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MEDICAL BILLING AND CODING TEST EXAM
2025 QUESTIONS AND CORRECT ANSWERS
Medical Insurance - ANSWER: Financial plan (the payer) that covers the cost of hospital and medical care Policyholder - ANSWER: Person who buys an insurance plan; the insured, subscriber, or guarantor Health Plan - ANSWER: Individual or group plan that provides or pays for the cost of medical care Benefits - ANSWER: What a health plan pays for services covered in an insurance policy; listed in the schedule of benefits. Medical Necessity - ANSWER: Reasonable services of provider (doctor or facility) consistent with professional medical standards. Covered Services - ANSWER: Determined as being medically
necessary and both reasonable and consistent with the standards for the diagnosis or treatment of injury or illness. Non-covered Services - ANSWER: Medical procedures not covered in a plans benefits. Individual Health Plan (I H P) - ANSWER: contract between individual and the plan known as direct pay. Group Health Plan (G H P) - ANSWER: contract between an employer or organization and the plan, the group members are insured as "subscribers". Disability Insurance - ANSWER: Replaces income lost because the insured cannot work Workers' Compensation Insurance - ANSWER: Provides benefits for an insured injured on the job Indemnity Insurance - ANSWER: Payment method is fee-for-service based on the contract's schedule of benefits,fee is paid AFTER the
provider for all necessary contracted services provided to each patient who is a plan member no matter how much medical care is received during the determined time period. Per member per month, (PMPM) - ANSWER: (per member per month): The "capitated rate" Capitation this amount is paid to the health care provider based on the schedule of benefits, no matter how much medical care is received during the determined time period. Point of Service Plan (PPO) - ANSWER: Combines features of both HMOs and PPOs Also called an "open access HMO "Allows members to see providers in or out of HMO's network Members pay more for out-of-network providers. Preferred Provider Organizations (PPO) - ANSWER: A managed care organization structured as a network of health care providers who agree to perform services for plan members at discounted fees; usually, plan members can receive services from non-network providers for a higher charge. PPOs control the cost of health care by: Directing patients' choices of providers Controlling use of services Requiring preauthorization for services Requiring Cost-sharing
Consumer-Driven Health Plans (CDHP) - ANSWER: Combine two elements: A Health Plan, Usually A PPO, That Has A High Deductible (Such As $1,000) And Low Premiums A Special "Savings Account" That Is Used To Pay Medical Bills Before The Deductible Has Been Met Cost Containment Plan Based On Consumerism: Idea That Patients Who Pay For Health Care Services Become More Careful Consumers. Private Payers - ANSWER: Have Contracts With Businesses To Provide Benefits For Their Employees...Better Rates Self-Funded Health Plans - ANSWER: The Organization "Insures Itself" A Company Creates Its Own Insurance Plan For Its Employees, Rather Than Using A Carrier; The Plan Assumes Payment Risk, Contracts With Physicians, And Pays For Claims From Its Funds. Medicare - ANSWER: Coverage For Those Age 65 And Older, People With Certain Disabilities, And People With Permanent Kidney Failure.
Etiquette - ANSWER: Manners, Describes Proper Protocol And Behavior In A Medical Practice. CMA - ANSWER: Certified Medical Assistant RMA - ANSWER: Registered Medical Assistant Fee For Service - ANSWER: Schedule Of Fees Set For Services Performed By Providers And Paid By The Patient Medical Billing Cycle - ANSWER: 10 Steps-Preregister Patients, Establish Fin Responsibility, Check In, Check Out, Review Coding Compliance, Check Billing Compliance, Prepare And Transmit Claims, Monitor Payer Adjudication, Generate Patient Statements, Follow Up Payments And Collections. Medical Chart - ANSWER: Paper chart stating, All patient contact related to medical care, office visits, conversations, and correspondence. Contents - CC - Chief complaint; PMH - past medical history; FH - family history; PI - present
illness; SH - social history; OH - occupational history (ex. Pa - mortician
- chemicals); PE - physical examination (assessment of the status of each body system); diagnostic and laboratory test results; consultation reports; past medical records; correspondence; providers notes; termination summary. CC - ANSWER: Chief complaint PMH - ANSWER: past medical history FH - ANSWER: family history PI - ANSWER: present illness SH - ANSWER: social history OH - ANSWER: occupational history PE - ANSWER: physical examination, (assessment of the status of
Processed. Paper Records-Are Created Manually Are Inexpensive To Create Include Handwritten Entries In A Medical Record. (CMS) Centers For Medicare And Medicaid Services, (Formerly HCFA) - ANSWER: Administers Medicare And Medicaid Regulates Medical Laboratory Testing Prevents Discrimination Based On Health Status Assesses The Quality Of Health Care Facilities Researches Effectiveness Of Health Care Management, Treatment, And Financing Combats fraud and abuse in government-sponsored programs HIPAA - ANSWER: (Health Insurance Portability And Accountability Act), Protects Peoples' Private Health Information Protects Health Insurance Coverage For Employees And Their Dependents If Job Status Changes Uncovers Fraud And Abuse Includes The Adoption Of Standards For Electronic Transmission In Health Care Industry
Physical Copy Of Medical Record - ANSWER: The Physical Medical Record Is The Property Of The Provider That Created Them. Information Contained Within The Medical Record - ANSWER: Belongs To The Patient. A Patient Can Request Copies Of Their Medical Record. HIPAA Privacy Rule - ANSWER: Law That Regulates The Use And Disclosure Of Patients' Protected Health Information (PHI). HIPAA Security Rule - ANSWER: Law That Requires Covered Entities To Establish Administrative, Physical, And Technical Safeguards To Protect The Confidentiality, Integrity And Availability Of Health Information HIPAA Electronic Health Care Transactions And Code Sets Standards - ANSWER: HIPAA Standards Governing That Every Provider Doing Business Electronically Must Use Same Standards For Transactions And Code Sets. Covered Entities Under HIPAA - ANSWER: Electronically Transmit HIPAA- Protected Information. Ces Are (1) Health Plans, (2) Health
legitimate reasons for sharing patients protected health information without authorization. Use minimum necessary standard- only release health information to the extent that it is needed. Minimum Necessary Standard - ANSWER: The HIPAA Standard That Requires Covered Entities To Release Only The Minimum Amount Of Patient Health Data To Meet The Need Of The Request. (DRS) Designated Record Set- - ANSWER: Providers = Medical And Billing Records Health Plans = Enrollment, Payment, Claim Decisions, And Medical Management System Data Patients Can= Access, Copy, And Inspect Information Request Amendments Obtain Accounting Of Disclosures Receive Information By Other Means Complain About Alleged Violations Standard Code Sets - ANSWER: Examples: ICD- 9 - CM, CPT, CDT, HCPCS.
