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A member of an office medical staff has documented a billing code for a more severe condition than the one documented in the patient's chart. This coding action is called:
a. a medical necessity
d. CPT coding
C: When a billing code makes a patient seems more severely ill than he really is,upcoding has occurred. Up coding is sometimes done intentionally to increase reimbursement, but it can also be done accidentally by an inexperienced coder. Consistently upcoding constitutes fraud.
A patient's medical insurance plan includes a clause that allows the insurance plan topay for initial treatment until payor responsibility is determined. This clause is called:
a. coordination of benefits
b. right of subrogation
c. an indemnity clause
d. a settlement
B: A right of subrogation clause allows insurance plans to pay for initial treatment until payor responsibility is ascertained. Coordination of benefits lets payors decrease payments by the amount of coverage provided by another medical insurance policy. An indemnity is a form of commercial medical insurance whereby the patient pays a deductible and a percentage of costs.
Which of these is true about preexisting conditions?
a. According to HIPAA, a medical insurance company is required to waive waiting
periods for preexisting conditions, provided there has been no lapse in coverage
b. A person diagnosed with asthma 20 years ago who has not needed any medical
treatment for the past 12 years is not considered to have a preexisting condition
c. Pregnancy is considered a preexisting condition
d. All of the above
- A: Medical insurance companies are required to waive the waiting period if there is no
- lapse in coverage. A preexisting condition is any condition for which a patient has ever
- received treatment regardless of how long it has been since the patient was last seen by a physician for the condition. According to HIPAA, pregnancy is no longer considered a preexisting condition.
. A patient has been admitted to the hospital to rule out a suspected condition. Which of
the following is true about billing codes for this patient?
a. You may code for the suspected condition as if it actually exists
b. You may code symptoms, but not the suspected c.ondition
c. You may skip coding until test results are available
d. You may code the rule-out diagnosis, but only for outpatients
B: Rule-outs or suspected diagnoses cannot be coded as if the suspected condition exists. This applies to both inpatients and outpatients. Under these conditions, you should code symptoms until a definitive diagnosis is made.
Which of the following applies to Tricare Prime?
a. It is an HMO option
b. It is a PPO option
c. It is a fee-for-service option
d. It covers all health care
- A: Tricare Prime is an HMO option. Tricare is the PPO option. Tricare Standard is the fee for-
- service option. Tricare Prime does not cover all health care procedures. There are some
- items that require preauthorization.
Which of the following applies to CHAMPVA?
a. It is valid for three of the seven uniformed services
b. CHAMPVA is part of the Tricare system
c. CHAMPVA coverage stops when the participants become eligible for Medicare
d. CHAMPVA covers veterans
. C: The Civilian Health and Medical Programs of Veterans Affairs (CHAMPVA) is a law allowing medical benefits to survivors and dependents of veterans who are permanently and completely disabled with a service-related condition. It is valid for all seven uniformed services. CHAMPVA is not part of the Tricare program. CHAMPVA coverage stops when a participant becomes eligible for Medicare.
Which of the following is a Social Security program that provides supplemental income
to eligible beneficiaries?
- D: SSI is part of the Social Security program. Its benefits are available to low-income
- people of any age who are disabled. AFDC (Aid to Families with Dependent Children) is a government program that assists low-income families. SCHIP (State Children's Health Insurance Program) provides assistance to low-income families who do not qualify for Medicaid.
All of the following are true about disability insurance EXCEPT:
a. disability insurance is most often limited to income replacement coverage
b. medical care is occasionally included in coverage
c. disability insurance is considered a medical plan
d. disability insurance only covers illness or injury not covered by workers'
- C: Disability insurance is not considered a medical plan. The rest of the answer choices
- are correct.
Medicare Part D
a. covers hospital/hospitalization expenses
b. provides a prescription drug benefit
c. is synonymous with Medicare Advantage
d. covers physician services, diagnostic tests, medical equipment, and ancillary services
- B: Medicare Part D provides prescription drug benefits. Medicare Part A covers hospital
- expenses. Medicare Part B covers services listed in D: Medicare Advantage is another name for Medicare Part C.
Laws that prevent physicians from receiving "kickbacks" for referrals and consultations
a. Stark laws
b. security standards for health information
c. false claims Jaws
d. HIPAA laws
A: Stark laws prevent physicians from receiving kickbacks for referrals and consultations.
Which of the following is NOT a prosthetic device?
a. wrist brace
c. artificial heart
d. gastric band
A: Prosthetic devices are artificial replacements for a part of the body that is missing due to birth defect or injury. Prosthetic devices can also be placed inside the body, such as an artificial heart, dentures, artificial lungs, or a gastric band. A wrist brace is an orthotic device. Orthotics are applied externally to a part of the body to support, align, or improve movement
Which of the following is true about viatical settlements?
a. They are classified as an insurance product
b. They are a type of death benefit
c. They involve sale of a life insurance policy to a third party before death occurs
d. When the policy is sold, it is not necessary for beneficiaries to sign a release to waive rights to the policy
- C: With via tical settlements, a third party purchases the policy (or a portion of it) at an
- amount that is less than the death benefit The third party then collects the death benefit after the seller dies. Viatical settlements are not an insurance product. They are also known as living benefits because the seller uses the funds to improve his quality of life prior to dying of a terminal illness. Beneficiaries must sign a waiver to give up rights to the policy.
Which of the following best describes the process of medical reconciliation?
a. It is a program that regularly assesses medical and nursing performance to ensure
quality of care
b. It is a process of comparing medications the patient is taking at the time of admission with what the hospital or a new setting is providing
c. It occurs when the wrong dose of a medication is given to a patient
d. It occurs when the wrong medication is given to a patient
- B: Medication reconciliation is done to prevent errors or accidental omissions of
- medications. A reconciliation is performed by comparing medications the patient is taking
- at the time of hospital admission with what the patient will be taking in the hospital.
- Answer A describes quality assurance, and answers C and D both describe a medication
The ORYX initiative:
a. requires healthcare organizations to report performance data to Joint Commission on
Accreditation of Healthcare Organizations (JCAHO) for accreditation
b. does not pertain to case management roles and responsibilities
c. was started by JCAHO in 2005
d. is not related to JCAHO
A: ORYX (Outcome Research Yields Excellence) requires hospitals to collect data and transmit them to The Joint Commission for a minimum of four core measure sets to evaluate the performance data for accreditation purposes. The initiative was started by The Joint Commission in 1997. Case managers who work in JCAHO-accredited organizations should understand the importance of case manager roles and responsibilities because they are crucial to accreditation.
Models that deliver coordinated, comprehensive, and accessible health and managed care from a primary care staff are known as:
a. medical home models
b. alternative care models
c. palliative care models
d. cost-benefit models
- A: Medical home models encourage a proactive and planned approach to health care. The primary care physician is at the center of the model along with involvement of the nonphysician staff.
Uncoordinated care that is given through multiple providers and organizations is called:
a. patient-centered care
b. chronic care model
c. fragmented care
d. transitions of care
- C: Fragmented care occurs when uncoordinated care is given via multiple clinicians and organizations. It is a widely recognized problem. Efforts are now focusing on improving communication among healthcare providers in situations such as when a patient is discharged from the hospital. Patient-centered care involves treating patients as partners in health care, urging them to take responsibility for their health, and involving them in planning. Chronic care models are models for assessment and treatment of chronically ill
Which of the following is true about "do not resuscitate" (DNR) orders?
a. A patient cannot request a DNR order on himself
b. All therapeutic interventions are stopped when a patient is DNR
c. DNR orders should be reviewed periodically and revised if needed
d. Staff can withhold food and water from a DNR patient
C: Adults can request DNR orders on themselves if they are mentally competent. Under DNR status, only resuscitative actions are withheld. All other therapeutic interventions continue, such as drawing blood, suctioning, and giving blood transfusions. DNR orders should be periodically reviewed and revised as needed.
