Which coding system is used to report procedures and services on claims?

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Which coding system is used to report procedures and services on claims?

Question Description

I’m working on a health & medical test / quiz prep and need support to help me learn.

1. The process of reporting __________ as numeric and alphanumeric characters on the insurance claim is called coding.

a. dates of service for procedures
b. diagnoses and procedures/services
c. health insurance claims identifiers
d. national provider identifiers
2. Which coding system is used to report procedures and services on claims?

a. CPT
b. ICD-10-CM
c. SNDO
d. SNOMED
3. The Healthcare Common Procedure Coding System (HCPCS) consists of __________ codes.

a. CPT and national
b. DSM and CDT
c. ICD-10-CM and ICD-10-PCS
d. SNOMED and SNDO
4. Which coding system is used to report procedures and services on inpatient hospital claims?

a. CPT
b. HCPCS level II
c. ICD-10-CM
d. ICD-10-PCS
5. Which are published by CMS and used to report procedures, services, and supplies not classified in CPT?

a. dental codes
b. disease codes
c. injury codes
d. national codes

Chapter 02: Introduction to Health Insurance

NONE

Chapter 03: Managed Health Care

1. Managed health care was developed as a way to provide affordable, comprehensive, prepaid health care services to __________.

a. enrollees
b. patients
c. payers
d. providers
2. The Healthcare Effectiveness Data and Information Set (HEDIS) was developed by the __________ and created standards to assess managed care systems in terms of membership, utilization of services, quality, access, health plan management and activities, and financial indicators.

a. Centers for Medicare and Medicaid Services (CMS)
b. Joint Commission
c. National Committee for Quality Assurance (NCQA)
d. Office of the Inspector General (OIG)
3. A managed care organization (MCO) is responsible for the health of a group of __________ and can be a health plan, hospital, physician group, or health system.

a. enrollees
b. patients
c. payers
d. providers
4. With managed care’s capitation financing method, if the physician provides services that cost less than the capitation amount, there is a profit, which the physician ___________.

a. distributes to all patients in the practice
b. keeps to reinvest in the medical practice
c. pays back to the managed care organization
d. reimburses to government third-party payers
5. The primary care provider (PCP) is responsible for __________.

a. being a gatekeeper to provide services at the highest possible cost
b. denying all referrals to specialists and inpatient hospital admissions
c. providing nonessential health care services to all patients
d. supervising and coordinating health care services for enrollees
6. Managed care plans that are “federally qualified” and those that must comply with state quality review mandates, or __________, are required to establish quality assurance programs.

a. laws
b. procedures
c. regulations
d. standards
7. A quality assurance program includes activities that __________ the quality of care provided in a health care setting.

a. assess
b. deny
c. provide
d. quantify
8. Many states have enacted legislation requiring a(n) __________ to review health care provided by managed care organizations.

a. external quality review organization
b. group of community members
c. subcommittee of state legislators
d. task force of out-of-state providers
9. The National Committee for Quality Assurance (NCQA) reviews managed care plans and develops report cards to __________.

a. allow health care consumers to make informed decisions when selecting a plan
b. control the quality and utilization of health care services to patient populations
c. establish punitive monetary penalties that are paid by poor quality providers
d. guarantee the financial stability of managed care plans and their organizations
10. Which is a method of controlling health care costs and quality of care by reviewing the appropriateness and necessity of care provided to patients prior to the administration of care or after care has been provided?

a. health information management
b. risk management
c. quality management
d. utilization management
11. Reviewing the appropriateness and necessity of care provided to patients prior to the administration of care is called __________ review, and such review after care has been provided is called __________ review.

a. prospective; retrospective
b. retrospective; prospective
12. Which is a review for medical necessity of inpatient care prior to the patient’s admission?

a. concurrent review
b. discharge planning
c. preadmission certification
d. preauthorization
13. Which is a review that grants prior approval for reimbursement of a health care service?

