What may lead to claim denials or improper service reimbursement?
A. Inaccurate physician documentation
B. Updated ICD-9-CM codes
C. HCPCS codes on outpatient surgeries
D. Reporting of multiple APGs
5. You're switching jobs on Monday. Which Act was developed, in part, to ensure that you have ongoing
insurance coverage during the change?
A. HIPAA
B. HP2010
C. BBA
D. OCIIO
6. When calculating expenses, what differs for each health care facility?
A. MS-DRG relative weight
B. ICD-9-CM diagnosis codes
C. The codes that are MCCs
D. Base rate
7. What did the government use to control skyrocketing health care costs?
A. SCHIP
B. Medigap
C. Retrospective payment system
D. Prospective payment system
8. Dr. S. is working within a reimbursement system where the insurance is billed after all the treatment has
been given to the patients. The main reason that he orders more tests, exams, and procedures under this
system is
A. to make a profit.
B. because no one has to pay for it.
C. fear of being sued.
D. to increase resource utilization.
9. What is used when billing outpatient claims?
A. CMS-1450
B. CMS-1500
C. UB-4
D. UB-92
10. Which system is used to bill for services used in a skilled nursing facility?
A. RBRVS
B. IPPS
C. RUGs
D. OPPS
11. When a physician is billing under the RBRVS system, he or she is using
A. ICD-9 procedure codes.
B. CPT/HCPCS codes.
C. APCs.
D. MS-DRGs.
12. What is best used to help plan home health care outcomes and assessments?
A. HAVEN
B. RAVEN
C. OASIS
D. MAC
13. If you want to see an orthopedic specialist for your broken leg but first have to check with your
primary care physician, you probably belong to a/an
A. HMO.
B. PPO.
C. POS.
D. EPO.
14. What was created to provide coverage for options that aren't covered under Medicare A or B?
A. Medicare Part D
B. Medicare+Choice
C. Medicare Part C
D. Medigap
15. Stan is on active military duty and, therefore, is probably receiving medical coverage from
A. Medicaid.
B. TRICARE.
C. CHAMPVA.
D. SCHIP.
16. You're a coder who's reviewing the record of a 62-year-old woman who was admitted to the hospital
with shortness of breath and minor chest pain. The doctor diagnosed the patient with Staphylococcus
aureus pneumonia and you assigned a code of 482.41. Additionally, you coded decompensated chronic
systolic congestive heart failure (as documented by the physician) as 428.22 and 428.0. The coding system
grouped the information into MS-DRG 178 (RW: 1.4860). The hospital has a base rate of $4,500.
What is the admitting diagnosis?
A. Pneumonia
B. Staphylococcus aureus
C. CHF
D. Shortness of breath
17. If you have 80-20 policy coverage, it means
A. the insured pays 80% of the expenses and you pay 20%.
B. you pay 80% of the expenses and the insured pays 20%.
C. you pay 80% of the expenses and the insurer pays 20%.
D. the insurer pays 80% of the expenses and you pay 20%.
18. Mr. B is an 82-year-old retired railroad worker who is having a mole removed at his physician's office.
What will the physician’s office bill to receive payment for this service?
A. Medicare Part A
B. Medicare Part B
C. Medicare Part D
D. Medicare Part C
19. You're a coder who's reviewing the record of a 62-year-old woman who was admitted to the hospital
with shortness of breath and minor chest pain. The doctor diagnosed the patient with Staphylococcus
aureus pneumonia and you assigned a code of 482.41. Additionally, you coded decompensated chronic
systolic congestive heart failure (as documented by the physician) as 428.22 and 428.0. The coding system
grouped the information into MS-DRG 178 (RW: 1.4860). The hospital has a base rate of $4,500.
What is the hospital's reimbursement for this patient under the PPS?
A. $6,687
B. $10,360
C. $3,028.26
D. $4,500
20. Before she can receive insurance benefits, Sally must pay the first $500 out of her own finances. What
is the $500 called?
