AAPC Certified Professional Coder and Biller (CPC®)2026 exam reviewer (key concept you need to know)

AAPC Certified Professional Coder and Biller (CPC®)2026 exam reviewer (key concept you need to know)

1 of 155 Definition

Term

only the minimum necessary

A key provision in HIPAA is the

protected health information

Minimum Necessary

should be shared to satisfy a

requirement. this means

particular purpose.

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True

False

2 of 155 Term

Definition

Medicare part A helps to cover:

the patient

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True

False

Correct definition

inpatient hospital care care provided in skilled nursing facilities hospice care home health care

3 of 155 Term

Definition

The ABN is a standardized form

Revised ABN CMS-R-131 and is

that

available with instructions as a free download on the CMS website.

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True

False

Correct definition

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

4 of 155

Definition

Term

Tabular List: Diagnosis codes

Volume 1 of the ICD-9-CM

organized in order by code

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True

False

5 of 155 Definition

Term

the efficiency and economy of

What is an NCD interpreted at

government programs to

the MAC level considered?

include investigation of suspected health care fraud or abuse.

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True

Correct definition

False

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

6 of 155 Definition

Term

$34.0376

Published conversion factor for CY 2011

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True

False

Correct definition

Published Conversion factor for CY 2012

7 of 155 Definition

Term

nervous

The tunica vaginalis is part of which system?

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True

Correct definition

False

Hemiplegia is a disorder caused by a defect in which anatomic system?

8 of 155 Definition

Term

payment for items or services

Italicized type

that are billed by providers in error that should not be paid for

by Medicare.

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True

False

Correct definition

Abuse consists of

9 of 155 Definition

Term

Classification of Industrial

Appendix B

Accidents According to Agency.

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True

Correct definition

False

Appendix D

10 of 155 Definition

Term

the provider documented more

A compliance plan may offer

specific information regarding

several benefits, including:

the patient's condition, but there is not a code in ICD-9-CM that reports the condition accurately Give this one a try later!

True

False

Correct definition

Selecting a code with the NEC classification means

11 of 155 Definition

Term

a single code is used to classify

Selecting a code with the NEC

2 diagnoses, a diagnosis with an

classification means

associated secondary process (manifestation), or a diagnosis with an associated complication Give this one a try later!

True

False

Correct definition

a combination code indicates

12 of 155 Term

Definition

NCD

Local Coverage Determinations

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True

False

Correct definition

National Coverage Determinations

13 of 155 Term

Definition

official coding and reporting

male reproductive

guidelines are provided by Give this one a try later!

True

False

Correct definition

CMS and NCHS

14 of 155 Definition

Term

signals the coder an additional

use additional code

code should be used, if the information is available, to provide a more complete picture of the diagnosis.

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True

False

15 of 155 Term

Definition

Commercial (non-Medicare)

private contracts between the

may develop their own medical

payer and practice or provider

policies which do not follow Medicare guidelines and are specified in

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True

False

16 of 155 Definition

Term

private insurers approved by

Medicare Part C plans are

Medicare.

managed by

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True

False

17 of 155 Definition

Term

medical necessity for services

Volume 3 of the ICD-9-CM

rendered.

includes procedure codes and is typically used by

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True

False

Correct definition

Volumes 1 and 2 are used to assign diagnosis codes that establish

18 of 155 Definition

Term

there is an unauthorized

HITECH requires that an

disclosure or use of his or her

individual be notified if

health information.

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True

False

19 of 155 Term

Definition

CY 2013 Conversion Factor

unspecified

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True

False

Correct definition

$25.0008

20 of 155 Term

Definition

boldface type

realize the varying cost based on geographic location

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True

False

Correct definition

used for all codes and titles in the Tabular list

21 of 155 Definition

Term

Geographic Practice Cost Index

PHI

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True

Correct definition

False

GPCI

22 of 155 Term

Definition

Formula for Calculating Facility

Revised ABN CMS-R-131 and is

Payment amounts

available with instructions as a free download on the CMS website.