a. concurrent review
b. discharge planning
c. preadmission certification
d. preauthorization
14. Which is a review for medical necessity of tests and procedures ordered during an inpatient hospitalization?

a. concurrent review
b. discharge planning
c. preadmission certification
d. preauthorization
15. Which involves arranging appropriate health care services for the patient who is being released from an inpatient hospitalization?

a. concurrent review
b. discharge planning
c. preadmission certification
d. preauthorization
16. Some managed care plans contract out utilization management services to a utilization review organization (URO), which is an entity that __________.

a. conducts a quality management program and completes focused review studies and medical audits
b. establishes a utilization management program and performs external utilization review services
c. performs risk management activities that result in appropriate in-service education for medical staff
d. provides a service to the organization to ensure that physicians have met credentialing requirements
17. Which involves the development of patient care plans for the coordination and provision of care for complicated cases in a cost-effective manner?

a. case management
b. risk management
c. quality management
d. utilization management
18. Prior to scheduling elective surgery, managed care plans often require a __________ during which another physician is asked to evaluate the necessity of surgery and recommend the most economical, appropriate facility in which to perform the surgery.

a. preauthorization
b. prospective review
c. retrospective review
d. second surgical opinion
19. Medicare and many states prohibit managed care contracts from containing __________, which prevent providers from discussing all treatment options with patients, whether or not the plan would provide reimbursement for services.

a. credentialing statements
b. gag clauses
c. physician incentives
d. profit margins
20. Physician incentives include payments made directly or indirectly to health care providers to __________ so as to save money for the managed care plan. Managed care plans that contract with Medicare or Medicaid must disclose information about physician incentive plans to CMS or state Medicaid agencies before a new or renewed contract receives final approval.

a. contractually provide limits and quotas for services
b. encourage them to reduce or limit patient services
c. prevent physicians from receiving payment for services
d. underwrite exotic travel and other bonuses for services
21. An integrated delivery system (IDS) is an organization of __________ that offer joint health care services to subscribers.

a. affiliated providers’ sites
b. government agencies
c. nonparticipating providers
d. third-party payers
22. A physician-hospital organization (PHO) is owned by hospital(s) and physician groups that obtain managed care plan contracts. The physicians __________ and provide health care services to plan members.

a. are employed by the PHO
b. calculate what they want to earn
c. maintain their own practices
d. purchase the PHO building
23. A management service organization (MSO) is usually owned by physicians or a hospital and provides practice management (administrative and support) services to __________.

a. government health programs
b. individual physician practices
c. managed care organizations
d. third-party payers
24. A group practice without walls (GPWW) establishes a contract that allows physicians to maintain their own offices and share services, such as __________.

a. admitting patients to the hospital
b. appointment scheduling and billing
c. performing surgical procedures
d. providing office services to patients
25. An integrated provider organization (IPO) manages the delivery of health care services offered by hospitals, physicians, and other health care organizations. Physicians associated with an IPO are considered __________.

a. employees
b. independent contractors
c. self-employed
d. temporary staff
26. A medical foundation is a nonprofit organization that contracts with and __________ the clinical and business assets of physician practices.

a. acquires
b. indentures
c. leases
d. liquidates
27. A health maintenance organization (HMO) is an alternative to traditional group health insurance coverage and provides comprehensive health care services to voluntarily enrolled members on a __________ basis.

a. fee-for-service
b. per diem
c. prepaid
d. retrospective
28. Which is associated with health care that is provided in an HMO-owned center or satellite clinic or by physicians who belong to a specially formed medical group that serves the HMO?

a. closed-panel HMO
b. open-panel HMO
29. Which is associated with health care that is provided by individuals who are not employees of the HMO or who do not belong to a specially formed medical group that serves the HMO?

a. closed-panel HMO
b. open-panel HMO
30. Which is associated with contracted health care services that are delivered to subscribers by participating physicians who are members of an independent multispecialty group practice?

