NHI Medical Office Procedures & Billing 3 — Questions and Answers
Question 1: A Medicare patient is responsible for paying 20% of the Medicare-approved amount after the deductible. This payment is called a:
- Premium
- Copayment
- Coinsurance (Correct answer)
- Deductible
Correct answer: Coinsurance
Coinsurance is a percentage of the approved amount that the patient pays after meeting their deductible; Medicare Part B coinsurance is typically 20%.
Question 2: Which HIPAA standard transaction set is used for healthcare claim submission?
- 837 (Correct answer)
- 835
- 270
- 276
Correct answer: 837
The HIPAA 837 transaction set is used for electronic submission of healthcare claims to payers.
Question 3: A medical office receives a payment from a secondary insurance payer. Which of the following should the biller do FIRST?
- Refund the payment to the patient
- Verify the primary insurance payment was applied first (Correct answer)
- Bill the patient for the remaining balance
- Write off the remaining balance
Correct answer: Verify the primary insurance payment was applied first
Before applying a secondary payment, the biller must confirm the primary insurance has already processed and paid the claim.
Question 4: What is the purpose of the National Provider Identifier (NPI)?
- To identify patients in a clinical database
- To assign billing codes to procedures
- To uniquely identify healthcare providers in standard transactions (Correct answer)
- To classify hospital departments for reimbursement
Correct answer: To uniquely identify healthcare providers in standard transactions
The NPI is a unique 10-digit identification number assigned to each covered healthcare provider for use in HIPAA standard transactions.
Question 5: A patient's balance after all insurance payments have been applied and adjustments made is called the:
- Allowed amount
- Billed charge
- Patient responsibility (Correct answer)
- Capitation rate
Correct answer: Patient responsibility
Patient responsibility is the remaining amount owed by the patient after all insurance payments and contractual adjustments have been posted.
Question 6: In scheduling terminology, 'double-booking' means:
- Scheduling a patient for two appointments in one day
- Scheduling two patients for the same appointment slot (Correct answer)
- Booking an appointment in two different scheduling systems
- Reserving an appointment for a specialist and a PCP simultaneously
Correct answer: Scheduling two patients for the same appointment slot
Double-booking is the practice of scheduling two patients for the same time slot, often used to accommodate urgent cases or reduce no-shows.
Question 7: Which coding system is used to report medical procedures and services for reimbursement in the United States?
- ICD-10-CM
- CPT (Current Procedural Terminology) (Correct answer)
- SNOMED CT
- DSM-5
Correct answer: CPT (Current Procedural Terminology)
CPT codes, maintained by the American Medical Association, are used to report medical, surgical, and diagnostic procedures to payers for reimbursement.
NHI Medical Office Procedures & Billing 3
A Medicare patient is responsible for paying 20% of the Medicare-approved amount after the deductible.
This payment is called a: