NAME:______ INSTITUTE HEALTH ED IHE INSTRUCTOR: Dr

* FINAL EXAMINATION * [Version #2]

SECTION I: MATCHING DIRECTIONS: { HEALTH CARE REIMBURSEMENT }: Match the following terms or phrases on the left hand column with their equivalent definitions found on the right hand column. In the `space' provided place `only' letters!

1. COMPETITIVE MEDICAL PLAN______A). an insurance for veterans that shares the medical bills of spouses and children of veterans

with the total, permanent and service connected disabilities and also covering dependents

of deceased veterans.

2. HEALTH MAINT ORGANIZATION____B). In some regions, this program is referred to as the Medi-Medi Program.

3. DISABILITY INCOME INS. ______C). a government sponsored program that provides non-military hospital & medical services

for dependents and spouses of active service personnel, the retired & their dependents,

and the dependents of deceased from active duty.

4. EXCLUSIVE PROVIDER ORG.______D). form of health insurance that provides payments to replace income if the insured is unable

to work because of illness, injury or disease

5. FOUNDATION FOR MED. CARE_____E). type of managed care plan in which the subscriber members are eligible for benefits only

when they use the services of a limited network of providers.

6. INDEPENDENT (INDIVIDUAL)

PRACTICE ASSOCIATION______F. This type of plan contracts with a number of physicians who agree to provide treatment in

their own offices or clinics for a fixed capitation payment per month.

7. MATERNAL & CHILD HLTH PGM____G). This is a form of contract medicine by which a large employer or any other organization

that can produce a large number of patients contracts with a hospital or group of physi-

cians to offer medical care at a reduced rate.

8. MEDICAID______H). . this is a non-state program that insures a person against on-the-job injury or illness.

9. MEDICARE______I). . a three part program that is hospital insurance, supplemental medical insurance or a plus

choice program for people 65 years of age and created by the 1965 Social Security Act.

10. MEDICARE/MEDICAID______J). Organization of physicians, sponsored by a state or local medical association, concerned

with the development and delivery of medical services and the cost of health care.

11. POINT OF SERVICE PLAN ______K). a managed care plan consisting of a network of physicians and hospitals that provides an

insurance company or employer with discounts on its services.

12. PREFERRED PROVIDER ORG. _____L). A state and federal program for children under 21 years with special health care needs.

13. TRICARE______M). a state program that is essentially insurance that covers off-the-job injury or sickness and

is paid for by deductions from a person's paycheck.

14. UNEMPLOYMENT COMP. DIS._____N). A state, federal and local program that provides health care benefits to indigent persons

on welfare (public assistance), the elderly who meet who meet certain financial require-

ments, and the disabled.

15. CHAMPVA ______O). . medical plan created by the 1982 Tax Equity and Fiscal Responsibility Act that allows for

enrollment of medicare patients into managed care plans.

16. WORKER'S COMP. INS. ______P). organization that provides a wide range of comprehensive health care services for a

specified group at a fixed periodic payment. The emphasis is on preventive care.

Physicians are reimbursed by capitation. An HMO may be sponsored by a wide variety of

organizations.

SECTION II: DIRECTIONS: MULTIPLE ANSWER QUESTION (MAQ){ HEALTH CARE REIMBURSEMENT }: Place a circle around the `letter' containing the `best' and most applicable answer. One answer only!

17. In which of the following health insurance plans is there specifically "no assignment" in regards to benefit payments?

a). Private Carriers e). Worker's Compensation

b). Managed Care f). Tricare

c). Medicaid g). Only answers "c" and "e" are correct

d). Medicare h). Only answers "d" and "f" are correct

18. Which of the following is the general definition of "assignment" of benefits?

a). the provider agrees to accept the allowable charge as the full fee and cannot charge the patient the difference between the

providers charge and the allowable charge.

b). the insurance check will be directed to the provider's office instead of to the patient address.

c). the transfer, after an event insured against, of an individual's legal right to collect an amount payable under an insurance contract.

d). Only answers "a" and "c" are correct

e). All of the above are correct.

19. Which of the following is the definition of "accepting assignment of benefits" for Tricare ?

a). the provider agrees to accept the allowable charge as the full fee and cannot charge the patient the difference between the

providers charge and the allowable charge.

b). the insurance check will be directed to the provider's office instead of to the patient address.

c). the transfer, after an event insured against, of an individual's legal right to collect an amount payable under an insurance contract.

d). Only answers "a" and "c" are correct

e). All of the above are correct.

