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Athl 235

ATLH 235 July 16, 2011 Take home Exam 46. Explain the difference between assignments of benefits and accept assignment. Ans: Assignment of benefits is when the provider receives reimbursement directly from the payer while accept assignment is when the provider accepts as payment in full whatever is paid on the claim by the payer. 47. What is the purpose of the new patient interview and check-in procedure? Ans: The purpose of the new patient interview and check-in procedure is to obtain information, schedule the patient for an appointment, and generate a patient record.


Explain the difference between a participating provider (PAR) and a nonparticipating provider (non-PAR). Ans: A participating provider (PAR) contracts with a health insurance plan and accepts whatever the plan pays for procedures or services perform while on the other hand a nonparticipating provider (non-PAR) does not contract with the insurance plan, and patients who elect to receive care from non-PARs will incur higher out-of-pocket expenses. 49. When a provider’s office contacts the payer to verify a patient’s insurance eligibility and benefit status, HIPAA privacy standards mandate that four areas of pertinent information be provided.

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Name them. Ans: Beneficiary last name and first initial, Beneficiary date of birth, Beneficiary health insurance claim number (HICN), and Beneficiary gender 50. Explain primary insurance versus secondary insurance. Ans: Primary insurance is the insurance plan responsible for paying healthcare insurance claims first. Once the primary insurance is billed and pays the contracted amount, the secondary plan is billed for the remainder, and so on. 51. What is the birthday rule? Ans: The birthday rule determines coverage by primary and secondary policies when each parent subscribes to a different health insurance plan.

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2. What is the gender rule? Ans: The gender rule is a rule that states that the father’s plan of the child or (dependents) is always primary when the child is covered by both parents. 53. Define encounter form, and distinguish between a superbill and a chargemaster. Ans: Encounter form is the financial record source document used by healthcare providers and other personnel to record treated diagnoses and services rendered to the patient during the current encounter. In the physician’s office an encounter form is called a superbill and in a hospital the encounter form is called chargemaster. 4. What is the patient ledger? Ans: Patient ledger is a permanent record of all financial transactions between the patient and the practice. 55. Define a day sheet. Ans: Day sheet is a chronologic summary of all transactions posted to individual patient ledgers/ accounts on a specific day. 56. What is a clearinghouse? Ans: A clearinghouse is a public or private entity that processes or facilitates the processing of nonstandard data elements into standard data elements. 57. List some examples of covered entities.

Ans: Worker’s Compensation, Military Health Systems, HealthCare clearinghouses, and Indian Health services 58. What is a claims attachment? Ans: A claim attachment is a set of supporting documentation or information associated with a healthcare claim or patient encounter. 59. What does the claims adjudication process verify? Ans: The claims adjudication process verify that the required information is available to process the claim, claim is not a duplicate, payer rules and procedures have been followed and procedures performed or services provided are covered benefits. 60. Explain allow charges.

Ans: Allow charges are the maximum amount the payer will allow for each procedure or service, according to the patient’s policy. 61. What is meant by the statement “to link the diagnosis with the procedure/service”? Ans: The statement “to link the diagnosis with the procedure/service means to match up the appropriate diagnosis with the procedure/service that was rendered to treat or manage the diagnosis 62. What is the purpose of the auditing process? Ans: It involves reviewing patient records and CMS-1500 or UB-04 claims to access coding accuracy and completeness of documentation. 3. Why is it necessary for Medicare patient to sign an Advance Beneficiary Notice? Ans: It is necessary for Medicare patient to sign an ABN because if the service rendered wasn’t medically necessary and the insurance don’t want to pay, by signing the form it indicated that you agree to pay for the service out of pocket. 64. Why does a provider use an encounter form? Ans: Providers uses encounter forms to ensure the accuracy of ICD-9-CM and HCPCS/CPT codes, and healthcare facilities should audit chargemasters to ensure the accuracy of HCPCS/CPT and UB-04 to revenue codes. 65.

What is outpatient code editor software and what is it used for? Ans: The outpatient code editor is software that edits outpatient claims submitted by hospital, community mental health centers, comprehensive outpatient rehabilitation facilities, and home health agencies. The software assigns ambulatory payment classifications (APCs) and reviews submissions for coding validity and coverage. 66. Why is the patient record important in a health care facility? Ans: A patient record serves as the business record for a patient encounter, and is maintained in a manual record or automated format. 7. What is the primary purpose of the patient record? Ans: The primary purpose of the patient record is to provide continuity of care. 68. Describe two major formats that health care providers use for documenting clinic notes. Ans: The two major formats that health care provider uses are narrative clinic notes and SOAP notes. A narrative clinic note is written in paragraph format. Soap notes are written in outline format. 69. Explain the four components of SOAP notes. Ans: The Subject part of the note contains the chief complaint and the patient’s description of the presenting problem.

