AAPC Official CPC Certification Study Guide Notes

"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 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)

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 Advantage

Medicare Part C plans are managed by

private insurers approved by Medicare.

Medicare Part D is a

prescription drug coverage program

Medicare Part D is a coverage provided by

private companies approved by Medicare

Medicare Part D is available to

all Medicare beneficiaries.

Medicare part A helps to cover:

inpatient hospital care

care provided in skilled nursing facilities

hospice care

home health care

Medicare payments for physician services are standardized using a

resource-based relative value scale

(RBRVS)

NCD

National Coverage Determinations

NCD explain

when Medicare will pay for items or services.

NP

Nurse Practitioner

OCR

Office of Civil Rights

OIG

Office of the Inspector General

OIG Compliance Program for Individual and Small Group Physician Practices include the following key actions

* 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

PA

Physician Assistant

PE

Physician Expense

PFS

Physician Fee Schedule

PHI

protected health information

PLI

Professional Liability Insurance

Published Conversion factor for CY 2012

$34.0376

Published conversion factor for CY 2011

$33.9764

RBRVS

Resource Based Relative Value System

RUC

Relative Value Update Committee

Resource costs for RBRVS are divided into three componentes:

physican work

practice expense

professional liability insurance

Sebacious glands are a part of which anatomic system?

Integumentary

The ABN form is entitled

Revised ABN CMS-R-131 and is available with instructions as a free download on the CMS website.

The ABN is a standardized form that

explains to the patient why Medicare may deny the particular service or procedure.

The OIG is mandated by public law to engage in activities to test

the efficiency and economy of government programs to include investigation of suspected health care fraud or abuse.

The amount on an ABN should be within how much of the cost to the patient?

$100 or 25% of cost

RATIONALE: 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.

The myocardium is thickest around which chamber of the heart?

left ventricle

The term "medical necessity refers to

whether a procedure or service is considered appropriate in a given circumstance.

The tunica vaginalis is part of which system?

male reproductive

Under the Privacy rule, the minimum necessary standard of HIPAA does not apply to

* 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

What OIG document should a provider review for potential problem areas that will receive special scrutiny in the upcoming year?

OIG work plan

What is an NCD interpreted at the MAC level considered?

LCD

Each MAC (Medicare Adminstrative Contractor) is responsible for interpreting national policies into regional policies, or Local Coverage Determinations

What is the result of a ureteral blockage?

Urine will not be able to flow from the kidney to the bladder

When does the OIG release a work plan outlining its priorities for the fiscal year ahead?

October

When should an ABN be signed?

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.

Which of the following has a refraction function in the eye?

macula

retina

lens

iris

lens

Which of the following is a function of the pancreas?

* supplies digestive enzymes

manufactures melatonin

* stimulates growth

* secretes vasopressin

supplies digestive enzymes

Which of the following is a renal calculus?

* Pyelectasia

* Hydroureter

* Nephrolithiasis

* Pyonephrosis

Nephrolithiasis

Who is responsible for interpreting national policies into regional polices, called LCDs?

each MAC

(Medicare Administrative Contractor)

Whose responsibility is it to develop and implement policies, best suited to its particular circumstances, to meet HIPAA requirements.

the entity covered by HIPAA

Work RVUs reflect

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.