MAA 138 Medical Billing & Coding FINAL Review

MAA 138 Medical Billing & Coding FINAL Review What is coordination of benefits? - ✔✔When the patient has two insurances; one is primary, one is secondary Are claim inquiries done by phone or in writing? - ✔✔Both Wha ...

MAA 138 Medical Billing & Coding FINAL Review What is coordination of benefits? - ✔✔When the patient has two insurances; one is primary, one is secondary Are claim inquiries done by phone or in writing? - ✔✔Both What is implied contract? - ✔✔When a patient goes to the doctor's office seeking medical services and the physician accepts the patient and agrees to render treatment and both parties agree Can a photocopy of a claim form be scanned with optical character recognition? Why or why not? - ✔✔No it must be the original claim with red print What could happen if a MAA completes a Medicare claim with information that is not true? - ✔✔Possible fines & imprisonment Who pays the medical bill for an emancipated minor? - ✔✔The emancipated minor What is a non-availability statement for TRICARE patients? - ✔✔Allows patient to obtain services from a nonmilitary medical facility Give 4 reasons why a claim might be denied - ✔✔Prior approval not received, incorrect code bundling, diagnosis and service don't match, specialty provider not eligible for services, location of procedure not eligible, service not covered, condition treated was preexisting, and missing information How many volumes are in ICD-9? - ✔✔3 When is a prospective internal audit performed? - ✔✔Before the billing is submitted What is redetermination? - ✔✔The first level of appeals for Medicare What is the timeframe claims are paid if sent electronically? By mail? - ✔✔Less than two weeks (7-14 days), 4-6 weeks by mail What is A/R and what does it mean? How does the collection process affect it? - ✔✔Accounts Receivable - money is owed to the doctor; slower the money is collected the higher the A/R What do you do when a claim has been rejected? - ✔✔Investigate it first, it might not be a covered service; correct it if possible; and resubmit What is a clearinghouse? How do they charge fees to the provider? - ✔✔Entity that receives EDI from the healthcare provider; they check the claims for errors, reject them and send them back to the provider and batch out the claims to third party payers that pass all the edits; It is a flat rate by claim or monthly fee What does encrypted data look like to unauthorized users? - ✔✔Gibberish or scrambled data What is an EOB? Can it contain information for more than one patient? - ✔✔It gives complete information about payment or nonpayment of the claim and is attached to the check; Yes When should we collect any payment due for services rendered? Why? - ✔✔At the time of the appointment; Because it is too expensive to collect money later for copays What does "batch" claims processing mean? - ✔✔A group of claims for different patients submitted at the same time What is assignment of benefits? - ✔✔Signature authorizes payment to be sent to the provider What is the result of down coding? - ✔✔Less reimbursement What does the term "pending claim" mean? - ✔✔Claim held in suspense or review Are cash refunds given to a patient who has paid with a credit card? - ✔✔No a credit voucher is used What is the age of Medicare recipients who are not disabled? - ✔✔65 years old Electronic or manually transmitted data to the insurance company is called? - ✔✔Claims submission What is the purpose of an insurance claims register? - ✔✔Follow up procedure for insurance claims How do you handle a patient who did not sign their check written to the doctor? - ✔✔Call them and have them come in and sign it or mail in another check What is the Fair Credit Reporting Act? - ✔✔Regulates agencies that either issue or use credit reports of patients regarding approval of credit What is reconsideration? How would you send the documents? - ✔✔Second level of Medicare appeals; Certified return receipt What is outsourcing? - ✔✔Using a billing service to send out the billing What is garnishment? - ✔✔To seize a portion of an employee's future wages to pay off a debt What kind of tone is used when writing the first collection letter to a patient? - ✔✔A friendly tone; ask why payment has not been made Which has more codes ICD-9 or ICD-10? - ✔✔ICD-10 Who refers patients on an HMO to see a specialist? - ✔✔Primary Care Physician What is statute of limitations? - ✔✔The maximum time during which a legal collection suit made be rendered against a debtor; maximum time a lawsuit may be filed When is an "Advanced Beneficiary Notice" used? - ✔✔Signed in advance when Medicare is not going to pay for a procedure What is "medical necessity"? - ✔✔Justifying medical services or procedures by the patient's diagnoses and symptoms Who is the guarantor? - ✔✔The