AAPC CPB Final Exam Study Guide

HIPPA OF 1996 includes a security rule that is established to provide what national stands for protecting and transmitting patient data. Which of the following is NOT true?

A) The security rule applies to healthcare providers, health plans, and any covered entity involved in the care of a patient.

B) The security role applies only to the Institute that initiates the release of protected health information

C) Standards for storing transmitting patient data and electronic form include portable electronic devices

D) The security rule states that safeguards must be in place to prevent unsecured release of information

B

Eight standard transactions were adopted for electronic data, interchange under HIPAA which of the following is not included as a standard transaction

A) payment and remittance advice

B) eligibility in a health plan

C) coordination of benefits

D) physician unique identify number

D

A claim is received by a payer that subsequently request the medical records for the date of service on the claim what procedure should be followed by the practice?

Only the date of service on the claim should be sent to the payer. The records can be sent as part of HIPAA based on treatment payment and operations.

HIPAA requires that privacy practice notices be provided in several circumstances, which of the following is not required

A) must be available on any website that practice maintains

B) must be provided upon request

C) must be presented to all patients

D) must be placed into the patient's file

D

When is subpoena is received by the practice for medical records, and what circumstances may the records be released according to the HIPAA privacy rule

A) the subpoena allows for the release of the medical records

B) this subpoena is accompanied by a court order, or the patient is notified, and given a chance to object

C) the individual must sign an authorization for release at the information

D) records cannot be released under any circumstances based on the subpoena

B

A physician received office space at a reduced rate for referring patients to the hospitals, outpatient physical therapy center. What law does this violate?

Anti-Kickback Statute

Federal healthcare plans include what payers?

Medicare, Medicaid, Tricare

One of the most severe penalties that can be associated with violations at the Social Security act is exclusion from federal healthcare plans, which of the following statements is true of excluded individuals?

A) physicians that have been excluded can build the patient for services, but cannot bill federal health plans

B) physicians that have been excluded can refer further patients to other facilities for treatment

C) physicians that have been excluded or prohibited from billing for any service to a federally administered health plan

D) physicians that have been excluded are exempt from billing for services, but are allowed to write prescriptions and order tests

C

A physician built claims to Medicare and Medicaid for procedures that were not performed on 800 patients resulting in loss of $2.6 million. Is this fraud or abuse?

Fraud; subject to the false claims act

The regulation of finance charges or interest, applied to outstanding balances, and medical practice is under what law?

Truth in Lending Act

What type of insurance is paid for by employers for employees and takes advantage of purchasing power of having large member numbers?

Group Health Plan

An internist sees a 20-year-old patient for an office visit. The patient needs to see an endocrinologist for a consultation regarding her diabetes. The internist is a participating provider in her plan. She can choose any provider she wishes for her consultation, but she will save money if she sees a specialist that is in her network. She does not require a referral for her consultation. What type of insurance does the patient have?

PPO

What are the options for a provider with regards to participation with Medicare?

Providers may participate, may choose not to participate, or may opt-out of Medicare

A family practitioner sees a Medicare patient and bills a 99213. This provider has opted out of Medicare. His fee for the service is $125. Medicare's approved amount is $73.08 and the patient has met $0 of his deductible. What can the provider bill a patient?

$125.00

Under the patient protection in affordable care act what is banned?

Lifetime limits

A Medicaid patient presents for services on the first day of the month. He has a $50 spenddown he's had no services this month. The visit for today was $100. If the patient wants to be covered as long as possible from today's visit, what can he do?

Turn the receipt into his caseworker and be eligible for two months of coverage

Which insurance is a healthcare benefit program for military personnel in all seven uniformed branches?

TRICARE

A patient has receipts for her dental cleaning, vision, exam and contact lenses. Her employer has set up special counts for each employee, there's no limit to the amount the employer can contribute and the balances roll over from year to year. What type of account is this?

Traditional healthcare reimbursement arrangement (HRA)

A patient presents to be seen in the office. He does not pay at the time the services are rendered as the provider is his primary care provider or gatekeeper. The large group practice has 800 covered members under this plan, and is paid on a monthly basis with a set amount that is based on the number of members covered and their ages. What type of plan is this?

Capitation

Why must a provider obtain an NPI number?

I. To submit claims

II. To prove that he is licensed

III. To be HIPAA compliant

IV. To guarantee payment by a health plan

a. I, II, III

b. II, III, IV

c. I, II, III, IV

d. I, III

D. I and III

The patient encounter begins with what step?