List the five (5) types of presenting problems from the most risk and least recovery to the least risk and most recovery:

a). ______b). ______c) ______d) ______e) ______

List the four (4) types of medical decision making, in order of complexity from most to least complex:

a). ______b). ______c. ______d) ______

22. Diagnosis codes are entered in ____?

a.Block 24

b.Block 33

c.Block 21

d.None of the above

The maximum number of ICD-9-CM codes that may appear on a single claim is ____?

a.Four

b.Six

c.Two

d.None of the above

The first code reported on a claim should be the ______?

a.Qualified diagnosis

b.Possible diagnosis

c.Primary diagnosis

d.None of the above

If a diagnosis is not treated or addressed during an encounter and is stated on a patient’s record, you should ____?

a.Not list the diagnosis

b.List the diagnosis as secondary

c.List the diagnosis as probable

d.None of the above

Until a definitive diagnosis is determined, which of the following diagnoses should be used ?

a.Rule out

b.Suspicious for

c.Possible

d.None of the above

Some claims require attachments such as _____?

Clinic notes
Operative reports
Discharge summaries
All of the above

SECTION III: FILL-IN BLANK DIRECTIONS: { MEDICAL CODING -1 }Fill-in the blank spaces with the most appropriate words or phrases that best completes the sentences. (Claims Management )

Describe how the name on the claim should be typed for the following patients:

The name on the ID card reads: James M. Apple, II ANS:______
The name on the ID card reads: Charles T. Treebark, Jr.ANS:______
The name on the ID card reads: DavidJ. Hurts, III ANS:______
The name on the ID card reads: Jake R. Elbow, Sr. ANS:______

What are three questions that must be asked to code surgeries properly?

______
______
______

CPT divides surgical procedures into which two main groups ?

a). ______b). ______

31. List three services/procedures included in a surgical package

a). ______b). ______c). ______

32. On what basis are minor surgical procedures to be billed? ______

33. Briefly describe “Unbundling”

______

34. Define the following:

A) Skin Lesion- ______

B) Excision of a Lesion- ______

C) Destruction of a Lesion- ______

35. List five things you must know when reporting the excision or destruction of lesions

1) ______

2) ______

3) ______

4) ______

5) ______

36. Layered closure requires the use of 2 codes. One is for the ______and one for the

______

37. If a physician reports the size of a lesion in inches, what must the coder do? ______

38. When converting the size of a lesion, one inch = ______

39. When there are multiple lacerations, which repair should be listed first? ______

SECTION IV: FILL-IN BLANK DIRECTIONS: { MEDICAL CODING -1 }: Fill-in the blank spaces with the most appropriate words or phrases that best completes the sentences. DIRECTIONS: MULTIPLE ANSWER QUESTION (MAQ): Place a circle around the `letter' containing the `best' and most applicable answer. One answer only!

Define the term “Balance Billing ? ______

______

What is the purpose of obtaining an ABN ? ______

______

List three forms of MSP Medicare beneficiaries often purchase to cover the Medicare deductible and coinsurance

requirements:

a). ______

b). ______

c). ______

List five advantages of joining a Medicare HMO ?

a). ______

b). ______

c). ______

d). ______

e). ______

For HMO authorized fee-for-service specialty care, the claim is sent directly to ?

The patient
Medicare
The HMO
Only a and b are correct
All of the above are correct
None of the above are correct

What is the deadline for filing Medicare HMO claims ?

90 days
60 days
45 days
one year
All of the above are correct
None of the above are correct

SECTION V: ADVANCED CODING: DIRECTIONS: Using the ICD or CPT, assign codes to the following:

