Free NHA CBCS Exam Flashcards

Pre-registration, registration/eligibility verification, charge capture, coding, claim submission, payment posting, and denial follow-up. Skipping eligibility before the visit causes the most downstream denials.

Written policies and procedures, designation of a compliance officer, training and education, internal monitoring and auditing, open lines of communication for reporting, enforcement of standards, and prompt corrective action. This framing is the OIG baseline for an effective compliance program.

Fraud is intentional misrepresentation for payment (e.g., upcoding, phantom billing); abuse is a practice inconsistent with sound business or medical practice that causes unnecessary cost. Both expose the provider to recovery, but fraud requires intent and is a federal crime under the False Claims Act.

Stark is a strict-liability civil ban on physician self-referrals to entities the physician has a financial relationship with for designated health services. The Anti-Kickback Statute is a criminal statute that prohibits remuneration intended to induce federal-program referrals.

RACs perform post-payment review of Medicare fee-for-service claims to recover overpayments (and identify underpayments) on a contingency-fee basis. They are distinct from MACs, which pay claims, and from CERT, which measures the national paid-claims error rate.

Protected Health Information is any individually identifiable health information held or transmitted by a covered entity. Adding any of the 18 HIPAA identifiers (name, email, SSN, dates tied to the individual, etc.) to a date of service or diagnosis makes the record PHI.

The Privacy Rule governs all PHI in any form (paper, oral, electronic). The Security Rule adds administrative, physical, and technical safeguards specifically for electronic PHI (ePHI). Security is a subset of Privacy focused on ePHI confidentiality, integrity, and availability.

Names, geographic identifiers smaller than state, dates (except year) tied to the individual, phone and fax numbers, email, SSN, medical record and account numbers, biometric identifiers, full-face photos, device serial numbers, and any other unique code. Removing all 18 under Safe Harbor de-identifies the data set.

Breaches affecting 500 or more individuals require notice to affected individuals, prominent media outlets, and HHS without unreasonable delay and within 60 calendar days of discovery. Breaches affecting fewer than 500 individuals are reported to HHS in an annual log within 60 days of the end of the calendar year.

HMOs require in-network PCP referrals for specialist visits to be covered. PPOs allow out-of-network visits at higher cost-sharing without a referral. EPOs combine the HMO in-network restriction with the PPO no-referral rule: no referrals required, but no out-of-network coverage except in emergencies.

When a patient has two insurers, COB determines which plan pays first (primary) and which pays second (secondary). The secondary payer only processes what the primary did not pay, and only up to its own fee schedule. COB never results in double payment.

When both parents cover a child, the plan of the parent whose birthday falls earlier in the calendar year is primary. Year of birth does not matter, only the month and day. A few states still use a 'gender rule' (father primary), but the birthday rule is the dominant standard.

Form CMS-R-131 given to a Medicare fee-for-service patient before a service that may not be covered. A properly signed ABN shifts financial liability to the patient if Medicare denies the claim. Without it, the provider must write off the charge.

Part A is hospital insurance; Part B covers physician and outpatient services; Part C (Medicare Advantage) bundles A and B through private insurers and often adds benefits; Part D covers prescription drugs through private plans. CBCS billing questions focus most on Parts B and C.

Medigap policies are private supplements sold to original Medicare beneficiaries to cover cost-sharing (deductibles, coinsurance, copayments) and some services Medicare does not cover. They do NOT work with Medicare Advantage; you cannot carry both at the same time.

MSP rules determine when Medicare is the secondary payer, such as working-aged beneficiaries with employer group health plan coverage, or liability/no-fault/workers' comp cases. The biller must bill the primary payer first; Medicare may pay as secondary only up to the residual amount.

The federal health-care program for active-duty service members, retirees, and their families. TRICARE generally pays secondary to Medicare for beneficiaries entitled to both. Claims are submitted on the CMS-1500 with the same field structure as commercial claims.