Scheduling an appointment

Which of the following does not qualify a patient for coverage under Medicare?

A) end stage renal disease (ESRD)

B) age 65 or older

C) under age 65 with disabilities

D) low-income individual

d. Low income individual

What is a claim that is sent for reimbursement that contains all the required data elements to process a claim referred to as?

clean claim

Listed below are examples of patient reminders for appointment appointments which one is HIPAA compliant?

A) this is the obstetrical office calling to remind you of your appointment Tuesday, April 12 at 9 AM for your annual exam

B) this is Dr. Smith's office calling to remind you of your appointment Tuesday, April 12 at 9 AM for your annual exam

C) this is confirm your appointment for your first prenatal visit with Dr. Jones. Please notify us if you are not able to keep this appointment.

D) this is the doctors office calling to remind you of your appointment Tuesday, April 12 at 9 AM

D

Which of the following statements is true regarding patient demographics?

A) demographic information can only be provided by the patient

B) patient demographic information can be released to a third-party without the patient's consent

C) patient demographic information entered incorrectly, can result in claim denials

D) claims processing is not affected by patient demographic information

C

The parent with whom the child resides is identified as what?

Custodial parent

A patient's insurance card will contain vital information that will allow a claim to be processed which of the following is not provided on the insurance card?

A) policy holder, group number

B) claim number, CPT code, diagnosis

C) policyholder, co-pay, deductible

D) claim address? group number

B

A child has brought to the doctors office by the mother to be seen the mother date of birth February 8, 1993 is the custodial parent and his remarried. She has an individual policy the father date of birth October 10, 1992 is covered by a policy from work. The stepfather is also covered at work which of the following is correct?

A) the mothers insurance is primary

B) the step parent is primary

C) the father is always primary

D) either the mother or father can be primary

A

HIPPA section 164.508 states that covered entities may not use or disclose protected information without a valid authorization, and what circumstances can a practice NOT release protected information without assigned authorization?

A) records sent to a physician asked to consult with the patient

B) payment of claims

C) records requested by the health department for communicable diseases

D) records requested for life insurance

D

Child presents for care with the father. Both parents have coverage date of birth for mother is March 21 and date of birth for father is June 20. The mother is covered by a COBRA. What is the primary covered for the child?

Father is primary because the mother has COBRA

Which statement is true regarding the ICD-10-CM codebook?

A) every code requires seven characters

B) the external cause of injuries index is the first index found in the ICD-10-CM codebook

C) and ICD-10-CM code can be reported directly from the ICD-10-CM alphabetic index

D) the abbreviation that indicates provider has documented a specific diagnostic cyst, but there is not a code for that specificity is NEC

D

If a patient has acute systolic heart failure, what is the main term that is used in the ICD-10-CM alphabetic index

Failure

Which sections of ICD-10-CM does a biller used to code for a physicians office?

ICD-10-CM alphabetic index and tabular list

In looking at the following list in the ICD 10, CM alphabetic index which coding is for curvature of the spine due to Charcot- Marie-Tooth disease?

Curvature

Spine(acquired) (angular) (idiopathic) (incorrect) (postural) — see Dorsopathy, deforming congenital Q67.5

Due to or associated with

Charcot-Marie-Tooth disease (see also subcategory M49.8) G60.0

Two codes may be required double check the tabular list to see both codes are accurate and determine which to code first

And looking at the Notes with this code, which statement is true?

K67 disorders of peritoneum and infectious diseases classified elsewhere

First underlying disease such as

Congenital syphilis(A50.0)

Helminthiasis (B65.0 - B83.9)

Excludes1:

peritonitis in chlamydia (A74.81)

Peritonitis in diphtheria (A36.89)

Peritonitis and gonococcal (A54.85)

Peritonitis in syphilis (late) (A52.74)

Peritonitis in tuberculosis (A18.31)

A) code K67 may be a first listed code

B) code K67 may be coded with A74.81

C) code K67 may never be coded with codes A74.81 A36.89, A54.85, A52.74, and A18.31

D) code K67 is a secondary code with codes A74.81, A38.89 or A52.74 being coded first

C

What is/are the correct code(s) for a patient with type one diabetic neuropathy?

E10.40

How many chapters does ICD-10-CM contain?

22

What general guideline is addressed in I.C.1.a.2.c?