a. direct contract model HMO
b. group model HMO
c. network model HMO
d. staff model HMO
31. Health care services provided to subscribers by physicians employed by the HMO are associated with a __________. Premiums and other revenue are paid to the HMO, and usually all ambulatory services are provided within HMO corporate buildings.

a. direct contract model HMO
b. group model HMO
c. network model HMO
d. staff model HMO
32. Which is associated with contracted health care services that are delivered to subscribers by individual physicians in the community?

a. direct contract model HMO
b. group model HMO
c. network model HMO
d. staff model HMO
33. Which is associated with contracted health care services that are provided to subscribers by two or more physician multispecialty group practices?

a. direct contract model HMO
b. group model HMO
c. network model HMO
d. staff model HMO
34. Which type of HMO contracts health services that are delivered to subscribers by physicians who remain in their own office settings?

a. independent practice association
b. point-of-service plan
c. preferred provider organization
d. triple-option plan
35. To create flexibility in managed care plans, some HMOs and preferred provider organizations have implemented a(n) __________, under which patients have freedom to use the managed care panel of providers or to self-refer to out-of-network providers.

a. independent practice association
b. point-of-service plan
c. preferred provider organization
d. triple option plan
36. A managed care network of physicians and hospitals that have joined together to contract with insurance companies, employers, or other organizations to provide health care to subscribers for a discounted fee is called a(n) __________.

a. independent practice association
b. point-of-service plan
c. preferred provider organization
d. triple option plan
37. Which is created when a number of people are grouped for insurance purposes and the cost of health care coverage is determined by employees’ health status, age, sex, and occupation?

a. cafeteria plan
b. managed care
c. risk pool
d. self-referral
38. Which is a private, not-for-profit organization that assesses the quality of managed care plans in the United States and releases the data to the public for consideration when selecting a managed care plan?

a. Centers for Medicare and Medicaid Services
b. department of health in each state
c. National Committee for Quality Assurance
d. The Joint Commission
39. Which consumer-directed health plan funds health care expenses with insurance coverage and the individual selects one of each type of provider to create a customized network and pays the resulting customized insurance premium?

a. customized sub-capitation plan
b. flexible spending account
c. health savings account
d. health reimbursement arrangement
40. Which consumer-directed health plan provides tax-exempt accounts offered by employers to any number of employees, which individuals use to pay health care bills? The employees contribute funds through a salary reduction agreement and withdraw funds to pay medical bills. Funds are exempt from both income tax and Social Security tax (and employers may also contribute). By law, employees forfeit unspent funds at the end of the year.

a. customized sub-capitation plan
b. flexible spending account
c. health savings account
d. health reimbursement arrangement
41. Which consumer-directed health plan allows participants to enroll in a relatively inexpensive high-deductible insurance plan and open a tax-deductible savings account to cover current and future medical expenses? Money deposited (and earnings) is tax-deferred, and money withdrawn to cover qualified medical expenses is tax-free. Money can be withdrawn for purposes other than health care expenses after payment of income tax plus a 15 percent penalty. Unused balances “roll over” from year to year, and if an employee changes jobs, he or she can continue to use the fund to pay for qualified health care expenses.

a. customized sub-capitation plan
b. flexible spending account
c. health savings account
d. health reimbursement arrangement
42. Which consumer-directed health plan allows tax-exempt accounts to be offered by employers with 50 or more employees, which individuals then use to pay health care bills? Funds must be used for qualified health care expenses, and unspent money can be accumulated for future years. If an employee changes jobs, he or she can continue to use the funds to pay for qualified health care expenses.

a. customized sub-capitation plan
b. flexible spending account
c. health savings account
d. health reimbursement arrangement
43. Which is a voluntary process that a health care facility or organization undergoes to demonstrate that it has met standards beyond those required by law?

a. accreditation
b. mandate
c. regulation
d. requirement
44. Accreditation organizations develop standards that are reviewed during an evaluation process that is conducted both offsite and onsite. The evaluation process is called a(n) __________.