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True

False

Correct definition

[(Work RVU Work GPCI) + (Transitioned Facility PE RVU PE GPCI) + (MP RVU MP GPCI)] CF

23 of 155 Definition

Term

Centers for Medicare and

NOS

Medicaid Give this one a try later!

True

False

Correct definition

CMS

24 of 155 Term

Definition

Incus, stapes, _____

how an injury occurred and where the injury occurred.

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True

False

Correct definition

malleus

25 of 155 Term

Definition

Never code directly from the

Index to Disease

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True

False

26 of 155 Term

Definition

HIPAA provides federal

personal health information

protections for

when held by covered entities.

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True

False

27 of 155 Term

Definition

Morphology codes consist of ___ 5 digits

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True

False

28 of 155 Term

Definition

OCR

Office of Civil Rights

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True

False

29 of 155 Definition

Term

Not elsewhere classifiable

NEC

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True

False

30 of 155 Definition

Term

the entity covered by HIPAA

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

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True

False

31 of 155 Definition

Term

List of 3 digit categories

Appendix D

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True

Correct definition

False

Appendix E

32 of 155 Term

Definition

A patient sustaining an injury to

intent

her great saphenous vein would have sustained injury to which of anatomical site?

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True

False

Correct definition

Leg

33 of 155 Term

Definition

RBRVS

Resource Based Relative Value System

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True

False

34 of 155 Definition

Term

the coder lacks the information

NOS is used only when

necessary to code to a more specific 4th or 5th digit subcategory

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True

False

35 of 155 Definition

Term

Healthcare Common Procedure

HCPCS

Coding System

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False

PHI

False

37 of 155 Term

Definition

Which of the following has a

lens

refraction function in the eye? macula retina lens iris Give this one a try later!

True

False

38 of 155 Term

Definition

Volume 3 of the ICD-9-CM

facilities for inpatient services.

includes procedure codes and is typically used by

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True

False

39 of 155

Term

Definition

The first 4 digits of a

medical necessity for services

morphology code identify the

rendered.

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True

False

Correct definition

histological type of the neoplasm

40 of 155 Term

Definition

Maintenance of hte ICD-9-CM

the Coordination and

is performed by

Maintenance Committee

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True

False

41 of 155

Definition

Term

their regional area

Medicare Part D is available to

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True

False

Correct definition

LCDs have jurisdiction only within

42 of 155 Definition

Term

realize the varying cost based

GPCI is used to

on geographic location

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True

False

43 of 155 Definition

Term

:, colon

The ___ is used after an incomplete term which requires one or more of the descriptions that follow to make it assignable to a given category

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True

False

44 of 155 Term

Definition

When does the OIG release a

Nephrolithiasis

work plan outlining its priorities for the fiscal year ahead?

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True

False

Correct definition

October

45 of 155 Definition

Term

the patient presents for

Medicare Part C plans are

treatment with no complaints.

managed by

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True

False

Correct definition

V codes are commonly used when

46 of 155 Term

Definition

AMA

American Medical Association

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True

False

47 of 155 Term

Definition

Nephrolithiasis

CMS will accept the ____________ for either a "potentially non=covered" service or for a statutorily excluded service Give this one a try later!

True

False

Correct definition

CMS-R-131

48 of 155 Definition

Term

Physician Fee Schedule

PFS

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True

False

49 of 155

Term

Definition

E/M OR E&M

prescription drug coverage program

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True

False

Correct definition

Evaluation and Management

50 of 155 Term

Definition

EHR

American Medical Association

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True

False

Correct definition

Electronic Health Record

51 of 155 Definition

Term

used for all exclusion notes and

Italicized type

to identify codes that should not be used for describing the primary diagnosis

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True

False

52 of 155 Term

Definition

Volume 3 of the ICD-9-CM

Alphabetic Index and Tabular List of Procedures: Procedures performed in the inpatient setting

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True

False

Medicare payments for physician services are standardized using a

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physician fee schedule

medical severity-diagnosis related group

resource-based relative value scale

prescription drug coverage program

(RBRVS)

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54 of 155 Term

The ICD-9-CM Coordination and Maintenance Committee, which is co-chaired by the

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Tabular List: Diagnosis codes organized in order by code

establishing medical necessity

NCHS (National Centers for Health Statistics) and the CMS (Centers for Medicare & Medicaid Services)

Office of the Inspector General

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55 of 155 Term

An ABN protects the provider's financial interest by

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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.