A. Co-insurance
B. Deductible
C. Co-pay
D. Indemnity
21. Patty Patient just had her appendix removed. The appendix removal appears on the claim form as a
_______ code.
A. procedure
B. provider
C. diagnosis
D. payer
22. An outpatient coder in Dr. Smith's office will use which codes for procedures?
A. ICD-9-CM
B. CPT
C. ICD-10-CM
D. HCPCS
23. If a physician is charging for a mole removal procedure based on what he and other physicians
generally for that procedure, he's probably using
A. ABG.
B. DRG.
C. UCR.
D. PPS.
24. Paul Patient is trying to get new insurance, but he fears he'll be denied due to his cancer diagnosis and
ongoing treatment. What was put in place to help patients like Paul avoid insurance denial due to their
current health conditions?
A. Affordable Care Act
B. Social Security Title XVIII
C. Healthy People 2010
D. Balanced Budget Act
25. What would a health care plan use to measure their quality and performance?
A. MSDRG.
B. RAVEN.
C. HAVEN.
D. HEDIS.
26. Dr. Smith's medical office group and the hospital in which he's affiliated are both examples of
A. providers.
B. suppliers.
C. payers.
D. resources.
27. Your grandmother has a question about her Medicare reimbursement, but it's 10:30 P.M. What
organization will answer her questions at this time of night?
A. OIG
B. HCPCS
C. SCHIP
D. CMS
28. It's January 2, 2011, and the hospital coder just assigned three diagnosis codes to a patient's record.
Which codes were probably used?
A. CPT
B. ICD-9-CM
C. ICD-10-CM
D. HCPCS
29. You're a coder who's reviewing the record of a 62-year-old woman who was admitted to the hospital
with shortness of breath and minor chest pain. The doctor diagnosed the patient with Staphylococcus
aureus pneumonia and you assigned a code of 482.41. Additionally, you coded decompensated chronic
systolic congestive heart failure (as documented by the physician) as 428.22 and 428.0. The coding system
grouped the information into MS-DRG 178 (RW: 1.4860). The hospital has a base rate of $4,500.
Which code is the principal diagnosis?
A. 428.22
B. 482.41
C. 178
D. 428.0
30. New Medicare payments systems and implementation of SCHIP both came out of the
A. Balanced Budget Act.
End of exam
B. Federal Act 33-2.
C. health maintenance organization.
D. retrospective payment system.
There are no tutors here who have expertise in this subject area.
Please use your text, study materials, and a good search engine or two to find your answers.
1. Go to http://www.google.com or http://www.bing.com
2. Type in cpt codes (or whatever search terms you need). Press Enter.
3. Read different search results until you find what you need.
4. Re-search with different search terms if you don't find all you need.
a
d
c
a
b
d
c
b
a
d
c
d
b
a
c
d
b
a
d
c
d
b
a
c
a
c
d
b
b
c
c
1. A. Inaccurate physician documentation
2. D. Reporting of multiple APGs
3. A. HIPAA
4. A. MS-DRG relative weight
5. A. SCHIP
6. D. Prospective payment system
7. D. to increase resource utilization
8. B. CMS-1500
9. C. RUGs
10. B. CPT/HCPCS codes
11. C. OASIS
12. A. HMO
13. D. Medigap
14. B. TRICARE
15. A. Pneumonia
16. B. you pay 80% of the expenses and the insured pays 20%
17. B. Medicare Part B
18. C. $3,028.26
19. B. Deductible
20. A. procedure
21. B. CPT
22. C. UCR
23. A. Affordable Care Act
24. D. HEDIS
25. A. providers
26. D. CMS
27. C. ICD-10-CM
28. B. 482.41
29. A. Balanced Budget Act
To determine the answers to the multiple-choice questions, you need to understand the concepts related to claim denials, reimbursement systems, insurance coverage, coding systems, healthcare facilities, and insurance plans. Here is an explanation to help you answer each question:
1. What may lead to claim denials or improper service reimbursement?
- Answer: A. Inaccurate physician documentation
- Explanation: Claim denials or improper reimbursement can occur if the physician's documentation is inaccurate or incomplete, which may result in coding errors or lack of supporting evidence for the services provided.
2. Which Act was developed, in part, to ensure ongoing insurance coverage during a job change?
- Answer: A. HIPAA (Health Insurance Portability and Accountability Act)
- Explanation: HIPAA includes provisions that aim to protect individuals' health insurance coverage when they change jobs or experience certain life events.
