CPC Certification Exam Study Guide

What is a pathologic fracture?
A. Overuse injury caused by repetitive forces placed on the bone (stress)
B. Fracture caused by some type of accident (traumatic)
C. A break in a weakened bone caused by disease
D. Any fall from a standing height (fragile)

C. A break in a weakened bone caused by disease

The prefix leuk/o means?
A. Hard
B. Soft
C. White
D. Red

C. White

Which of the following is NOT part of the sinuses?
A. Ethmoid
B. Turbinate
C. Sphenoid
D. Maxillary

B. Turbinate

Where is the brachial artery located?
A. In the upper arm
B. In the lower leg
C. In the upper leg
D. In the head

A. In the upper arm

Which of the following would NOT be considered medically necessary?
A. A bacterial uterine culture for symptoms indicative of a possible UTI.
B. A diagnostic pap smear for personal and family history of cervical cancer.
C. Plastic surgery on a patient that wants a smaller and straighter nose.
D. A thyroid function test for a patient on drug therapy for primary hypothyroidism.

C. Plastic surgery on a patient that wants a smaller and straighter nose.

A Medicare patient is hospitalized three days with pneumonia. Which part of Medicare is responsible to help cover the hospital stay?
A. Part C
B. Part B
C. Part D
D. Part A

D. Part A

Which statement is TRUE for reporting burn or corrosion codes?
A. Nonhealing burns are coded as sequlae codes
B. When sequencing burn codes the lowest degree is always reported as the primary code
C. A burn due to a chemical, use the corrosion code.
D. An infection burn site is reported with one code.

C. A burn due to a chemical, use the corrosion code.

Modifiers 1P, 2P, and 3P go on which codes?
A. Anesthesia codes
B. ICD-10-CM Codes
C. Category II CPT Codes
D. Category I CPT Codes

C. Category II CPT Codes

What does the lab term presumptive mean in code range 80305-80307?
A. Drug test results that indicate possible, but not definitive, presence of drugs and or metabolites.
B. Specific identification of individual drugs and drug metabolites.
C. The descriptor of a device that measures multiple analytes.
D. A term used to describe definitive identification/quantitation procedures that are secondary to presumptive screening methods.

Medicare Part A

helps cover inpatient hospital care, as well as care provided in skilled nursing facilities, hospice care, and home healthcare.

Medicare Part B

helps cover medically necessary physicians services, outpatient care, and other medical services (including some preventive care services) not covered under Medicare Part A. Medicare Part B is an optional benefit for which the patient must pay a premium, and which generally requires a yearly deductible and co-insurance.

Medicare Part C

AKA Medicare Advantage. combines the benefits of Medicare Part A, Part B, and sometimes Part D. The plans are managed by private insurers approved by Medicare. The plans may charge different co-pays, co-insurance, or deductible for services.

Medicare Part D

“D is for Drugs” - a prescription drug program available to all Medicare beneficiaries. Private companies approved by Medicare provide coverage.

How do you qualify for Medicare?

people over the age 65, blind or disabled individuals, or people with permanent kidney failure or end-stage renal disease (ESRD)

Medicaid

health insurance assistance program for some low-income people (especially children and pregnant women) sponsored by federal and state governments.

RBRVS

resource-based relative value scale

used by Medicare for payments for physician services. resource costs are divided into 3 components: physician work, practice expense, and professional liability insurance.

Medical Necessity

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

ABN (Advance Beneficiary Notice)

a standardized form that explains to the patient why Medicare may deny the service or procedure.

Protects the providers financial interest by creating a paper trail that CMS requires before a provider can bill the patient for payment if coverage is denied for the states service or procedure.

“hold harmless” clause

prohibits the billing to the patient for anything other than co-pays or deductibles.

The Health Insurance Portability and Accountability Act of 1996 or HIPAA

provides federal protections for protected health information when held by covered entities.

Health Information Technology for Economic and Clinical Health Act or HITECH

enacted as part of the American Recovery and Reinvestment Act of 2009 (ARRA).

• strengthens HIPAA rules by addressing privacy and security concerns associated with the electronic transmission of health info.

• allows patients to request an audit trail showing all disclosures of their health info made through an electronic record.

• requires that an individual be notified if there’s an unauthorized disclosure or use of his or her health information.

Office Inspector General (OIG)

mandated by public law to engage in activities to test the efficiency and economy of government programs to include investigation of suspected healthcare fraud or abuse.

fraud

to purposely bill for services that were never given or to bill for a service that has a higher reimbursement than the service provided.