Whether the patient is newly diagnosed

What are the correct codes for benign hypertensive, heart disease and stage 3a chronic kidney disease?

I13.10 and N18.31

What is/are the correct code(s) for a patient with acute on chronic maxillary sinusitis

J01.00 and J32.0

What does the icon indicate for procedure code 20974?

Modifier 51 cannot be used for procedure code 20974

What option shows the correct way to report procedure code 22515?

A) 22515

B) 22514, 22515

C) 22514, 22515, 77012

D) 22515, 77012

B

What is the full descriptor for CPT code 35632

Bypass graft, with other than vein; ilio-celiac

What is the CBT coding for removal of a pancreatic calculus?

48020

What CPT coding is reported for removal of two skin tags?

11200

A patient is seen in the ED after having an auto accident. The patient is new to this provider. What sub category of E/M is reported?

Emergency department services; new or establish patient

A patient is seen by his family provider at the providers office. The patient last saw the provider four years prior which range of codes would code be selected from?

99202-99205

A patient is admitted to the hospital for observation on date of service 01-02-XX and discharge from observation on date of service 01-03-XX. Which range of codes would the code(s) be selected from for the admit, and discharge from observation?

Admit 99221-99223; discharge 99238-99239

A patient is seen for a follow-up visit in the hospital. A medically appropriate history exam and MDM of low complexity were documented. What E/M code is reported?

99231

A 43-year-old established patient is seen for his annual preventative exam by the family physician. A medically appropriate history and exam and medical decision making of low complexity performed. What E/M code is reported?

99396

What is the CPT code for anesthesia performed for surgical arthroscopy on the ankle?

01464

Anesthesia procedures, 00830 (4 base units), and 00832 (6 base units) are both performed. How are these reported on the claim form?

00832 with a time units for both procedures

Rationale: when reporting multiple anesthesia procedures during one surgical session, the anesthesia code with the most anesthesia base units is reported with the time units for both procedures.

What CPT code is reported for a diagnostic proctosigmoidoscopy?

45300

What guidance is found under CPT code 64492?

Use 64492 in conjunction with 64490, 64491

Which reporting option below is correct for CPT code 69424?

A) 69424-50

B) 69424-50, 69420

C) 69433, 69424

D) 69801, 69424

A

What CPT code is reported for an MRI of the brain without contrast

70551

A provider orders, a lipid panel. According to the practice standards, this includes a complete blood panel (85027), total cholesterol (82465), HDL cholesterol (83718), And triglycerides (84478). What is reported on the claim form?

80061, 85027

Which reporting option below is correct for immunization administration for vaccines or toxoids?

A) 90460, 90474

B) 90471, 90473

C) 90461, 90474

D) 90472, 90474

A

Which reporting option below is correct use of the modifier 50?

A) 19318-50

B) 36251-50

C) 36252-50

D) 69801-50

A

Which reporting option below is correct to use of a modifier with an E/M code?

A) 99213-22

B) 99213-25

C) 99213-59

D) 999,213-54, 55, 56

B

What abbreviation is used for a drug or biological given into the subdural space of the spinal cord?

IT

When 8 mg of Dilaudid are given intravenously, how many units are reported?

2

What is the correct code and units to report for 80 mg of Depo-Medrol given IM?

J1040 x 1

What are C codes used for in the HCPCS Level II code book?

Reporting outpatient services by hospitals paid under the OPPS

What codes are NOT reported by Medicare?

S Codes

What HCPCS Level II code and unit(s) is reported for 4 boxes of alcohol wipes?

A4245 X 4

Patient is given 15 mg of methotrexate sodium IM for rheumatoid arthritis given from 5 mg vials. What HCPCS Level II code and unit(s) is reported?

J9250 x 3

Select the supply code for an insertion tray that has a two way all silicone Foley catheter with a drainage bag?

a. A4312

b. A4314

c. A4315

d. A4311

C

An audiologist provides a battery for a hearing device to a patient. What HCPCS Level II code is reported for the battery?

V5266

A female patient is getting a right and left breast mastectomy bra with integrated form breast prothesis. What HCPCS Level II code is reported?

L8002

Based on this portion of the NCCI table, which statement is correct?

Column 1 Column 2 Modified 0 = not allowed 1= allowed 9 - n/a

11042 11000 1

A) 11000 can never be reported with 11042

B) When 11042 is reported, 11000 should be reported as an add-on code

C) 11000 can be reported with 10042 when circumstances qualify for an NCCI modifier

D) NCCI edits do not apply to the code pair 10042 & 11000

C

Which of the following statements is TRUE about medical necessity?

