Review these essential study notes for the AAPC CPC exam. This quick reference guide covers key coding guidelines, anatomical terminology, modifier usage, and frequently tested procedures.
Q: “hold harmless clause”
Answer: * found in some non-Medicare health plan contracts* prohibits billing to patient for anything beyond deductibles and co-pays.
Q: 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
Q: A healthcare clearing house is a
Answer: entity that processes nonstandard health information they receive from another entity into a standard format
Q: 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.
Q: A medically necessary service is the
Answer: least radical service/procedure that allows for effective treatment of the patients’ complaint or condition
Q: A patient sustaining an injury to her great saphenous vein would have sustained injury to which of anatomical site?
Answer: Leg
Q: APC
Answer: Ambulatory Payment Classification
Q: ARRA
Answer: American Recovery and Reinvestment Act (of 2009)
Q: ASC
Answer: Ambulatory Surgical Centers
Q: Abuse consists of
Answer: payment for items or services that are billed by providers in error that should not be paid for by Medicare.
Q: 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.
Q: An entity that processes nonstandard health information they receive from another entity into a standard format is considered what?
Answer: Clearinghouse
Q: As a part of Health Care Reform, the Affordable Care Act of 2010 amended the definition of fraud to remove the __________ requirement
Answer: intent
Q: By statute, all work RVUs, must be examined no less often than
Answer: every 5 years
Q: CF
Answer: Coversion Factor – fixed dollar amount used to translate the RVUs into fees
Q: CMS
Answer: Centers for Medicare and Medicaid
Q: CMS developed polices regarding medical necessity are based on regulations found in title XVIII, $1862(a) of the
Answer: Social Security Act
Q: CMS will accept the ____________ for either a “potentially non=covered” service or for a statutorily excluded service
Answer: CMS-R-131
Q: CMS-R-131
Answer: ABN formorAdvance Beneficiary Notice which explains to the patient why Medicare may deny the particular service or procedure.
Q: CPT
Answer: Current Procedural Terminology
Q: CY 2013 Conversion Factor
Answer: $25.0008
Q: 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
Q: DRG
Answer: Diagnosis Related Group
Q: Does Medicare Part B generally require a yearly deductable and copayment?
Answer: yes
Q: E/M OR E&M
Answer: Evaluation and Management
Q: EHR
Answer: Electronic Health Record
Q: Formula for Calculating Facility Payment amounts
Answer: [(Work RVU Work GPCI) + (Transitioned Facility PE RVU PE GPCI) + (MP RVU MP GPCI)] CF
Q: Formula for Non-Facility Pricing Amount
Answer: [(Work RVU Work GPCI) + (Transitioned Non-Facility PE RVU PE GPCI) + (MP RVU MP GPCI)] (CF)
Q: GPCI
Answer: Geographic Practice Cost Index
Q: GPCI is used to
Answer: realize the varying cost based on geographic location
Q: HCPCS
Answer: Healthcare Common Procedure Coding System
Q: HHS
Answer: Department of Health and Human Services
Q: HIPAA provides federal protections for
Answer: personal health information when held by covered entities.
Q: HIPAA stands for
Answer: Health Insurance Portability and Accountability Act of 1996
Q: HITECH
Answer: The Health Information Technology for Economic and Clinical Health Act
Q: HITECH allows patients to request
Answer: an audit trail showing all disclosures of their health information made through an electronic record.
Q: HITECH requires that an individual be notified if
Answer: there is an unauthorized disclosure or use of his or her health information.
Q: HITECH was enacted as part of
Answer: the American Recovery and Reinvestment Act of 2009 (ARRA)
Q: HMO
Answer: Health Maintenence Organization
Q: Hemiplegia is a disorder caused by a defect in which anatomic system?
Answer: nervous
Q: ICD-9-CM
Answer: International Classification of Disease, 9th Clinical Modification
Q: IF:Work RVUs = 0.48Work GPCI = 1.000Practice Expense CPCI = 0.943MP GPCI = 0.572transitioned non-facility practice RVUs = 0.70Calculate 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)
Q: 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)
Q: If an NCD doesn’t exist for a particular item, its up to the ______ to determine coverage.
Answer: MAC
Q: 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
Q: Incus, stapes, _____
Answer: malleus
Q: Intentional billing of services not provided is considered
Answer: Local Coverage Determinations
Q: LCD
Answer: their regional area
Q: LCDs have jurisdiction only within
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
Q: LCDs give guidance when
Answer: Malpractice
Q: MP
Answer: Medical Severity-Diagnosis Related Group
Q: MS-DRG
Answer: a health insurance assistance program for some low-income people
Q: Medicaid is a
Answer: state by state basis adhering to certain federal guidelines.
