Name: _____________________________________________ Date: _______________
1. A CPT code has ___5_____ digits and an ICD-9-CM code has ___3-5____ digits.
2. Explain the difference between a CPT code and an ICD-9-CM code.
CPT (Current Procedural Terminology), standardized numeric system (5 digits without modifiers) is used to report WHAT medical services and procedures are done to the patient.
ICD9 (International Classification of Diseases – Ninth Edition) a Universal coding system is used to describe WHY a service was performed. Codes range from 3-5 digits.
3. What is the purpose of a modifier?
To identify in certain circumstances that a service or procedure has been altered by some specific circumstance but it has not changed the basic definition or code (this is the literal CPT book definition, but anything remotely close to this is acceptable).
4. What are E&M codes?
Evaluation and Management Codes that describe different levels of physician “visits” in various healthcare settings.
5. What does “COB” stand for? Coordination of Benefits
6. What insurance information do you obtain when the patient contacts our office with new insurance?
Guarantor name, guarantor DOB, guarantor policy and group number, new insurance name, address for claims submission, effective date of new policy, and (if possible) termination date of previous policy.
7. If the patient has Medicare and Medicaid, which insurance would you bill first?
Medicare would always be billed first.
8. What does HIPAA stand for? And what does it mean to you? Health Insurance Portability and Accountability Act.
HIPAA designates certain standards and procedures that must be followed to keep secure PHI (protected Health Information). HIPAA also calls for standardization of transaction code sets and various privacy laws (looking for some level of knowledge about the general concept of HIPAA).
9. How would you handle each of the following EOB rejections?
Procedure not a covered benefit
(Looking for an answer that will show that they will NOT automatically write off the amount, but bill it to the patient. Not necessarily looking for long explanations about Medicare and ABN’s, but it would be a PLUS if they went into that much detail.)
Patient not eligible on the date of service
Bill the patient using the denial and indicating that the patient is responsible. (Again looking to be sure that they won’t write it off – further answers about contacting the patient to obtain new insurance information is a plus but not necessary, depending on the office.)
Applied to deductible: Transfer the balance applied to the deductible to the patient’s account.
Bundled Service: Write off and do not bill the patient. (Again looking for an answer that shows they know it isn’t billable to the patient. If further answer talks about being sure it is a bundled procedure and CCI edits, then it’s a big plus.)
10. What is a CMS 1500 used for? : Billing services to insurance plans
Multiple Choice
1. A “crossover” claim is:
a. When Medicare forwards a claim electronically to a secondary insurance carrier
2. An EOB is:
c. Explanation of Benefits
3. When a physician accepts “assignment” for a Medicare patient, the physician:
a. Agrees to have Medicare pay him/her directly
4. A Remittance is received without payment and the message indicates that the referring/ ordering physician NPI is needed. What should you do?
b. Resubmit the claim with the correct NPI
5. A patient calls and says her insurance will pay her claim if you use a different diagnosis code than was billed. What do you do?
d. Pull the Medical Record and give it to a certified coder for review and resolution
Matching – Select the correct letter
| _E_ | E&M | A. | A provider who is participating in the plan |
| _C_ | PHI | B. | Provides coverage for physician and outpatient services |
| _F_ | Secondary Insurance | C | Protected Health Information |
| _J_ | PCP | D | A federal health insurance program that provides benefits to indigent or low income people. |
| _H_ | PPO | E | Key components are: history, examination, and medical decision making |
| _A_ | Par Provider | F | The insurer that reimburses for benefits after the primary insurer has paid |
| _B_ | Medicare Part B | G | Coverage for hospital, nursing homes, home health. and inpatient care |
| _G_ | Medicare Part A | H | A plan that contracts with providers to provide services on a discounted basis. Members must stay “in plan” or pay a greater co pay or portion of their bill. |
| _D_ | Medicaid | I | A statement that is mailed to both the patient and the provider explaining claim adjudication and payment |
| _I_ | EOB | J | Primary Care Physician |
True/False
| True | False | Providers are always required to take commercial insurance companies contractual adjustments. |
| True | False | A patient over the age of 65 who is working will still always have Medicare as his/her primary insurance coverage. |
| True | False | If you receive a payment reduction due to “out of network” you are allowed to bill the patient the balance on the claim. |
| True | False | A co-pay is a specified flat amount for a designated service, usually paid for at the time of service. |
| True | False | You are not allowed to bill patients for out of timely denials if you are a contracted provider with that plan. |
| True | False | If you receive a denial from an insurance plan for “duplicate claim,” you must write off the balance on the account for that date of service. |
| True | False | ABN’s are not needed for services which will be denied based on statutory exclusion (services which are never covered by Medicare). |
| True | False | You do not need to send a primary insurance EOB along with the claim form when billing a secondary insurance. |
| True | False | When billing an E&M service with a procedure and using the -25 modifier, the modifier is always attached to the procedure. |
| True | False | Coinsurance is what the patient must pay before their coverage begins |
Applicant Signature: ______________________________________________________
35 Questions Total
____ Right answers
____ Score (X/35)
