Certified Billing & Coding Specialist Exam Review with
all Correct & 100% Verified Answers |Latest Version |
Already Graded A+
What are Medical Ethics? ✔Correct Answer-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? ✔Correct Answer-Carrying out one's
responsibilities with integrity, dignity, respect, honesty, competence, fairness, and trust
Compliance regulations ✔Correct Answer-Most billing-related cases are based on HIPAA and False
Claims Act
Health Insurance Portability & Accountability Act (HIPAA) ✔Correct Answer-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? ✔Correct Answer-Title 1: Insurance Reform
Title 2: Administrative Simplification
What is Title 1 of HIPAA? ✔Correct Answer-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? ✔Correct Answer-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)? ✔Correct Answer-Federal law that prohibits submitting a
fraudulent claim or making a false statement or representation in connection with a claim. Also
protects & rewards whistle-blowers
What is the National Correct Coding Initiative (NCCI)? ✔Correct Answer-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? ✔Correct Answer-2:
1.Column 1/ Column 2 (previously called Comprehensive/ Component) Edits
2.Mutually Exclusive Edits
,Column 1/ Column 2 edits (NCCI) ✔Correct Answer-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) ✔Correct Answer-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? ✔Correct Answer-
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? ✔Correct Answer-The
Office of Inspector General (OIG)
Fraud ✔Correct Answer-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? ✔Correct Answer-State & Federal agencies as well as private insurance
companies
What are common forms of fraud? ✔Correct Answer-billing for services not furnished, unbundling,
and misrepresenting diagnosis to justify payment
Abuse ✔Correct Answer-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? ✔Correct Answer-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? ✔Correct
Answer-Risk Management
Patient Confidentiality ✔Correct Answer-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? ✔Correct Answer-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? ✔Correct Answer-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? ✔Correct Answer-"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? ✔Correct Answer-Documentation of the
patients social and medical history, family history, physical exam findings, progress notes, radiology
and lab results, consultation reports and correspondence to patients
Is the foremost tool of clinical care and communication
What is a medical report? ✔Correct Answer-part of the medical record & is a permanent legal
document that formally states the consequences of the patients exam or treatment in letter or
report form
IT IS THIS RECORD THAT PROVIDES INFO NEEDED TO COMPLETE THE INSURANCE CLAIM FORM
Reasons for Documentation ✔Correct Answer-Important that every patient seen by Dr. has
comprehensive legible documentation about patients illness, treatment and plans for following
reasons:
* Avoidance of denied or delayed payment by insurance company investigating the medical necessity
of service
* Enforcement of medical record-keeping rules by insurance company's requiring accurate
documentation that supports procedure & diagnosis codes
* Subpoena of medical records by state investigators or the court for review
* Defense of professional liability claim
Retention of Medical Records ✔Correct Answer-Is governed by state & local laws & may vary from
state-to-state. Most Dr. are required to retain records indefinitely, deceased patient records should
be kept for at least 5 years
-algia ✔Correct Answer-pain
-emia ✔Correct Answer-blood condition
-itis ✔Correct Answer-inflammation
-megaly ✔Correct Answer-enlargement
-meter ✔Correct Answer-measure
-oma ✔Correct Answer-tumor, mass
-osis ✔Correct Answer-abnormal condition
-pathy ✔Correct Answer-disease condition
-rrhagia ✔Correct Answer-bursting forth of blood
-rrhea ✔Correct Answer-discharge, flow
all Correct & 100% Verified Answers |Latest Version |
Already Graded A+
What are Medical Ethics? ✔Correct Answer-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? ✔Correct Answer-Carrying out one's
responsibilities with integrity, dignity, respect, honesty, competence, fairness, and trust
Compliance regulations ✔Correct Answer-Most billing-related cases are based on HIPAA and False
Claims Act
Health Insurance Portability & Accountability Act (HIPAA) ✔Correct Answer-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? ✔Correct Answer-Title 1: Insurance Reform
Title 2: Administrative Simplification
What is Title 1 of HIPAA? ✔Correct Answer-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? ✔Correct Answer-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)? ✔Correct Answer-Federal law that prohibits submitting a
fraudulent claim or making a false statement or representation in connection with a claim. Also
protects & rewards whistle-blowers
What is the National Correct Coding Initiative (NCCI)? ✔Correct Answer-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? ✔Correct Answer-2:
1.Column 1/ Column 2 (previously called Comprehensive/ Component) Edits
2.Mutually Exclusive Edits
,Column 1/ Column 2 edits (NCCI) ✔Correct Answer-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) ✔Correct Answer-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? ✔Correct Answer-
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? ✔Correct Answer-The
Office of Inspector General (OIG)
Fraud ✔Correct Answer-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? ✔Correct Answer-State & Federal agencies as well as private insurance
companies
What are common forms of fraud? ✔Correct Answer-billing for services not furnished, unbundling,
and misrepresenting diagnosis to justify payment
Abuse ✔Correct Answer-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? ✔Correct Answer-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? ✔Correct
Answer-Risk Management
Patient Confidentiality ✔Correct Answer-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? ✔Correct Answer-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? ✔Correct Answer-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? ✔Correct Answer-"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? ✔Correct Answer-Documentation of the
patients social and medical history, family history, physical exam findings, progress notes, radiology
and lab results, consultation reports and correspondence to patients
Is the foremost tool of clinical care and communication
What is a medical report? ✔Correct Answer-part of the medical record & is a permanent legal
document that formally states the consequences of the patients exam or treatment in letter or
report form
IT IS THIS RECORD THAT PROVIDES INFO NEEDED TO COMPLETE THE INSURANCE CLAIM FORM
Reasons for Documentation ✔Correct Answer-Important that every patient seen by Dr. has
comprehensive legible documentation about patients illness, treatment and plans for following
reasons:
* Avoidance of denied or delayed payment by insurance company investigating the medical necessity
of service
* Enforcement of medical record-keeping rules by insurance company's requiring accurate
documentation that supports procedure & diagnosis codes
* Subpoena of medical records by state investigators or the court for review
* Defense of professional liability claim
Retention of Medical Records ✔Correct Answer-Is governed by state & local laws & may vary from
state-to-state. Most Dr. are required to retain records indefinitely, deceased patient records should
be kept for at least 5 years
-algia ✔Correct Answer-pain
-emia ✔Correct Answer-blood condition
-itis ✔Correct Answer-inflammation
-megaly ✔Correct Answer-enlargement
-meter ✔Correct Answer-measure
-oma ✔Correct Answer-tumor, mass
-osis ✔Correct Answer-abnormal condition
-pathy ✔Correct Answer-disease condition
-rrhagia ✔Correct Answer-bursting forth of blood
-rrhea ✔Correct Answer-discharge, flow
