Download AAPC Official CPC Certification Study Guide Notes: Key Concepts and Definitions and more Study Guides, Projects, Research Medicine in PDF only on Docsity!
1 / 16
AAPC Official CPC Certification Study Guide Notes
1. "hold harmless clause": * found in some non-Medicare health plan contracts
- prohibits billing to patient for anything beyond deductibles and co-pays.
2. 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
3. A healthcare clearing house is a: entity that processes nonstandard health information
they receive from another entity into a standard format
4. 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.
5. A medically necessary service is the: least radical service/procedure that allows for
effective treatment of the patients' complaint or condition
6. A patient sustaining an injury to her great saphenous vein would have sustained injury to
which of anatomical site?: Leg
7. APC: Ambulatory Payment Classification
8. ARRA: American Recovery and Reinvestment Act (of 2009)
9. ASC: Ambulatory Surgical Centers
10. Abuse consists of: payment for items or services that are billed by providers in error that
should not be paid for by Medicare.
2 / 16
11. 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.
12. An entity that processes nonstandard health information they receive from another entity into a
standard format is considered what?: Clearinghouse
13. As a part of Health Care Reform, the Affordable Care Act of 2010 amended the definition of fraud
to remove the requirement: intent
14. By statute, all work RVUs, must be examined no less often than: every 5 years
15. CF: Conversion Factor - fixed dollar amount used to translate the RVUs into fees
16. CMS: Centers for Medicare and Medicaid
17. CMS developed polices regarding medical necessity are based on regula- tions found in title
XVIII, $1862(a) of the: Social Security Act
18. CMS will accept the for either a "potentially non=covered" service or
for a statutorily excluded service: CMS-R-
19. CMS-R-131: ABN form
or Advance Beneficiary Notice which explains to the patient why Medicare may deny the particular service or procedure.
20. CPT: Current Procedural Terminology
21. CY 2013 Conversion Factor: $25.
22. Commercial (non-Medicare) may develop their own medical policies which do not follow
4 / 16 of his or her health information.
38. HITECH was enacted as part of: the American Recovery and Reinvestment Act of 2009
(ARRA)
39. HMO: Health Maintenance Organization
40. Hemiplegia is a disorder caused by a defect in which anatomic system?: -
nervous
41. ICD-9-CM: International Classification of Disease, 9th Clinical Modification
42. IF:
**Work RVUs = 0. Work GPCI = 1. Practice Expense CPCI = 0.943 MP GPCI =
transitioned non-facility practice RVUs = 0. 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)
43. 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 Beneficiary Notice of NonCoverage (Advance Beneficiary Notice, or ABN)
5 / 16
44. If an NCD doesn't exist for a particular item, its up to the to
determine coverage.: MAC
45. If an inbuilding pharmacy delivers medication (for home use) to an indi- vidual receiving
outpatient chemotherapy, which part of Medicare should be billed for the pain medication by the pharmacy?: Part D
46. Incus, stapes, : malleus
47. Intentional billing of services not provided is considered:
48. LCD: Local Coverage Determinations
49. LCDs have jurisdiction only within: their regional area
50. LCDs give guidance when: * a given service is indicated or necessary,
- give guidance on coverage limitations
- describe the specific CPT codes to which the policy applies
- lists IICD-9-CM codes that support medical necessity for the given service or procedure
51. MP: Malpractice
52. MS-DRG: Medical Severity-Diagnosis Related Group
53. Medicaid is a: a health insurance assistance program for some low-income people
54. Medicaid is administered on a: state by state basis adhering to certain federal guidelines.
55. Medicare Part B helps to cover: medically necessary physicians' services outpatient care
other medical services (including some preventative services) not covered under Part A
56. Medicare Part B premiums are paid by: the patient
57. Medicare Part C combines the benefits of: Part A and Part B and sometimes Part D
7 / 16
- 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
71. PA: Physician Assistant
72. PE: Physician Expense
73. PFS: Physician Fee Schedule
74. PHI: protected health information
75. PLI: Professional Liability Insurance
76. Published Conversion factor for CY 2012: $34.
77. Published conversion factor for CY 2011: $33.
78. RBRVS: Resource Based Relative Value System
79. RUC: Relative Value Update Committee
80. Resource costs for RBRVS are divided into three components:: physician work
practice expense
8 / 16 professional liability insurance
81. Sebaceous glands are a part of which anatomic system?: Integumentary
82. The ABN form is entitled: Revised ABN CMS-R-131 and is available with instructions as a
free download on the CMS website.