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.

medically necessary physicians' services ouptatient care other medical services (including some preventative services) not covered under Part A

there is an unauthorized disclosure or use of his or her health information.

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56 of 155

Definition

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

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Medicare Part C combines the benefits of

The ABN form is entitled

The term "medical necessity

The ABN is a standardized form that

refers to

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57 of 155 Definition

how an injury occurred and where the injury occurred.

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E codes are used to report

Z codes are used to report

M codes are used to report

V codes are used to report

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58 of 155

Term

HITECH was enacted as part of

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the Medicare Prescription Drug,

the Patient Protection and Affordable Care Act of 2010

Improvement, and Modernization Act of 2003

the American Recovery and Reinvestment Act of 2009 (ARRA)

the Health Insurance Portability And Accountability Act of 1996

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59 of 155 Definition

The Health Information Technology for Economic and Clinical Health Act

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HITECH

MIPS

KAIZEN

FCA

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60 of 155 Definition

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

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multiple choice question.

compliance plan

work plan

personal activity report

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61 of 155 Definition

Coversion Factor - fixed dollar amount used to translate the RVUs into fees

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CF

LCD

ICD-9-CM

GPCI

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62 of 155 Term

Resource costs for RBRVS are divided into three componentes:

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prescription drug coverage program

medicare advantage

physican work private companies approved by medicare

practice expense professional liability insurance

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63 of 155 Definition

advancements in medical knowledge of disease and disease processes, where ICD-9_CM has become outdated and insufficient.

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ICD-8 remains sufficient

ICD-11 is not yet implemented

ICD-10 accommodates

ICD-10 is unnecessary

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64 of 155 Term

What is an NCD interpreted at the MAC level considered?

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LCD

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

there is an unauthorized disclosure or use of his or her health information.

inpatient hospital care care provided in skilled nursing facilities hospice care home health care

[(Work RVU Work GPCI) + (Transitioned Non-Facility PE RVU PE GPCI) + (MP RVU MP GPCI)] (CF)

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65 of 155 Term

Medicare Part B premiums are paid by

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the insurance company

the government

the dentist

the patient

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66 of 155 Term

A compliance plan may offer several benefits, including:

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conventions, general coding guidelines, and chapter specific guidelines

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

* more accurate payment of claims * fewer billing mistakes * improved documentation and more accurate coding * less chance of violating self-referral and anti-kickback status

the causal condition note indicates this code may be assigned as a diagnosis when the causal condtion is unknown or not applicable. If a causal condition is known, the code should be sequenced as the principal diagnosis.

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67 of 155 Term

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)

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Authorization for Non-Covered Services (ANCS)

Consent for Non-Covered Procedures (CNCP)

Advance Beneficiarly Notice of NonCoverage (Advance Benefiary Notice, or ABN)

Notice of Medical Service Denial (NMSD)

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68 of 155

Term

ICD-9CM is published in ___ volumes

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3

Medicare Advantage

an audit trail showing all disclosures of their health information made through an electronic record.

$34.0376

Don't know?

69 of 155 Definition

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.

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When should an ABN be signed?

Work RVUs reflect

HITECH allows patients to request

LCDs give guidance when Don't know?

70 of 155 Definition

Part A and Part B and sometimes Part D

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Medicare Part C is also called

Medicare Part D is available to

Medicare Part C combines the benefits of

HIPAA provides federal protections for

Don't know?

71 of 155 Term

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?

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MAC

Leg

CMS-R-131

Part D

Don't know?

