Medical billing and coding chapter 1

Question 1

assessment

Answer 1

part of doctor’s note, the diagnosis

Question 2

cms

Answer 2

center for medicare and medical services, government group that controls medicare and medicaid

Question 3

claims examiner

Answer 3

person who checks claim, works for the insurance company

Question 4

clearing house

Answer 4

middle man that checks claim between provider and the insurance company

Question 5

cms 1450

Answer 5

form used for hospital billing, (ub04)

Question 6

cms 1500

Answer 6

form used for outpatient billing, not hospital related

Question 7

code

Answer 7

alpha numeric digits given diseases and procedures

Question 8

coder

Answer 8

person assigning the codes

Question 9

coding

Answer 9

getting the codes

Question 10

CAC

Answer 10

computer assisted coding programs that help you get your codes

Question 11

continuity of care

Answer 11

documentation to help doctor keep patient info

Question 12

CPT

Answer 12

current procedural terminology, procedure coding system

Question 13

demographic data

Answer 13

patient information: name, phone number, emergency contact inforation

Question 14

DSM

Answer 14

diagnostic and statistical manual of mental disorders, book codes for mental disorders

Question 15

diagnostic management plan

Answer 15

doctor’s plan for patient treatment

Question 16

discharge note

Answer 16

note doctor does for discharging patient from hospital

Question 17

documentation

Answer 17

paperwork on everything related to patient,

Question 18

downcoding

Answer 18

reducing codes on procedure, coding less

Question 19

EHR

Answer 19

electrical health record patient chart on computer

Question 20

EMR

Answer 20

electrical medical record

Question 21

HCPCS

Answer 21

health care common procedure codes, coding system for out of normal procedures

Question 22

healthcare provider

Answer 22

any doctor /any person or medical care facility

Question 23

HIPAA

Answer 23

health insurance portability and accountability act 1996, privacy policy

Question 24

health plan

Answer 24

any type of insurance plan

Question 25

hospitalist

Answer 25

doctor that only works at a hospital, stationed there, does not own their own practice

Question 26

ICD

Answer 26

international classification of diseases diagnosis or disease coding

Question 27

CPT

Answer 27

procedures

Question 28

MA

Answer 28

medical assistant in doctor’s office, not a nurse

Question 29

medical coding process

Answer 29

how do we code?

Question 30

medical necessity

Answer 30

showing proof for need to do procedure must match the codes

Question 31

Medical Record

Answer 31

patient chart

Question 32

NDC

Answer 32

national drug codes used to code medications

Question 33

objective

Answer 33

doctors findings with examine and conversation

Question 34

overcoding

Answer 34

coding to higher than necessary

Question 35

patient record

Answer 35

patient chart

Question 36

plan

Answer 36

what the doctor is going to do with the patient

Question 37

problem list

Answer 37

list of medical problems a patient has

Question 38

POR

Answer 38

problem oriented record charting system/ way by the doctor

Question 39

progress notes

Answer 39

doctor’s notes on the patient

Question 40

provider

Answer 40

any medical facility or doctor of healthcare

Question 41

SOC

Answer 41

1. source oriented record
2. share of cost- amount the patient pays with insurance

Question 42

subjective

Answer 42

part of Dr. note that says patients complaints

Question 43

teaching hospital

Answer 43

hospital connected to a university that is used for students learning

Question 44

therapeutic plan

Answer 44

treatment plan for the patient

Question 45

third-party administrator

Answer 45

insurance co

Question 46

third-party payer

Answer 46

insurance co

Question 47

UB-04

Answer 47

form used for hospital billing

Question 48

unbundling

Answer 48

coding separately when services should be coded as a bundle

Question 49

upcoding

Answer 49

coding higher than documented (same as overcoding)