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Medical Coding Exam 3 with precise detailed solutions, Exams of Medicine

National University (NU)Medicine

Medical Coding Exam 3 with precise detailed solutions

Typology: Exams

2024/2025

Available from 07/11/2025

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Medical |! Coding |! Exam |! 3 |! with |! precise |!
detailed |! solutions
1. Group |! health |! insurance: |! subsidizd |! by |! Employers |! or |! other |!
organizations
2. Individual |! health |! insurance: |! individuals |! and |! families |! that |! do |! not |! have
|! access |! to |! group |! insurance |! (regulated |! by |! states, |! traditional |! plans, |! high
|! risk, |! short |! term |! medical, |! managed |! care: |! HMO/PPO)
3. Public |! health |! insurance: |! federal |! or |! state |! government |!
(medicare, |! medicaid, |! SCHIP, |! TRICARE)
4. Single |! Payer |! system: |! centralized |! health |! care |! system |! adopted |! by |!
some |! Western |! nations |! (Canada)
5. Socialized |! medicine: |! type |! of |! single |! payer |! system |! in |! which |! the |!
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1 |! / |! 23

Medical |! Coding |! Exam |! 3 |! with |! precise |!

detailed |! solutions

  1. Group |! health |! insurance: |! subsidizd |! by |! Employers |! or |! other |! organizations
  2. Individual|!health|!insurance:|! individuals|!and|!families|!that|!do|!not|!have |!access|!to |! group|!insurance|!(regulated|!by|!states,|!traditional|!plans,|!high |! risk,|! short|! term|! medical, |! managed |! care: |! HMO/PPO)
  3. Public |! health |! insurance: |! federal |! or |! state |! government |! (medicare, |! medicaid, |! SCHIP, |! TRICARE)
  4. Single |! Payer |! system: |! centralized|! health|! care|! system|! adopted|! by|! some|! Western |! nations |! (Canada)
  5. Socialized |! medicine: |! type|! of|! single|! payer|! system|! in|! which|! the|!

2 |! / |! 23 government|! owns |! and |! operates |! health |! care |! facilities |! and |! providers |! (Finland/Great |! Britain)

  1. Universal |! health |! insurance: |! goal |! of |! providing |! every |! individual |! with |! access |! to |! health |! coverage |! (Affordable |! Care |! Act)
  2. Who |! files |! claims |! on |! behalf |! of |! the |! patient?: |! Health |! Care |! Practices
  3. Which |! Health |! Insurance |! companies |! require |! providers |! to |! file |! claims?: |! BCBS |! & |! Medicare
  4. What |! has |! become |! a |! specialty |! career?: |! Claims |! processing
  5. Hold |! Harmless |! Clause: |! patient|! is|! not|! responsible|! for|! paying|! what|! the|! insurance |! plan |! denies
  6. No |! balance |! billing: |! protects |! patients |! from |! being |! billed |! amount |!

4 |! / |! 23

  1. UB|! 04 |! (Uniform |! Billing |! Form) |! /|! CMS|! 1450:|! institutional|! provider|! can|! use|! for|! the |! billing |! of |! medical |! and |! mental |! health |! claims |! (Facility |! Billing)
  2. UB |! 04 |! Form |! / |! CMS |! 1450:

5 |! / |! 23

  1. ICD |! codes:|! diagnostic |! codes
  2. CPT |! codes:|! procedural |! codes
  3. Third|! Party|! Payers|! definition:|! an|! organization|! that|! pays|! for|! healthcare|! services |! on |! behalf |! of |! a |! patient
  4. Third |! Party |! Payers |! Examples: |! Health |! Maintenance |! Organization |! (HMO) |! Preferred |! Provider |! Organization |! (PPO) POS Government|! plans|! (Tricare,|! Medicaid,|! Medicare) |! HDHP/HSA

7 |! / |! 23

  1. Career |! Opportunities: |! Health |! Insurance |! Specialist, |! Claims |! Examiner, |! Claims |! Benefit |! Advisor, |! Coding |! Specialist, |! Medical |! Billing |! and |! Insurance|! Verification, |! Edu- |! cator
  2. Claims |! Examiner: |! employed |! by |! a |! third-party |! payer |! to |! review |! claims |! to |! deter- |! mine |! if |! reasonable |! and |! medically |! necessary
  3. Professional |! Credentials: |! AAPC, |! AAMA, |! AHIMA, |! AMBA, |! MAB
  4. AAPC:|! American |! Academy |! of |! Professional |! Coders
  5. AAMA:|! American |! Association |! of |! Medical |! Assistants
  6. AHIMA:|! American |! Health |! Information |! Management |! Association
  7. AMBA:|! American |! Medical |! Billing |! Association
  8. MAB:|! Medical |! Association |! of |! Billers

8 |! / |! 23

  1. Statutory |! Law: |! legislation |! passed |! by |! either |! state |! legislature |! or |! the |! Congress |! of |! the |! US

10 |! / |! 23

  1. Retention|! of|! Records|! for|! HIPPA: |! 6 |! years|! (health|! insurance|! claims;|! and|! 2 |! years |! after |! a |! patients |! death)
  2. HIPAA: |! Health |! Insurance |! Portability |! and |! Accountability |! Act |! (1996)
  3. Why |! was |! HIPAA |! passed?: |! because |! of |! concerns |! about |! fraud
  4. HIPAA |! Provisions: |! limiting |! exclusions |! for |! pre-existing |! medical |! conditions, |! credit|! for|! prior|! health|! coverage|! and|! process|! for|! transmitting|! certificates|! to|! new|! group |! health |! plan/issuer
  5. COBRA: |! Consolidated |! Omnibus |! Budget |! Reconciliation |! Act |! (1986)
  6. What |! does |! COBRA |! do?: |! amends |! the |! Employee |! Retirement |! Income |! Security |! Act,|! the|! Internal|! Revenue|! Code|! and|! the|! Public|! Health|! Service|! Act|! to|! provide|! contin- |! uation |! of |! group |! health |!

