Midterm Exam Chapter 2 to 9 & 16

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Question #1

Which of the following are reason codes that require a formal appeal?

A not related to diagnoses

B claim processing error

C both noncovered emergency services and not related to diagnoses

D noncovered emergency services

Question #2

If a physician requests a peer review that results in confirmation that services were NOT medically necessary:

A the insurance carrier will pay for the review.

B there is no charge for the review.

C the patient should be billed for the review.

D the physician must pay for the review.

Question #3

Reasons for follow-up include:

A unclear denial of payment is received.

B reimbursement is received for an unknown patient.

C All of these.

D an incorrect payment is received.

Question #4

If a claim is denied because services were provided before insurance coverage was in effect, the medical office specialist should:

A bill the patient.

B wait until the effective date of the coverage, then bill the insurance carrier.

C write off the entire amount.

D change the date of service and resubmit the claim.

Question #5

An examination and verification of claims and supporting documentation submitted by a physician is known as a(n):

A review.

B reconsideration.

C audit.

D appeal.

Question #6

If a physician who ordered a test personally reviews the results to supplement information from the physician who prepared the test report, the work would add to the level of the:

A All of these.

B amount and/or complexity of data to be reviewed.

C number of diagnoses or management options.

D risk of significant complications, morbidity, and/or mortality.

Question #7

If a physician documents that an exam included the measurement of a patient’s blood pressure, the system examined would be the:

A musculoskeletal system.

B respiratory system.

C neurological system.

D cardiovascular system.

Question #8

An independent audit should be performed a minimum of:

A once a year.

B twice a year.

C once a quarter.

D once a month.

Question #9

An internal audit would determine:

A All of these.

B whether procedures were coded correctly.

C the coder’s skill and knowledge.

D if additional training is needed for office staff.

Question #10

A postpayment audit would verify:

A sign-in sheets and appointment scheduling practices.

B patient insurance eligibility.

C patient insurance identification number.

D date of service.

Question #11

The best way to be sure that an intended action will NOT be subject to investigation as fraud is to:

A base the decision on past practices.

B obtain an advisory opinion from the Office of Inspector General (OIG) and Centers for Medicare and Medicaid Services (CMS).

C get the advice of an attorney.

D submit the claim, and request an explanation if denied.

Question #12

Billing the parts of a bundled procedure as separate procedures is referred to as:

A downcoding.

B bundling.

C unbundling.

D upcoding.

Question #13

When each reported service is connected to a diagnosis that supports the procedure as medically necessary, the claim is referred to as:

A authorized.

B complete.

C clean.

D accurate.

Question #14

HCPCS Level II national codes are used in claims submitted to:

A public and private insurers.

B public insurers only.

C private insurers only.

D self-funded plans only.

Question #15

The code for durable medical equipment (DME) would be found in the:

A Level III HCPCS code book.

B Level II HCPCS code book.

C This is not considered a HCPCS code.

D Level I HCPCS code book.

Question #16

HCPCS Level II codes in the range C1300—C9899 would be used for:

A diagnostic radiology services.

B private payer codes.

C orthotic procedures.

D temporary hospital outpatient.

Question #17

A large-group practice will frequently contract out its billing and accounts receivable.

A False

B True

Question #18

The Certified Professional Coder (CPC) certification is awarded through the:

A American Health Information Management Association.

B National Healthcareer Association.

C American Academy of Professional Coders.

D National Center for Competency Testing.

Question #19

The duties and responsibilities of a privacy compliance officer may include all of the following EXCEPT:

A data entry of patient demographics.

B posting payments or making adjustments to patient accounts.

C explaining DNR orders to patients and their family members.

D answering questions about privacy regulations.

Question #20

The duties and responsibilities of a medical biller may include all of the following EXCEPT:

A explaining HIPAA regulations.

B submitting insurance claims.

C analyzing patient charge information.

D contacting insurance carriers on incorrectly paid claims.

Question #21

The healthcare professional who is responsible for answering questions and explaining topics such as HIPAA privacy regulations, living wills, and do-not-resuscitate orders (DNRs) to patients and their family members is the:

A privacy compliance officer.

B medical collector.

C insurance verification representative.

D admitting clerk.

Question #22

The healthcare professional who researches data in medical records in order to accurately document diagnoses and procedures and obtain maximum reimbursement for physicians is the:

A payment poster.

B medical coder.

C medical office assistant.

D medical collector.

Question #23

A practice with 10 or more physicians would generally be categorized as a:

A small-group practice.

B large-group practice.

C solo practice.

D private practice.

Question #24

Managed care is a system in which physicians contract to participate in a health insurance network and healthcare delivery is:

A monitored to control costs.

B at the discretion of the physician.

C provided only by in-network physicians.

D based on the patient’s ability to pay.

Question #25

Details about the health status or cause of death of parents, siblings, and children would be part of a:

A past history.

B family history.

C social history.

D history of present illness.

Question #26

Details about a patient’s current employment or school history would be part of a:

A social history.

B history of present illness.

C family history.

D past history.

