CBCS Exam Study Guide
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CBCS practice test NHA 2024-2025 CBCS Practice Que... Chapter 2
254 terms 150 terms Teacher 26 terms
monika_maytum Preview avery_michelle Preview m_timeshares
Claims assistant professional or claims manager, Coding
Specialist, Collection Manager, Electronic Claims Processor,
Medical Billing & Coding as a
Insurance Billing Specialist, Insurance Coordinator, Insurance
Career
Counselor, Medical Biller, Medical & Financial Records
Manager, Billing & Coding Specialist
Standards of conduct based on moral principle. They are
What are Medical Ethics? 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 carrying out one's responsibilities w/ integrity, dignity, respect,
behavior boundaries mean? honesty, competence, fairness, & trust.
Legal Aspects of of Medical ...
Billing & Coding:
Most billing-related cases are based on HIPPA and False Claims
Compliance regulations:
Act
Enacted in 1996, created by the Health Care Fraud & Abuse
Health Insurance Portability &
Control Program-enacted to check for fraud and abuse in the
Accountability Act (HIPPA)
Medicare/Medicaid Programs and private payers
What are the 2 provisions of Title I: Insurance Reform
HIPPA? Title II: Administrative Simplification
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
What is Title I of HIPPA?
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.
, 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
What is Title II of HIPPA?
health-related financial & administrative activities electronically 2)
Implementation of privacy & security procedures to prevent the
misuse of health info by ensuring confidentiality
Federal law that prohibits submitting a fraudulent claim or making
What is the False Claims Act
a false statement or representation in connection w/ a claim. Also
(FCA)?
protects & rewards whistle-blowers.
Developed by CMS to promote the national correct coding
What is the National Correct
methodologies & to control improper coding that lead to
Coding Initiative (NCCI)?
inappropriate payment of Part B health ins claims.
2: 1)Column 1/Column 2 (prev called
How many edits does NCCI
Comprehensive/Component) Edits
include?
2) Mutually Exclusive Edits
Identifies code pairs that should not be billed together b/c 1
Column 1/Column 2 edits (NCCI) code (Column 1) includes all the services described by another
code (Column 2)
ID's code pairs that, for clinical reasons, are unlikely to be
Mutually Exclusive Edits (NCCI)
performed on the same pt on the same day
What are the possible delayed processing & payment of claims reduced payments,
consequences of inaccurate denied claims fine and/or imprisonment exclusion from payer's
coding and incorrect billing? programs, loss of dr's license to practice med
Who has the task of investigate The Office of Inspector General (OIG)
and prosecuting health care
fraud & abuse?
knowingly & intentionally deceiving or misrepresenting info that
Fraud 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 ins co's
What are common forms of billing for services not furnished, unbundling, & misrepresenting
fraud? diagnosis to justify payment
incidences or practices, not usually considered fraudulent, that
Abuse are inconsistent w/ the accepted medical business or fiscal
practices in the industry.
submitting a claim for services/procedures performed that is not
What are examples of Abuse? medically necessary, and excessive charges for services,
equipment or supplies.
What is a method use to Risk Management
minimize danger, hazards, &
liabilities associated w/ abuse?
All pt's have right to privacy & all info should remain privileged.
Patient Confidentiality 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 When using for TPO, Treatment (primarily for the purpose of
(Protected Health Information) discussion of pt's case w/ other dr's) Payment (providers submit
w/o specific authorization under claims on behalf of pt's) & Operations (for purposes such as
the HIPPA Privacy Rule? training staff & quality improvement)
Save
Students also studied
Flashcard sets Study guides
CBCS practice test NHA 2024-2025 CBCS Practice Que... Chapter 2
254 terms 150 terms Teacher 26 terms
monika_maytum Preview avery_michelle Preview m_timeshares
Claims assistant professional or claims manager, Coding
Specialist, Collection Manager, Electronic Claims Processor,
Medical Billing & Coding as a
Insurance Billing Specialist, Insurance Coordinator, Insurance
Career
Counselor, Medical Biller, Medical & Financial Records
Manager, Billing & Coding Specialist
Standards of conduct based on moral principle. They are
What are Medical Ethics? 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 carrying out one's responsibilities w/ integrity, dignity, respect,
behavior boundaries mean? honesty, competence, fairness, & trust.
Legal Aspects of of Medical ...
Billing & Coding:
Most billing-related cases are based on HIPPA and False Claims
Compliance regulations:
Act
Enacted in 1996, created by the Health Care Fraud & Abuse
Health Insurance Portability &
Control Program-enacted to check for fraud and abuse in the
Accountability Act (HIPPA)
Medicare/Medicaid Programs and private payers
What are the 2 provisions of Title I: Insurance Reform
HIPPA? Title II: Administrative Simplification
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
What is Title I of HIPPA?
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.
, 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
What is Title II of HIPPA?
health-related financial & administrative activities electronically 2)
Implementation of privacy & security procedures to prevent the
misuse of health info by ensuring confidentiality
Federal law that prohibits submitting a fraudulent claim or making
What is the False Claims Act
a false statement or representation in connection w/ a claim. Also
(FCA)?
protects & rewards whistle-blowers.
Developed by CMS to promote the national correct coding
What is the National Correct
methodologies & to control improper coding that lead to
Coding Initiative (NCCI)?
inappropriate payment of Part B health ins claims.
2: 1)Column 1/Column 2 (prev called
How many edits does NCCI
Comprehensive/Component) Edits
include?
2) Mutually Exclusive Edits
Identifies code pairs that should not be billed together b/c 1
Column 1/Column 2 edits (NCCI) code (Column 1) includes all the services described by another
code (Column 2)
ID's code pairs that, for clinical reasons, are unlikely to be
Mutually Exclusive Edits (NCCI)
performed on the same pt on the same day
What are the possible delayed processing & payment of claims reduced payments,
consequences of inaccurate denied claims fine and/or imprisonment exclusion from payer's
coding and incorrect billing? programs, loss of dr's license to practice med
Who has the task of investigate The Office of Inspector General (OIG)
and prosecuting health care
fraud & abuse?
knowingly & intentionally deceiving or misrepresenting info that
Fraud 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 ins co's
What are common forms of billing for services not furnished, unbundling, & misrepresenting
fraud? diagnosis to justify payment
incidences or practices, not usually considered fraudulent, that
Abuse are inconsistent w/ the accepted medical business or fiscal
practices in the industry.
submitting a claim for services/procedures performed that is not
What are examples of Abuse? medically necessary, and excessive charges for services,
equipment or supplies.
What is a method use to Risk Management
minimize danger, hazards, &
liabilities associated w/ abuse?
All pt's have right to privacy & all info should remain privileged.
Patient Confidentiality 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 When using for TPO, Treatment (primarily for the purpose of
(Protected Health Information) discussion of pt's case w/ other dr's) Payment (providers submit
w/o specific authorization under claims on behalf of pt's) & Operations (for purposes such as
the HIPPA Privacy Rule? training staff & quality improvement)