Removal of foreign body in tendon sheath, simple. Code(s): ______
Puncture aspiration of cyst of breast. Code(s): ______
Incision and drainage of thyroid gland cyst. Code(s): ______
Abrasion, single lesion. Code(s): ______
Destruction of four flat warts. Code(s): ______
Incision and drainage of ankle abscess. Code(s): ______
Incision and drainage of wrist hematoma. Code(s): ______
Aspiration thyroid cyst. Code(s): ______
Laparoscopy with bilateral total pelvic lymphadenectomy and periaortic lymph node biopsy. Code(s): ______
Acute prostatitis due to streptococcus. Code(1): ______Code(2): ______
Gangrene, left great toe, due to Diabetes Mellitus type I. Code(1): ______Code(2): ______
Vitamin D-resistant Rickets. Code(s): ______
Newborn female delivered in the hospital by cesarean delivery

with evidence of cleft palate and cleft lip. Code(1): ______Code(2): ______

59. Flaccid hemiplegia affecting the dominant side due to cerebrovascular accident 4 months ago.

Residual and cause are flaccid hemiplegia, dominant side, CVA. Code(s): ______

60. Tumor abdomen, uncertain behavior. Code(1): ______M-Code(2): ______

61. Hepatocellular adenoma. Code(1): ______M-Code(2): ______

62. A 62 year – old male admitted to the hospital with acute subendocardial myocardial infarction. Code(s): ______

63. A 24 year – old woman at 28 weeks’ gestation has hypothyroidism. Code(1): ______Code(2): ______

64. Cellulitis left foot and ankle due to staphylococcus. Code(1): ______Code(2): ______Code(3): ______

65. Newborn female delivered in the hospital by cesarean delivery with evidence of cleft palate and cleft lip. Code(1): ______Code(2): ______

66. A patient develops gastrointestinal bleeding while taking Motrin as prescribed for abdominal cramping

(Hint: Generic Motrin). Code(1): ______Code(2): ______

67. Acute renal failure develops in a patient following a cardiac catheterization and the patient is admitted for dialysis.

Code(1): ______Code(2): ______

SECTION VI: ADVANCED CODING: REPORTS / DIRECTIONS: Interpret and assign codes to the following report (you may use the ICD or CPT Code books):

INDICATION: Prolonged fetal heart rate deceleration.

PROCEDURE: Vacuum assisted vaginal delivery.

COMPLICATIONS: Shoulder dystocia, relieved with McRobert’s maneuver.

PREAMBLE: The patient is a 33 year old gravida 3, para 2, 38 week, 3 days gestation, admitted for induction secondary to pelvic pain. The patient received Pitocin and had artificial rupture of membranes and with this was able to progress to complete dilation. She then began pushing and some prolonged fetal heart rate deceleration down to about 90 beats per minute were noted. Because of this, a decision was made to proceed with vacuum extraction to assist in expediting delivery.

PROCEDURE NOTE: Maternal bladder was emptied using straight catheter. Pelvic examination was carried out and the cervix was confirmed to be fully dilated. Fetal vertex was present at +1 station. The small kiwi cup vacuum was then applied to the fetal vertex. On the second pull, there was one pop off but this was after good descent of the fetal head had been achieved. Baby then delivered and was a live-born male infant. There was some moderate shoulder dystocia present and this was relieved with McRobert’s maneuver. The baby was handed off to the NICU team and is currently in the NICU for further observation. Apgar’s are not available at this time. Cord blood gas is also pending.

There was a small second degree peritoneal tear. This was repaired using 3-0 chromic in the usual manner. The patient tolerated this procedure well. Estimated blood loss during delivery was 200 cc.

68. Code(1): ______Code(2): ______Code(3): ______

Code(4): ______Code(5): ______Code(6): ______

SECTION VII: MATCHING DIRECTIONS: { CLAIMS PROCESSING }: Match the following terms or phrases on the left hand column with their equivalent definitions found on the right hand column. In the `space' provided place `only' letters!

69. Comprehensive code______A). this is a performance number that each physician or provider gets for each group office or clinic in

which he or she practices. In medicare each member has an eight character PPIN which collabor-

ates to that groups location in addition to the group number.

70. UNBUNDLING ______B). this is a medicare lifetime 10 digit number issued to providers. When adopted it is recognized by

Medicaid, Medicare, Tricare & CHAMPVA programs and eventually will be used by private

insurance carriers.

71. MODIFIER ______C). this is any medicare claim that contains complete, necessary information but is illogical or incorrect.

72.  ______D). this means that the claim was submitted within the program or policy time limit and contains all the

necessary information so it can be processed and paid promptly.

73. ______E). this is a carrier assigned number that every physician uses to render services to patients when

submitting claim forms for insurance purposes.

74.  ______F). A single code that describes or covers two or more component codes that are bundled together as

one unit.

