurance policy is issued

57
Q

define exclusion:

A

injury or illness that is excluded from the policy

58
Q

is Medicare only for retired person age 65 and older? Why?

A

No, also for certain individuals who are disabled at any age with end stage renal disease, permanent kidney disorders, and required dialysis or transplant

59
Q

when coding from the ICD-9-CM in a doctor’s office, which volumes should you use?

A

Volumes 1 & 2

60
Q

what is another name for the CMS-1500 claim for?

A

universal claim form

61
Q

what is the birthday rule?

A

when both parents have insurance, it determines that a parent whose bday falls first in the calendar year is the primary insurance

62
Q

ICD-9 identifies:

A

diagnosis

63
Q

CPT identifies:

A

procedures

64
Q

which codes have a modifier?

A

CPT

65
Q

why do we use standard coding systems to report diagnosis and procedures?

A

to facilitate payment from third party payers

66
Q

is the secondary insurance billed first?

A

no, the primary is billed first

67
Q

which claim form is used to bill medicare?

A

CMS-1500

SEQUENCE 2 FINAL (3 decks)

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