A) Medical necessity is determined by the physician that provides care to the patient.

B) Medicare will reimburse for any services provided by the physician

C) Medical necessity is a determination that decides if a service has been reported on the correct claim form.

D) Medical necessity is a determination made by the payer to decide if a service is necessary for treatment prevention of illness, or to diagnose a patient.

D

Who were the NCCI edits originally developed to be used by?

Medicare Administrative Carriers

The NCCI edits have Column 1 and Column 2 codes and provide an indicator to determine whether a modifier can be used. Which indicator is used to tell the biller a modifier is never allowed?

0

What are services that are a standard of medical/surgical practice?

Integral and included in the procedure

The provider performs a transforaminal epidural with fluoroscopy (imaging guidance) into the left side of the thoracic spine (64479). He also performs an aspiration/injection into the left trochanteric bursa (20610). Based on this portion of the NCCI table and the scenario below, which modifier is appropriate to report?

Column 1 Column 2 Modifier PTP Edit Rationale

64479 20610 1 misuse of col 2 and col 1 codes

XS

What is an MUE?

Edits showing the maximum number of times a procedure can be performed for one beneficiary in one date of service.

A patient has a breast biopsy with placement of localization device (19083) with subsequent mastectomy (19310) at the same session after the biopsy is proven to be malignant. What modifier would be used for this scenario?

58

NCCI policy specifically discusses what 3 modifiers?

a. 58, 59, 78

b. 25, 58, 59

c. LT, RT, 25

d. 27, 59, 91

25, 58, 59

Facility charges are reported on which claim form?

UB-04 claim form

What does the acronym NUCC stand for?

National Uniform Claim Committee

What revisions does the CMS-1500 claim form undergo?

Multiple reviews prior to approval and implementation

What transaction is NOT specified in the 5010 transaction standards?

A) Claims institutional, Professional and Dental

B) Eligibility requests and responses

C) Acknowledgement for healthcare insurance

D) Acknowledgement for patient payments

D

What regulation requires claims to be sent electronically unless unusual circumstances are met?

Electronic Claims Act (ECA)

CMS-1500

When two or more diagnosis codes reported in item 21 support a procedure how many diagnosis codes should the provider report in item 24E for Medicare claims?

1

When a provider "accepts assignment", what happens to the difference between the charged amount and the allowed amount?

it is considered a contractual write-off

What is the POS code to report services rendered in an urgent care facility?

20

CMS-1500

Item 14 Qualifer is used to indicate what information?

A) Onset of Current Symptoms or Illness

B) Location of injury

C) LMP

D) both A and C

D) both A and C

Prior authorization is reported in Item 23. What other information can be reported in this area of the CMS-1500 claim form?

Mammography pre-certification number

UB-04

What does the abbreviation FL refer to?

Form locator

UB-04

What is the bill code that is reported for a free-standing clinic?

073X

Where can the guidelines be found for proper completion of claim forms be found?

Private payer website and policy manual and Medicare Claims Processing Manual

When reporting procedure codes on the UB-04 claim form, what is FL46- Units of Service?

Indicates the number of times the procedure was performed

UB-04

A patient is admitted to the hospital with pneumonia. Which FL would be used to report the patient's admitting diagnosis?

FL 69

Cost-based fee scedules are developed using which of the following?

A) RBRVS methodology

B) Total cost of every procedure or service listed in the CPT

C) Total cost of all procedure the physician will perform

D) Malpractice insurance and office operating costs

C

What is the physician payment schedule determined by?

The insurance payer

Given the following information:

National conversion factor $33.08

RVU value of 3.26

What is the provider's fee schedule for 99203 (new patient office visit) using the above values?

$108.00

Rationale: The correct fee would be $108.00. Multiply $33.08 (national CF) x 3.26 (RVU value) + $107.84. This calculation is rounded the nearest whole dollar, which would set the fee for 99203 at $108.00

What will happen if there is failure to post a contractual adjustment to a patient's account?

It will leave a balance on the patient's account that should not be there.

Which of the following tasks is the most basic of the billing process?

A) Claims follow up

B) Status report monitoring

C) Data entry

D) Patient follow up

C

What is the function of a claim scrubber?

To identify errors that will prevent a claim from being paid