Q: Medicaid is adminisitered on a
Answer: medically necessary physicians’ servicesouptatient careother medical services (including some preventative services) not covered under Part A
Q: Medicare Part B helps to cover
Answer: the patient
Q: Medicare Part B premiums are paid by
Answer: Part A and Part B and sometimes Part D
Q: Medicare Part C combines the benefits of
Answer: Medicare Advantage
Q: Medicare Part C is also called
Answer: private insurers approved by Medicare.
Q: Medicare Part C plans are managed by
Answer: prescription drug coverage program
Q: Medicare Part D is a
Answer: private companies approved by Medicare
Q: Medicare Part D is a coverage provided by
Answer: all Medicare beneficiaries.
Q: Medicare Part D is available to
Answer: inpatient hospital carecare provided in skilled nursing facilitieshospice carehome health care
Q: Medicare part A helps to cover:
Answer: resource-based relative value scale(RBRVS)
Q: Medicare payments for physician services are standardized using a
Answer: National Coverage Determinations
Q: NCD
Answer: when Medicare will pay for items or services.
Q: NCD explain
Answer: Nurse Practitioner
Q: NP
Answer: Office of Civil Rights
Q: OCR
Answer: Office of the Inspector General
Q: OIG
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
Q: OIG Compliance Program for Individual and Small Group Physician Practices include the following key actions
Answer: Physician Assistant
Q: PA
Answer: Physician Expense
Q: PE
Answer: Physician Fee Schedule
Q: PFS
Answer: protected health information
Q: PHI
Answer: Professional Liability Insurance
Q: PLI
Answer: $34.0376
Q: Published Conversion factor for CY 2012
Answer: $33.9764
Q: Published conversion factor for CY 2011
Answer: Resource Based Relative Value System
Q: RBRVS
Answer: Relative Value Update Committee
Q: RUC
Answer: physican workpractice expenseprofessional liability insurance
Q: Resource costs for RBRVS are divided into three componentes:
Answer: Integumentary
Q: Sebacious glands are a part of which anatomic system?
Answer: Revised ABN CMS-R-131 and is available with instructions as a free download on the CMS website.
Q: The ABN form is entitled
Answer: explains to the patient why Medicare may deny the particular service or procedure.
Q: The ABN is a standardized form that
Answer: the efficiency and economy of government programs to include investigation of suspected health care fraud or abuse.
Q: The OIG is mandated by public law to engage in activities to test
Answer: $100 or 25% of costRATIONALE: 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.
Q: The amount on an ABN should be within how much of the cost to the patient?
Answer: left ventricle
Q: The myocardium is thickest around which chamber of the heart?
Answer: whether a procedure or service is considered appropriate in a given circumstance.
Q: The term “medical necessity refers to
Answer: male reproductive
Q: The tunica vaginalis is part of which system?
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
Q: Under the Privacy rule, the minimum necessary standard of HIPAA does not apply to
Answer: OIG work plan
Q: What OIG document should a provider review for potential problem areas that will receive special scrutiny in the upcoming year?
Answer: LCDEach MAC (Medicare Adminstrative Contractor) is responsible for interpreting national policies into regional policies, or Local Coverage Determinations
Q: What is an NCD interpreted at the MAC level considered?
Answer: Urine will not be able to flow from the kidney to the bladder
Q: What is the result of a ureteral blockage?
Answer: October
Q: When does the OIG release a work plan outlining its priorities for the fiscal year ahead?
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.
Q: When should an ABN be signed?
Answer: lens
Q: Which of the following has a refraction function in the eye?macularetinalensiris
Answer: supplies digestive enzymes
Q: Which of the following is a function of the pancreas?* supplies digestive enzymesmanufactures melatonin* stimulates growth* secretes vasopressin
Answer: Nephrolithiasis
Q: Which of the following is a renal calculus?* Pyelectasia* Hydroureter* Nephrolithiasis* Pyonephrosis
Answer: each MAC(Medicare Administrative Contractor)
Q: Who is responsible for interpreting national policies into regional polices, called LCDs?
Answer: the entity covered by HIPAA
Q: Whose responsibility is it to develop and implement policies, best suited to its particular circumstances, to meet HIPAA requirements.
Answer: 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.
Q: Work RVUs reflect
Answer: a written set of instructions outlining the process for coding and submitting accurate claims, and what to do if mistakes are found.
Q: compliance plan
Answer: to purposely bill for srevices that were never given or to bill for a service that has a higher reimbursement than the service provided.
Q: fraud
Answer: American Medical Association
Q: AMA
Answer: NCHS (National Centers for Health Statistics) and theCMS (Centers for Medicare & Medicaid Services)
Q: The ICD-9-CM Coordination and Maintenance Committee, which is co-chaired by the
Answer: the Coordination and Maintenance Committee
Q: Maintenance of hte ICD-9-CM is performed by
Answer: advancements in medical knowledge of disease and disease processes, where ICD-9_CM has become outdated and insufficient.