Patient Protection and Affordable Care Act of 2010 (ACA)

amended the definition of fraud to remove the intent of requirement.

• The person doesn’t have to possess knowledge of the violation for it to still be considered an offense.

abuse

payment for items or services that are billed by providers in error that should not be paid for by Medicare.

compliance plan

a written set of instructions outlining the process for coding and submitting accurate claims, and what to do if mistakes are found.

Compliance plan benefits

• More accurate payment of claims

• Fewer billing mistakes

• Improved documentation and more accurate coding

• Less chance of violating self-referral and anti-kickback statutes

AMA

American Medical Association

APM

Advanced Alternative Payment Models

ASC

Ambulatory Surgery Centers

CF

Conversion Factor

CMS

Centers for Medicare and Medicaid Services

CMS-HCC

Centers for Medicare and Medicaid Services- Hierarchal Condition Category

DRG

Diagnosis Related Group

EIN

Employer Identification Number

GPCI

Geographic Practice Cost Index

HMO

Health Maintenance Organization

LCD

Local Coverage Determinations

MAC

Medicare Administrative Contractor

MACRA

Medicare Access and CHIP Reauthorization Act

MIPS

Merit-Based Incentive Payment Systems

MP

Malpractice

MS-DRG

Medicare Severity - Diagnosis Related Group

NCD

National Coverage Determination

NPI

National Provider Identifier

OCR

Office for Civil Rights

PE

Physician Expense

PFS

Physician Fee Schedule

PHI

Protected Health Information

PPACA

Patient Protection and Affordable Care Act

PLI

Professional Liability Insurance

RUC

Relative Value Scale (RVS) Update Committee

RVU

Relative Value Unit

What is medical coding?

a. reporting services on a CMS-1500

b. translating medical documentation into codes

c. programming an EHR

d. creating a 5010 electronic file for transmission

b. translating medical documentation into codes

which is NOT a covered entity of HIPAA?

a. Medicare

b. Workers compensation

c. Dentists

d. Pharmacies

b. Worker’s compensation

which one falls under a commercial payer?

a. Medicare

b. Medicaid

c. Blue Cross Blue Shield

d. All of the above

c. Blue Cross Blue Shield

when should an ABN be signed?

a. when a service is considered medically necessary by Medicare.

b. when a service is not expected to be covered by Medicare.

c. routinely for any services given to a Medicare patient.

d. after a service is denied and the patient should be billed.

b. when a service is not expected to be covered by Medicare.

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

a. $250 of cost

b. $100 or 25% of cost

c. $10 or 10% of cost

d. $100 or 10% of cost

b. $100 or 25% of cost

an entity that processes nonstandard health information they receive from another entity into a standard format is considered what?

a. billing company

b. electronic health record vendor

c. clearinghouse

d. practice management vendor

c. clearinghouse

what is PHI?

a. personal history information

b. problem with history of infection

c. partial health interaction

d. protected health information

d. protected health information

intentional billing of services not provided is considered ___.

a. deceptive billing

b. fraud

c. abuse

d. common practice

b. fraud

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

a. compliance program guidance

b. safe harbor regulations

c. red flag rules

d. OIG work plan

d. OIG work plan

Blephar/o

eyelid

Bucc/o

cheek

Cholecyst/o

gallbladder

Colp/o

vagina

Cyst/o

a fluid sac or pouch,, urinary bladder

Derm/o

skin

Encephal/o

brain

Enter/o

intestine

Hem/o, hemat/o

blood

My/o

muscle

Myel/o

spinal cord, bone marrow

Onych/o

nail

Oste/o

bone

Phleb/o

vein

Pulm/o, pulmon/o

lungs

Synov/i

synovial fluid, joint, or membranerelated to synovial joints

Ab-

away from

Ad-

toward, near

Ante-

before

Ec-, ecto-

out, outside

End/o-

in, within

Mon/o-

one

Poly-

many, much

Post-

after, behind

-centesis

puncture, tap

-desis

binding, fusion

-ectomy

excision, surgical removal

-graphy

act of recording data

-pexy

surgical fixation

-plasty

plastic repair, plastic surgery, reconstruction

-tripsy

crushing

anatomic position

the standard body position.

Upright, face-forward position with the arms by the side and palms facing forward. The feet are parallel and slightly apart.

Anterior (ventral)

toward the front of the body

Posterior (dorsal)

toward the back of the body

Medial

toward the midline of the body

Lateral

toward the side of the body

Proximal

nearer to the point of attachment or to a given reference point

Distal

farther from the point of attachment or from a given reference point