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 both noncovered emergency services and not related to diagnoses

B not related to diagnoses

C claim processing error

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 physician must pay for the review.

B there is no charge for the review.

C the insurance carrier will pay for the review.

D the patient should be billed for the review.

Question #3

Reasons for follow-up include:

A All of these.

B an incorrect payment is received.

C reimbursement is received for an unknown patient.

D unclear denial of 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 wait until the effective date of the coverage, then bill the insurance carrier.

B bill the patient.

C change the date of service and resubmit the claim.

D write off the entire amount.

Question #5

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

A reconsideration.

B appeal.

C review.

D audit.

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 neurological system.

B respiratory system.

C musculoskeletal 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 whether procedures were coded correctly.

B All of these.

C if additional training is needed for office staff.

D the coder’s skill and knowledge.

Question #10

A postpayment audit would verify:

A date of service.

B patient insurance identification number.

C patient insurance eligibility.

D sign-in sheets and appointment scheduling practices.

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 submit the claim, and request an explanation if denied.

C get the advice of an attorney.

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

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 accurate.

B authorized.

C clean.

D complete.

Question #14

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

A public insurers only.

B private insurers only.

C self-funded plans only.

D public and private insurers.

Question #15

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

A Level III HCPCS code book.

B This is not considered a HCPCS code.

C Level II HCPCS code book.

D Level I HCPCS code book.

Question #16

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

A private payer codes.

B temporary hospital outpatient.

C diagnostic radiology services.

D orthotic procedures.

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 National Center for Competency Testing.

B American Academy of Professional Coders.

C American Health Information Management Association.

D National Healthcareer Association.

Question #19

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

A answering questions about privacy regulations.

B data entry of patient demographics.

C posting payments or making adjustments to patient accounts.

D explaining DNR orders to patients and their family members.

Question #20

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

A explaining HIPAA regulations.

B analyzing patient charge information.

C submitting insurance claims.

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 admitting clerk.

B insurance verification representative.

C privacy compliance officer.

D medical collector.

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 medical coder.

B payment poster.

C medical office assistant.

D medical collector.

Question #23

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

A solo practice.

B large-group practice.

C private practice.

D small-group practice.

Question #24

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

A provided only by in-network physicians.

B monitored to control costs.

C based on the patient’s ability to pay.

D at the discretion of the physician.

Question #25

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

A history of present illness.

B family history.

C past history.

D social history.

Question #26

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

A family history.

B social history.

C past history.

D history of present illness.

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 3 years.

B 5 years.

C 1 year.

D 2 years.

Question #28

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

A consultations.

B hospital (inpatient) services.

C office and other outpatient services.

D emergency room services.

Question #29

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

A Category II CPT codes.

B Category I CPT codes.

C ICD-10-CM codes.

D Category III 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 1992

B 1986

C 2006

D 1977

Question #31

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

A particularly severe flu epidemic has occurred.

B person may have been exposed to certain communicable diseases.

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

D patient or staff member has a prison record.

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

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

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

Question #33

The code next to the main term is called the:

A default code.

B specified code.

C combination code.

D primary code.

Question #34

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

A the cause or origin of the disease.

B treatments of the disease.

C another name for the disease.

D a better description of 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 External Causes Index.

B Tabular List of Diseases and Injuries.

C Alphabetic Index.

D Neoplasm Table.

Question #36

The ICD-10-PCS is used to report:

A inpatient procedure coding.

B proper diagnosis coding.

C proper mortality 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 record a patient’s office visits or inpatient days.

C report patient demographic information.

D report specific procedures and services.

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 coding.

C encryption.

D transcription.

Question #39

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

A Centers for Medicare and Medicaid Services (CMS).

B Office for Civil Rights (OCR).

C American Medical Association (AMA).

Question #40

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

A electronically transmitted data.

B protected health information.

C managed care plan information.

D secure medical data.

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 disciplinary actions.

B criminal activity.

C malpractice history.

D salary history.

Question #42

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

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

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

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

D make frequent referrals to contracted network specialists.

Question #43

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

A providers in the contracted network.

B benefits of participating in the managed care plan.

C deductible and coinsurance amounts that patients must pay.

D medical services covered under the managed care plan.

Question #44

A medical office specialist must do all the following EXCEPT:

A be familiar with managed care terms.

B know the Patient Bill of Rights.

C promote the provider network.

D explain the ACO to the patient.

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 list of employers with MCO contracts.

C the time limit for submitting claims to the MCO.

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 individual practice association.

B group model.

C preferred provider model.

D open access model.

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 minimize malpractice suits.

C enroll more members in the health plan.

D maintain their income.

Question #48

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

A internal medicine doctor.

B dermatologist.

C general practitioner.

D family practitioner.

Question #49

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

A diagnostic code.

B allowed amount.

C adjusted amount.

D billed 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 provider networks and discounted fees for services.

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

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Midterm Exam Chapter 2 to 9 & 16

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