Certified Billing & Coding Specialist
Exam Review 2023
What are Medical Ethics? - Answer-Standards of conduct based on moral principle. they
are
... [Show More] 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? - Answer-Carrying out
one's responsibilities with integrity, dignity, respect, honesty, competence, fairness, and
trust
Compliance regulations - Answer-Most billing-related cases are based on HIPAA and
False Claims Act
Health Insurance Portability & Accountability Act (HIPAA) - 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? - Answer-Title 1: Insurance Reform
Title 2: Administrative Simplification
What is Title 1 of HIPAA? - 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? - 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)? - 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)? - 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? - Answer-2:
1.Column 1/ Column 2 (previously called Comprehensive/ Component) Edits
2.Mutually Exclusive Edits
Column 1/ Column 2 edits (NCCI) - 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) - 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? -
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? - AnswerThe Office of Inspector General (OIG)
Fraud - 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? - Answer-State & Federal agencies as well as private insurance
companies
What are common forms of fraud? - Answer-billing for services not furnished,
unbundling, and misrepresenting diagnosis to justify payment
Abuse - 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? - 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? - Answer-Risk Management
Patient Confidentiality - 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? - 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?... [Show Less]