Medical Billing and Compliance Terms Quiz
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Questions and Answers

What is the definition of a 'hold harmless clause'?

  • Mandates annual reviews of contracts
  • Prohibits billing to patient for anything beyond deductibles and co-pays (correct)
  • Defines payment terms for providers
  • Allows additional charges for services rendered

    • What are some benefits of a compliance plan?

    More accurate payment of claims, fewer billing mistakes, improved documentation and more accurate coding, less chance of violating self-referral and anti-kickback status.

    What is a healthcare clearinghouse?

    An entity that processes nonstandard health information they receive from another entity into a standard format.

    What does the Minimum Necessary requirement in HIPAA imply?

    <p>Only the minimum necessary protected health information should be shared to satisfy a particular purpose.</p> Signup and view all the answers

    What is a medically necessary service?

    <p>The least radical service/procedure that allows for effective treatment of the patient's complaint or condition.</p> Signup and view all the answers

    If a patient sustains an injury to her great saphenous vein, which anatomical site is affected?

    <p>Leg</p> Signup and view all the answers

    What does APC stand for?

    <p>Ambulatory Payment Classification</p> Signup and view all the answers

    What is ARRA?

    <p>American Recovery and Reinvestment Act (of 2009)</p> Signup and view all the answers

    What are ASC?

    <p>Ambulatory Surgical Centers</p> Signup and view all the answers

    What does it mean when abuse consists of billing errors?

    <p>Payment for items or services that are billed by providers in error that should not be paid for by Medicare.</p> Signup and view all the answers

    What is an ABN and its purpose?

    <p>Advance Beneficiary Notice protects the provider's financial interest by creating a paper trail that CMS requires before a provider can bill the patient if Medicare denies coverage.</p> Signup and view all the answers

    What is the definition of fraud in the context of the Affordable Care Act?

    <p>The Affordable Care Act amended the definition of fraud to remove the intent requirement.</p> Signup and view all the answers

    How often must all work RVUs be examined?

    <p>Every 5 years</p> Signup and view all the answers

    What is the Conversion Factor (CF)?

    <p>A fixed dollar amount used to translate the RVUs into fees.</p> Signup and view all the answers

    What does CMS stand for?

    <p>Centers for Medicare and Medicaid Services</p> Signup and view all the answers

    What legislation regulates medical necessity policies developed by CMS?

    <p>Social Security Act, specifically title XVIII, $1862(a)</p> Signup and view all the answers

    What is the purpose of CMS-R-131?

    <p>CMS-R-131 is the ABN form used for informing patients about potentially non-covered services.</p> Signup and view all the answers

    What does CPT stand for?

    <p>Current Procedural Terminology</p> Signup and view all the answers

    What year is the Conversion Factor CF $25.0008 for?

    <p>CY 2013</p> Signup and view all the answers

    Commercial non-Medicare health plans develop medical policies specified in what?

    <p>Private contracts between the payer and practice or provider.</p> Signup and view all the answers

    What does DRG stand for?

    <p>Diagnosis Related Group</p> Signup and view all the answers

    Does Medicare Part B generally require a yearly deductible and copayment?

    <p>True</p> Signup and view all the answers

    What do E/M or E&M codes refer to?

    <p>Evaluation and Management</p> Signup and view all the answers

    What does EHR stand for?

    <p>Electronic Health Record</p> Signup and view all the answers

    What is the formula for calculating facility payment amounts?

    <p>[(Work RVU * Work GPCI) + (Transitioned Facility PE RVU * PE GPCI) + (MP RVU * MP GPCI)] * CF</p> Signup and view all the answers

    What is the formula for Non-Facility Pricing Amount?

    <p>[(Work RVU * Work GPCI) + (Transitioned Non-Facility PE RVU * PE GPCI) + (MP RVU * MP GPCI)] * (CF)</p> Signup and view all the answers

    What does GPCI stand for?

    <p>Geographic Practice Cost Index</p> Signup and view all the answers

    What is GPCI used for?