Coding systems for diseases; treatments and procedures; supplies. National Patient ID (Individual Identifier) - ANSWER: unique individual identification system to be created under HIPAA national identifiers. Employer Identification Number (EIN) National Provider Identifier (NPI) Fraud - ANSWER: Act of deception used to take advantage of another person, (Lie). Example - billing when the task was not done. Abuse - ANSWER: Act that misuses public funds. Example - billing when the task was not necessary. Filing something TRUTHFULLY because it was done but something that was not necessary..."abusing the system"...fine the "loop holes" . False Claims Act - ANSWER: Prohibits Submitting Fraudulent Claim Or Making False Statements Or Representation In Connection With A Claim.
Primary If The Patient Has Coverage Under Two Plans, The Patient's Longest Running Plan Is Primary And The Other Plan Is Secondary. A Third, Or Tertiary, Plan Or A Supplemental Plan May Also Be In Effect. A Patient's Plan Is Also Primary If The Patient Is: Listed As A Dependent On Another Person's Plan Covered Under A Government-Sponsored Plan, That Is In Addition To An Employer's Plan Retired, But Covered Under A Working Spouse's Plan Birthday Rule - ANSWER: If The Dependent Child Is Covered Under Both Parents. The Guideline That Determines Which Of Two Parents With Medical Coverage Has The Primary Insurance For A Child; The Parent Whose Day Of Birth Is Earlier In The Calendar Year Is Considered Primary. "Exception To Birthday Rule": If The Patient Is A Dependent Child Of Divorced Or Separated Parents, Primary Insurance Is Determined In The Following Order:
1) Plan Of Custodial Parent
2) Plan Of Spouse Of Custodial Parent If Remarried
3) Plan Of Parent Without Custody
(PAR) Participating Provider - ANSWER: Provider Who Agrees To Provide Medical Services To A Payer's Policyholders According To A Contract (Non PAR) : Nonparticipating Provider - ANSWER: Provider Who Does Not Join A Particular Health Plan Insured - ANSWER: Policyholder Or Subscriber To A Health Plan Or Policy Subscriber - ANSWER: The Insured/ The Policy Holder Assignment Of Benefits - ANSWER: Authorization Allowing Benefits To Be Paid Directly To A Provider Smart Cards - ANSWER: Smart Cards Are Being Introduced By Health Plans. These Replace The Use Of A Social Security Number With
Prior Authorization Number - ANSWER: Identifying Code Assigned By A Government Program Or Health Insurance Plan When Preauthorization Is Required; Also Called The Certification Number. Certification Number - ANSWER: Number Returned Electronically By A Health Plan When Approving A Referral Authorization Request. HIPAA Referral Certification And Authorization - ANSWER: : HIPAA X12 278 Transaction In Which A Provider Asks A Health Plan For Approval Of A Service And Gets A Response Referral Number - ANSWER: Authorization Number Given To The Referred Physician Referral Waiver - ANSWER: Document A Patient Signs To Guarantee Payment When A Referral Authorization Is Pending Primary Insurance - ANSWER: Health Plan That Pays Benefits First Secondary Insurance - ANSWER: Second Payer On A Claim
Tertiary Insurance - ANSWER: Third Payer On A Claim Supplemental Insurance - ANSWER: Health Plan That Covers Services Not Normally Covered By A Primary Plan COB, (Coordination Of Benefit) - ANSWER: Explains How An Insurance Policy Will Pay If More Than One Policy Applies HIPAA Coordination Of Benefits - ANSWER: HIPAA X12 837 Transactions Sent To A Secondary Or Tertiary Payer Gender Rule - ANSWER: Coordination Of Benefit Rule For A Child Insured Under Both Parents' Plan Payer Communications - ANSWER: Payer Communications Are Documented In The Financial Record Rather Than The Medical (Clinical) Record Encounter Form - ANSWER: List Of The Diagnoses, Procedures, And Charges For A Patient's Visit. (Specially Designed Encounter Forms , Sometimes Called Hospital Charge Tickets, Are Used When The
