AAPC Official CPC Certification Study Guide Notes

AAPC Official CPC Certification Study Guide Notes "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 CF - Coversion Factor - fixed dollar amount used to translate the RVUs into fees CMS - Centers for Medicare and Medicaid CMS developed polices regarding medical necessity are based on regulations found in title XVIII, $1862(a) of the - Social Security Act CMS will accept the ____________ for either a "potentially non=covered" service or for a statutorily excluded service - CMS-R-131 CMS-R-131 - ABN form or Advance Beneficiary Notice which explains to the patient why Medicare may deny the particular service or procedure. CPT - Current Procedural Terminology CY 2013 Conversion Factor - $25.0008 Commercial (non-Medicare) may develop their own medical policies which do not follow Medicare guidelines and are specified in - private contracts between the payer and practice or provider DRG - Diagnosis Related Group Does Medicare Part B generally require a yearly deductable and copayment? - yes E/M OR E&M - Evaluation and Management EHR - Electronic Health Record Formula for Calculating Facility Payment amounts - [(Work RVU * Work GPCI) + (Transitioned Facility PE RVU * PE GPCI) + (MP RVU * MP GPCI)] * CF Formula for Non-Facility Pricing Amount - [(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 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? - Part D Incus, stapes, _____ - malleus Intentional billing of services not provided is considered - LCD - Local Coverage Determinations LCDs have jurisdiction only within - their regional area 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 MP - Malpractice MS-DRG - Medical Severity-Diagnosis Related Group Medicaid is a - a health insurance assistance program for some low-income people Medicaid is adminisitered on a - state by state basis adhering to certain federal guidelines. Medicare Part B helps to cover - 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 - the patient 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.