    <p>To realize the varying cost based on geographic location.</p> Signup and view all the answers

    What does HCPCS stand for?

    <p>Healthcare Common Procedure Coding System</p> Signup and view all the answers

    What does HHS stand for?

    <p>Department of Health and Human Services</p> Signup and view all the answers

    What kind of protections does HIPAA provide?

    <p>Federal protections for personal health information when held by covered entities.</p> Signup and view all the answers

    What does HIPAA stand for?

    <p>Health Insurance Portability and Accountability Act of 1996</p> Signup and view all the answers

    What is HITECH?

    <p>The Health Information Technology for Economic and Clinical Health Act.</p> Signup and view all the answers

    What can patients request under HITECH?

    <p>An audit trail showing all disclosures of their health information made through an electronic record.</p> Signup and view all the answers

    What does HITECH require if there is unauthorized disclosure of health information?

    <p>That an individual is notified.</p> Signup and view all the answers

    What was HITECH enacted as part of?

    <p>The American Recovery and Reinvestment Act of 2009 (ARRA).</p> Signup and view all the answers

    What does HMO stand for?

    <p>Health Maintenance Organization</p> Signup and view all the answers

    What system is hemiplegia a disorder of?

    <p>Nervous system</p> Signup and view all the answers

    What does ICD-9-CM stand for?

    <p>International Classification of Diseases, 9th Clinical Modification</p> Signup and view all the answers

    What is the non-facility pricing amount for CPT code 99212 using a CF of $33.9764 if Work RVUs = 0.48 and Work GPCI = 1.000?

    <p>$39.51 Non-facility pricing amount</p> Signup and view all the answers

    What notice must a practice obtain if a service fails to support medical necessity requirements?

    <p>Advance Beneficiary Notice of Non-Coverage (ABN)</p> Signup and view all the answers

    If an NCD doesn't exist for a particular item, whose responsibility is it to determine coverage?

    <p>MAC (Medicare Administrative Contractor)</p> Signup and view all the answers

    Which part of Medicare should be billed for medication delivered for home use during outpatient chemotherapy?

    <p>Part D</p> Signup and view all the answers

    Complete the series: Incus, stapes, _____

    <p>Malleus</p> Signup and view all the answers

    What is considered intentional billing of services not provided?

    <p>Fraud</p> Signup and view all the answers

    What does LCD stand for?

    <p>Local Coverage Determinations</p> Signup and view all the answers

    What governs the jurisdiction of LCDs?

    <p>Their regional area.</p> Signup and view all the answers

    When do LCDs give guidance?

    <p>When a service is indicated or necessary, coverage limitations, specific CPT codes applicable, and related ICD-9-CM codes.</p> Signup and view all the answers

    What does MP stand for?

    <p>Malpractice</p> Signup and view all the answers

    What does MS-DRG stand for?

    <p>Medical Severity-Diagnosis Related Group</p> Signup and view all the answers

    How is Medicaid defined?

    <p>A health insurance assistance program for some low-income people.</p> Signup and view all the answers

    On what basis is Medicaid administered?

    <p>State by state basis adhering to certain federal guidelines.</p> Signup and view all the answers

    What services does Medicare Part B help cover?

    <p>Medically necessary physicians' services, outpatient care, and other medical services not covered under Part A.</p> Signup and view all the answers

    Who pays for Medicare Part B premiums?

    <p>The patient</p> Signup and view all the answers

    What does Medicare Part C combine?

    <p>The benefits of Part A and Part B and sometimes Part D.</p> Signup and view all the answers

    What is another name for Medicare Part C?

    <p>Medicare Advantage</p> Signup and view all the answers

    Who manages Medicare Part C plans?

    <p>Private insurers approved by Medicare.</p> Signup and view all the answers

    What is Medicare Part D?

    <p>A prescription drug coverage program.</p> Signup and view all the answers

    Who provides Medicare Part D coverage?