Q: ICD-10 accommodates
Answer: 3
Q: ICD-9CM is published in ___ volumes
Answer: Tabular List: Diagnosis codes organized in order by code
Q: Volume 1 of the ICD-9-CM
Answer: Index to Diseases: Diagnosis codes organized in an alphabetic index
Q: Volume 2 of the ICD-9-CM
Answer: Alphabetic Index and Tabular List of Procedures: Procedures performed in the inpatient setting
Q: Volume 3 of the ICD-9-CM
Answer: medical necessity for services rendered.
Q: Volumes 1 and 2 are used to assign diagnosis codes that establish
Answer: establishing medical necessity
Q: The first step in 3rd party reimbursement is
Answer: 1. knowledge of the emergent nature or severity of the patient’s complaint or condition2. All signs, symptoms, complaints, or background facts describing the reason for care, such as required follow-up care.
Q: Information required by payers to determine the need for care
Answer: facilities for inpatient services.
Q: Volume 3 of the ICD-9-CM includes procedure codes and is typically used by
Answer: the patient presents for treatment with no complaints.
Q: V codes are commonly used when
Answer: screening testsroutine physicalspersonal or family history of a disease or disorder
Q: examples of common reasons to report V codes:
Answer: it must meet the definition of a principle or first-listed diagnosis code
Q: In order for a V code to be listed first,
Answer: how an injury occurred and where the injury occurred.
Q: E codes are used to report
Answer: Morphology of Neoplasms
Q: Appendix A
Answer: 5
Q: Morphology codes consist of ___ digits
Answer: histological type of the neoplasm
Q: The first 4 digits of a morphology code identify the
Answer: behavior of the neoplasm
Q: The fifth digit in a morphology code indicates
Answer: Deleted 10/1/2004 – contained Glossary of Mental Disorders.
Q: Appendix B
Answer: Classification of Drugs by American Hospital Formulary Service List Number and Their ICD-9-CM equivalents
Q: Appendix C
Answer: assist in coding of adverse effects
Q: Appendix C is available to
Answer: Classification of Industrial Accidents According to Agency.
Q: Appendix D
Answer: statistical purposes. It provides information about employment injuries.
Q: Appendix D is used primarily for
Answer: List of 3 digit categories
Q: Appendix E
Answer: Appendix E; 3 digit categories in ICD-9-CM
Q: __________ _________ provides an alternative view of the contents of ICD-9-CM and contains the _____ _____ ______ _____ _______
Answer: conventions, general coding guidelines, and chapter specific guidelines
Q: Section I of the official guidelines includes
Answer: Not elsewhere classifiable
Q: NEC
Answer: the ICD-9-CM system does not provide a code specific for the patient’s condition.
Q: NEC is used when
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
Q: Selecting a code with the NEC classification means
Answer: Not otherwise specified
Q: NOS
Answer: unspecified
Q: NOS is the equivalent of
Answer: the coder lacks the information necessary to code to a more specific 4th or 5th digit subcategory
Q: NOS is used only when
Answer: Brackets are used to enclose synonyms, alternate wording, or explanatory phrases
Q: []
Answer: indicate multiple codes are required
Q: slanted brackets
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
Q: :
Answer: :, colon
Q: 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: used for all codes and titles in the Tabular list
Q: boldface type
Answer: used for all exclusion notes and to identify codes that should not be used for describing the primary diagnosis
Q: Italicized type
Answer: terms following “excludes” notes are to be reported with a code from another category.
Q: excludes
Answer: appears immediately after a three-digit code title to further define or clarify the category
Q: includes
Answer: signals the coder an additional code should be used, if the information is available, to provide a more complete picture of the diagnosis.
Q: use additional code
Answer: When sequencing codes, the codes listed under the “use additional code” are secondary
Q: When seeing the instruction to use additional code, which code goes first?
Answer: 282.42, 517.3
Q: 282.42 Sickle-cell thalassemia with crisis** Sickle-cell thalassemia with vaso-occlusive pain** Thalassemia Hb-S disease with crisisUse 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:
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
Q: Code first
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.
Q: use addtional code, if applicable
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
Q: a combination code indicates
Answer: this term indicates the code describes a disease or syndrome named after a person
Q: eponym
Answer: essential modifiers are subterms listed below the main term in alphabetical order, and are indented 2 spaces
Q: modifiers
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.
Q: other
Answer: CMS and NCHS
Q: official coding and reporting guidelines are provided by
Answer: Index to Disease
Q: Never code directly from the
Answer: Health Insurance Claim Number