HIPAA, Medicare, and Medical Coding Guidelines, Exams of Nursing

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Guide Notes(Notes, definitions and

questions from AAPC CPC Study

Guide Medical Coding Prep)

"hold harmless clause" - 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: - 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 - 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 site? - 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

Guide Notes(Notes, definitions and

questions from AAPC CPC Study

Guide Medical Coding Prep)

CF - Answer Coversion Factor - fixed dollar amount used to translate the RVUs into fees CMS - Answer Centers for Medicare and Medicaid CMS developed polices 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-131 - Answer ABN form or Advance Beneficiary Notice which explains to the patient why Medicare may deny the particular service or procedure. CPT - Answer Current Procedural Terminology CY 2013 Conversion Factor - Answer $25. Commercial (non-Medicare) may develop their own medical policies which do not follow Medicare guidelines and are specified in - Answer private contracts between the payer and practice or provider DRG - Answer Diagnosis Related Group Does Medicare Part B generally require a yearly deductable and copayment? - Answer yes E/M OR E&M - Answer Evaluation and Management EHR - Answer Electronic Health Record Formula for Calculating Facility Payment amounts - Answer [(Work RVU * Work GPCI) + (Transitioned Facility PE RVU * PE GPCI) + (MP RVU * MP GPCI)] * CF Formula for Non-Facility Pricing Amount - Answer [(Work RVU * Work GPCI) + (Transitioned Non-Facility PE RVU * PE GPCI) + (MP RVU * MP GPCI)] * (CF) GPCI - Answer Geographic Practice Cost Index

Guide Notes(Notes, definitions and

questions from AAPC CPC Study

Guide Medical Coding Prep)

Calculate non-facility pricing amount for cpt code 99212 using 2011 CF of $33.9764 - 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) - 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. - 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
• lists IICD-9-CM codes that support medical necessity for the given service or procedure MP - Answer Malpractice MS-DRG - Answer Medical Severity-Diagnosis Related Group Medicaid is a - Answer a health insurance assistance program for some low-income people Medicaid is adminisitered on a - Answer state by state basis adhering to certain federal guidelines.

Guide Notes(Notes, definitions and

questions from AAPC CPC Study

Guide Medical Coding Prep)

Medicare Part B helps to cover - Answer medically necessary physicians' services ouptatient care other medical services (including some preventative services) not covered under Part A Medicare Part B premiums are paid by - Answer the patient Medicare Part C combines the benefits of - Answer Part A and Part B and sometimes Part D Medicare Part C is also called - Answer Medicare Advantage Medicare Part C plans are managed by - Answer private insurers approved by Medicare. Medicare Part D is a - Answer prescription drug coverage program Medicare Part D is a coverage provided by - Answer private companies approved by Medicare 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

Guide Notes(Notes, definitions and

questions from AAPC CPC Study

Guide Medical Coding Prep)

The ABN form is entitled - Answer Revised ABN CMS-R-131 and is available with instructions as a free download on the CMS website. The ABN is a standardized form that - Answer explains to the patient why Medicare may deny the particular service or procedure. The OIG is mandated by public law to engage in activities to test - Answer the efficiency and economy of government programs to include investigation of suspected health care fraud or abuse. The amount on an ABN should be within how much of the cost to the patient? - Answer $100 or 25% of cost RATIONALE: CMS instructions stipulate, "Notifires msut 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. The myocardium is thickest around which chamber of the heart? - Answer left ventricle The term "medical necessity refers to - Answer whether a procedure or service is considered appropriate in a given circumstance. The tunica vaginalis is part of which system? - Answer male reproductive Under the Privacy rule, the minimum necessary standard of HIPAA does not apply to

• 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? - Answer OIG work plan What is an NCD interpreted at the MAC level considered? - Answer LCD

Guide Notes(Notes, definitions and

questions from AAPC CPC Study

Guide Medical Coding Prep)

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? - 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 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 - 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 polices, called LCDs? - Answer each MAC (Medicare Administrative Contractor)

Guide Notes(Notes, definitions and

questions from AAPC CPC Study

Guide Medical Coding Prep)

Information required by payers to determine the need for care - Answer 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 - Answer facilities for inpatient services. V codes are commonly used when - Answer the patient presents for treatment with no complaints. examples of common reasons to report V codes: - 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.

Guide Notes(Notes, definitions and

questions from AAPC CPC Study

Guide Medical Coding Prep)

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 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 - Answer :, colon boldface type - Answer used for all codes and titles in the Tabular list Italicized type - Answer used for all exclusion notes and to identify codes that should not be used for describing the primary diagnosis excludes - Answer terms following "excludes" notes are to be reported with a code from another category.

Guide Notes(Notes, definitions and

questions from AAPC CPC Study

Guide Medical Coding Prep)

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