AAPC Chapter 1 Review - The Business of Medicine Already Passed

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AAPC Chapter 1 Review - The Business of Medicine Already Passed Which statement describes a medically necessary service? A. Performing a procedure/service based on cost to eliminate wasteful servic... es. B. Using the least radical service/procedure that allows for effective treatment of the patient's complaint or condition. C. Using the closest facility to perform a service or procedure. D. Using the appropriate course of treatment to fit within the patient's lifestyle. ✔✔*Answer: B. Using the least radical service/procedure that allows for effective treatment of the patient's complaint or condition.* Rationale: Medical necessity is using the least radical services/procedure that allows for effective treatment of the patient's complaint or condition. According to the example LCD from Novitas Solutions, which of the following conditions is considered a systemic condition that may result in the need for routine foot care? A. Arthritis B. Chronic venous insufficiency C. Hypertension D. Muscle weakness ✔✔*Answer: B. Chronic venous insufficiency* Rationale: According to the LCD, Chronic venous insufficiency is a systemic condition that may result in the need for routine foot care. What form is provided to a patient to indicate a service may not be covered by Medicare and the patient may be responsible for the charges? A. LCD B. CMS-1500 C. UB-04 D. ABN ✔✔*Answer: D. ABN * Rationale: An Advanced Beneficiary Notice (ABN) is used when a Medicare beneficiary requests or agrees to receive a procedure or service that Medicare may not cover. This form notifies the patient of potential out of pocket costs for the patient. Select the TRUE statement regarding ABNs. A. ABNs may not be recognized by non-Medicare payers. B. ABNs must be signed for emergency or urgent care. C. ABNs are not required to include an estimate cost for the service. D. ABNs should be routinely signed by Medicare Beneficiaries in case Medicare doesn't cover a service. ✔✔*Answer: A. ABNs may not be recognized by non-Medicare payers.* Rationale: ABNs may not be recognized by non-Medicare payers. Providers should review their contracts to determine which payers will accept an ABN for services not covered. When presenting a cost estimate on an ABN for a potentially noncovered service, the cost estimate should be within what range of the actual cost? A. $25 or 10 percent B. $100 or 10 percent C. $100 or 25 percent D. An exact amount ✔✔*Answer: C. $100 or 25 percent* Rationale: CMS instructions stipulate, "Notifiers must make a good faith effort to insert a reasonable estimate...the estimate should be within $100 or 25 percent of the actual costs, whichever is greater." Who would NOT be considered a covered entity under HIPAA? A. Doctors B. HMOs C. Clearinghouses D. Patients ✔✔*Answer: D. Patients* Rationale: Covered entities in relation to HIPAA include healthcare providers, health plans, and healthcare clearinghouses. The patient is not considered a covered entity although it is the patient's data that is protected. Under HIPAA, what would be a policy requirement for minimum necessary? A. Only individuals whose job requires it may have access to protected health information. B. Only the patient has access to his or her own protected health information. C. Only the treating provider has access to protected health information. D. Anyone within the provider's office can have access to protected health information. ✔✔*Answer: A. Only individuals whose job requires it may have access to protected health information.* Rationale: It is the responsibility of a covered entity to develop and implement policies best suited to its particular circumstances to meet HIPAA requirements. As a policy requirement, only those individuals whose job requires it may have access to protected health information. Which act was enacted as part of the American Recovery and Reinvestment Act of 2009 (ARRA) and affected privacy and security? A. HIPAA B. HITECH C. SSA D. ACA ✔✔*Answer: B. HITECH* Rationale: The Health Information Technology for Economic and Clinical Health Act (HITECH) was enacted as a part of the American Recovery and Reinvestment Act of 2009 (ARRA) to promote the adoption and meaningful use of health information technology. Portions of HITECH strengthen HIPAA rules by addressing privacy and security concerns associated with the electronic transmission of health information. What document assists provider offices with the development of compliance manuals? A. OIG Compliance Plan Guidance B. OIG Work Plan C. OIG Suggested Rules and Regulations D. OIG Internal Compliance Plan ✔✔*Answer: A. OIG Compliance Plan Guidance* Rationale: The OIG has offered compliance program guidance to form the basis of a voluntary compliance program for physician offices. Although this was released in October 2000, it is still considered as active compliance guidance today What document is referenced when looking for potential problem areas identified by the government indicating scrutiny of the services? A. OIG Compliance Plan Guidance B. OIG Security Summary C. OIG Work Plan D. OIG Investigation Plan ✔✔*Answer: C. OIG Work Plan* Rationale: On its website, the OIG releases a Work Plan outlining its priorities. Within the Work Plan, potential problem areas with claims submissions are listed and will be targeted with special scrutiny. What type of profession, other than coding, might skilled coders enter? ✔✔*Consultants, educators, medical auditors Consultants, educators, medical auditors* What is the difference between outpatient and inpatient coding? ✔✔*Inpatient coders use ICD10-CM and ICD-10-PCS. Inpatient coders use ICD-10-CM and ICD-10-PCS.