    <p>Private companies approved by Medicare.</p> Signup and view all the answers

    Is Medicare Part D available to all Medicare beneficiaries?

    <p>True</p> Signup and view all the answers

    What services does Medicare Part A help cover?

    <p>Inpatient hospital care, care provided in skilled nursing facilities, hospice care, home health care.</p> Signup and view all the answers

    How are Medicare payments for physician services standardized?

    <p>Using a resource-based relative value scale (RBRVS).</p> Signup and view all the answers

    What does NCD stand for?

    <p>National Coverage Determinations</p> Signup and view all the answers

    What does an NCD explain?

    <p>When Medicare will pay for items or services.</p> Signup and view all the answers

    What does NP stand for?

    <p>Nurse Practitioner</p> Signup and view all the answers

    What does OCR stand for?

    <p>Office of Civil Rights</p> Signup and view all the answers

    What does OIG stand for?

    <p>Office of the Inspector General</p> Signup and view all the answers

    What are the key actions in OIG Compliance Program for Individual and Small Group Physician Practices?

    <p>Implement standards, designate compliance officer, train staff, conduct audits, respond to violations, develop communication channels, enforce disciplinary standards.</p> Signup and view all the answers

    What does PA stand for?

    <p>Physician Assistant</p> Signup and view all the answers

    What does PE stand for?

    <p>Physician Expense</p> Signup and view all the answers

    What does PFS stand for?

    <p>Physician Fee Schedule</p> Signup and view all the answers

    What does PHI stand for?

    <p>Protected Health Information</p> Signup and view all the answers

    What does PLI stand for?

    <p>Professional Liability Insurance</p> Signup and view all the answers

    What was the published conversion factor for CY 2012?

    <p>$34.0376</p> Signup and view all the answers

    What was the published conversion factor for CY 2011?

    <p>$33.9764</p> Signup and view all the answers

    What does RBRVS stand for?

    <p>Resource Based Relative Value System</p> Signup and view all the answers

    What does RUC stand for?

    <p>Relative Value Update Committee</p> Signup and view all the answers

    What are the resource costs for RBRVS divided into?

    <p>Physician work, practice expense, professional liability insurance.</p> Signup and view all the answers

    What anatomical system do sebaceous glands belong to?

    <p>Integumentary system</p> Signup and view all the answers

    What is the ABN form entitled?

    <p>Revised ABN CMS-R-131.</p> Signup and view all the answers

    What does the ABN standardize?

    <p>The ABN standardizes communication regarding why Medicare may deny particular services.</p> Signup and view all the answers

    What is the OIG mandated to test?

    <p>The efficiency and economy of government programs, including health care fraud investigation.</p> Signup and view all the answers

    The amount on an ABN should be within how much of the cost to the patient?

    <p>$100 or 25% of cost</p> Signup and view all the answers

    Which chamber of the heart is the myocardium thickest around?

    <p>Left ventricle</p> Signup and view all the answers

    What does the term 'medical necessity' refer to?

    <p>Whether a procedure or service is considered appropriate in a given circumstance.</p> Signup and view all the answers

    The tunica vaginalis is part of which system?

    <p>Male reproductive system</p> Signup and view all the answers

    Under the Privacy rule, the minimum necessary standard of HIPAA does not apply to what?

    <p>Disclosures for treatment, disclosures to the individual, and certain compliance disclosures.</p> Signup and view all the answers

    What document should a provider review for potential problem areas in the OIG work plan?

    <p>OIG work plan</p> Signup and view all the answers

    What is an NCD interpreted at the MAC level considered?

    <p>LCD (Local Coverage Determination)</p> Signup and view all the answers

    What results from a ureteral blockage?

    <p>Urine will not be able to flow from the kidney to the bladder.</p> Signup and view all the answers

    When does the OIG release a work plan outlining its priorities for the fiscal year ahead?

    <p>October</p> Signup and view all the answers

    When should an ABN be signed?