The Objective part of the note contains documentation of measurable or objective observations made during physical examination and diagnostic testing. The Assessment contains the diagnostic statement and may include the physician’s rationale for the diagnosis. The Plan is the statement of the physician’s future plans for the work-up and medical management of the case. 70. In which two locations can diagnostic test results be found? Ans: Diagnostic test result can be found in clinic notes and laboratory reports. 71. List the information hospitals and ambulatory surgical centers need to complete their operative reports.

Ans: Date of the surgery, patient identification, pre-and postoperative diagnosis, list of the procedures performed, name of primary and secondary surgeons who perform surgery. 72. Name four areas of information that the body of the operative report contains. Ans: The body of the operative report contains simple versus complaint, repair, endoscopy, and biopsy. 73. What is the reason an insurance specialist should be careful to never assign multiple, separate codes to describe a procedure when the CPT manual has a single code that classifies all the individual components of the procedure performed by the physician?

Ans: Because a monetary value is associated with each CPT code. 74. What is the purpose of the outpatient code editor (OCE) and what is it used for? Ans: 75. What is the function of local coverage determinations (LCDs)? Ans: The function of LCD is specifying under what clinical circumstances a serviced and coded correctly. 76. Name the two ways in which an Authorization for Release of Medical Information can be obtained. Ans: By asking the patient to sign in Block 12, Patients of Authorized Person’s Signature, of the CMS-1500 claim.

Or ask the patients to sign a special release form that is customized by each practice and specifically names the patient’s health plan and to enter it on signature on file. 77. Define Outpatient Observation Services. Ans: Outpatient Observation Services means a well-defined set of specific, clinically appropriate services, which includes ongoing short-term treatment, assessment, and reassessment before a decision can be made regarding whether patients will require further treatment as hospital inpatients or if they are able to be discharge. 78. Define the concept of “direct admission”.

Ans: A direct admission is when a physician in the community refers a patient to the hospital for observation, by passing emergency department or a clinic. 79. What is a combined medical/surgical case? Ans: Surgical/medical cases which the patients admitted to the hospital as a medical case but, after testing requires surgery, are billed according to the instruction in items. 80. List some circumstances in which a letter from the provider would need to accompany a CMS-1500 claim. Ans: A patient’s stay in the hospital is prolonged because of medical or psychological complications.

An outpatient or office procedure is performed as an inpatient procedure because the patient is a high-risk case. 81. Explain why payers flag claims for investigation when an X is entered in one or more of the YES boxes in Block 10 of the CMS-1500 claim. Ans: Because it might be an indication that they are paying with a certain type of payment like workers compilation, automobile insurance company, homeowners, business, or another form of liability. Or sometimes they have no record for but, most providers deny the payment altogether. 82.

Explain what “incident to” refers to. Ans: ”Incident to” refers to when a physician is out of the office on the day the NPP provides services to the patient, another physician in the same group can provide direct supervision to meet the “incident to” requirements. 83. Why was the National Plan and Provider Enumeration System (NPPES) developed? Ans: The NPPES was developed by CMS to assign the healthcare provider and health plan identifiers and to serve as a database from which to extract data. 84. Name the three entities covered by HIPAA.

Ans: Health Plans, Healthcare clearinghouse, and Healthcare providers 85. Explain the difference between assignments of benefits and accept assignment. Ans: The difference is that if the patient does not sign Block 13 of CMS-1500 claim the payer of the insurance reimbursement to the patient however if the patient says yes in the block 27 the provider then agrees to accept the payment in full whatever the payer reimburses. This is call Accept assignment. Now if the patient does sign in Block 13 of the CMS-1500 of the claim it is instruct that the payer is to directly reimburse the provider. 6. What is a first-listed code? Ans: The first-listed code is basically the code that is reported as the major reason the patient was treated for by the healthcare provider. 87. Give two examples of chronic conditions that always affect patient care because they require medical management. Ans: A chronic condition that may need medical management is Diabetes Mellitus and Hypertension. 88. Identical procedures or services can be reported on the same line if two of the four circumstances apply.

Ans: Identical procedures or services that can be reported on the same line are: * Procedures were performed on consecutive days in the same month * The same code is assigned to the procedures/ services reported. * Identical charges apply to the assigned code. * Block 24G (Days or Units) is completed. 89. What is the billing entity? Ans: Billing entity is the legal business name of the practice of the provider. 90. How is a secondary claim processed? Ans: The secondary insurance claim is filed only after the remittance advice generated as a result of processing the primary claim has been received by the medical practice.

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