person who signs to accept responsibility to pay the bill What is a premium? - ✔✔The amount of money paid to keep the policy in effect What is a deductible? - ✔✔Specific amount of money paid by the patient each year before the policy benefits begin What is the Notice of Privacy Practices? - ✔✔It explains to the patient how their health information is used; the patient needs to sign an acknowledgement of receipt of the NPP Define participating provider. - ✔✔A provider who has a contractual agreement with an insurance plan to render care to eligible beneficiaries and bills the insurance company directly Define ledger card. - ✔✔A patient's financial record or account Give another name for "encounter form." What is it? - ✔✔Superbill; Attached to each patient's chart, contains patient's name, date, DOB, procedure codes and the ICD-9 codes Give the name of the universal claim form - ✔✔CMS 1500 Explain "New" vs. "Established" patient - ✔✔NP: one who has not seen the doctor or anyone in the office for the past 3 years; Est. patient: has seen the doctor or another physician in the same group practice Explain what a National Provider Identifier (NPI) is - ✔✔10 digit number that is assigned to identify every provider List the "rebilling" process - ✔✔Investigate the reason the claim needs to be rebilled, send in a corrected claim or claim correction form, bill the patient every 30 days even when the insurance is expected to pay, note in the claim form in box 19 that it is a resubmission, post an entry on the patient's account to note that the claim was resubmitted What is a "dun message"? - ✔✔Phrases printed on statements to inform or remind the patient about nonpayment Why do we copy the patient's insurance card? Which sides do we copy? - ✔✔To have accurate insurance information; Both sides What is the first digit of an ICD-9 code? - ✔✔Alpha or numeric What are the advantages of electronic claim submission? - ✔✔Faster payment and accurate audit trail When can you appeal a claim denial? - ✔✔No reason was given for the denial; unusual circumstances prevent it, precertification of the service, amount of payment was reduced by the insurance provider What is dual coverage? - ✔✔When the patient has two insurance policies; one is primary and the other is secondary The insurance company with the first responsibility for payment of a bill for medical services is known as... - ✔✔Primary Insurance What is an insurance appeal? - ✔✔A request for payment to a third party payer asking for a review of an insurance claim that has been denied A "skip" refers to? - ✔✔A patient who owes a balance and moves without leaving a forwarding address What is a "write-off?" - ✔✔An uncollectable debt that needs to be subtracted from the patient's account Federal government workers are covered by whom for workers compensation? - ✔✔Federal Law What is an insurance inquiry? - ✔✔A follow-up effort made to an insurance company to locate the status of an insurance claim Written disclosure is required when you have how many payment installments? - ✔✔Four or more What is a clean claim? - ✔✔A claim found to contain all data elements required for processing When do you code with an unlisted procedure code? - ✔✔When the doctor develops a new technique for performing a procedure that is not described in the CPT or HCPCS book Do you code "care for wound infections" separate or together with other services? - ✔✔Separate What doesn't a wound exploration procedure include? - ✔✔Laparotomy Laser removal of condylomata is identified as? - ✔✔Destruction of lesions Is "saphenous vein" coded together or separate from a coronary artery bypass procedure? - ✔✔Together What is ultrasonography? - ✔✔A diagnostic technique that uses high frequency, inaudible sound waves that bounce off body tissues and provide recorded information What is a HCPCS Level II J code? Does Medicare use them? - ✔✔Supply of the drug, Yes Medicare does use them How many digits does an ICD-10 code have? - ✔✔Minimum of 3 Maximum of 7 Does the ICD-10 code begin with a number or letter? - ✔✔Letter and then numbers Define preauthorization - ✔✔Verification of coverage against the proposed care or procedure Define stale claim - ✔✔Submitted by the provider after health insurers allowable submission time limit Define predetermination - ✔✔Verification of the maximum amount the insurer will cover Define precertification - ✔✔Requires that a health plan be notified before a certain diagnostic or surgical procedures are performed 00100-01999 is which CPT Category? - ✔✔Anesthesiology 10021-69999 is which CPT Category? - ✔✔Surgery 70000-79999 is which CPT Category? - ✔✔Radiology 80000-89356 is which CPT Category? - ✔✔Pathology & Laboratory 90000-99602 is which CPT Category? - ✔✔Medicine 99201-99499 is which CPT Category? - ✔✔Evaluation and Management