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 noncovered emergency services

B both noncovered emergency services and not related to diagnoses

C not related to diagnoses

D claim processing error

Question #2

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

A the patient should be billed for the review.

B the insurance carrier will pay for the review.

C there is no charge for the review.

D the physician must pay for the review.

Question #3

Reasons for follow-up include:

A All of these.

B unclear denial of payment is received.

C reimbursement is received for an unknown patient.

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 change the date of service and resubmit the claim.

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

C bill the patient.

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 appeal.

B audit.

C reconsideration.

D review.

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 number of diagnoses or management options.

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

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 respiratory system.

B cardiovascular system.

C musculoskeletal system.

D neurological system.

Question #8

An independent audit should be performed a minimum of:

A twice a year.

B once a year.

C once a quarter.

D once a month.

Question #9

An internal audit would determine:

A the coder’s skill and knowledge.

B if additional training is needed for office staff.

C All of these.

D whether procedures were coded correctly.

Question #10

A postpayment audit would verify:

A patient insurance eligibility.

B patient insurance identification number.

C date of service.

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

B get the advice of an attorney.

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

D base the decision on past practices.

Question #12

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

A downcoding.

B upcoding.

C unbundling.

D bundling.

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 clean.

B authorized.

C complete.

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 self-funded plans only.

D private insurers only.

Question #15

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

A Level II HCPCS code book.

B Level III 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 private payer codes.

B orthotic procedures.

C temporary hospital outpatient.

D diagnostic radiology services.

Question #17

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

A True

B False

Question #18

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

A American Academy of Professional Coders.

B American Health Information Management Association.

C National Center for Competency Testing.

D National Healthcareer Association.

Question #19

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

A explaining DNR orders to patients and their family members.

B data entry of patient demographics.

C answering questions about privacy regulations.

D posting payments or making adjustments to patient accounts.

Question #20

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

A submitting insurance claims.

B explaining HIPAA regulations.

C contacting insurance carriers on incorrectly paid claims.

D analyzing patient charge information.

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 medical coder.

B medical collector.

C medical office assistant.

D payment poster.

Question #23

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

A large-group practice.

B small-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 based on the patient’s ability to pay.

C at the discretion of the physician.

D provided only by in-network physicians.

Question #25

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

A social history.

B history of present illness.

C past history.

D family history.

Question #26

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

A past history.

B social history.

C family 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 2 years.

C 1 year.

D 5 years.

Question #28

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

A consultations.

B emergency room services.

C office and other outpatient services.

D hospital (inpatient) services.

Question #29

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

A Category III CPT codes.

B Category I CPT codes.

C ICD-10-CM codes.

D Category II 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 1992

C 1986

D 1977

Question #31

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

A patient or staff member has a prison record.

B particularly severe flu epidemic has occurred.

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

D person may have been exposed to certain communicable diseases.

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

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

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

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

Question #33

The code next to the main term is called the:

A primary code.

B specified code.

C default code.

D combination code.

Question #34

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

A a better description of the disease.

B treatments of the disease.

C another name for the disease.

D the cause or origin 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 Alphabetic Index.

C Tabular List of Diseases and Injuries.

D Neoplasm Table.

Question #36

The ICD-10-PCS is used to report:

A outpatient procedure coding.

B proper mortality coding.

C inpatient procedure coding.

D proper diagnosis coding.

Question #37

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

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

B determine medical necessity for covered procedures and services.

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 encryption.

B transcription.

C coding.

D translation.

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 electronically transmitted data.

B secure medical data.

C protected health information.

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 malpractice history.

B disciplinary actions.

C criminal activity.

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 medical services covered under the managed care plan.

B providers in the contracted network.

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 know the Patient Bill of Rights.

D be familiar with managed care terms.

Question #45

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

A the list of employers with MCO contracts.

B when payment should be received from the MCO.

C how much the physician will be paid for services.

D the time limit for submitting claims to the MCO.

Question #46

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

A preferred provider model.

B individual practice association.

C group 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 enroll more members in the health plan.

B minimize malpractice suits.

C maintain their income.

D deliver MCO-required preventive care.

Question #48

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

A dermatologist.

B general practitioner.

C family practitioner.

D internal medicine doctor.

Question #49

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

A diagnostic code.

B billed amount.

C allowed amount.

D adjusted 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 discounted fees for services.

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

D provider networks and regular premium increases.

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Midterm Exam Chapter 2 to 9 & 16

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