72 of 155 Definition

instruction used in categories not intended to be the principal diagnosis. These codes are written in italics with a note. The note requires the underlying disease (etiology) be recorded first and the particular manifestation be recorded second. This note only appears in the tabular index

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Code first

Database first

Code also note

Object first

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73 of 155 Term

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

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When sequencing codes, the codes listed under the "use additional code" are secondary

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 concovered by Medicare to advise the patient of potential financial responsibility.

1. knowledge of the emergent nature or severity of the patient's complaint or condition 2. All signs, symptoms, complaints, or background facts describing the reason for care, such as required follow-up care.

$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.

Don't know?

74 of 155 Term

LCD

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Local Coverage Determinations

National Coverage Determinations

Patient Identifiers

Quarterly Provider Updates

Don't know?

75 of 155 Definition

essential modifiers are subterms listed below the main term in alphabetical order, and are indented 2 spaces

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other

indented codes

miscellaneous codes

modifiers

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76 of 155 Term

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

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Clearinghouse

Tricare

Participating Provider

Chargemaster

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77 of 155 Definition

Brackets are used to enclose synonyms, alternate wording, or explanatory phrases

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APC

EHR

[]

OCR

Don't know?

78 of 155 Term

ICD-9-CM

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International Classification of Disease, 9th Clinical Modification

International Classification of Disease, 10th Clinical Modification

International Classification of Health Conditions, 9th Revision

International Coding Directory, 9th Edition

Don't know?

79 of 155 Term

Medicare Part D is a coverage provided by

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nonprofit organizations approved

by Medicare

private companies approved

by Medicare

state health departments

federal government agencies Don't know?

80 of 155 Term

Appendix A

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Appendix E; 3 Digit Categories in ICD-9-CM

Morphology of Neoplasms

:, Colon

Lens

Don't know?

81 of 155 Term

APC

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MAC

Ambulatory Payment Classification

All Patient Diagnosis Related Groups Assignment Of Benefits (apdrg)

Ambulatory Surgical Centers

Don't know?

82 of 155 Definition

statistical purposes. It provides information about employment injuries.

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Appendix D is used primarily for

Appendix B

Medicare Part C plans are managed by

Appendix C

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83 of 155 Definition

"other" or "other specified" codes (usually with 4th digit 8 or 5th digit 9 are used when the information in the medical record provides detail for which a specific code does not exist.

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ICD-9-CM

EHR

NEC

other

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84 of 155 Term

DRG

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Major Diagnostic Category

Health Maintenance Organization

Diagnosis Related Group

Evaluation And Management

Don't know?

85 of 155 Term

Appendix C is available to

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assist in identifying chronic disease stages

assist in coding of adverse effects

guide in classifying surgical procedures

support in coding routine medical tests

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86 of 155 Definition

state by state basis adhering to certain federal guidelines.

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A compliance plan may offer several benefits, including:

In order for a V code to be listed first,

Medicaid is adminisitered on a

use addtional code, if applicable

Don't know?

87 of 155 Definition

the causal condition note indicates this code may be assigned as a diagnosis when the causal condtion is unknown or not applicable. If a causal condition is known, the code should be sequenced as the principal diagnosis.

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use only when condition is resolved

sequence as secondary diagnosis

do not use any additional code

use addtional code, if applicable

Don't know?

88 of 155 Term

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

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Physician Fee Schedule

OIG work plan

Oig internal compliance plan

Oig security summary

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89 of 155 Term

NOS

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Deleted 10/1/2004 - contained Glossary of Mental Disorders.

282.42, 517.3

"other" or "other specified" codes (usually with 4th digit 8 or 5th digit 9 are used when the information in the medical record provides detail for which a specific code does not exist.

Not otherwise specified

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90 of 155 Term

ARRA

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American Reform and Reorganization Act (of 2009)

American Recovery and Restructuring Act (of 2009)

American Recovery and

American Rehabilitation and

Reinvestment Act (of 2009)

Reinvestment Act (of 2009)

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91 of 155 Definition

an audit trail showing all disclosures of their health information made through an electronic record.