* What is a mid-level provider? ✔✔*Mid-level providers include physician assistants (PA) and nurse practitioners (NP).* What are the different parts of Medicare? ✔✔*Part A, B, C, D* Evaluation and management (E/M) services are often provided and documented in a standard format. One such format is SOAP notes. What does SOAP represent? ✔✔*Subjective, Objective, Assessment, Plan* What are five tips for coding operative (op) reports? ✔✔*Diagnosis code reporting, start with the procedures listed, Look for key words, Highlight unfamiliar words, Read the body* What is medical necessity? ✔✔*Relates to whether a procedure or service is considered appropriate in a given circumstance.* What is not a common reason Medicare may deny a procedure or service? ✔✔*Covered service* Under the Privacy Rule, the minimum necessary standard does NOT apply to what type of disclosures? ✔✔*Disclosures to the individual who is the subject of the information.* Which is not one of the seven key components of an internal compliance plan? ✔✔*Conduct training but not perform education on practice standards and procedures.* What type of insurance is Medicare Part D? ✔✔*Prescription drug coverage available to all Medicare beneficiaries.* Rationale: Medicare Part D is a prescription drug program available to all Medicare beneficiaries for a fee. Private companies approved by Medicare provide the coverage. Which of the following is a BENEFIT of electronic transactions? ✔✔*Timely submission of claims* Rationale: Electronic claims benefit the provider office by allowing timely submissions to the insurance carrier and proof of transmission of the claims. What type of health insurance provides coverage for low-income families? ✔✔*Medicaid * Rationale: Medicaid is a health insurance assistance program for some low-income people (especially children and pregnant women) sponsored by federal and state governments. Which coding manuals do outpatient coders focus on learning? ✔✔*CPT®, HCPCS Level II and ICD-10-CM * Rationale: Outpatient coding focuses on provider services. Outpatient coders will focus on learning CPT®, HCPCS Level II and ICD-10-CM. According to the AAPC Code of Ethics, which term is NOT listed as an ethical principle of professional conduct? ✔✔*Efficiency * Rationale: It shall be the responsibility of every AAPC member, as a condition of continued membership, to conduct themselves in all professional activities in a manner consistent with ALL of the following ethical principles of professional conduct: · · Integrity · Respect · Commitment · Competence · Fairness · Responsibility LCDs only have jurisdiction in their ____. ✔✔*Region * Rationale: LCDs only have jurisdiction within their region. Professionals who specialize in coding are called: ✔✔*Coding specialists * Rationale: Professionals who specialize in coding are called medical coders or coding specialists. A covered entity does NOT include ✔✔*Patients* The Medicare program is made up of several parts. Which part covers provider fees without the use of a private insurer? ✔✔*Part B * Rationale: Medicare Part B helps to cover medically necessary provider services, outpatient care and other medical services (including some preventive services) not covered under Medicare Part A. Medicare Part B is an optional benefit for which the patient pays a monthly premium, an annual deductible, and generally has a 20% co-insurance except for preventive services covered under the healthcare law. The Medicare program is made up of several parts. Which part is affected by the Centers for Medicare & Medicaid Services - Hierarchical Condition Categories (CMS-HCC)? ✔✔*Part C * Rationale: Accurate and thorough diagnosis coding is important for Medicare Advantage (Part C) claims because reimbursement is impacted by the patient's health status. The Centers for Medicare & Medicaid Services-hierarchical condition category (CMS-HCC) risk adjustment model provides adjusted payments based on a patient's diseases and demographic factors. If a coder does not include all pertinent diagnoses and comorbidities, there may be loss of additional reimbursement to which the provider is entitled. What type of provider goes through approximately 26 ½ months of education and is licensed to practice medicine with the oversight of a physician? ✔✔*Physician Assistant (PA) * Rationale: Physician Assistants are licensed to practice medicine with physician supervision. A PA program takes approximately 26 ½ months to complete. The OIG recommends that provider practices enforce disciplinary actions through well publicized compliance guidelines to ensure actions that are ______. ✔✔*Consistent and