Download AAPC Official CPC Certification Study Guide Notes: Key Concepts and Definitions and more Exams Nursing in PDF only on Docsity!
AAPC Official CPC Certification Study
Guide Notes
"hold harmless clause" - correct answer * 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: - correct 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 clearing house is a - correct 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 - correct answer only the minimum necessary protected health information should be shared to satisfy a particular purpose. A medically necessary service is the - correct 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 site? - correct answer Leg APC - correct answer Ambulatory Payment Classification ARRA - correct answer American Recovery and Reinvestment Act (of 2009)
ASC - correct answer Ambulatory Surgical Centers Abuse consists of - correct 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 - correct 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? - correct answer Clearinghouse As a part of Health Care Reform, the Affordable Care Act of 2010 amended the definition of fraud to remove the __________ requirement - correct answer intent By statute, all work RVUs, must be examined no less often than - correct answer every 5 years CF - correct answer Coversion Factor - fixed dollar amount used to translate the RVUs into fees CMS - correct answer Centers for Medicare and Medicaid CMS developed polices regarding medical necessity are based on regulations found in title XVIII, $1862(a) of the - correct answer Social Security Act CMS will accept the ____________ for either a "potentially non=covered" service or for a statutorily excluded service - correct answer CMS-R- CMS-R-131 - correct answer ABN form or
HHS - correct answer Department of Health and Human Services HIPAA provides federal protections for - correct answer personal health information when held by covered entities. HIPAA stands for - correct answer Health Insurance Portability and Accountability Act of 1996 HITECH - correct answer The Health Information Technology for Economic and Clinical Health Act HITECH allows patients to request - correct answer an audit trail showing all disclosures of their health information made through an electronic record. HITECH requires that an individual be notified if - correct answer there is an unauthorized disclosure or use of his or her health information. HITECH was enacted as part of - correct answer the American Recovery and Reinvestment Act of 2009 (ARRA) HMO - correct answer Health Maintenence Organization Hemiplegia is a disorder caused by a defect in which anatomic system? - correct answer nervous ICD-9-CM - correct 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 $33.9764 - correct answer $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) - correct answer 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. - correct 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? - correct answer Part D Incus, stapes, _____ - correct answer malleus Intentional billing of services not provided is considered - correct answer LCD - correct answer Local Coverage Determinations
Medicare Part D is a - correct answer prescription drug coverage program Medicare Part D is a coverage provided by - correct answer private companies approved by Medicare Medicare Part D is available to - correct answer all Medicare beneficiaries. Medicare part A helps to cover: - correct answer inpatient hospital care care provided in skilled nursing facilities hospice care home health care Medicare payments for physician services are standardized using a - correct answer resource-based relative value scale (RBRVS) NCD - correct answer National Coverage Determinations NCD explain - correct answer when Medicare will pay for items or services. NP - correct answer Nurse Practitioner OCR - correct answer Office of Civil Rights OIG - correct answer Office of the Inspector General
OIG Compliance Program for Individual and Small Group Physician Practices include the following key actions - correct answer * 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 - correct answer Physician Assistant PE - correct answer Physician Expense PFS - correct answer Physician Fee Schedule PHI - correct answer protected health information PLI - correct answer Professional Liability Insurance Published Conversion factor for CY 2012 - correct answer $34. Published conversion factor for CY 2011 - correct answer $33. RBRVS - correct answer Resource Based Relative Value System RUC - correct answer Relative Value Update Committee
Under the Privacy rule, the minimum necessary standard of HIPAA does not apply to - correct answer
- 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? - correct answer OIG work plan What is an NCD interpreted at the MAC level considered? - correct answer 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? - correct 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? - correct answer October When should an ABN be signed? - correct answer 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 - correct answer lens Which of the following is a function of the pancreas?
- supplies digestive enzymes manufactures melatonin
- stimulates growth
- secretes vasopressin - correct answer supplies digestive enzymes Which of the following is a renal calculus?
- Pyelectasia
- Hydroureter
- Nephrolithiasis
- Pyonephrosis - correct answer Nephrolithiasis Who is responsible for interpreting national policies into regional polices, called LCDs? - correct 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. - correct answer the entity covered by HIPAA
Volumes 1 and 2 are used to assign diagnosis codes that establish - correct answer medical necessity for services rendered. The first step in 3rd party reimbursement is - correct answer establishing medical necessity Information required by payers to determine the need for care - correct answer 1. knowledge of the emergent nature or severity of the patient's complaint or condition
- 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 - correct answer facilities for inpatient services. V codes are commonly used when - correct answer the patient presents for treatment with no complaints. examples of common reasons to report V codes: - correct answer screening tests routine physicals personal or family history of a disease or disorder In order for a V code to be listed first, - correct answer it must meet the definition of a principle or first-listed diagnosis code E codes are used to report - correct answer how an injury occurred and where the injury occurred. Appendix A - correct answer Morphology of Neoplasms Morphology codes consist of ___ digits - correct answer 5 The first 4 digits of a morphology code identify the - correct answer histological type of the neoplasm
The fifth digit in a morphology code indicates - correct answer behavior of the neoplasm Appendix B - correct answer Deleted 10/1/2004 - contained Glossary of Mental Disorders. Appendix C - correct answer Classification of Drugs by American Hospital Formulary Service List Number and Their ICD-9-CM equivalents Appendix C is available to - correct answer assist in coding of adverse effects Appendix D - correct answer Classification of Industrial Accidents According to Agency. Appendix D is used primarily for - correct answer statistical purposes. It provides information about employment injuries. Appendix E - correct answer List of 3 digit categories __________ _________ provides an alternative view of the contents of ICD-9-CM and contains the _____ _____ ______ _____ _______ - correct answer Appendix E; 3 digit categories in ICD-9-CM Section I of the official guidelines includes - correct answer conventions, general coding guidelines, and chapter specific guidelines NEC - correct answer Not elsewhere classifiable NEC is used when - correct 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 - correct 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
When seeing the instruction to use additional code, which code goes first? - correct answer 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: - correct answer 282.42, 517. Code first - correct 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 addtional code, if applicable - correct answer 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 - correct 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 - correct answer this term indicates the code describes a disease or syndrome named after a person modifiers - correct answer essential modifiers are subterms listed below the main term in alphabetical order, and are indented 2 spaces
other - correct 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 - correct answer CMS and NCHS Never code directly from the - correct answer Index to Disease HICN - correct answer Health Insurance Claim Number
