AAPC CPB Final

Health plan, clearinghouses, and any entity transmitting health information is considered by the Privacy Rule to be a:

covered entity

Which of the following is not a covered entity in the Privacy Rule

healthcare consulting firm

A request for medical records is received for a specific date of service from patient's insurance company with regards to a submitted claim. No authorization for release of information is provided. What action should be taken?

release reqt to ins co

How many national priority purposes under the Privacy Rules for disclosure of specific PHI without an individual's authorization or permission?

12

A health plan sends a request for medical records in order to adjudicate a claim. Does the office have to notify the patient or have them sign a release to send the information?

no

A practice sets up a payment plan with a patient. If more than four installments are extended to the patient, what regulation is the practice subject to that makes the practice a creditor?

Truth in Lending Act

Which of the following situations allows release of PHI without authorization from the patient?

workers comp

misusing any information on the claim, charging excessively for services or supplies, billing for services not medically necessary, failure to maintain adequate medical or financial records, improper billing practices, or billing Medicare patients at a higher fee scale that non-Medicare patients.

abuse

A claim is submitted for a patient on Medicare with a higher fee than a patient on Insurance ABC. What is this considered by CMS?

abuse

According to the Privacy Rule, what health information may not be de-identified?

phys provider number

making false statements or misrepresenting facts to obtain an undeserved benefit or payment from a federal healthcare program

fraud

All the following are considered Fraud, EXCEPT:

inadequate med recd

A hospital records transporter is moving medical records from the hospital to an off-site building. During the transport, a chart falls from the box on to the street. It is discovered when the transporter arrives at the off-site building and the number of charts is not correct. What type of violation is this?

breach

impermissible release or disclosure of information is discovered

breach

What standard transactions is NOT included in EDI and adopted under HIPAA?

waiver of liability

The Federal False Claim Act allows for claims to be reviewed for a standard of how many years after an incident?

7

A new radiology company opens in town. The manager calls your practice and offers to pay $20 for every Medicare patient you send to them for radiology services. What does this offer violate?

anti kickback laws

A private practice hires a consultant to come in and audit some medical records. Under the Privacy Rule, what is this consultant considered?

biz associate

Medicare overpayments should be returned within ___ days after the overpayment has been identified

60

HIPAA mandated what entity to adopt national standards for electronic transactions and code sets?

HHS

Entities that have been identified as having improper billing practices is defined by CMS as a violation of what standard?

abuse

In addition to the standardization of the codes (ICD-10, CPT, HCPCS, and NDC) used to request payment for medical services, what must be used on all transactions for employers and providers?

unique id

A person that files a claim for a Medicare beneficiary knowing that the service is not correctly reported is in violation of what statute?

False Claims Act

Medicare was passed into law under the title XVIII of what Act?

SS Act

While working in a large practice, Medicare overpayments are found in several patient accounts. The manager states that the practice will keep the money until Medicare asks for it back. What does this action constitute?

fraud

A practice agrees to pay $250,000 to settle a lawsuit alleging that the practice used X-rays of one patient to justify services on multiple other patients' claims. The manager of the office brought the civil suit. What type of case is this?

qui tam

OIG, CMS, and Department of Justice are the government agencies enforcing ________.

fed abuse and fraud laws

A practice allows patients to pay large balances over a six month time period with a finance charge applied. The patient receives a statement every month that only shows the unpaid balance. What does this violate?

TILA

An insurance plan that provides a gatekeeper to manage the patient's health care is known as a/an

HMO

a corporate umbrella for management of diversified healthcare delivery systems

IPO

An employee has signed up for a program through her employer. It allows her to put pre-tax money away from her paycheck in order to pay for out-of-pocket healthcare expenses. She may contribute up to $2650 (2018) per year. If she does not use all of the money during the current year, she forfeits it. What is this?

FSA

Which option is not considered an MCO?

HSA

A Medicare patient presents after slipping and falling in a neighbor's walkway. The cement had a large crack, which caused the pavement to raise and be unsteady. The neighbor has contacted his homeowner's insurance and they are accepting liability and have initiated a claim. How should the visit be billed?

Homeowners, then Medicare

Insurance coverage provided by an organization that is not an employer (such as a membership organization or credit card company that offer benefits to its members) is what kind of group insurance?

association group

office bills Medicare, but the patient receives the payment and the office must collect their fee from the patient. The office, by state law, can charge the patient a limiting charge that is 10 percent above the Medicare fee schedule amount. What type of Medicare provider is this physician?

non par

A patient presenting for care does not have an insurance card and is billed CPT 99213 for $100. The patient pays $100 to the provider. A week later, the patient presents verification of coverage through Medicaid for this date of service. What process should be followed?

file a claim to Medicaid w EOB

Medicare part without a monthly charge if worked for 10+ years

A

Managed Care Organizations (MCOs) place the physician at financial risk for the care of the patient and are reimbursed by

capitation

Which of the following is NOT evaluated in the credentialing process?

phys req for priviledges

HSA is ____________________ to employees

tax free income

What type of plan allows an insurer to administer straight indemnity insurance, an HMO, or a PPO insurance plans to its members?

triple option

A healthcare organization with 2 hospitals, 20 clinics, and 3 urgent care centers belongs to an ACO program. They have been in the shared savings program for two years and are now eligible to move large payments to a population-based model as they have been successful in keeping costs down and have met all the CMS benchmarks set for them. What type of ACO is this?

