Medical Coding and Claims

Question 1

abuse

Answer 1

an unreasonable and generally unacceptable departure from precedent and custom with one person taking advantage of another person or set of circumstances; abuse may or may not be unlawful

Question 2

adverse effect

Answer 2

a pathologic reaction to a drug that occurs when appropriate doses are given

Question 3

appeal

Answer 3

a request to a authority for a decision

Question 4

benign tumor

Answer 4

a nonmalignant lesion that is not invasive or metastatic

Question 5

chief complaint

Answer 5

a patient’s statement describing symptoms and conditions that are the reason for seeking health-care services

Question 6

claim

Answer 6

a bill sent to the insurance carrier for payment related to patient care

Question 7

clean claim

Answer 7

completed insurance claim form submitted to a carrier without deficiencies or errors

Question 8

CMS 1500

Answer 8

universal health insurance claim form used in the physician’s office

Question 9

comorbidity

Answer 9

a condition that exists along with the condition for which the patient is receiving treatment

Question 10

concurrent use

Answer 10

similar services provided to the patient on the same day by a different physician

Question 11

consultation

Answer 11

services rendered by a physician whose opinion or advice is requested by another physician or agency in the evaluation or treatment of a patient’s problem

Question 12

counseling

Answer 12

discussion with patient or family concerning diagnosis, recommendations, risks, benefits, prognosis, and necessary condition-related education

Question 13

critical care

Answer 13

intensive care in acute life-threatening conditions requiring constant beside attention by the physician

Question 14

Current Procedural Terminology (CPT)

Answer 14

coding system first published by the American Medical Association in 1966; a manual, updated annually, that contains the codes for procedures and services preformed by doctors and other select medical personnel

Question 15

dirty claim

Answer 15

a claim held or rejected by the insurance carrier due to problems or errors

Question 16

E code

Answer 16

a supplementary classification of ICD-9 coding that denotes the external cause of an injury rather than a disease

Question 17

eponym

Answer 17

the name of a disease or procedure derived from the name of a place or person

Question 18

established patient

Answer 18

a person who has received care from the physician or another physician of the same specialty in the same group practice within 3 years

Question 19

etiology

Answer 19

the cause of a disease

Question 20

explanation of benefits (EOB)

Answer 20

synonymous with remittance advice (RA); a correspondence by the insurance company informing the patient and medical office the amount paid for a claim and why

Question 21

fraud

Answer 21

intentional and unlawful deception for gain that results in harm to another person or organization

Question 22

gang visits

Answer 22

billing for individual visits when not all the patients present during the visit received services

Question 23

General Equivalency Mapping (GEM)

Answer 23

a crosswalk between the ICD-9 and the ICD-10

Question 24

Healthcare Common Procedure Coding System (HCPCS - hicpics)

Answer 24

a method developed by the Health Care Finance Administration for coding procedures and other services delivered to Medicare patients

Question 25

in situ

Answer 25

neoplasm confined to the site of origin

Question 26

International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9 or ICD-9-CM)

Answer 26

a coding system published by the US Department of Health and Human Services to classify diseases and injuries

Question 27

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

Answer 27

diagnostic coding system to replace the ICD-9

Question 28

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

Answer 28

procedural coding system to replace the CPT system in hospitals

Question 29

late effect

Answer 29

a residual condition occurring after the acute phase is over

Question 30

malignant tumor

Answer 30

a neoplasm with invasive and metastatic properties

Question 31

new patient

Answer 31

a person who has not received care from the physician or another physician of the same specialty in the same group practice within 3 or more years

Question 32

Not elsewhere classified (NEC)

Answer 32

a term used in ICD-9 coding when information is not available to code the term in a more specific category

Question 33

Not otherwise specified (NOS)

Answer 33

a term used in ICD-9 coding for unspecified diagnosis

Question 34

phantom billing

Answer 34

billing for services or supplies not provided

Question 35

ping-ponging

Answer 35

unnecessary or excessive referrals of patients to other providers and back to primary office

Question 36

point of service (POS)

Answer 36

facility where the health-care service took place

Question 37

primary diagnosis

Answer 37

the symptoms, conditions, and initial impressions, diagnosed as the cause for the patient seeking health-care services

Question 38

principal diagnosis

Answer 38

the definitive diagnosis

Question 39

remittance advice (RA)

Answer 39

synonymous with explanation of benefits (EOB), correspondence by the insurance company informing the patient and medical office the amount paid for a claim and why

Question 40

split billing

Answer 40

charging for several visits when services were performed during one visit

Question 41

superbill

Answer 41

also called an encounter form; a charge form custom-designed for the specific medical practice; lists the ICD-9 and CPT codes common to the services of that practice

Question 42

unbundling

Answer 42

using several CPT codes to identify procedures normally covered by a single code

Question 43

upcoding

Answer 43

deliberately using an incorrect code to bill at a higher rate

Question 44

V codes

Answer 44

ICD-9 codes identifying health care visits for reasons other than illness

Question 45

yo-yoing

Answer 45

scheduling the patient for unnecessary follow-up visits