75. ⊘ ______G). permits the physician to indicate circumstances in which a procedure as performed differs in some

way from that described by its usual code.

76.  ______H). this fee meets the criteria of the usual fee and is in the opinion of the medical review committee,

justifiable, considering the special circumstances of the patient and case.

77.  ______I). this claim happens when the medicare contractor cannot process a claim for a particular service or

bill type.

78. CUSTOMARY FEE ______J). this is a claim submitted with errors or one requiring manual processing for resolving problems or

one rejected for payment. Pending or suspense claims are placed in this category because

something is holding the claim back from payment (review)

79. REASONABLE FEE ______K). this is the code sign for an “add on code”.

80. INCOMPLETE CLAIM ______L). this is a number issued by the medicare fiscal intermediary to each physician who renders medical

service to medicare recipients used for identification purposes on CMA 1500 claim forms.

81. DINGY CLAIM ______M). this code sign indicates “ a revised code”.

82. DIRTY CLAIM ______N). this fee is in the range of the fees charged by providers of similar training and experience in a given

geographic area.

83. INVALID CLAIM ______O). this is the code sign for a modifier which generally has a negative sign with two digit number.

84. CLEAN CLAIM ______P). this is the code sign for “a new or revised text”.

85. PIN NUMBER ______Q). this is the code sign for a “new code”.

86. NPI NUMBER ______R). term used to define coding and billing numerous CPT codes to identify procedures that usually are

described by a single code.

87. UPIN NUMBER ______S). this can be any medicare claim missing required information. It is generally identified to the

provider so that it can be resubmitted.

88. PPIN number______T). this code sign implies “service includes surgical procedure only”.

SECTION VIII: MATCHING DIRECTIONS: { CLAIMS PROCESSING }: Match the following terms or phrases on the left hand column with their equivalent definitions found on the right hand column. In the `space' provided place `only' letters!

89. DME Number ______A). this is an insurance claim submitted to an insurance carrier that is discarded by the system because of a techni-

cal error (omission or erroneous information) or because it does not follow medicare instructions. It is usually

returned to the provider for corrections or changes so that it may be processed properly for payment.

90. DIGITAL CLAIM______B). a device that can read typed characters at a very high speed and then converts them to digitized computer

characters within files to be saved on disk.

91. EIN NUMBER ______C). this means that the claim was submitted within the program or policy time limit and contains all the neces-

sary information so it can be processed and paid promptly.

92. FACILITY NUMBER______D). this is the universal insurance claim form developed and approved the American Medical Assoc as well as

centers for for medicare and Medicaid services. It is used by physicians and other professionals to bill output

services and supplies for tricare, medicare & some Medicaid programs as well as private insurance carriers and

managed care plans.

93. GROUP PROVIDER NUMBER___E). these are insurance claims with no staples or highlighted areas and with non-deformed bar codes.

94. ELECTRONIC CLAIM______F). this is a license issued to a physician who has passed the state medical examinations and indicates his/her right

to practice medicine in the state where issued.

95. OCR______G). this is a claim sent to the insurance carrier as a paper claim by fax & never printed to paper at receiving end.

86. REJECTED CLAIM______H). this is given to medicare providers who charge patients a fee for supplies and equipment such as crutches,

urinary catheters, ostomy supplies, surgical dressings and so forth which must be billed through medicare

using this number.

87. OTHER CLAIMS ______I)). this is an insurance claim held in suspense because of review or other reasons. These claims may be cleared

for payment or denied.

88. PAPER CLAIM______ J). this claim is submitted to an insurance carrier via a central processing unit (CPU), tape diskette, direct data

entry, direct wire, dial in telephone or personal computer via modem and are never printed on paper.

89. PENDING CLAIM______ K). this is the name given to all medicare claims not considered ‘clean’. They are claims that require investigation

or development on a pre-payment basis to determine if medicare is the primary or secondary carrier.

90. PHYSICALLY CLEAN CLAIM____L). this is a number assigned to a number of physicians submitting insurance claim forms under one name and

reporting income under one name. It is used instead of the individual PIN number for the performing provider.

91. CLEAN CLAIM______M).this is an individual’s (provider) federal tax identification number which is issued by the Internal Revenue

Service for income tax purposes.

92. CMS 1500______N).this is an institutional number serving as a provider such as hospitals, labs, nursing, etc which is used to bill