PAR PAR Medical Terminology and Clinical Documentation 2 — Questions and Answers
Question 1: What does 'EOB' stand for, and who typically receives it?
- Explanation of Benefits; sent to the patient and/or provider after a claim is processed (Correct answer)
- Evidence of Billing; sent to CMS for audit purposes
- Estimate of Balance; sent to the patient before service
- Enrollment of Benefits; sent to HR when coverage begins
Correct answer: Explanation of Benefits; sent to the patient and/or provider after a claim is processed
An EOB (Explanation of Benefits) is a statement from the insurer detailing how a claim was processed, including amounts billed, allowed, paid, and the patient's responsibility.
Question 2: What defines a 'clean claim' in medical billing?
- A claim submitted with all required data elements completed accurately and no missing or invalid information (Correct answer)
- A claim that has been paid in full with no patient balance
- A claim that has been audited and confirmed free of fraud
- A claim submitted within 30 days of the date of service
Correct answer: A claim submitted with all required data elements completed accurately and no missing or invalid information
A clean claim contains all required data elements, has no errors or missing information, and can be processed for payment without additional information from the provider.
Question 3: What does 'COB' stand for in insurance, and why is it important?
- Coordination of Benefits; it determines which payer is primary when a patient has multiple insurance plans (Correct answer)
- Certificate of Benefits; it outlines what a policy covers
- Confirmation of Billing; it verifies that a claim was received
- Cost of Benefits; it calculates total employer insurance expense
Correct answer: Coordination of Benefits; it determines which payer is primary when a patient has multiple insurance plans
COB (Coordination of Benefits) prevents duplicate payments by establishing the order in which multiple insurance plans pay a claim.
Question 4: What is a CPT modifier, and when would a patient access representative need to know about it?
- A two-character code appended to a CPT code to indicate that a service was altered in some way without changing its definition (Correct answer)
- A note added to a claim explaining why a service was delayed
- A code used to indicate a patient's preferred language
- A designation showing that a provider is out of network
Correct answer: A two-character code appended to a CPT code to indicate that a service was altered in some way without changing its definition
A CPT modifier provides additional information about a procedure without changing its description, such as indicating a bilateral procedure or a service performed by a different provider.
Question 5: What does 'CMS' stand for in the US healthcare system?
- Centers for Medicare & Medicaid Services (Correct answer)
- Clinical Management System
- Certified Medical Staff
- Comprehensive Medical Services
Correct answer: Centers for Medicare & Medicaid Services
CMS (Centers for Medicare & Medicaid Services) is the federal agency within HHS that administers Medicare, Medicaid, CHIP, and the Health Insurance Marketplace.
Question 6: What is the key difference between 'inpatient' and 'outpatient' status for billing purposes?
- Inpatient requires a formal physician admission order for overnight stay; outpatient services are provided without a formal admission (Correct answer)
- Inpatient means the patient paid out of pocket; outpatient means insurance was billed
- Inpatient services are only for Medicare patients; outpatient for commercial insurance
- Inpatient is billed using CPT codes; outpatient uses ICD-10 codes only
Correct answer: Inpatient requires a formal physician admission order for overnight stay; outpatient services are provided without a formal admission
Inpatient status is based on a physician's order for admission with an expectation of at least two midnights of care, while outpatient services are provided without a formal hospital admission.
PAR PAR Medical Terminology and Clinical Documentation 2
What does 'EOB' stand for, and who typically receives it?