Which of the following is/are a health literacy assessment tool?
d. All of the above
- D: All of the answers given are health literacy assessment tools. Rapid Estimate of Adult Literacy in Medicine (REALM) is a word recognition test that consists of 22 common
- medical words. The patient is asked to pronounce as many words as possible out loud. The
- REALM-SF is the short form of the same exam. MART (medical terminology Achievement Reading Test places several medical words in small print on a simulated prescription bottle. The patient is then asked to read the label.
According to Lewin's change theory, the "moving stage" occurs when:
a. the need for change is recognized
b. the process for creating awareness for change is started
c. a change becomes permanent
d. the need for change is accepted and implemented
- D: Lewin's change theory is commonly used in nursing. There are three stages:
- unfreezing, moving, and refreezing. During the unfreezing stage, the need for change is
- recognized. During moving, the need for change is accepted and implemented. Refreezing occurs when a change becomes permanent.
A prospective payment system (PPS):
a. is a Medicare payment based on a patient's diagnosis at the time of hospital admission
b. is the same as a fee-fo r-service system
c. is part of Medicare supplemental insurance
d. is similar to Medicare Part C
- A: A PPS is a Medicare payment based on a patient's diagnosis at the time of admission
- to the hospital.
A physician ordered a lab test for a patient. The lab machine malfunctioned and only
produced partial results. Medicare was billed for the full test. This type of fraud is called:
a. reflex testing
b. defective testing
c. test fraud
d. double billing
- B: This is a form offraud known as defective testing. If equipment fails during testing, yielding partial or no results, you cannot bill as if the test was completed in full. Double billing refers to charging more than once for the same service. Reflex testing occurs
- whenever results of a test fall within a given range and a secondary test is done based on
- the initial results. For instance, if a TSH level is abnormal, a reflex test would include a full
- thyroid profile. It is fraudulent to run a reflex test and bill for it if it was not ordered by the
A patient with mild paresis of one arm is going to need an assistive device to aid with
walking. Which of the following is the most appropriate type of cane for this patient?
a. C cane
b. functional grip cane
c. quad cane
- C: The quad cane would be most appropriate for this patient. It has a rectangular base
- with four supports that contact the walking surface. These are more appropriate for
- patients who need more balance assistance, such as those with mild paresis of an arm or a mild hemiparesis. The simplest cane is the C cane, a straight cane with a curved handle for those who need slight assistance. A functional grip cane has a straight rather than curved handle and allows for an improved grip and more support than C canes. Hemi-walkers have a much larger base than a quad cane and provide more support for patients with more severe hemiplegia.
All of the following are components of a functional capacity evaluation EXCEPT:
a. musculoskeletal screening
b. review of the medical record
d. testing of physical ability
c. literacy screening
- C: A functional capacity evaluation includes grading strength activities, position
- tolerance activities, and mobility activities. It also includes a review of the medical record and evaluation of the musculoskeletal system. Literacy screening is not a component of the functional capacity evaluation.
Which of these is true about prescription assistance programs?
a. Most people don't know about them
b. They are available to patients with Medicaid
c. They are available to non-U.S. residents
d. Most people find them easy to apply for
- A: Over 200 pharmaceutical companies have prescription assistance programs to help
- uninsured persons who are unable to afford their medications. Few people know about
- these programs. Moreover, people who know about them find the application process
- challenging and confusing. To be eligible, the patient cannot have Medicaid or health
Which of the following disqualifies a spouse from COBRA benefits?
a. reduction in the employee's work hours
b. voluntary or involuntary employment termination due to gross misconduct by the
c. legal separation or divorce of the covered employee
d. death of the covered employee
- B: A spouse of a covered employee is eligible for COBRA benefits for the events
- described in answers A, C, and D. Termination of employment due to gross misconduct
- results in no benefits for the spouse
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