Medicaid is state-administered and jointly funded with the federal government. Eligibility is income- and category-based (children, pregnant women, disabled, long-term care). Coverage and fee schedules vary by state, so billers must verify per-state benefits and prior authorization rules.

ICD-10-CM codes are updated annually and effective October 1 (a fiscal-year cycle). CPT, in contrast, updates January 1. Using outdated ICD-10-CM codes after October 1 causes claim denials and rejected 837 transactions.

ICD-10-CM (Clinical Modification) is the diagnosis code set used in all care settings. ICD-10-PCS (Procedure Coding System) is the inpatient hospital procedure set with seven-character alphanumeric codes; it is NOT used in physician or outpatient billing.

Categories are 3 characters; subcategories add a 4th, 5th, or 6th character; a 7th character is required for certain injury, fracture, and encounter codes (A initial encounter, D subsequent, S sequela, and T for some). Placeholder x fills empty positions when a 7th character is required.

'Code First' means the etiology or underlying condition is coded before the manifestation (e.g., diabetes before diabetic neuropathy). 'Use Additional Code' notes require reporting an associated condition to fully describe the encounter. Missing either note triggers denials.

Z-codes (Z00-Z99) report reasons for encounters that are not injuries or illnesses: screenings, immunizations, status codes (post-surgical, long-term drug use), and encounters for administrative or legal purposes. They can be primary in outpatient settings but should not be listed twice.

When documentation shows two conditions linked by an etiology-manifestation relationship, code both as a single combination code if one exists (e.g., E11.22 diabetes with diabetic nephropathy). Use the specific combination code in preference to two separate codes when the documentation supports it.

CPT Category I is organized by section: Evaluation and Management (99202-99499), Anesthesia (00100-01999), Surgery (10004-69990), Radiology (70010-79999), Pathology and Laboratory (80047-89398), and Medicine (90281-99607). Each section has its own guidelines and parenthetical notes.

CPT codes are updated annually by the American Medical Association (AMA) and effective January 1. ICD-10-CM updates October 1. Using prior-year CPT codes after January 1 results in claim denials even when documentation supports the service.

Category III codes (0051T-0999T and the 0XXX range) report emerging or experimental services and procedures for data collection. They are temporary and replaced by Category I codes when adoption grows; payers often deny them as investigational.

Modifier -25 indicates a significant, separately identifiable E/M service on the same day as a procedure. It must be supported by documentation above and beyond the procedure's usual pre- and post-service work. -25 is one of the most audited modifiers.

-59 indicates a procedure or service was distinct from another on the same day that would normally bundle into one comprehensive code. It overrides NCCI Procedure-to-Procedure edits. -59 is heavily abused; use the more specific X{EPSU} alternatives (XE, XS, XP, XU) when they better describe the distinction.

HCPCS Level II is the alphanumeric code set (A0000-V9999) for products and services not in CPT: durable medical equipment, prosthetics, orthotics, supplies, ambulance transport, certain drugs, and Medicare-specific codes (G, J, Q, K levels). Annual update is effective January 1.

-50 indicates a procedure was performed bilaterally on paired organs (e.g., bilateral knee arthroscopy). Most payers reimburse at 150% of the single-procedure fee (100% plus 50%). It is reported as a single line item with -50, not as two separate lines.

-51 (multiple procedures) reports secondary or add-on procedures performed at the same session; payers apply a multiple-procedure reduction. -59 (distinct procedural service) overrides bundling edits. Use -59 only when the code pair would otherwise bundle; use -51 for multiple distinct procedures.

-76 is a repeat of the same procedure by the same provider on the same day. -78 is a return to the operating room for a related procedure during the global period. -79 is an unrelated procedure during the global period. -91 is a repeat diagnostic test (not a procedure).

-GZ: service not medically necessary, no ABN given (provider writes off). -GA: ABN on file, expect denial (patient liable). -GY: service statutorily excluded from Medicare (patient liable). -GX: item not reasonable and necessary and patient signed ABN (patient liable).

