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AAPC OFFICIAL CPC CERTIFICATION
EXAM QUESTIONS AND ANSWERS
"hold harmless clause" answer: * found in some non-Medicare health plan contracts
- prohibits billing to patients for anything beyond deductibles and copays.
A compliance plan may offer several benefits, including: answer: * more accurate payment of claims
- fewer billing mistakes
- improved documentation and more accurate coding
- less chance of violating self-referral and anti-kickback status
A healthcare clearinghouse is a answer: entity that processes nonstandard health information they receive from another entity into a standard format
A key provision in HIPAA is the Minimum Necessary requirement. this means answer: only the minimum necessary protected health information should be shared to satisfy a particular purpose.
A medically necessary service is the answer: least radical service/procedure that allows for effective treatment of the patients' complaint or condition
A patient sustaining an injury to her great saphenous vein would have sustained injury to which of anatomical sites? answer: Leg
APC answer: Ambulatory Payment Classification
ARRA answer: American Recovery and Reinvestment Act (of 2009)
ASC answer: Ambulatory Surgical Centers
Abuse consists of
answer: payment for items or services that are billed by providers in error that should not be paid for by Medicare.
An ABN protects the provider's financial interest by answer: creating a paper trail that CMS requires before a provider can bill the patient for payment if Medicare denies coverage for the stated service or procedure.
An entity that processes nonstandard health information they receive from another entity into a standard format is considered what? answer: Clearinghouse
As a part of Health Care Reform, the Affordable Care Act of 2010 amended the definition of fraud to remove the __________ requirement answer: intent
By statute, all work RVUs, must be examined no less often than answer: every 5 years
CF answer: Conversion Factor - fixed dollar amount used to translate the RVUs into fees
CMS answer: Centers for Medicare and Medicaid
CMS developed policies regarding medical necessity are based on regulations found in title XVIII, $1862(a) of the answer: Social Security Act
CMS will accept the ____________ for either a "potentially non=covered" service or for a statutorily excluded service answer: CMS-R-
CMS-R- answer: ABN form
or
Advance Beneficiary Notice which explains to the patient why Medicare may deny the particular service or procedure.
answer: Department of Health and Human Services
HIPAA provides federal protections for answer: personal health information when held by covered entities.
HIPAA stands for answer: Health Insurance Portability and Accountability Act of 1996
HITECH answer: The Health Information Technology for Economic and Clinical Health Act
HITECH allows patients to request answer: an audit trail showing all disclosures of their health information made through an electronic record.
HITECH requires that an individual be notified if answer: there is an unauthorized disclosure or use of his or her health information.
HITECH was enacted as part of answer: the American Recovery and Reinvestment Act of 2009 (ARRA)
HMO answer: Health Maintenance Organization
Hemiplegia is a disorder caused by a defect in which anatomic system? answer: nervous
ICD-9-CM answer: International Classification of Disease, 9th Clinical Modification
IF:
Work RVUs = 0.
Work GPCI = 1.
Practice Expense CPCI = 0.
MP GPCI = 0.
transitioned non-facility practice RVUs = 0.
Calculate non-facility pricing amount for cpt code 99212 using 2011 CF of $33. answer: $39.51 Non-facility pricing amount
(physician office, private practice)
If a service fails to support medical necessity requirements per the LCD, and the service is not covered, the practice would be responsible for obtaining a(n) answer: Advance Beneficiary Notice of NonCoverage (Advance Beneficiary Notice, or ABN)
If an NCD doesn't exist for a particular item, it's up to the ______ to determine coverage. answer: MAC
If an inbuilding pharmacy delivers medication (for home use) to an individual receiving outpatient chemotherapy, which part of Medicare should be billed for the pain medication by the pharmacy? answer: Part D
Incus, stapes, _____ answer: malleus
Intentional billing of services not provided is considered answer:
LCD answer: Local Coverage Determinations
LCDs have jurisdiction only within answer: their regional area
LCDs give guidance when answer: * a given service is indicated or necessary,
- give guidance on coverage limitations
- describe the specific CPT codes to which the policy applies
Medicare Part D is available to answer: all Medicare beneficiaries.
Medicare part A helps to cover: answer: inpatient hospital care
care provided in skilled nursing facilities
hospice care
home health care
Medicare payments for physician services are standardized using a answer: resource-based relative value scale
(RBRVS)
NCD answer: National Coverage Determinations
NCD explain answer: when Medicare will pay for items or services.
NP answer: Nurse Practitioner
OCR answer: Office of Civil Rights
OIG answer: Office of the Inspector General
OIG Compliance Program for Individual and Small Group Physician Practices include the following key actions answer: * Implement compliance and practice standards through the development of written standards and procedures.
- designate a compliance officer or contact to monitor compliance efforts and enforce practice standards
- conduct appropriate training and education of practice standards and procedures
- conduct internal monitoring and auditing through the performance of periodic audits
- respond appropriately to detected violations through the investigation of allegations through the investigation of allegations and the disclosure of incidents to appropriate government entities
- Develop open lines of communication
- Enforce disciplinary standards through well-publicized guidelines
PA answer: Physician Assistant
PE answer: Physician Expense
PFS answer: Physician Fee Schedule
PHI answer: protected health information
PLI answer: Professional Liability Insurance
Published Conversion factor for CY 2012 answer: $34.
Published conversion factor for CY 2011 answer: $33.