Question #27

A new patient is considered one who has NOT received professional services from the physician or another physician of the same specialty in the same group within the past:

A 5 years.

B 2 years.

C 1 year.

D 3 years.

Question #28

The most-often reported evaluation and management (E/M) services are:

A emergency room services.

B office and other outpatient services.

C consultations.

D hospital (inpatient) services.

Question #29

The temporary codes used for emerging technology, services, or procedures are:

A Category III CPT codes.

B Category II CPT codes.

C ICD-10-CM codes.

D Category I CPT codes.

Question #30

In what year did CMS require state Medicaid agencies to use CPT codes for reporting outpatient hospital procedures as part of the Omnibus Budget Reconciliation Act?

A 2006

B 1986

C 1992

D 1977

Question #31

Providers are legally obligated to disclose protected health information (PHI) to public health authorities when a:

A person may have been exposed to certain communicable diseases.

B patient or staff member has a prison record.

C patient has returned from a trip to a country with poor sanitation.

D particularly severe flu epidemic has occurred.

Question #32

Each medical practice must appoint a person to serve as its Privacy Compliance Officer, who must be familiar with federal and state privacy regulations in order to:

A respond to requests for medical records and handle privacy-related complaints.

B file monthly reports with the office of the state insurance commissioner.

C respond to insurance carriers’ questions and handle patient billing complaints.

D represent the practice in any lawsuits that arise over privacy issues.

Question #33

The code next to the main term is called the:

A default code.

B combination code.

C primary code.

D specified code.

Question #34

Subterms in an ICD-10-CM entry may show:

A treatments of the disease.

B the cause or origin of the disease.

C a better description of the disease.

D another name for the disease.

Question #35

To locate the correct code for the first encounter, the medical specialist must first look for the term in the:

A Neoplasm Table.

B External Causes Index.

C Tabular List of Diseases and Injuries.

D Alphabetic Index.

Question #36

The ICD-10-PCS is used to report:

A proper diagnosis coding.

B proper mortality coding.

C inpatient procedure coding.

D outpatient procedure coding.

Question #37

ICD-10-CM codes submitted on insurance claim forms are used to:

A determine medical necessity for covered procedures and services.

B report patient demographic information.

C report specific procedures and services.

D record a patient’s office visits or inpatient days.

Question #38

The process of scrambling and encoding electronic data to prevent it from being read by unauthorized users is known as:

A translation.

B encryption.

C transcription.

D coding.

Question #39

A person who has a privacy complaint can file it with the:

A Office for Civil Rights (OCR).

B American Medical Association (AMA).

C Centers for Medicare and Medicaid Services (CMS).

Question #40

Under the HIPAA Privacy Rule, a patient’s medical record and payment history are considered:

A protected health information.

B electronically transmitted data.

C secure medical data.

D managed care plan information.

Question #41

The credentialing process of a managed care organization (MCO) will examine each physician’s background for evidence of all of the following EXCEPT:

A salary history.

B malpractice history.

C disciplinary actions.

D criminal activity.

Question #42

In plans that require the primary care physician (PCP) to play a gatekeeper role, the PCP is given incentives to:

A treat the patient as much as possible without a specialist referral unless absolutely necessary.

B make frequent referrals to contracted network specialists.

C see as many patients each day as possible, even if this means less time with each patient.

D expand office hours and/or staff to permit more patients to be seen each day.

Question #43

The schedule of benefits section of a managed care contract lists the:

A providers in the contracted network.

B medical services covered under the managed care plan.

C benefits of participating in the managed care plan.

D deductible and coinsurance amounts that patients must pay.

Question #44

A medical office specialist must do all the following EXCEPT:

A promote the provider network.

B explain the ACO to the patient.

C be familiar with managed care terms.

D know the Patient Bill of Rights.

Question #45

A managed care contract should clearly state all of the following EXCEPT:

A when payment should be received from the MCO.

B the time limit for submitting claims to the MCO.

C the list of employers with MCO contracts.

D how much the physician will be paid for services.

Question #46

All of the following are types of health maintenance organizations (HMOs) EXCEPT the:

A preferred provider model.

B open access model.

C group model.

D individual practice association.

Question #47

By accepting lower payments from MCOs, physicians are forced to see more patients each day in order to:

A deliver MCO-required preventive care.

B enroll more members in the health plan.

C minimize malpractice suits.

D maintain their income.

Question #48

In a managed care organization (MCO), a primary care physician (PCP) is any of the following EXCEPT:

A family practitioner.

B internal medicine doctor.

C dermatologist.

D general practitioner.

Question #49

To determine the amount due from a patient, it is necessary to know the:

A adjusted amount.

B diagnostic code.

C billed amount.

D allowed amount.

Question #50

Managed care systems ensure the delivery of high-quality care while managing costs through:

A prohibiting the use of out-of-network providers.

B provider networks and regular premium increases.

C discounted fees for services and mandatory high deductibles across all health plans.

D provider networks and discounted fees for services.

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Midterm Exam Chapter 2 to 9 & 16

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