appropriate * Rationale: The OIG recommends that a provider practice's enforcement and disciplinary mechanisms ensure that violations of the practice's compliance policies will result in consistent and appropriate sanctions, including the possibility of termination, against the offending individual. What does MAC stands for? ✔✔*Medicare Administrative Contractor * Rationale: Medicare Administrative Contractor (MAC) Voluntary compliance programs also provide benefits by not only helping to prevent erroneous or ____, but also by showing that the provider practice is making additional good faith efforts to submit claims appropriately. ✔✔*Fraudulent claims * Rationale: Voluntary compliance programs also provide benefits by not only helping to prevent erroneous or fraudulent claims, but also by showing that the provider practice is making additional good faith efforts to submit claims appropriately. The AAPC offers over 500 local chapters across the country for the purpose of ✔✔*Continuing education and networking* Rationale: The AAPC offers over 500 local chapters across the country. Through local chapters, AAPC members can obtain continuing education, gain leadership skills and network. The ____describes whether specific medical items, services, treatment procedures or technologies are considered medically necessary under Medicare. ✔✔*National Coverage Determinations Manual * Rationale: The National Coverage Determinations Manual describes whether specific medical items, services, treatment procedures or technologies are considered medically necessary under Medicare. What does CMS-HCC stand for? ✔✔*Centers for Medicare & Medicaid Services - Hierarchal Condition Category * Rationale: Centers for Medicare & Medicaid Services - Hierarchal Condition Category Which option below is NOT a covered entity under HIPAA? ✔✔*Workers' Compensation * Rationale: The definition of health plan in the HIPAA regulations excludes any policy, plan or program that provides or pays for the cost of excepted benefits. Excepted benefits include: • Coverage only for accident or disability income insurance, or any combination thereof; • Coverage issued as a supplement to liability insurance; • Liability insurance, including general liability insurance and automobile liability insurance; • Workers' compensation or similar insurance; • Automobile medical payment insurance; • Credit-only insurance; • Coverage for onsite medical clinics; • Other similar insurance coverage, specified in regulations, under which benefits for medical care are secondary or incidental to other insurance benefits. What is the definition of medical coding? ✔✔*Translating documentation into numerical/alphanumerical codes used to obtain reimbursement. * Rationale: Medical coding is the process of translating a healthcare provider's documentation of a patient encounter into a series of numeric or alphanumeric codes.* What will the scope of a compliance program depend on? ✔✔*The size and resources of the provider's practice. * Rationale: The scope of a compliance program will depend on the size and resources of the provider practice. The minimum necessary rule applies to ✔✔*Covered entities taking reasonable steps to limit use or disclosure of PHI * Rationale: The Privacy Rule generally requires covered entities to take reasonable steps to limit the use or disclosure of, and requests for, protected health information to the minimum necessary to accomplish the intended purpose. The minimum necessary standard does not apply to the following: · 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 Health Insurance Portability and Accountability Act (HIPAA) Administrative Simplification Rules. · Disclosures to the Department of Health & Human Services (HHS) when disclosure of information is required under the Privacy Rule for enforcement purposes. · Uses or disclosures that are required by other law. What is the purpose of National Coverage Determinations? ✔✔*To explain CMS policies on when Medicare will pay for items or services. * Rationale: National Coverage Determinations (NCD) explain CMS policies on when Medicare will pay for items or services. Local Coverage Determinations are administered by whom? ✔✔*Each regional MAC * Rationale: Each Medicare Administrative Contractor (MAC) is responsible for interpreting national policies into regional policies. What form is used to submit a provider's charge to the insurance carrier? ✔✔*CMS-1500 * Rationale: Once documentation is translated into codes, it is then sent on a CMS-1500 form to the insurance carrier for reimbursement. According to the OIG, internal monitoring and auditing should be performed by what means? ✔✔*Periodic audits. * Rationale: A key component of an effective compliance program includes internal monitoring and auditing through the performance of periodic audits. This ongoing evaluation includes not only whether the provider practice's standards and procedures are in fact current and accurate, but also whether the compliance program is working, (for example, whether individuals are properly carrying out their responsibilities and claims are submitted appropriately) [Show More]

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