CBCS Exam Study Guide questions and answers 100% CORRECT
Medical Billing & Coding as a Career Correct Answer: *Claims assistant professional or claims manager,
*Coding Specialist, * Collection Manager, *Electronic Claims Processor, *Insurance Billing Specialist, *
Insurance Coordinator, *Insurance Counselor, *Medical Biller, *Medical & Financial Records Manager, *
Billing & Coding Specialist
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, co-workers, the gov, and ins co's.
What does acting within ethical behavior boundaries mean? Correct Answer: carrying out one's
responsibilities w/ integrity, dignity, respect, honesty, competence, fairness, & trust.
Legal Aspects of of Medical Billing & Coding: Correct Answer: ...
Compliance regulations: Correct Answer: Most billing-related cases are based on HIPPA and False
Claims Act
Health Insurance Portability & Accountability Act (HIPPA) 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 the 2 provisions of HIPPA? Correct Answer: Title I: Insurance Reform
Title II: Administrative Simplification
What is Title I of HIPPA? Correct Answer: Insurance Reform-primary purpose is to provide continuous
ins coverage for worker & their dependents when they change or lose jobs. Also *Limits the use of
preexisting conditions exclusions *Prohibits discrimination from past or present poor health
*Guarantees certain employees/indv the right to purchase new health ins coverage after losing job
*Allows renewal of health ins cov regardless of an indv's health cond. that is covered under the
particular policy.
What is Title II of HIPPA? 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 w/ 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 ins claims.
,How many edits does NCCI include? Correct Answer: 2: 1)Column 1/Column 2 (prev 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
b/c 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 performed on the same pt 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 med
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 ins co's
What are common forms of fraud? Correct Answer: billing for services not furnished, unbundling, &
misrepresenting diagnosis to justify payment
Abuse Correct Answer: incidences or practices, not usually considered fraudulent, that are inconsistent
w/ 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, & liabilities associated w/ abuse? Correct Answer:
Risk Management
Patient Confidentiality Correct Answer: All pt's have right to privacy & all info should remain privileged.
Only discuss pt info when necessary to do job. Obtain a signed consent form to release medical info to
ins co or other individual.
When may providers use PHI (Protected Health Information) w/o specific authorization under the HIPPA
Privacy Rule? Correct Answer: When using for TPO, Treatment (primarily for the purpose of discussion
of pt's case w/ other dr's) Payment (providers submit claims on behalf of pt's) & Operations (for
purposes such as training staff & 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 w/in 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 indv or service
submitting the claim. ****Some dr's contract w/ a billing service (clearinghouse) to handle claims
submission, & 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 & omissions is not needed in the instance. ******However, if dr
ever asks the ins biller to do the least bit questionable, such as write of pt's balances for certain pt's
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 pt's social &
medical history, family history, physical exam findings, progress notes, radiology & lab results,
consultation reports and correspondence to pt- 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 pt's exam or treatment in letter or report form. IT IS THIS
RECORD THAT PROVIDES INFO NEEDED TO COMPLETE THE INS CLAIM FORM.
Reasons for Documentation Correct Answer: Important that every pt seen by dr has comprehensive
legible documentation about pt's illness, treatment, & plans for following reasons:
*Avoidance of denied or delayed payment by ins co investigating the medical necessity of services
*Enforcement of medical record-keeping rules by ins co 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 pt records should be kept for @
least 5 years
Med Term Correct Answer: ...
Diagnosis suffixes: Correct Answer: ...
-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
Medical Billing & Coding as a Career Correct Answer: *Claims assistant professional or claims manager,
*Coding Specialist, * Collection Manager, *Electronic Claims Processor, *Insurance Billing Specialist, *
Insurance Coordinator, *Insurance Counselor, *Medical Biller, *Medical & Financial Records Manager, *
Billing & Coding Specialist
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, co-workers, the gov, and ins co's.
What does acting within ethical behavior boundaries mean? Correct Answer: carrying out one's
responsibilities w/ integrity, dignity, respect, honesty, competence, fairness, & trust.
Legal Aspects of of Medical Billing & Coding: Correct Answer: ...
Compliance regulations: Correct Answer: Most billing-related cases are based on HIPPA and False
Claims Act
Health Insurance Portability & Accountability Act (HIPPA) 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 the 2 provisions of HIPPA? Correct Answer: Title I: Insurance Reform
Title II: Administrative Simplification
What is Title I of HIPPA? Correct Answer: Insurance Reform-primary purpose is to provide continuous
ins coverage for worker & their dependents when they change or lose jobs. Also *Limits the use of
preexisting conditions exclusions *Prohibits discrimination from past or present poor health
*Guarantees certain employees/indv the right to purchase new health ins coverage after losing job
*Allows renewal of health ins cov regardless of an indv's health cond. that is covered under the
particular policy.
What is Title II of HIPPA? 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 w/ 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 ins claims.
,How many edits does NCCI include? Correct Answer: 2: 1)Column 1/Column 2 (prev 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
b/c 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 performed on the same pt 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 med
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 ins co's
What are common forms of fraud? Correct Answer: billing for services not furnished, unbundling, &
misrepresenting diagnosis to justify payment
Abuse Correct Answer: incidences or practices, not usually considered fraudulent, that are inconsistent
w/ 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, & liabilities associated w/ abuse? Correct Answer:
Risk Management
Patient Confidentiality Correct Answer: All pt's have right to privacy & all info should remain privileged.
Only discuss pt info when necessary to do job. Obtain a signed consent form to release medical info to
ins co or other individual.
When may providers use PHI (Protected Health Information) w/o specific authorization under the HIPPA
Privacy Rule? Correct Answer: When using for TPO, Treatment (primarily for the purpose of discussion
of pt's case w/ other dr's) Payment (providers submit claims on behalf of pt's) & Operations (for
purposes such as training staff & 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 w/in 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 indv or service
submitting the claim. ****Some dr's contract w/ a billing service (clearinghouse) to handle claims
submission, & 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 & omissions is not needed in the instance. ******However, if dr
ever asks the ins biller to do the least bit questionable, such as write of pt's balances for certain pt's
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 pt's social &
medical history, family history, physical exam findings, progress notes, radiology & lab results,
consultation reports and correspondence to pt- 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 pt's exam or treatment in letter or report form. IT IS THIS
RECORD THAT PROVIDES INFO NEEDED TO COMPLETE THE INS CLAIM FORM.
Reasons for Documentation Correct Answer: Important that every pt seen by dr has comprehensive
legible documentation about pt's illness, treatment, & plans for following reasons:
*Avoidance of denied or delayed payment by ins co investigating the medical necessity of services
*Enforcement of medical record-keeping rules by ins co 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 pt records should be kept for @
least 5 years
Med Term Correct Answer: ...
Diagnosis suffixes: Correct Answer: ...
-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