a. audit
b. inspection
c. review
d. survey

Chapter 04: Processing an Insurance Claim

1. Which means the provider agrees to accept what the insurance company allows or approves as payment in full for the claim?

a. accept assignment
b. assignment of benefits
2. Health insurance plans may include a(n) __________ provision, which means that when the patient has reached that limit for the year, appropriate patient reimbursement to the provider is determined.

a. assignment of benefits
b. coinsurance and copayment
c. deductible
d. out-of-pocket payment
3. Which person is responsible for paying the charges?

a. enrollee
b. guarantor
c. patient
d. payer
4. A participating provider (PAR) contracts with a health insurance plan and accepts whatever the plan pays for procedures or services performed. This means that PARs __________ allowed to bill patients for the difference between the contracted rate and their normal fee.

a. are
b. are not
5. A nonparticipating provider (nonPAR) is an out-of-network provider who does not contract with the insurance plan, and patients who elect to receive care from non-PARs will incur higher out-of-pocket expenses. The patient __________ expected to pay the difference between the insurance payment and the provider’s fee.

a. is not
b. is usually
6. Which is the insurance plan responsible for paying health care insurance claims first?

a. primary insurance
b. secondary insurance
c. supplemental insurance
d. tertiary insurance
7. Secondary insurance is the insurance plan that is billed after the primary insurance plan has paid its contracted amount and the provider’s office has received a(n) __________ from the primary payer.

a. CMS-1500 claim
b. encounter form
c. explanation of benefits
d. remittance advice
8. When a child lives with both parents, and each parent subscribes to a different health insurance plan, the primary and secondary policies are determined by applying the birthday rule. The individual who holds the primary policy for dependent children is the spouse whose birth __________.

a. day occurs earlier in the month
b. month and day occur earlier in the calendar year
c. month, day, and year occur earlier
d. year occurs earlier
8. When applying the birthday rule, if policyholders have identical birthdays, the policy in effect the __________ is considered primary.

a. longest
b. shortest
9. A child is listed as a dependent on both his father’s and his mother’s group insurance policies. The father’s birth date is March 20, 1977, and the mother’s birth date is March 6, 1979. Which policy is primary?

a. father’s policy
b. mother’s policy
10. Which is the financial record source document used by health care providers and other personnel to record treated diagnoses and services rendered to the patient during the current visit?

a. CMS-1500 claim
b. encounter form
c. explanation of benefits
d. remittance advice
11. Which is the financial record source document used by health care providers and other personnel in a physician’s office setting to record treated diagnoses and services rendered to the patient during the current visit?

a. CMS-1500 claim
b. explanation of benefits
c. remittance advice
d. superbill
12. Which is the financial record source document used by health care providers and other personnel in a hospital outpatient setting to select codes for treated diagnoses and services rendered to the patient during the current visit?

a. chargemaster
b. explanation of benefits
c. remittance advice
d. superbill
13. Which is a manual permanent record of all financial transactions between the patient and the practice?

a. health record
b. insurance claim
c. patient ledger
d. remittance advice
14. Which is a computerized permanent record of all financial transactions between the patient and the practice?

a. health record
b. patient account record
c. patient ledger
d. remittance advice
15. The manual daily accounts receivable journal is also known as the __________, and it is a chronologic summary of all transactions posted to individual patient ledgers/accounts on a specific date.

a. day sheet
b. explanation of benefits
c. patient ledger
d. superbill
16. Which is the electronic or manual transmission of claims data to payers or clearinghouses for processing?

a. claims adjudication
b. claims payment
c. claims processing
d. claims submission
17. When selecting a clearinghouse, providers may also want to determine whether it is accredited by the __________.

a. Centers for Medicare and Medicaid Services
b. Electronic Healthcare Network Accreditation Commission
c. Joint Commission
d. National Committee for Quality Assurance
18. Covered entities are required to use mandated national standards when conducting any of the defined transactions covered under HIPAA. Which is an example of a covered entity?

