Practice Exam 1 Flashcards
car accident
bill insurance first to get a denial then submit claim to auto insurance.
Managed Care who allows patients to self-refer?
PPO
POS
CAQH
handles credentialing for many payers
Tricare for active-duty service members?
Tricare Prime
Forms needs for work related injusty?
First Report of injury form
Progress report
CMS1500
State and Federal guidelines apply to?
Medicaid
FDCPA = Fair Debt Collection Practices Act
not allowed to call after odd hours
HCPCS/CPT code assigned a “1” means?
one unit of service
on a single DOS
ABN Advanced Beneficiary Notice
explains financial responsibility if Medicare denies payment
Fair Credit Reporting Act
protects information collected by consumer
CMS standard form in which providers agree to?
Submit claims to Medicare
Have authorization from beneficiary
Retain documents and medical records
research/correct claim discrepancies
Scenario in which Medicare billed as secondary?
72yo with Employer insurance
66yo injured at work, but no Employer insurance.
Dr’s can’t bill for multiple lab draw fee just because the MA misses.
fradulent
According to CMS which are included in Global package for surgical procedures?
Surgical procedure performed.
Post Op infection treated in the office.
ACO = Accountable Care Organization
Group of doctors, healthcare providers, hospitals who coordinate care to Medicare patients.
Medicare will list which of the following?
Effective Date of coverage
Entitled to Part A or B
NOT: address, ss, phone, physician, when coverage ends
You discover a claim overpaid by Medicare?
False Claims Act requires a refund
EPSDT = Early Periodic Screening Diagnostic & Treatment
Pediatric checkups are covered
Policy to write off as courtesy is?
Fraud
can’t write off for any patients.
Patient’s insurance requires Preauthorization for all surgical procedures.
NOT if it’s an emergency
Security involves safekeeping of PHI
Employer must
Set up policies to protect PHI.
Require employees to sign confidentiality agreement.
to prevent incorrect patient information
Photo Id
Ins Card
Registration Form
Office policy usually is to follow up on oldest accounts with highest balance.
pay attention to the “age of account” and balance
How may I help you Mrs. Jones
Violates HIPAA
example of overpayment that must be refunded is?
duplicate processing of a cliam
steps to file an appeal
- form required by payer
- review reason for denial to see error
- documentation
- keep copies
- appeal asap if you’re certain of error
when nonparticipating provider files claim to BC/BS, how is payment processed?
the payment is sent to patient and patient must pay the provider.
A married couple both have insurance. Who carries primary insurance for their children?
Husband: DOB 2/3/87
Wife: DOB 4/4/84
Husband, because month & day are before hers
Rule: (year of birth not considered)
Claim denied for not submitted timely. What to do?
Check the date. If submitted timely resend to payer.
Procedure cost $2500.00
Deductible $500
PPO covers 80%
what’s the patient responsibility?
$900.00
2500 * .80 is 1600
2500-1600 is 400 (patient pays)
add $500 deductible. Total $900
An allowed collection policy after patient’s bankruptcy?
Any claims after bankruptcy date.
CPT code denied as bundled services.
Resubmit CPT with Modifier 59
(To show procedure was distinct from other procedure)
CPT code denied as inclusive.
A corrected claim should be filed with the original CPT.
(no modifiers mentioned here)
Medicare primary.
AARP is medigap.
On the CMS1500 9d enter (line for insurance name of plan name)
on line 9d enter:
COBA medigap claim based identifier ID
Frequency of care on UB04 indicates?
Type of Bill
New patient.
No complaints.
Seen by PA. How do you bill?
Bill under PA
Office visit.
Low MDM required for HBP.
also, two planter warts destroyed.
How is this reported?
99213 E/M for OP
17110-59 procedure with modifier
59 modifier indicates distinct procedure
CPT 19101 open incisional biopsy
Use Modifier 51
to indicate more than one procedure was performed.
HCPCS Level 11 for Depo-Provera injection 100 mg
J1050 x 100
Excision of squamous cell carcinoma.
Requires wound closure.
11642 (removal)
12051-51
repair &
51 more than one procedure was performed.
for electronic data interchanges which codes sets are required?
Inpatients are reported with HCPCS Level 11
Outpatients are reported with CPT and HCPCS Level 11
Surgery for hernia
Paiten f/u visit and has a lump on tailbone.
Dr. treats it.
Can it be billed?
E/M evaluation & management with
Modifier 24 to indicate unrelated to surgery
Clearinghouse report shows C44.50 must be valid. What do you do?
Review medical records for 6th character, correct claim, resubmit.
Correct sequence.
bilateral tympanostomy
adenotonsillectomy
42820
69436-50
referral for gangrene
E10.52
Which elements are incorrect?
CPT code (s)
Diagnosis and Correlation
cataract surgery
insertion of lens
66984
H26.32
T38.0X54
Policy
f/u on 90 days highest balance
WC 121 days was the oldest and highest amount.
