What may lead to claim denials or improper service reimbursement?

Question

A. Inaccurate physician documentation
B. Updated ICD-9-CM codes
C. HCPCS codes on outpatient surgeries
D. Reporting of multiple APGs
5. You're switching jobs on Monday. Which Act was developed, in part, to ensure that you have ongoing
insurance coverage during the change?
A. HIPAA
B. HP2010
C. BBA
D. OCIIO
6. When calculating expenses, what differs for each health care facility?
A. MS-DRG relative weight
B. ICD-9-CM diagnosis codes
C. The codes that are MCCs
D. Base rate
7. What did the government use to control skyrocketing health care costs?
A. SCHIP
B. Medigap
C. Retrospective payment system
D. Prospective payment system
8. Dr. S. is working within a reimbursement system where the insurance is billed after all the treatment has
been given to the patients. The main reason that he orders more tests, exams, and procedures under this
system is
A. to make a profit.
B. because no one has to pay for it.
C. fear of being sued.
D. to increase resource utilization.
9. What is used when billing outpatient claims?
A. CMS-1450
B. CMS-1500
C. UB-4
D. UB-92
10. Which system is used to bill for services used in a skilled nursing facility?
A. RBRVS
B. IPPS
C. RUGs
D. OPPS
11. When a physician is billing under the RBRVS system, he or she is using
A. ICD-9 procedure codes.
B. CPT/HCPCS codes.
C. APCs.
D. MS-DRGs.
12. What is best used to help plan home health care outcomes and assessments?
A. HAVEN
B. RAVEN
C. OASIS
D. MAC
13. If you want to see an orthopedic specialist for your broken leg but first have to check with your
primary care physician, you probably belong to a/an
A. HMO.
B. PPO.
C. POS.
D. EPO.
14. What was created to provide coverage for options that aren't covered under Medicare A or B?
A. Medicare Part D
B. Medicare+Choice
C. Medicare Part C
D. Medigap
15. Stan is on active military duty and, therefore, is probably receiving medical coverage from
A. Medicaid.
B. TRICARE.
C. CHAMPVA.
D. SCHIP.
16. You're a coder who's reviewing the record of a 62-year-old woman who was admitted to the hospital
with shortness of breath and minor chest pain. The doctor diagnosed the patient with Staphylococcus
aureus pneumonia and you assigned a code of 482.41. Additionally, you coded decompensated chronic
systolic congestive heart failure (as documented by the physician) as 428.22 and 428.0. The coding system
grouped the information into MS-DRG 178 (RW: 1.4860). The hospital has a base rate of $4,500.
What is the admitting diagnosis?
A. Pneumonia
B. Staphylococcus aureus
C. CHF
D. Shortness of breath
17. If you have 80-20 policy coverage, it means
A. the insured pays 80% of the expenses and you pay 20%.
B. you pay 80% of the expenses and the insured pays 20%.
C. you pay 80% of the expenses and the insurer pays 20%.
D. the insurer pays 80% of the expenses and you pay 20%.
18. Mr. B is an 82-year-old retired railroad worker who is having a mole removed at his physician's office.
What will the physician’s office bill to receive payment for this service?
A. Medicare Part A
B. Medicare Part B
C. Medicare Part D
D. Medicare Part C
19. You're a coder who's reviewing the record of a 62-year-old woman who was admitted to the hospital
with shortness of breath and minor chest pain. The doctor diagnosed the patient with Staphylococcus
aureus pneumonia and you assigned a code of 482.41. Additionally, you coded decompensated chronic
systolic congestive heart failure (as documented by the physician) as 428.22 and 428.0. The coding system
grouped the information into MS-DRG 178 (RW: 1.4860). The hospital has a base rate of $4,500.
What is the hospital's reimbursement for this patient under the PPS?
A. $6,687
B. $10,360
C. $3,028.26
D. $4,500
20. Before she can receive insurance benefits, Sally must pay the first $500 out of her own finances. What
is the $500 called?
A. Co-insurance
B. Deductible
C. Co-pay
D. Indemnity
21. Patty Patient just had her appendix removed. The appendix removal appears on the claim form as a
_______ code.
A. procedure
B. provider
C. diagnosis
D. payer
22. An outpatient coder in Dr. Smith's office will use which codes for procedures?
A. ICD-9-CM
B. CPT
C. ICD-10-CM
D. HCPCS
23. If a physician is charging for a mole removal procedure based on what he and other physicians
generally for that procedure, he's probably using
A. ABG.
B. DRG.
C. UCR.
D. PPS.
24. Paul Patient is trying to get new insurance, but he fears he'll be denied due to his cancer diagnosis and
ongoing treatment. What was put in place to help patients like Paul avoid insurance denial due to their
current health conditions?
A. Affordable Care Act
B. Social Security Title XVIII
C. Healthy People 2010
D. Balanced Budget Act
25. What would a health care plan use to measure their quality and performance?
A. MSDRG.
B. RAVEN.
C. HAVEN.
D. HEDIS.
26. Dr. Smith's medical office group and the hospital in which he's affiliated are both examples of
A. providers.
B. suppliers.
C. payers.
D. resources.
27. Your grandmother has a question about her Medicare reimbursement, but it's 10:30 P.M. What
organization will answer her questions at this time of night?
A. OIG
B. HCPCS
C. SCHIP
D. CMS
28. It's January 2, 2011, and the hospital coder just assigned three diagnosis codes to a patient's record.
Which codes were probably used?
A. CPT
B. ICD-9-CM
C. ICD-10-CM
D. HCPCS
29. You're a coder who's reviewing the record of a 62-year-old woman who was admitted to the hospital
with shortness of breath and minor chest pain. The doctor diagnosed the patient with Staphylococcus
aureus pneumonia and you assigned a code of 482.41. Additionally, you coded decompensated chronic
systolic congestive heart failure (as documented by the physician) as 428.22 and 428.0. The coding system
grouped the information into MS-DRG 178 (RW: 1.4860). The hospital has a base rate of $4,500.
Which code is the principal diagnosis?
A. 428.22
B. 482.41
C. 178
D. 428.0
30. New Medicare payments systems and implementation of SCHIP both came out of the
A. Balanced Budget Act.
End of exam
B. Federal Act 33-2.
C. health maintenance organization.
D. retrospective payment system.

Answer 1

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Answer 2

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