a. banks that handle medical office payroll
b. companies that performs human resources
c. ERISA-covered health benefit plans
d. outsourced physical plant management
19. Electronic claims are submitted directly to the payer after being checked for accuracy by billing software or a health care clearinghouse, which results in a __________ claim that contains all required data elements needed to process and pay the claim.

a. clean
b. electronic
c. submitted
d. unassigned
20. A claims attachment is __________ documentation associated with a health care claim or patient encounter.

a. coding
b. payment
c. remittance
d. supporting
21. Coordination of benefits (COB) is a provision in __________ health insurance policies intended to keep multiple insurers from paying benefits covered by other policies.

a. all
b. commercial
c. group
d. private
22. Which involves sorting claims upon submission to collect and verify information about the patient and provider?

a. claims adjudication
b. claims payment
c. claims processing
d. claims submission
23. Which involves comparing the claim to payer edits and the patient’s health plan benefits to verify that the required information is available to process the claim, the claim is not a duplicate, payer rules and procedures have been followed, and procedures performed or services provided are covered benefits?

a. claims adjudication
b. claims payment
c. claims processing
d. claims submission
24. Any procedure or service reported on the claim that is not included on the master benefit list is a noncovered benefit and will result in claims __________.

a. approval
b. denial
c. payment
d. submission
25. Procedures and services provided to a patient without proper authorization from the payer, or that were not covered by a current authorization, are called __________ services.

a. approved
b. denied
c. submitted
d. unauthorized
26. The claim is also checked against the __________, which is an abstract of all recent claims filed on each patient and helps determine whether the patient is receiving concurrent care for the same condition by more than one provider.

a. chargemaster
b. common data file
c. encounter form
d. list of pre-existing conditions
27. Claims adjudication involves making a determination about __________ charges, which is the maximum amount the payer will permit for each procedure or service, according to the patient’s policy.

a. allowed
b. denied
c. inconsistent
d. irregular
28. Which is the total amount of covered medical expenses a policyholder must pay each year out-of-pocket before the insurance company is obligated to pay any benefits?

a. coinsurance
b. copayment
c. deductible
d. premium
29. A policyholder or __________ is the person in whose name the insurance policy is issued.

a. beneficiary
b. employee
c. patient
d. provider
30. Which is the percentage the patient pays for covered services after the deductible has been met and the copayment has been paid?

a. coinsurance
b. copayment
c. deductible
d. premium
31. Which is the fixed amount the patient pays each time he or she receives health care services?

a. coinsurance
b. copayment
c. deductible
d. premium
32. A remittance advice submitted to the provider electronically is called an electronic remittance advice (ERA), and __________.

a. different information is included as compared with a paper-based remittance advice
b. it contains identical information to the information on a paper-based remittance advice
c. payers are required to increase the amount of reimbursement paid to the provider
d. similar information is included in the exact format as a paper-based remittance advice
33. Medicare calls its remittance advice a(n) __________.

a. explanation of benefits
b. electronic remittance advice
c. Medicare summary notice
d. provider remittance notice
34. Providers have the option of arranging for __________, which means that payers deposit reimbursement for health care services to the provider’s account electronically.

a. electronic data interchange
b. electronic flat file formats
c. electronic funds transfer
d. electronic media claims
35. Which is considered a financial source document from which an insurance claim is generated?

a. CMS-1500 claim
b. encounter form
c. ledger card
d. patient record
36. Which claims are organized by month and insurance company after submission to the payer, but for which processing is not complete?

a. closed claims
b. clean claims
c. open claims
d. unassigned claims
37. Which claims are filed according to year and insurance company and include those for which all processing, including appeals, has been completed?

a. clean claims
b. closed claims
c. open claims
d. unassigned claims
38. Which claims are organized by year and are generated for providers who do not accept assignment?

a. cl
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