AAPC CPC Chapter 1 Questions and Answers 100% Pass

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AAPC CPC Chapter 1 Questions and Answers 100% Pass Medical coding ✔✔process of translating a healthcare provider's documentation of a patient encounter into a series of numeric or alphanumeric ... codes Health information coders, medical record coders, coder/abstractors, coding specialists ✔✔coders who specialize in coding inpatient hospital services MS-DRG ✔✔Medical Severity-Diagnosis Related Groups MS-DRG are used to: ✔✔determine the amount the hospital will be reimbursed if the patient is covered by Medicare or other insurance programs using the MS-DRG system Cancer (or tumor) registrars ✔✔maintain facility, regional, and national databases of cancer patients EHR ✔✔electronic health record Other roles coders can have: ✔✔consultants, educators, medical auditors Outpatient coders ✔✔use CPT, HCPCS Level II, and ICD-10-CM codes; work in provider offices, outpatient clinics, and facility outpatient departments; also use Ambulatory Payment Classifications (APCs); have more interaction with providers Inpatient coders ✔✔use ICD-10-CM and ICD-10-PCS codes; also use MS-DRGs for reimbursement; have less interation directly with providers Remittance advice (RA) / Explanation of Benefits (EOB) ✔✔explains the payer's determination in payment Scope of practice ✔✔practice guidelines for each level of a provider individually dictated by states Mid-level Provider (MLP) ✔✔include physician assistants (PA) and nurse practitioners (NP); aka physician extenders Physician Assistant (PA) ✔✔Works under the supervision of physicians; PA program takes approximately 26 1/2 months to complete after completion of a bachelor's degree Nurse Practitioner (NP) ✔✔have a master's degree in nursing Two types of payers: ✔✔private insurance plans and government insurance plans Medicare ✔✔primary government payer in the U.S.; provides coverage for people 65 and older, blind, disabled, and people with permanent kidney failure or end-stage renal disease (ESRD) Medicare Part A ✔✔Inpatient coverage, home health, hospice, skilled nursing facilities; also defines limits of Medicare usage Medicare Part B ✔✔The part of the Medicare program that pays medically necessary provider services, preventative services, durable medical equipment, and other services and supplies. Medicare Part C (Medicare Advantage Plans) ✔✔combines benefits of Part A, B, and sometimes D; managed by private insurers approved by Medicare; may charge different copays, coinsurance, or deductibles CMS-HCC ✔✔Centers for Medicare & Medicaid Services-Hierarchical Condition Category Medicare Part D ✔✔Prescription drug coverage Medicaid ✔✔health insurance assistance program sponsored by federal and state governments for low-income people Limiting charge ✔✔set limits on what the patient can be charged SOAP ✔✔subjective, objective, assessment, plan Subjective ✔✔patient's statement about his or her health, includes symptoms Objective ✔✔provider's examination and documentation of the patient's illness Assessment ✔✔evaluation and conclusion made by the provider; where you find the diagnoses Plan ✔✔course of action E/M ✔✔Evaluation and Management Operative Report coding tips ✔✔1. Highlight unfamiliar words 2. Use post-operative Dx for coding; if pathology report available, use pathology report for Dx 3. Start with procedures listed 4. Look for key words 5. Read the body Medical Necessity ✔✔the lease radical service/procedure that allows for effective treatment of the pt's complaint or condition National Coverage Determinations Manual ✔✔describes whether specific medical items, services, treatment, procedures, or technologies can be paid for under Medicare National Coverage Determination (NCD) ✔✔explain when Medicare will pay for items or services Medicare Administrative Contractor (MAC) ✔✔responsible for interpreting national policies into regional policies Local Coverage Determination (LCD) ✔✔decisions by MACs that define what codes are needed and when an item or service will be covered; have jurisdiction only within their region Advance Beneficiary Notice (ABN) ✔✔a standardized form that explains to the pt why Medicare may deny the service or procedure; protects the provider's financial interest Common reasons Medicare denies a procedure or service: ✔✔1. Medicare doesn't pay for the procedure/service for the pt's condition 2. Medicare doesn't pay for the procedure/service as frequently as proposed 3. Medicare doesn't pay for experimental services Reasonable estimate on an ABN ✔✔$100 or 25%, whichever is greater Non-Medicare payers may not recognize: ✔✔ABN Health Insurance Portability and Accountability Act (HIPAA) ✔✔provides federal protections for protection health information when held by covered entities; five part act Covered entity under HIPAA ✔✔doctors, clinics, psychologists, dentists, chiropractors, nursing homes, pharmacies, health insurance companies, HMOs, company health plans, government programs, healthcare clearinghouse HCFAC ✔✔Health Care Fraud and Abuse Control Program; designed to coordinate federal, state, and local law enforcement activities with respect to healthcare fraud and abuse HCPCS ✔✔Healthcare Common Procedure Coding System CPT ✔✔Current Procedural Terminology CDT ✔✔Current Dental Terminology ICD-10-CM ✔✔International Classification of Diseases, 10th Revision, Clinical Modification NDC ✔✔National Drug Code Minimum necessary ✔✔only the minimum necessary protected health information should be shared to satisfy a particular purpose PHI ✔✔Protected Health Information HITECH Act of 2009 ✔✔Health Information Technology for Economic and Clinical Health Act; made into a law to promote the adoption and meaningful use of health information technology MACRA ✔✔Medicare Access and CHIP Reauthorization Act of 2015; repealed sustainable growth rate (SGR) formula for physician payment updates in Medicare, prevented scheduled reductions in physician payments, and provided 0.5% rate increases to Medicare Part B single conversion factor QPP ✔✔Quality Payment Program MIPS ✔✔Merit-based Incentive Payment System will be a budget neutral program successful reporters will earn incentive payments by unsuccessful reporters. CMS ✔✔Centers for Medicare and Medicaid Services Promoting Interoperability (PI) ✔✔promotes secure exchange of health information and the use of certified electronic health record technology for coordination of care CEHRT ✔✔Certified Electronic Health Record Technology APMs ✔✔Advanced Alternative Payment Models Office of the Inspector General (OIG) ✔✔government agency tasked to protect the integrity of HHS programs, and the health and welfare ofthe beneficiaries of those programs; offers compliance program guidance OIG Compliance Program Guidance ✔✔Seven key components: 1. conducting internal monitoring and auditing through periodic audits 2. implementing compliance and practice standards through development of written standards and procedures 3. designating a compliance officer or contact 4. conducting appropriate training and education 5. responding appropriately to detected violations 6. developing open lines of communication 7. enforcing disciplinary standards through well-publicized guidelines OIG Work Plan ✔✔sets forth a plan outlining its priorities for the fiscal year and beyond AAPC ✔✔American Academy of Professional Coders (founded 1988) AAPC Code of Ethics ✔✔Integrity, respect, commitment, competence, fairness, responsibility HHS ✔✔Department of Health and Human Services PPACA ✔✔Patient Protection and Affordable Care Act of 2010 TPO ✔✔Treatment, payment, and healthcare operations [Show More]

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