AAPC Official CPC Certification Study Guide Notes. Verified. Rated A+

AAPC Official CPC Certification Study Guide Notes. Verified. Rated A+ "hold harmless clause" - ✔✔-* found in some non-Medicare health plan contracts * prohibits billing to patient for anything beyond deductibles and ...

AAPC Official CPC Certification Study Guide Notes. Verified. Rated A+ "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 Nonfacility 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 Advantag