Question1 #

Physician give Medicine or Injection he will mention dose of that injection

I.e. Insulin 1500 mcq

Codes available 250 mcq

Suppose code J2356- 250 mcq

J2356 x6

250 mcg code A

100 Mcg Code B

Question2:
What required to give injection to a patient
Syringe- A1234
Medicine - J1234
Route of Administration -96372

A patient came to physician office, physician give one injection in office and also give supply of
4 injection.

A1234x5
J1234x5
96372x1

Question3:
Physician Prescribe chair
Adult
Fully automatic
With hand rest
With Cushion

1. Adult, semiautomatic, hand rest, cusion

2. Child, Fully automatic, hand rest, cusion
3. adult , Fully automatic, hand rest. Cushion
4. Adult, fully automatic without hand rest, cusion

Question4:

Physician give 500 mg drug

codes : 50 mg , 100 mg, 250 mg

Question #5
Screening Colonoscopy

High risk colonoscopy Criteria:

● A personal history of colorectal cancer or certain types of polyps
● A family history of colorectal cancer
● A personal history of inflammatory bowel disease (ulcerative colitis or Crohn’s
disease)
● A confirmed or suspected hereditary colorectal cancer syndrome, such as
familial adenomatous polyposis (FAP) or Lynch syndrome (hereditary non-
polyposis colon cancer or HNPCC)
● A personal history of getting radiation to the abdomen (belly) or pelvic area to
treat a prior cancer
●
 Question: 6

Phsysician use Steristrips 15 cm and their is code available for 1 cm

Compliance:
Medicare Parts:
https://medicareadvantage.home.blog/2019/09/28/medicare-part-a-b-c-d/

Part A- Hospital
Part B- Physician
Part C Hospital and physician both
Part D- Pharmacy
Physician Billing: physician always use CMS1500 form for billing purpose, Whether provide
service in Hospital, Nursing home, OPD, or his office.

Hospital billing always done on UB-04

Hospital billing it always happen on UB04

ABN- Advanced beneficiary notification this form always filled before service provided

Fraud: Service not provided bt physician billed the service to insurance company
Abuse: Manipulation in service codes

What is healthcare fraud?

Healthcare fraud is the intentional deception or misrepresentation made by an individual, knowing that the
misrepresentation could result in some unauthorized benefit to them or to others. The most common kind of
healthcare fraud involves false statements or deliberate omission of information that is critical in the
determination of authorization and payment for services. Healthcare fraud can result in significant monetary
liabilities and, in some cases, subject the perpetrator to criminal prosecution.
What is the difference between healthcare fraud and healthcare abuse?
The difference between fraud and abuse is the intent behind the action. Fraud is intentional deception or
misrepresentation with knowledge that the information is false. Abuse involves actions that are inconsistent
with sound fiscal, business or accepted behavioral healthcare practices and result in an unnecessary cost or
in reimbursement for services that are not medically necessary or that fail to meet professionally recognized
standards for healthcare. Abuse can result in the same process impediments and unnecessary cost of care
as fraud.
What are some common examples of healthcare fraud?
Some of the most common examples of these types of fraudulent acts include:

● Billing for services that were never rendered—either by using genuine patient information,
sometimes obtained through identity theft, to fabricate entire claims or by padding claims with
charges for procedures or services that did not take place.
● Billing for more expensive services or procedures than were actually provided or performed,
commonly known as “upcoding.”
● Performing medically unnecessary services solely for the purpose of generating insurance
payments.
● Falsifying a patient’s diagnosis to justify tests, surgeries or other procedures that aren’t
medically necessary.
● Billing a patient more than the co-payment amount for services that were prepaid or paid in full
by the benefit plan under the terms of a managed care contract.
● Accepting kickbacks for patient referrals.
● Waiving patient co-payments or deductibles and over-billing the insurance carrier or benefit
plan.

Why should I be concerned about healthcare fraud?