83. The ABN is a standardized form that: explains to the patient why Medicare may deny the
particular service or procedure.
84. The OIG is mandated by public law to engage in activities to test: the effi- ciency and economy
of government programs to include investigation of suspected health care fraud or abuse.
85. The amount on an ABN should be within how much of the cost to the patient?: $100 or
25% of cost RATIONALE: CMS instructions stipulate, "Notifiers must make a good faith effort to insert a reasonable estimate....the estimate should be within $100 or 25% of the actual costs, whichever is greater.
86. The myocardium is thickest around which chamber of the heart?: left ven- tricle
10 / 16
94. When should an ABN be signed?: 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.
95. Which of the following has a refraction function in the eye?
macula retina lens iris: lens
96. Which of the following is a function of the pancreas?
*** supplies digestive enzymes manufactures melatonin
- stimulates growth
- secretes vasopressin:** supplies digestive enzymes
97. Which of the following is a renal calculus?
*** Pyelectasia
- Hydroureter
- Nephrolithiasis
- Pyonephrosis:** Nephrolithiasis
98. Who is responsible for interpreting national policies into regional polices, called LCDs?: each
MAC
11 / 16 (Medicare Administrative Contractor)
99. Whose responsibility is it to develop and implement policies, best suited to its particular
circumstances, to meet HIPAA requirements.: the entity covered by HIPAA
100. Work RVUs reflect: 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.
101. compliance plan: a written set of instructions outlining the process for coding and
submitting accurate claims, and what to do if mistakes are found.
102. fraud: to purposely bill for services that were never given or to bill for a service that
has a higher reimbursement than the service provided.
103. AMA: American Medical Association
104. The ICD-9-CM Coordination and Maintenance Committee, which is co-chaired by
the: NCHS (National Centers for Health Statistics) and the CMS (Centers for Medicare & Medicaid Services)
105. Maintenance of the ICD-9-CM is performed by: the Coordination and Main- tenance
Committee
106. ICD-10 accommodates: advancements in medical knowledge of disease and disease
processes, where ICD-9_CM has become outdated and insufficient.
107._____________________________ ICD-9CM is published in volumes: 3
108. Volume 1 of the ICD-9-CM: Tabular List: Diagnosis codes organized in order by code
109. Volume 2 of the ICD-9-CM: Index to Diseases: Diagnosis codes organized in an
alphabetic index
110. Volume 3 of the ICD-9-CM: Alphabetic Index and Tabular List of Procedures: Procedures
13 / 16
123. Appendix B: Deleted 10/1/2004 - contained Glossary of Mental Disorders.
124. Appendix C: Classification of Drugs by American Hospital Formulary Service List
Number and Their ICD-9-CM equivalents
125. Appendix C is available to: assist in coding of adverse effects
126. Appendix D: Classification of Industrial Accidents According to Agency.
127. Appendix D is used primarily for: statistical purposes. It provides information about
employment injuries.
128. Appendix E: List of 3 digit categories
129. provides an alternative view of the contents of ICD-9-CM
and contains the : Appendix E; 3 digit categories in ICD-9-CM
130. Section I of the official guidelines includes: conventions, general coding guidelines,
and chapter specific guidelines
131. NEC: Not elsewhere classifiable
132. NEC is used when: the ICD-9-CM system does not provide a code specific for the
patient's condition.
133. Selecting a code with the NEC classification means: the provider docu- mented more
specific information regarding the patient's condition, but there is not a code in ICD-9-CM that reports the condition accurately
134. NOS: Not otherwise specified
135. NOS is the equivalent of: unspecified
136. NOS is used only when: the coder lacks the information necessary to code to a more
14 / 16 specific 4th or 5th digit subcategory
137. []: Brackets are used to enclose synonyms, alternate wording, or explanatory phrases
138. slanted brackets: indicate multiple codes are required
139. :: 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
140. The is used after an incomplete term which requires one or more of the
descriptions that follow to make it assignable to a given category: :, colon
141. boldface type: used for all codes and titles in the Tabular list
142. Italicized type: used for all exclusion notes and to identify codes that should not be
used for describing the primary diagnosis
143. excludes: terms following "excludes" notes are to be reported with a code from
another category.
144. includes: appears immediately after a three-digit code title to further define or clarify
the category
145. 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.
146. 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
147. 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:**
16 / 16
156. HICN: Health Insurance Claim Number