11 |! / |! 23 coverage |! that |! otherwise |! might |! be |! terminated.|! (continuation |! of |! coverage |! if |! job |! is |! lost; |! 18-36 |! months)

  1. Medicare |! Fraud |! and |! Abuse |! Laws: |! False |! Claims |! Act |! (FCA) |! Anti-Kickback |! Statute |! (AKS) Physician|! Self-Referral|! Law|! (Stark|! Law) |! Social |! Security |! Act United |! States |! Criminal |! Code
  2. What |! was |! the |! beginning |! of |! the |! Opioid |! Crisis?: |! Dr.|! Schultz/pain |! pills |! being |! prescribed |! and |! dispensed |! by |! "pain |! clinics"
  3. HIPPA |! II:|! Established|! Identifiers |! for |! third-party |! payers|! (identifier |! numbers:|! plan, |! individual, |! provider, |! standard |! employer)

13 |! / |! 23 facilities

14 |! / |! 23

  1. CPT: |! Current |! Procedural|! Terminology
  2. Who |! uses |! the |! five-character |! CPT |! codes?: |! insurers |! to |! help |! determine |! the |! amount |! of |! reimbursement |! that |! practitioner |! will |! receive
  3. When |! Diagnostic |! Code |! matches|! CPT |! Code |! it|! is |! a: |! Medical|! Necessity|! (appro- |! priate |! procedure |! for |! the |! diagnosis)
  4. Who |! owns |! the |! CPT |! codes?: |! American |! Medical |! Association |! (AMA)
  5. How |! often |! are |! CPT |! Codes |! updated?: |! annually
  6. Essential |! Elements |! in |! Reporting |! CPT |! Codes: |! medical |! terminology |! anatomy

16 |! / |! 23

  1. Scope: |! most |! appropriate |! level |! of |! service
  2. Evidence: |! treatment |! is |! known |! to |! be |! effective
  3. Value: |! treatment |! is |! cost-effective |! compared |! to |! alternatives
  4. Center |! for |! Medicare |! and |! Medicaid |! (CMS): |! Administered |! by |! Federal |! Govt, |! Determines |! reimbursement, Insurance |! Companies |! follow |! ruling
  5. PPS: |! Prospective |! Payment |! System
  6. Largest |! Medicare |! Payment |! Systems: |! Impatient |! prospective,|! Outpatient |! prospective, Physician|! fee|! schedule, |! Skilled |!

17 |! / |! 23 nursing |! facility

  1. Ambulance |! Fee |! Schedule: |! First |! PPS
  2. ESRD|! Composite|! Rate |! Payment|! System: |! End|! Stage|! Renal|! Disease,|! 2 |! service |! groups: |! Dialysis |! and |! Associated |! Routine |! Services |! (Bundling)
  3. What |! PPS |! gets |! reimbursement |! rates |! for |! 60-day |! episodes |! of |! health |! care?- : |! Home |! Health |! PPS
  4. Diagnosis-Relates |! Group |! (DRG) |! are |! related |! to: |! Hospital |! Inpatient |! PPS
  5. DRG|! rate|! adjustments|! increased|! medicare|! payments|! for: |!

19 |! / |! 23

  1. Skilled |! Nursing |! Facility |! EMR: |! RAVEN
  2. Impatient |! Rehabilitation |! Facility |! EMR: |! IRVEN
  3. Home |! Health |! Agency |! EMR: |! HAVEN
  4. Components |! of|! RVUs:|! Physician|! work, |! Practice |! expense, |! Malpractice |! expense
  5. CMS |! Manual |! System: |! Internet-only |! manual |! (IOMs)
  6. Coding |! Compliance: |! conformity |! to |! established |! coding |! guidelines |! and |! regula- |! tions
  7. Medical |! Review: |! program |! to |! reduce |! payment |! errors |! by |!

20 |! / |! 23 addressing |! provider |! billing |! errors |! from |! initial |! coding, |! performed |! by |! Medicare |! Administrative |! Contractors |! (MACs)

  1. Unbundling: |! charging |! for |! multiple |! CPT |! codes |! separately |! - |! ILLEGAL
  2. The |! practice |! of |! unbundling |! and |! charging |! for |! multiple |! CPT |! codes |! is |! either- : |! Unintentional |! based |! on |! misinterpretation |! of |! coding |! guidelines, |! Intentionally |! done |! to |! maximize |! reimbursement
  3. Physician |! query |! process: |! Computer-Assisted |! Coding |! is |! a |! tool |! for |! accurate |! coding.|! While |! mostly |! performed |! manually |! this |! will |! become |! more |! routinely |! utilized |! with |! advancement |! of |! EMR.
  4. "Incident|! to": |! NPP|! billing|! without|! Supervising|! physician|! (impacts|!