RBRVS answer: Resource Based Relative Value System
RUC answer: Relative Value Update Committee
Resource costs for RBRVS are divided into three components: answer: physician work
practice expense
professional liability insurance
- Disclosures to the US Dept of Health and Human Services when disclosure of info is required under the Privacy Rule for enforcement purposes.
- Uses or disclosures that are required by other law
What OIG document should a provider review for potential problem areas that will receive special scrutiny in the upcoming year? answer: OIG work plan
What is an NCD interpreted at the MAC level considered? answer: LCD
Each MAC (Medicare Administrative Contractor) is responsible for interpreting national policies into regional policies, or Local Coverage Determinations
What is the result of a ureteral blockage? answer: Urine will not be able to flow from the kidney to the bladder
When does the OIG release a work plan outlining its priorities for the fiscal year ahead? answer: October
When should an ABN be signed? answer: When a service is not expected to be covered by Medicare.
RATIONALE: This form explains to the patient why a service MAY be denied by Medicare. The ABN form should be completed for services potentially con-covered by Medicare to advise the patient of potential financial responsibility.
Which of the following has a refraction function in the eye?
macula retina lens iris answer: lens
Which of the following is a function of the pancreas?
- supplies digestive enzymes manufactures melatonin
- stimulates growth
- secretes vasopressin answer: supplies digestive enzymes
Which of the following is a renal calculus?
- Pyelectasia
- Hydroureter
- Nephrolithiasis
- Pyonephrosis answer: Nephrolithiasis
Who is responsible for interpreting national policies into regional policies, called LCDs? answer: each MAC
(Medicare Administrative Contractor)
Whose responsibility is it to develop and implement policies, best suited to its particular circumstances, to meet HIPAA requirements. answer: the entity covered by HIPAA
Work RVUs reflect answer: The relative levels of time and intensity associated with furnishing a Medicare PFS service and account for ~50% of the total payment associated with a service.
compliance plan answer: a written set of instructions outlining the process for coding and submitting accurate claims, and what to do if mistakes are found.
fraud answer: to purposely bill for services that were never given or to bill for a service that has a higher reimbursement than the service provided.
AMA answer: American Medical Association
The ICD-9-CM Coordination and Maintenance Committee, which is co-chaired by the answer: NCHS (National Centers for Health Statistics) and the
CMS (Centers for Medicare & Medicaid Services)
answer: screening tests routine physicals personal or family history of a disease or disorder
In order for a V code to be listed first, answer: it must meet the definition of a principle or first-listed diagnosis code
E codes are used to report answer: how an injury occurred and where the injury occurred.
Appendix A answer: Morphology of Neoplasms
Morphology codes consist of ___ digits answer: 5
The first 4 digits of a morphology code identify the answer: histological type of the neoplasm
The fifth digit in a morphology code indicates answer: behavior of the neoplasm
Appendix B answer: Deleted 10/1/2004 - contained Glossary of Mental Disorders.
Appendix C answer: Classification of Drugs by American Hospital Formulary Service List Number and Their ICD-9-CM equivalents
Appendix C is available to answer: assist in coding of adverse effects
Appendix D answer: Classification of Industrial Accidents According to Agency.
Appendix D is used primarily for answer: statistical purposes. It provides information about employment injuries.
Appendix E answer: List of 3 digit categories
__________ _________ provides an alternative view of the contents of ICD-9-CM and contains the _____ _____ ______ _____ _______ answer: Appendix E; 3 digit categories in ICD-9-CM
Section I of the official guidelines includes answer: conventions, general coding guidelines, and chapter specific guidelines
NEC answer: Not elsewhere classifiable
NEC is used when answer: the ICD-9-CM system does not provide a code specific for the patient's condition.
Selecting a code with the NEC classification means answer: the provider documented more specific information regarding the patient's condition, but there is not a code in ICD-9-CM that reports the condition accurately
NOS answer: Not otherwise specified
NOS is the equivalent of answer: unspecified
NOS is used only when answer: the coder lacks the information necessary to code to a more specific 4th or 5th digit subcategory
[] answer: Brackets are used to enclose synonyms, alternate wording, or explanatory phrases
slanted brackets answer: indicate multiple codes are required
: answer: colon is used in Volume I (tabular list) after an incomplete term requiring one or more of the descriptions that follow to make it assignable to a given category
answer: instruction used in categories not intended to be the principal diagnosis. These codes are written in italics with a note. The note requires the underlying disease (etiology) be recorded first and the particular manifestation be recorded second. This note only appears in the tabular index
use additional code, if applicable answer: the causal condition note indicates this code may be assigned as a diagnosis when the causal condition is unknown or not applicable. If a causal condition is known, the code should be sequenced as the principal diagnosis.
a combination code indicates answer: a single code is used to classify 2 diagnoses, a diagnosis with an associated secondary process (manifestation), or a diagnosis with an associated complication
eponym answer: this term indicates the code describes a disease or syndrome named after a person
modifiers answer: essential modifiers are subterms listed below the main term in alphabetical order, and are indented 2 spaces
other answer: "other" or "other specified" codes (usually with 4th digit 8 or 5th digit 9 are used when the information in the medical record provides detail for which a specific code does not exist.
official coding and reporting guidelines are provided by answer: CMS and NCHS
Never code directly from the answer: Index to Disease
HICN answer: Health Insurance Claim Number