Pioneer

What is the largest health program in the United States?

Medicare

a unique 10-digit identification number required by HIPAA

NPI

Medicaid plans provide for low-income families. Which statement regarding Medicaid is NOT correct?

All plans offer HMOs

A new physician comes in to the practice that is just out of medical school. He will need to be able to see patients in the office and at the hospital. What process will he need to undergo in order to be able to participate with Medicare and other health plans?

credentialling

NPI numbers have two types of entities - identify the two types:

group and sole proprietor

NPI

National Provider Identifier

Which of the following services is NOT covered under Medicare Part B?

Home Health

ACOs are formed with ___ lives

5000

HMOs are formed with ___ lives

100,000 +

When insurance coverage is being verified, which of the following is NOT a method on which to rely?

patient

When a fee ticket (encounter form) is not completed, what procedure would NOT be acceptable?

no charge

Information about deductibles, copays, eligibility dates, and benefit plans is completed during what step?

verify benefits

determine primary and secondary coverage

birthday rule

Which of the following is NOT considered a part of the authorized process when the patient signs the consent for payment?

auth for treatment

Patient types help to classify the patients based on

payer, ins type

Life Cycle of a Claim

submission

processing

adjudication

payment/denial

What authorizes information to be sent to the insurance payer so payment of medical benefits can be processed?

consent for payment

Amount of expenses that must be paid before any payment is made by the insurance company

deductible

BCBS member #:

3 letters then 9 numbers

When charges are entered and all required components are verified by the claims editing system, what would this be considered as?

clean claim

When does the processing of an insurance claim for a patient begin?

when appt scheduled

When a patient is seen for evaluation and the decision is made for a minor procedure that is performed on the same day, which modifier is appended to the claim to allow reimbursement for the E/M and the procedure?

25

A 68-year-old Medicare patient presented for an annual examination and had no complaints. Her claim, billed as 99387, was denied. Was this billed correctly? If not, how is this encounter correctly billed?

it depends on doc

If a procedure is performed on a 72-year-old Medicare patient which code category is preferred for reporting?

G code HCPCS

The NCCI policy manual is updated:

annually

The part of National Correct Coding Initiative (NCCI) that places frequency limitations on codes that can be billed on a single date of service by a single provider is called:

MUE

provide limitations of frequency on codes that can be billed in a single day by a single provider for a beneficiary.

MUE

NCCI edits are updated by CMS and released

quarterly

When using the Practitioner PTP Edits table, an NCCI tool, the modifier indicator of 0 (zero) tells the user:

mod not allowed

Indicates specific CPT code pairs that can be reported on the same day for the same beneficiary by the same provider.

NCCI file

The Medicaid NCCI program consists of six methodologies. Each methodology is composed of ___ components

4

Medicare states that reporting bundled codes in addition to the major procedural code is considered to be unbundling, and if repeated with frequency it is considered to be:

fraud

When looking at the NCCI Edit tables, Column 1 codes are indicated as payable. Column 2 codes contain the codes that are:

not payable without mod

What modifier is required when a procedure is performed on the same day as an E/M service and both should be paid and not considered bundled?

25

What modifier is used to indicate two procedures are performed on the same day and should not be bundled?

59

NCDs are released by which of the following entities:

CMS

Reporting a service based on an LCD requires the CPB to look at coverage guidance for the procedure being performed. Coverage guidance would NOT include:

experimental procedures

Which of the following modifiers are not used to bypass NCCI edits?

76, 77

Services that are performed for treatment or diagnosis of an injury, illness, or disease in accordance with generally accepted standards of medical practice defines:

medical necessity

Codes that are considered to be bundled are based on Centers for Medicare & Medicaid (CMS) standards called:

NCCI

An E/M service that is performed during a post-operative period, but is not related to the surgical procedure that was performed, can be billed with which modifier?

24

Medicare provides a list of questions to ask beneficiaries that helps determine if Medicare is primary or secondary. Where can this information be found?

MSP Manual

What type of code reports the event(s) related to the billing period on the UB-04 claim form?

occurrence codes

What is the purpose of the standard CMS-1500 claim form?

pro services for phys

FL 35 and FL 36 are used on the UB-04 claim form to identify occurrence span code and dates. When is this section completed?

inpt services

When entering the patient's name on the CMS-1500 claim form, what punctuation should be used?

comma

A ___ is used to indicate an inpatient service is reported on an outpatient claim.

condition code

The UB-04 claim form is also called:

CMS 1450

Determination of the insurer's payment amount after the member's insurance benefits have been applied.

adjudication

___ provider with overall responsibility for the patient's medical care during hospitalization.

attending

Identify the correct format to enter the date of birth on a paper CMS-1500 claim form

MMDDCCYY

On the UB-04 claim form, the type of bill is identified by a four-digit numerical code. The first digit is a leading zero, what does the second digit represent?

facility type

Medicare refers to the insured's ID as the:

health ins claim number

The provider accepts a contractual write-off of the difference between the charged amount and the allowed amount.

accepting assignment

Which regulation established claim standards for electronic filing requirements when a provider uses a computer with software to submit an electronic claim?

HIPAA

Which is NOT used for data entry?

intl audit sys

________ is when the provider has limited access to payer and patient data elements on their patients only.

extranet

When a batch of claims is submitted electronically to a clearinghouse a report is sent to the provider. Which feedback does this report from the clearinghouse identify?

claims sent to payer/rejected