AAPC Official CPC Certification Study Guide Notes-100% tutor verified -2024-2025.docx, Exams of Advanced Education

Download AAPC Official CPC Certification Study Guide Notes-100% tutor verified -2024-2025.docx and more Exams Advanced Education in PDF only on Docsity! AAPC Official CPC Certification Study Guide Notes- 100% tutor verified -2024-2025 "hold harmless clause" * found in some non-Medicare health plan contracts * prohibits billing to patient for anything beyond deductibles and co-pays. A compliance plan may offer several benefits, including: * 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 clearing house is a 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 only the minimum necessary protected health information should be shared to satisfy a particular purpose. A medically necessary service is the 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 site? Leg APC Ambulatory Payment Classification ARRA American Recovery and Reinvestment Act (of 2009) ASC Ambulatory Surgical Centers Abuse consists of 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 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? Clearinghouse As a part of Health Care Reform, the Affordable Care Act of 2010 amended the definition of fraud to remove the __________ requirement intent By statute, all work RVUs, must be examined no less often than every 5 years [(Work RVU Work GPCI) + (Transitioned Non-Facility PE RVU PE GPCI) + (MP RVU MP GPCI)] (CF) GPCI Geographic Practice Cost Index GPCI is used to realize the varying cost based on geographic location HCPCS Healthcare Common Procedure Coding System HHS Department of Health and Human Services HIPAA provides federal protections for personal health information when held by covered entities. HIPAA stands for Health Insurance Portability and Accountability Act of 1996 HITECH The Health Information Technology for Economic and Clinical Health Act HITECH allows patients to request an audit trail showing all disclosures of their health information made through an electronic record. HITECH requires that an individual be notified if there is an unauthorized disclosure or use of his or her health information. HITECH was enacted as part of the American Recovery and Reinvestment Act of 2009 (ARRA) HMO Health Maintenence Organization Hemiplegia is a disorder caused by a defect in which anatomic system? nervous ICD-9-CM International Classification of Disease, 9th Clinical Modification IF: Work RVUs = 0.48 Work GPCI = 1.000 Practice Expense CPCI = 0.943 MP GPCI = 0.572 transitioned non-facility practice RVUs = 0.70 Calculate non-facility pricing amount for cpt code 99212 using 2011 CF of $33.9764 $39.51 Non-facility pricing amount (physician office, private practice) If a sevice fails to support medical necessity requirements per the LCD, and the service is not covered, the practice would be responsible for obtaining a(n) Advance Beneficiarly Notice of NonCoverage (Advance Benefiary Notice, or ABN) If an NCD doesn't exist for a particular item, its up to the ______ to determine coverage. MAC Medicare Part C combines the benefits of Part A and Part B and sometimes Part D Medicare Part C is also called Medicare Advantage Medicare Part C plans are managed by private insurers approved by Medicare. Medicare Part D is a prescription drug coverage program Medicare Part D is a coverage provided by private companies approved by Medicare Medicare Part D is available to all Medicare beneficiaries. Medicare part A helps to cover: inpatient hospital care care provided in skilled nursing facilities hospice care home health care Medicare payments for physician services are standardized using a resource-based relative value scale (RBRVS) NCD National Coverage Determinations NCD explain when Medicare will pay for items or services. NP Nurse Practitioner OCR Office of Civil Rights OIG Office of the Inspector General OIG Compliance Program for Individual and Small Group Physician Practices include the following key actions * Implement compliance and practice standards through the development of written standards and procedures. * designate a compliance officer or contac 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 entitities * Develop open lines of communication * Enforce disciplinary standards through well-publicized guidelines PA Physician Assistant PE Physician Expense PFS Physician Fee Schedule The myocardium is thickest around which chamber of the heart? left ventricle The term "medical necessity refers to whether a procedure or service is considered appropriate in a given circumstance. The tunica vaginalis is part of which system? male reproductive Under the Privacy rule, the minimum necessary standard of HIPAA does not apply to * disclosures to or requests by a health care provider for treatment purposes * disclosures to the individual who is the subject of the information * uses or disclosures made pursuant to an individual's authorization * uses or disclosures required for compliance with the HIPAA Administrative Simplification Rules * 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? OIG work plan We have an expert-written solution to this problem! What is an NCD interpreted at the MAC level considered? LCD Each MAC (Medicare Adminstrative Contractor) is responsible for interpreting national policies into regional policies, or Local Coverage Determinations What is the result of a ureteral blockage? 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? October When should an ABN be signed? When a service is not expecgted 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 lens Which of the following is a function of the pancreas? * supplies digestive enzymes manufactures melatonin * stimulates growth * secretes vasopressin supplies digestive enzymes Which of the following is a renal calculus? * Pyelectasia * Hydroureter * Nephrolithiasis * Pyonephrosis Nephrolithiasis Who is responsible for interpreting national policies into regional polices, called LCDs? Volumes 1 and 2 are used to assign diagnosis codes that establish medical necessity for services rendered. The first step in 3rd party reimbursement is establishing medical necessity Information required by payers to determine the need for care 1. knowledge of the emergent nature or severity of the patient's complaint or condition 2. All signs, symptoms, complaints, or background facts describing the reason for care, such as required follow-up care. Volume 3 of the ICD-9-CM includes procedure codes and is typically used by facilities for inpatient services. V codes are commonly used when the patient presents for treatment with no complaints. examples of common reasons to report V codes: screening tests routine physicals personal or family history of a disease or disorder In order for a V code to be listed first, it must meet the definition of a principle or first-listed diagnosis code E codes are used to report how an injury occurred and where the injury occurred. Appendix A Morphology of Neoplasms Morphology codes consist of ___ digits 5 The first 4 digits of a morphology code identify the histological type of the neoplasm The fifth digit in a morphology code indicates behavior of the neoplasm Appendix B Deleted 10/1/2004 - contained Glossary of Mental Disorders. Appendix C Classification of Drugs by American Hospital Formulary Service List Number and Their ICD-9-CM equivalents Appendix C is available to assist in coding of adverse effects Appendix D Classification of Industrial Accidents According to Agency. Appendix D is used primarily for statistical purposes. It provides information about employment injuries. Appendix E List of 3 digit categories __________ _________ provides an alternative view of the contents of ICD-9- CM and contains the _____ _____ ______ _____ _______ Appendix E; 3 digit categories in ICD-9-CM Section I of the official guidelines includes conventions, general coding guidelines, and chapter specific guidelines includes appears immediately after a three-digit code title to further define or clarify the category use additional code signals the coder an additional code should be used, if the information is available, to provide a more complete picture of the diagnosis. When seeing the instruction to use additional code, which code goes first? When sequencing codes, the codes listed under the "use additional code" are secondary 282.42 Sickle-cell thalassemia with crisis ** Sickle-cell thalassemia with vaso-occlusive pain ** Thalassemia Hb-S disease with crisis Use additional code for the type of crisis, such as: ** acute chest syndrome (517.3) **splenic sequestration (289.52) correct sequence for sickle-cell thalassemia crisis with acute chest syndrome in correct sequence are: 282.42, 517.3 Code first 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 addtional code, if applicable the causal condition note indicates this code may be assigned as a diagnosis when the causal condtion is unknown or not applicable. If a causal condition is known, the code should be sequenced as the principal diagnosis. a combination code indicates 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 this term indicates the code describes a disease or syndrome named after a person modifiers essential modifiers are subterms listed below the main term in alphabetical order, and are indented 2 spaces other "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 CMS and NCHS Never code directly from the Index to Disease HICN Health Insurance Claim Number