Medical Reimbursement Exam 1

Front 1

What year was the Principles of Medical Ethics adopted?

Back 1

1980. The Principle of Medical Ethics of the AMA guides physician's standards of conduct for honorable behavior behavior in the practice of medicine.

Front 2

Name some illegal coding practices

Back 2

1) Using code numbers and modifiers (wrongfully upcoming) to increase payment when the documentation does not warrant it.
2) Coding services or procedures that were not performed
3) Unbundling services provided into separate codes when one code is available and includes all the services
4) Failing to code a relevant condition or complication
5) coding another condition as the principle diagnoses or primary diagnoses when most of the patients treatment is for the preexisting condition

Front 3

Physicians are legally responsible for staffs actions
TRUE OR FALSE

Back 3

TRUE! Vicarious Liability or Respondent Superior.

Front 4

Can billers and coders be held personally responsible for billing errors?

Back 4

YES!

Front 5

What do you do when leaving a voice mail for a patient

Back 5

Be very brief. Just leave your name, office name and contact number for a call back.

Front 6

What is the name of the modern codes of ethics adopted by the AMA?

Back 6

Principles of Medical Ethics

Front 7

Concurrent care. Is it illegal?

Back 7

This is a tricky one actually. Concurrent care can be unethical, possibly not illegal, but may not be in the best interest of the patient. If two providers are caring for the patient for the same issue, then they must be collaborating together to provide optimal care for the patient

Front 8

Define Illegal

Back 8

Prohibited by law

Front 9

Define Unethical

Back 9

Morally wrong, lacking moral principles

Front 10

Define Fraud

Back 10

A deception deliberately practiced in order to secure unfair or unlawful gain

Front 11

Define Abuse

Back 11

A corrupt practice or customer, improper or exessive use of treatment

Front 12

What are the two main types of billing?

Back 12

1)Facility billing-hospitals, rehabilitation, centers
Professional billing-Physicians or NPP

Front 13

What is Health Insurance Reform

Back 13

provides continuous insurance coverage for workers and their insured dependents when they change or lose jobs. The reform also limits the use of pre-existing conditions (starts in Jan 2014)

Front 14

Administrative Simplifications

Back 14

Aids to reduce administrative costs and burdens. Additionally, ensures the privacy and security of an individuals health data

Front 15

Can you disclose Protected Health Information in workers compensation cases?

Back 15

YES. You may disclose PHI as authorized by the laws related to workers compensation

Front 16

What is confidential information?

Back 16

IT IS PRIVILEGED communication that be be disclosed onl with the patients permission

Front 17

Examples of non-privileged information

Back 17

Patients name, city of residence, date of admission or discharge
*Facts unrelated to the treatment of the patient*

Front 18

Is speaking over the telephone considered to be electronic transmission?

Back 18

NO.

Front 19

Healthcare provider

Back 19

a person trained and licensed to provide care to the patient
a place that is licensed to give healthcare (e.g. hospital, nursing home, etc.)

Front 20

Privacy officer

Back 20

Compliance
Setting polices
Training and managing staff regarding HIPPA and patient rights

Front 21

Security officer

Back 21

Protects computer and networking systems

Front 22

Healthcare clearinghouse

Back 22

independent organization that received insurance claims from the physicians office, performs software edits, and redistributes the claims electronically to various third party payers

Front 23

What is Coordination of Benefits

Back 23

reimbursement of benefits to determine which carrier is going to be primary and which is going to be secondary.

Front 24

Explain the "Birthday Rule"

Back 24

In regards to dependent children, if state legislature has adopted the bday rule, which most have, person's who's bday (MONTH AND DAY NOT YEAR) falls earlier in the year will be the primary. If both parents have the same bday, the one with the longest coverage is primary.

Front 25

What are the time filing limits

Back 25

This varies from 30 days to 1 1/2 years for filling insurance claim for the date of service

Front 26

What type of law governs private health insurance

Back 26

State insures laws regulate the way policies are written and minimum requirement of coverage

Front 27

How many workers does a company need to have that would require them to provide COBRA

Back 27

20 or more. Insurance can be extended up to 18 months.

Front 28

What was the act that was created to protect workers and family

Back 28

HIPAA act of 1966

Front 29

What program covers children under 21 that have special health needs

Back 29

MCHP: Maternal and child health program program

Front 30

Problem Focused Examination

Back 30

limited examination of the affected body area or organ system described in 1-5 elements

Front 31

SOAP

Back 31

S- subjective, patient words, chief complaint
O-objective, data, facts, findings
A-assessment, medical decision making
P-plan, documenting the plan of treatment for the patient

Front 32

Expanded problem focused

Back 32

limited examination of the affected body area or organ system with at least six elements identified

Front 33

Proscriptive Review

Back 33

Pre-billing audit or review

Front 34

Retrospective Review

Back 34

This is done AFTER billing the insurance carriers
EXTERNAL AUDIT

Front 35

Clone doumentation

Back 35

Basic copy and pasting from one medical record to another
Be very careful when using templates

Front 36

IDC-9 Volume 1

Back 36

Tabular list

Front 37

IDC-9 Volume 2

Back 37

Alphabetic Index of Disease

Front 38

IDC-9 Volume 3

Back 38

Tabular list and Alphabetic Index of Procedures (used primarily in hospital setting)

Front 39

Established patient

Back 39

One who has received professional services from the physician or another physician of the same specialty who belongs to the same group within the past THREE years

Front 40

How long should you keep health records

Back 40

Minimum of 6-10 years, Most physicians retain health record of all living patients indefinitely

Front 41

Consultation

Back 41

Services rendered by a physician whose option or advice is requested by another physician or agency in the evaluation or treat of a patients illness

Front 42

Primary diagnosis

Back 42

Main reason for the visit (chief complaint) usually used in outpatient (doctors office)

Front 43

Principle diagnosis

Back 43

Condition established after study that prompted to the hospitalization

Front 44

Global periods

Back 44

The global surgical period extends from no more than one day before the day of surgery to as long as it is necessary for typical postoperative follow up care to be completed
usually 0,10,30,90 days

Front 45

Diagnose related procedures

Back 45

Always use a five digit code when dealing with diseases such as diabetes because other complications will arise or accompany this disease

Front 46

Cod Sequencing

Back 46

The correct order of diagnostic coding (1,2,3,4) when submitting an insurance claim.

Front 47

THe assignment of benefits

Back 47

Transfer, after an event insured against, of an individuals legal right to collect an amount payable under an insurance contract.