-95 marks a synchronous telehealth service rendered via real-time audio and video. Pair it with place-of-service 02 (other than patient home) or POS 10 (patient home) for professional claims under Medicare's permanent telehealth rules.

For 99202-99215 (office and outpatient E/M), the 2021 AMA rules level the visit by either Medical Decision Making (MDM) complexity or total time spent on the date of service. History- and exam-driven levels were eliminated for these codes. Inpatient and emergency E/M still use the older framework.

Total time on the date of service includes both face-to-face and non-face-to-face activities: review of records, documentation, coordination of care, and counseling. The time must be documented to support a time-based level; counseling and coordination time count toward the total.

MDM complexity is set by two of three elements: (1) number and complexity of problems addressed, (2) amount and complexity of data reviewed, and (3) risk of complications or morbidity. The highest two of the three determine the level, not the average of all three.

The primary E/M visit goes first when it is the chief reason for the encounter. When a procedure dominates (e.g., a procedure under anesthesia), the procedure is the principal code and the E/M is secondary with modifier -25 if it is separately identifiable.

Block 21 lists ICD-10-CM diagnoses (up to 12), 24A date of service, 24E diagnosis pointer, 24F charge, 24G units, 24J rendering NPI, and 33 billing provider. Block 21 must list the primary diagnosis first; the 24E pointer ties each service line to one of those diagnoses.

The UB-04 is the institutional claim form used by hospitals, SNFs, and hospice for inpatient and outpatient services. It uses Form Locators (FL) numbered 1 through 81; key locators include FL42 revenue codes, FL45 service units, and FL67-FL80 procedure codes.

A 10-digit, intelligence-free identifier for covered providers under HIPAA. It replaced the legacy UPIN, NSC, and Medicare ID. The check digit is calculated with the Luhn formula. Each provider has one NPI and each organization has one; required on all standard transactions.

837P and 837I are professional and institutional claim submissions. 835 is the Electronic Remittance Advice (ERA) with payment detail. 999 is the functional acknowledgement confirming receipt of the 837. 277CA is the claim acknowledgement with payer acceptance or rejection status per claim.

Each payer sets a deadline for submitting claims after the service date. Medicare fee-for-service allows one calendar year from the date of service. Many commercial payers allow 90 to 180 days. Late-filed clean claims are denied for timely filing and are usually not appealable through standard routes.

CARC (Claim Adjustment Reason Code) explains why a claim line was adjusted, e.g., 96 non-covered service or 197 prior authorization absent. RARC (Remittance Advice Remark Code) provides additional context, e.g., N130 service not covered for this condition. Both appear on the 835 ERA.

NCCI Procedure-to-Procedure (PTP) edits flag code pairs that normally bundle and cannot be billed together (overridable with -59 in some cases). Medically Unlikely Edits (MUE) flag units of service above a maximum plausible number per provider per beneficiary per date.

1) Redetermination by the MAC; 2) Reconsideration by a Qualified Independent Contractor (QIC); 3) Administrative Law Judge (ALJ) hearing; 4) Medicare Appeals Council review; 5) Federal district court. Each level has time limits and minimum dollar thresholds for escalation.

Resubmission (frequency code 7) sends a corrected claim when the original had an error, such as wrong DOS or wrong NPI. An appeal (reconsideration) challenges a denial you believe was wrongly made. Resubmitting when an appeal is required produces a duplicate denial and burns timely filing time.

Billed minus allowed equals the contractual adjustment. Patient owes deductible plus coinsurance plus copay. Insurance paid equals allowed minus patient responsibility. Verify the ERA's contractual adjustment matches your payer contracts; under-adjustments signal patient balance-billing risk.

Under the ACA's federal 60-day overpayment rule, a Medicare overpayment must be reported and refunded within 60 days of identification. Failure to do so exposes the provider to False Claims Act liability. Credit balances on the books must be reviewed and resolved within this window.