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66 Cards in this Set
- Front
- Back
Mrs. Caulfield is an 80-year-old female with Medicare as her primary insurance carrier. Mrs. Caulfield also has Metlife to cover her Medicare annual deductible and 20% of charges not covered by medicare. Metlife is a type of _____________ policy for Mrs. Caulfield. |
medigap |
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A medical discount card is or is not a health insurance ID card |
is not |
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Suzie Smith pays $25 at each office visit to her primary care provider. This amount is her responsibility to pay per her insurance coverage. This type of payment before each office visit is called a _______. |
copay |
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Preferred provider organizations (PPO) and health maintenance organizations (HMO) are examples of ____ ____ ____. |
managed care plans |
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A medical insurance coverage policy requires the policyholder to pay a monthly ______________. |
premium |
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Medicare is a type of ________ insurance plan |
managed care |
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Medigap is or is not a type of primary insurance coverage |
is not |
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The amount of a patient's co-payment is found on his or her ___ ___ ____. |
insurance ID card |
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A 25-year-old single female has coverage with her employer. This person does not have any children. She has a(n) _______________ type of insurance |
individual |
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Why is it important to copy both the front & back of an insurance card? |
The front contains billing info such as group and policy numbers, subscribers, etc. The back contains the address to which you submit claims. |
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A patient who has no health insurance is called |
self pay |
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The insurance that is billed first for the patient is called |
primary |
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Another name for secondary insurance is |
supplemental |
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List three synonyms for the term policyholder |
subscriber, beneficiary, insured |
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Describe the difference between co-payment and co-insurance |
Co-payment is the set amount a subscriber pays for each service, while a co-insurance is a set percentage the insured pays of the cost of each service |
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A nongovernmental plan that usually pays 80 percent and makes the patient responsible for 20 percent is called an _____ plan |
indemnity |
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CMS stands for |
Centers for Medicare and Medicaid Services |
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2 plans regulated by CMS are |
Medicare, Medicaid |
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CMS contracts with a ____ to pay Part B claims |
carrier |
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List 3 types of medical care plans that require a patient to pay a co-payment |
PPO, HMO, POS |
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List 5 types of managed care plans |
HMO, PPO, POS, Medicare managed care plan, Medicaid managed care plan |
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Describe the difference between in network and out of network |
In network means the medical providers you are visiting are contracted into your managed care plan, while out of network means that they are not. |
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Describe what capitation means and list an advantage and disadvantage of capitation |
Capitation means a monthly payment is being made to a provider for patients seen within an HMO plan. The advantage being if patients are not seen in that month the provider will still see payment, the disadvantage being if the provider sees a patient multiple times the amount paid does not increase. |
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Describe fee-for-service arrangements |
System in which the physician is paid a specific amount for each service |
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Some plans require that a patient obtain a _____ to see a specialist |
referral |
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Name 3 types of Tricare plans |
Tricare Prime Tricare Standard Tricare Extra |
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Which 2 Tricare plans are available only to retired service members and their families |
Standard, Extra |
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Two health plans that refer to their members as beneficiaries are ___ and ___ |
Medicare, Tricare
|
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Give an example of new health insurance coverage that some insurance companies now offer |
employee/significant other |
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Which health insurance plan premiums increase as the family size increases |
Medicaid Managed Care Plan |
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Describe what a medical discount card is and how it differs from the health insurance ID card |
A card that a patient can receive a discount from on services if the provider participates. No money is paid for the services like in an insurance situation. |
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Numbers, letters, or a combination of both describing procedures, services, and diagnoses are called |
codes |
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The coding system used to report services, supplies, injections/medicine, and durable medical equipment
|
HCPCS
|
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The coding manual that includes Evaluation and Management codes (99201-99499) is the |
CPT manual |
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A modifier is a _____ character _____, ____ or _________ descriptor |
2 alpha, numeric alpha-numeric |
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4 examples of modifier usage |
An additional service was performed Unusual events occurred Referencing a specific body site Only part of a service was performed
|
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These codes are easily identified due to the alphanumeric nature, i.e. J3265 |
HCPCS |
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Procedures and E/M codes are reported using |
CPT aka Level 1 codes |
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2 types of modifiers are |
CPT & HCPCS |
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A ______ modifier can be used with either a CPT or national code |
HCPCS |
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Code used to report Diagnosis is an |
ICD-9 code |
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Name the 2 volumes of ICD-9-CM used for physician billing |
Volume 1 Volume 2 |
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Which volume of the ICD-9 manual is alphabetical |
volume 2 |
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Codes used to report external causes of injury are called |
E-codes |
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Codes used to report a patient seen for a reason other than injury or disease |
V-codes |
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Accurate coding reduces the risk of |
audit from insurance companies |
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A new patient is one who has never been seen or who has not been seen in the past _____ _____ |
36 months |
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Another name for the superbill |
encounter form |
|
Superbill |
form listing CPT, HCPCS, and ICD-9 codes used to record services performed for the patient and the patient's diagnosis(es) for a given visit |
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Privacy enforcement in the office is regulated by |
HIPAA |
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History, physical exam info, and diagnoses related to a patient are kept in the |
medical chart |
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Person responsible for assigning an ICD-9 code on a superbill |
The coder or the physician |
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Codes used for hospital visits are found on the |
hospital sheet |
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What is the importance of a thoroughly completed patient registration form? |
A thoroughly completed registration form will provide additional contact information if the need for collection arises |
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How might a physician present his hospital billing to the medical biller if a hospital sheet is not used |
On the admit/discharge sheet |
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How does the frequency of billing vary from office to office, or if working for a medical billing company? |
Some may submit claims daily, once a week, or twice weekly. Medical billing companies may submit on a weekly basis. |
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Index to diseases |
ICD-9-CM Volume 2 |
|
ICD-9-CM volume 3 |
used to code "inpatient" hospital procedures |
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Each procedure code ______ ___ ____to a diagnosis code on the claim form |
must be linked |
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Evaluation and Management (E/M) codes for Office visits distinguish patients as |
New or Established |
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For an office visit an ___________ or ________ is used to record CPT and ICD-9 codes |
encounter form , superbill |
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HIPAA is defined as |
Health Insurance Portability and Accountability Act |
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This sheet is generated at hospital release and lists patient demographic information |
Admit/discharge sheet
|
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Dr. Baker sees eight patients on her rounds at a local hospital. Which individual would typically complete the hospital billing sheet for these eight patients? |
Dr. Baker |
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In relation to Tricare Prime, the insurance coverage for military personnel, what does the acronym MTF mean? |
Military Treatment Facility |
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A _________ is when a patient is referred to a provider (usually a specialist) for their "opinion or advise" regarding the patients illness/ disease or injury at the request of another provider these services can be rendered in the hospital or in an office setting. |
consult(ation) |