The services that you provide to Magellan members are subject to both federal and state laws and contract
requirements designed to prevent fraud, waste and abuse in government programs (such as Medicare and
Medicaid) and private insurance. We have a comprehensive compliance program in place, including policies
and procedures to address the prevention of fraud, waste and abuse. Magellan, in conjunction with
appropriate government agencies, actively pursues all suspected cases of fraud, waste and abuse. Learn
more about fraud, waste and abuse and Magellan’s compliance program.
How can I prevent healthcare fraud and abuse?
You can avoid fraud and abuse by taking the time to ensure all member information you submit is accurate
and the services provided are in the best interest of your patient. When considering member care and
submitting authorization requests and claims to Magellan, ask yourself the following questions:

● Have I listed the right patient and verified eligibility?

● Have I verified the patient’s identity with the appropriate picture identification?
● Is this service medically necessary?
 ● Do I have the correct diagnostic and CPT codes?
● Are my dates of service correct and length of each session accurate?
● Have the services for which I am billing been performed?

PHI- Protected Health Information-

HIPAA- Health Information Portability and Accountability ACT
Stark Law: to prevent kickbacks

Coding Guidelines:

1. Which statement is false regarding the instructions for use of the CPT codebook?

A. Special report should accompany the use of an unlisted procedure code

B. Main body of category I section consists of six section with each section divided into
subsection and subcategories.
C. Instructions listed in parenthetical notes typically indicate that a code should not be reported
with other code(s) and will prevent errors of highest probability but are not all inclusive.
D. Guidelines provide explanations for specific section application.
2. The patient's managed care plan requires that physicians report patient management codes
for pregnant patients. Which of the following pieces of information must be documented in the
medical record in order to report 0501F

A. Blood pressure, Weight, Uterine size, fetal heart tones, urine protein and LMP
B. Blood pressure, weight, uterine size, fetal heart tones, urine protein, EDD, DOS, and LMP
C. Blood pressure, weight, uterize size, fetal heart tones, urine protein, LMP
D. Blood pressure, Weight, urine protein, uterine size, fetal heart tones, EDD, and DOS

3. An intermediate therapeutic radiology simulation-aided procedure (CPT code 77280-77290)

is reported for the

A. Simulation of single treatment area of interest

B. Simulation of three separate treatment area of interest
C. Simulation of two treatment areas
D. Simulation of five separate treatment areas

4. The CPT manual provides full descriptions of medical procedures although some description
requires use of a semicolon (;) to distinguish among closely related procedures.

What is the full description of CPT code 35840

A. Exploration for postoperative hemorrhage, thrombosis or infection; abdomen

B. Exploration for postoperative hemorrhage, thrombosis or infection; excluding abdomen
C. Exploration for postoperative hemorrhage, thrombosis or infection; neck and or abdomen
D. Exploration for postoperative hemorrhage, thrombosis or infection; neck, chest abdomen,
and or extremity

5. An established patient is seen today to discuss her diagnosis of gallstones. The physician
reviews all the test results. He recommends the patient have laparoscopic cholecystectomy. He
discusses the surgery with her and the possible complications. The patient agrees to the
surgery and is schedule for the surgery next day. What code and modifier would be reported for
these services.
A. 47562-57
B. 47579-59
C. 99201-25
D. 99212-57

6. Coding guidelines for assigning ICD 9 CM Codes for neoplasm, states that if documented
which of the following should be referenced first to locate the correct code.

A. The neoplasm table in the Alphabetic index

B. The tabular list
C. The histological term in the Alphabetic Index
D. The histological term in the Tabular list
7. The patient's managed care plan requires that physicians counsel their patients about habits
adverse to their health for data purposes. In this case, the patient is heavy smoker (more than
one pack of cigarettes/day) and the physician provides advice on the benefits of quitting the
habit during an encounter for a preventive medicine service

which of the following codes is reported for the purposes of data collection

A. 4000F
B. 4001F
C. 40047F
D. 4011F

8. A patient suffering from idiopathic dystonia is seen today and receives the following Boulinum
injections: three muscle injections in both upper extremities; seven muscles in the left leg and
six muscles in the right leg, and seven injections in paraspinal muscles. What is the correct
coding for these procedures