    <p>When a service is not expected to be covered by Medicare.</p> Signup and view all the answers

    Which of the following has a refraction function in the eye?

    <p>Lens</p> Signup and view all the answers

    Which of the following is a function of the pancreas?

    <p>Supplies digestive enzymes</p> Signup and view all the answers

    Which of the following is a renal calculus?

    <p>Nephrolithiasis</p> Signup and view all the answers

    Who is responsible for interpreting national policies into regional policies called LCDs?

    <p>Each MAC (Medicare Administrative Contractor)</p> Signup and view all the answers

    Whose responsibility is it to develop and implement policies to meet HIPAA requirements?

    <p>The entity covered by HIPAA.</p> Signup and view all the answers

    What do work RVUs reflect?

    <p>The relative levels of time and intensity associated with furnishing a Medicare PFS service and account for approximately 50% of the total payment.</p> Signup and view all the answers

    Study Notes

    Medical Billing and Compliance Terms

    • Hold Harmless Clause: Prevents providers from billing patients beyond deductibles or co-pays in some non-Medicare contracts.
    • Compliance Plan Benefits: Enhances claim accuracy, reduces billing errors, improves documentation and coding, mitigates self-referral and anti-kickback violations.
    • Healthcare Clearinghouse: Converts nonstandard health information into a standardized format.
    • HIPAA Minimum Necessary Requirement: Only shares essential protected health information for specific purposes.
    • Medically Necessary Service: The simplest effective treatment for a patient's condition.

    Anatomy and Medical Coding

    • Great Saphenous Vein Injury: Relates to the leg.
    • APC: Stands for Ambulatory Payment Classification.
    • CMS: Centers for Medicare and Medicaid.
    • GPCI: Geographic Practice Cost Index, reflects varying costs due to location.

    Medicare and Medicaid Insights

    • Medicaid: Health assistance for low-income individuals, state-administered per federal guidelines.
    • Medicare Parts Overview:
      • Part A: Covers inpatient hospital care, skilled nursing, hospice, and home health care.
      • Part B: Encompasses outpatient care and physician services.
      • Part C: Combines A and B, known as Medicare Advantage, managed by private insurers.
      • Part D: Prescription drug coverage, provided by private companies.
    • NCD and LCD: National Coverage Determinations set national guidelines; Local Coverage Determinations are region-specific interpretations by MACs.
    • ABN: Advance Beneficiary Notice protects providers by creating a billing trail upon Medicare denial.
    • OIG Compliance Program: Mandates monitoring compliance, training, audits, and addressing potential violations.
    • Fraud Definition under ACA: Removed intent requirement for fraud allegations.

    Health Information Technology

    • EHR: Electronic Health Record, digital version of patients' paper charts.
    • HITECH Act: Enhances privacy and security provisions of HIPAA, includes patient rights to audit trails of their health information.

    Coding Systems and Payment Models

    • CPT: Current Procedural Terminology used for coding medical services.
    • DRG: Diagnosis Related Group used to classify hospital cases.
    • RBRVS: Resource-Based Relative Value Scale, standardizes physician service payments.
    • Formula for Facility Payments: Combines RVUs, GPCI, and CF to determine payment amounts.

    Miscellaneous Medical Knowledge

    • Hemiplegia: Disorder in the nervous system.
    • Sebaceous Glands: Part of the integumentary system.
    • Nephrolithiasis: Refers to kidney stones (renal calculus).
    • Myocardium: Thickest in the left ventricle of the heart.

    Important Government and Regulatory Agencies

    • HHS: Department of Health and Human Services responsible for health policy and services.
    • OCR: Office of Civil Rights, upholds HIPAA regulations.
    • OIG: Office of the Inspector General, investigates healthcare fraud and efficiency in government programs.

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    Description

    Test your knowledge on key terms and concepts related to medical billing, compliance, and medical coding. This quiz covers essential regulations, the role of healthcare clearinghouses, and important aspects of Medicare and Medicaid. Perfect for students and professionals in the healthcare field.

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