AAPC Official CPC Certification Study Guide Notes

AAPC Official CPC Certification Study Guide Notes "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 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-131 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 $25.0008 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 GPCI is used to - Answer realize the varying cost based on geographic location HCPCS - Answer Healthcare Common Procedure Coding System HHS - Answer Department of Health and Human Services HIPAA provides federal protections for - Answer personal health information when held by covered entities. HIPAA stands for - Answer Health Insurance Portability and Accountability Act of 1996 HITECH - Answer The Health Information Technology for Economic and Clinical Health Act HITECH allows patients to request - Answer an audit trail showing all disclosures of their health information made through an electronic record. HITECH requires that an individual be notified if - Answer there is an unauthorized disclosure or use of his or her health information. HITECH was enacted as part of - Answer the American Recovery and Reinvestment Act of 2009 (ARRA) HMO - Answer Health Maintenence Organization Hemiplegia is a disorder caused by a defect in which anatomic system? - Answer nervous ICD-9-CM - Answer 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 - 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. 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