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Certified Billing & Coding Specialist Exam Review – COMPLETE SOLUTIONS 394 Questions with 100% Correct Answers

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Certified Billing & Coding Specialist Exam Review – COMPLETE SOLUTIONS 394 Questions with 100% Correct Answers What are Medical Ethics? - ✔✔Standards of conduct based on moral principle. they... are generally accepted as a guide for behavior towards pt's, dr's, coworkers, the gov, and ins co's What does acting within ethical behavior boundaries mean? - ✔✔Carrying out one's responsibilities with integrity, dignity, respect, honesty, competence, fairness, and trust Compliance regulations - ✔✔Most billing-related cases are based on HIPAA and False Claims Act Health Insurance Portability & Accountability Act (HIPAA) - ✔✔Enacted in 1996, created by the Health Care Fraud & Abuse Control Program- enacted to check for fraud and abuse in the Medicare/ Medicaid Programs and private payers What are 2 provisions of HIPAA? - ✔✔Title 1: Insurance Reform Title 2: Administrative Simplification What is Title 1 of HIPAA? - ✔✔Insurance Reform-primary purpose is to provide continuous coverage for workers & their dependents when they change or lose jobs. Also Limits the use of pre-existing conditions exclusions Prohibits discrimination from past or present poor health Guarantees certain employees/ individual the right to purchase new health insurance coverage after losing job Allows renewal of health insurance coverage regardless of an individuals health condition that is covered under the particular policy What is Title 2 of HIPAA? - ✔✔Administrative Simplification- goal is to focus on the health care practice setting to reduce administrative cost & burdens. Has 2 parts 1) development and implementation of standardized health related financial & administrative activities electronically 2) implementation of privacy & security procedures to prevent the misuse of health info by ensuring confidentiality What is the False Claims Act (FCA)? - ✔✔Federal law that prohibits submitting a fraudulent claim or making a false statement or representation in connection with a claim. Also protects & rewards whistleblowers What is the National Correct Coding Initiative (NCCI)? - ✔✔Developed by CMS to promote the national correct coding methodologies & to control improper coding that lead to inappropriate payment of Part B health insurance claims How many edits does NCCI include? - ✔✔2: 1.Column 1/ Column 2 (previously called Comprehensive/ Component) Edits 2.Mutually Exclusive Edits Column 1/ Column 2 edits (NCCI) - ✔✔Identifies code pairs that should not be billed together because 1 code (Column 1) includes all the services described by another code (Column 2) Mutually Exclusive Edits (NCCI) - ✔✔ID's code pairs that, for clinical reasons, are unlikely to be preformed on the same patient on the same day What are the possible consequences of inaccurate coding and incorrect billing? - ✔✔delayed processing & payment of claims, reduced payments, denied claims fine and or imprisonment, exclusion from payer's programs, loss of Dr.'s license to practice medicine Who has the task of investigate and prosecuting health care fraud & abuse? - ✔✔The Office of Inspector General (OIG) Fraud - ✔✔knowingly & intentionally deceiving or misrepresenting info that may result in unauthorized benefits. it is a felony and can result in fines and or prison Who audits claims? - ✔✔State & Federal agencies as well as private insurance companies What are common forms of fraud? - ✔✔billing for services not furnished, unbundling, and misrepresenting diagnosis to justify payment Abuse - ✔✔incidences or practices, not usually considered fraudulent, that are inconsistent with the accepted medical business or fiscal practices in the industry What are examples of Abuse? - ✔✔submitting a claim for services/ procedures performed that is not medically necessary, and excessive charges for services, equipment or supplies What is a method use to minimize danger, hazards and liabilities associated with abuse? - ✔✔Risk Management Patient Confidentiality - ✔✔All patient's have right to privacy and all info should remain privileged. Only discuss patient info when necessary to do job. Obtain a signed consent form to release medical info to insurance company or other individual When may a provider use PHI (Protected Health Information) without specific authorization under the HIPAA Privacy Rule? - ✔✔When using TPO, Treatment (primarily for the purpose of discussion of patient's case with other Dr's) Payment (providers submit claims on behalf of patients) Operations (for purposes such as training staff and quality improvement) What is Employer Liability? - ✔✔Means physicians are legally responsible for their own conduct and any actions of their employees (designee) performed within the context of their employment. Referred to as "vicarious liability" A.K.A " respondent superior"- "let the master answer". Means employee can be sued & brought to trial What is Employee Liability? - ✔✔"Errors & Omissions Insurance"- protection against loss of monies caused by failure through error or unintentional omission on the part of the individual or service submitting the claim. ***Some Dr.'s contract with a billing service (clearinghouse) to handle claims submission and some agreements contain a clause stating that the Dr. will hold the co harmless from "liability resulting from claims submitted by the service for any account", means Dr. is responsible for mistakes made by billing service, errors and omissions is not needed in the instance.*** However, if the Dr. ever asks the insurance biller to do the least bit questionable, such as write off patients balances for certain patients automatically, make sure you have a legal document or signed waiver of liability relieving you of responsibility for such actions. What is a Medical Record & what is it comprised of? - ✔✔Documentation of the patients social and medical history, family history, physical exam f [Show More]

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