A. 64642x2, 64644 x2, 64646

B. 64642, 64643, 64644, 64645, 64647
C. 64642, 64643, 64645, 64645
D. 64643, 64645, 64647

9. Which statement regarding lesion excision is true

A. Codes are selected by measuring the greatest clinical diameter of a lesion excluding the
margin required to complete the excision
B. Excision is defined as full thicness removal of a lesion including marging and includes simple
closure when performed
C. Excision is defined as partial thicness removal of a lesion, including margins and includes
simple closure when performed
D. Excision is defined as full thickness removal of a lesion including margins and includes
intermediate closure when performed

10. ERCP was performed by physician in his outpatient office with lithotripsy to destroy biliary
duct stone with radiological supervision and interpretation.

A. 43264, 74329

B 43261, 74329

C. 43265, 74328
D. 43265

11. Chemotherapy infusion with normal saline for 1 hr 50 mins.

A. 96365

B. 96409, 96411

C. 96413, 96415, 96360, 96361

D. 96413, 96415
12. Which of the following means “to destroy or break down”?

a. -pnea b. -lysis c. ambi- d. iso-

13. What is the crackling sound heard when bone or irregular cartilage surfaces rub together?

a. Bradycardia b. Bruit c. Crepitation d. Croupous

14. How could a hiatal hernia be described?

a. A protrusion of part of the stomach through the diaphragm

b. A protrusion of part of the esophagus through the larynx

c. A protrusion of part of the stomach through the rectum

d. A protrusion of part of the esophagus through the oropharynx

Compliance:

15. The Health Insurance portability and Accountability Act was enacted on August 21, 1996,
which established and funded a health care Fraud and Abuse program to

A. Combat fraud and abuse committed against Medicare and Medicaid health programs
B. Require Medicare to be accountable to senior citizens and provide preventive health services
C. Combat fraud and abuse committed against all health plans, both public and private.
D. Identify health plans that were issuing erroneous payments on claims

16. The term eligible professional (EP) is associated with which of the following

A. EMTALA
B. PQRS
C. HIPPA
D. CHIPS

17. What form is used for billing physician services performed in an outpatient hospital facility

A. UB-04
B. CMS-1500
C. MS-DRG
D. ABN

18. The term medical necessity relates to ____

A. The least radical procedure or service considered appropriate to effectively treat the patient's
condition
B. Condition that require medical attention
C. Making sure required payment is met for procedure or service
D. Using the closest facility to perform a service or procedure

19. Which government agency offers compliance program guidance for physician practices

A. Center for Medicare and Medicaid services

B. American Medical Association
C. Office of the inspector general
D. Health insurance portability and accountability act

20. Which of the following fraud and abuse scenario is most commonly fraud

A. Under documentation by the physician leading to under coding by the coder

B. Rquiring an ABN if the service is not counted medical necessity
C. Intentional violation of no rules
D. Following whichever set of guidelines 95 and 97 that lead to the highest paid code

21. HIPAA was created with which goal in mind

A. To identify providers who do not transmit claims electronically
B. To provide an incentive for providers who implement an electronic health record
C. To allow for standardized code set claims transmission

22. When PHI is disclosed without the consent of the patient

a. To the guardian / parents whose age is above 18.

b. HHS involved in compliance investigation

c. CMS be involved.

d. OIG investigation

23. What is the patient’s right when it involves making change in the personal medical record?

a. A patient must work through an attorney to revise any portion of the personal medical
information.

b. They should be able to obtain copies of the medical record and request correction of errors
and mistakes

c. It is a violation of the federal healthcare law to revise a patient medical record.

d. Revision of the patient medical record depends solely on the facility’s compliance program
policy.

24 . Access login and autolock are what kind of methods for protecting information?

a. Mechanical safeguards

b. Technical safeguards

c. Verbal measures

d. Written policies

25. Security provision of HIPAA

a. Provides standards for MS-DRG payment.

b. Provides data privacy and security provisions for safeguarding medical information.
c. Provides a list of confidential patient data whenever required.

d. Allows physicians to share patient information with other patients.

26. Which of the following is not a healthcare reform?

a. HITECH

b. 5010

c. CPT-5

d. ARRA