3. When calculating expenses, what differs for each healthcare facility?
- Answer: D. Base rate
- Explanation: The base rate is the standard amount determined by each healthcare facility that forms the basis for calculating expenses and reimbursement. It can vary from one facility to another.
4. What did the government use to control skyrocketing healthcare costs?
- Answer: D. Prospective payment system
- Explanation: The government implemented a prospective payment system to control healthcare costs by setting fixed reimbursement rates based on specific criteria and conditions.
5. The main reason that Dr. S. orders more tests, exams, and procedures under a reimbursement system where the insurance is billed after all the treatment has been given to the patients is:
- Answer: D. to increase resource utilization.
- Explanation: In a fee-for-service reimbursement system, where the insurance is billed after the treatment, some healthcare providers may be motivated to order more tests, exams, and procedures to increase their revenue and resource utilization.
6. What is used when billing outpatient claims?
- Answer: B. CMS-1500
- Explanation: The CMS-1500 form is commonly used to bill outpatient claims for services provided by healthcare providers.
7. Which system is used to bill for services used in a skilled nursing facility?
- Answer: C. RUGs (Resource Utilization Groups)
- Explanation: RUGs is a classification system used to determine reimbursement for services provided in a skilled nursing facility.
8. When a physician is billing under the RBRVS system, he or she is using:
- Answer: B. CPT/HCPCS codes.
- Explanation: The Resource-Based Relative Value Scale (RBRVS) system uses the Current Procedural Terminology (CPT) and Healthcare Common Procedure Coding System (HCPCS) codes for billing and determining reimbursement.
9. What is best used to help plan home health care outcomes and assessments?
- Answer: C. OASIS (Outcome and Assessment Information Set)
- Explanation: OASIS is a standardized assessment tool used for home health agencies to collect and measure patient data and outcomes.
10. If you want to see an orthopedic specialist for your broken leg but first have to check with your primary care physician, you probably belong to a/an:
- Answer: A. HMO (Health Maintenance Organization)
- Explanation: HMOs typically require patients to get a referral from their primary care physician before seeking specialized care.
11. What was created to provide coverage for options that are not covered under Medicare Parts A or B?
- Answer: D. Medigap
- Explanation: Medigap, also known as Medicare Supplement Insurance, is private health insurance designed to fill the gaps in coverage provided by Medicare Parts A and B.
12. If you have 80-20 policy coverage, it means:
- Answer: A. The insured pays 80% of the expenses and you pay 20%.
- Explanation: In an 80-20 policy coverage arrangement, the insured individual is responsible for paying 20% of the expenses, and the insurance provider covers the remaining 80%.
13. An outpatient coder in Dr. Smith's office will use which codes for procedures?
- Answer: B. CPT
- Explanation: Outpatient coders typically use the Current Procedural Terminology (CPT) codes to code procedures performed in an outpatient setting.
14. Paul Patient is trying to get new insurance, but he fears he'll be denied due to his cancer diagnosis and ongoing treatment. What was put in place to help patients like Paul avoid insurance denial due to their current health conditions?
- Answer: A. Affordable Care Act
- Explanation: The Affordable Care Act (ACA) prohibits insurers from denying coverage or charging higher premiums based on pre-existing conditions, such as cancer.
15. What would a health care plan use to measure their quality and performance?
- Answer: D. HEDIS (Healthcare Effectiveness Data and Information Set)
- Explanation: HEDIS is a set of performance measures used by health plans to evaluate and report their quality of care and service performance.
16. Your grandmother has a question about her Medicare reimbursement, but it's 10:30 P.M. What organization will answer her questions at this time of night?
- Answer: D. CMS (Centers for Medicare and Medicaid Services)
- Explanation: CMS provides information and assistance regarding Medicare benefits and reimbursement, including offering customer support and answering beneficiaries' questions.
17. Which Act was responsible for the implementation of new Medicare payment systems and SCHIP?
- Answer: A. Balanced Budget Act
- Explanation: The Balanced Budget Act of 1997 introduced various changes to Medicare, including the implementation of new payment systems and the creation of the State Children's Health Insurance Program (SCHIP).
Please note that this is not an exhaustive list of explanations for all the questions, but it should help you understand the concepts related to each question and assist you in finding the correct answer.