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HITECH requires patients to receive

HITECH allows patients to modify

HITECH mandates patients to

HITECH allows patients to

approve

request

Don't know?

92 of 155 Term

By statute, all work RVUs, must be examined no less often than

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every 5 years

annually

every 10 years

every 2 years

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93 of 155 Definition

Index to Diseases: Diagnosis codes organized in an alphabetic index

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Volume 3 of the ICD-9-CM

Volume 1 of the ICD-9-CM

Volume 2 of the ICD-10-CM

Volume 2 of the ICD-9-CM

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94 of 155 Term

__________ _________ provides an alternative view of the contents of ICD-9CM and contains the _____ _____ ______ _____ _______

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Appendix G; 5 digit classifications in ICD-9-CM

Appendix F; 4 digit subcategories in ICD-9-CM

Appendix H; 2 digit groupings in ICD-9-CM

Appendix E; 3 digit categories in ICD-9-CM

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95 of 155 Definition

this term indicates the code describes a disease or syndrome named after a person

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sub-term

eponym

homonym

etiology

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96 of 155 Term

NEC is used when

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the ICD-9-CM system provides multiple codes for the same condition.

the ICD-9-CM system does not provide a code specific for the patient's condition.

the ICD-9-CM system includes a code for every possible condition.

the ICD-9-CM system lists a general code for common symptoms.

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97 of 155 Term

NOS is the equivalent of

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deficient

continuous

unspecified

provisional

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98 of 155 Term

CMS developed polices regarding medical necessity are based on regulations found in title XVIII, $1862(a) of the

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Social Security Act

Health Maintenance Act

Family Medical Leave Act

Fair Labor Standards Act

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99 of 155 Term

PA

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Physician Assistant

Nurse

Veterinarian

Therapist

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100 of 155 Definition

terms following "excludes" notes are to be reported with a code from another category.

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summarizes

identifies

other

excludes

Don't know?

101 of 155 Definition

medically necessary physicians' services ouptatient care

cover

102 of 155 Term

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

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$39.51 Non-facility pricing amount (physician office, private practice)

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

entity that processes nonstandard health information they receive from another entity into a standard

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

format

Don't know?

103 of 155 Definition

* 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

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A patient sustaining an injury to her great saphenous vein would have sustained injury to which of anatomical site?

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

Commercial (non-Medicare) may develop their own medical policies which do not follow Medicare

What is an NCD interpreted at the MAC level considered?

guidelines and are specified in Don't know?

104 of 155 Term

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

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Skipped

Correct answer each MAC (Medicare Administrative Contractor)

105 of 155 Term

HICN

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Skipped

Correct answer Health Insurance Claim Number

106 of 155 Term

When seeing the instruction to use additional code, which code goes first?

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Skipped

Correct answer When sequencing codes, the codes listed under the "use additional code" are secondary

107 of 155

Term

Medicare Part C is also called

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Skipped

Correct answer Medicare Advantage

108 of 155 Term

MP

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Skipped

Correct answer Malpractice

109 of 155 Term

The fifth digit in a morphology code indicates

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Skipped

Correct answer behavior of the neoplasm

110 of 155 Definition

when Medicare will pay for items or services.

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Skipped

Correct answer

NCD explain

111 of 155 Term

282.42 Sickle-cell thalassemia with crisis ** Sickle-cell thalassemia with vaso-occlusive pain ** Thalassemia Hb-S disease with crisis Use additional code for the type of crisis, such as: ** acute chest syndrome (517.3) **splenic sequestration (289.52) correct sequence for sickle-cell thalassemia crisis with acute chest syndrome in correct sequence are:

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Skipped

Correct answer 282.42, 517.3

112 of 155 Term

RUC

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Skipped

Correct answer Relative Value Update Committee

113 of 155 Term

Medicare Part D is available to

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Skipped

Correct answer all Medicare beneficiaries.

114 of 155

Term

OIG

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Skipped

Correct answer Office of the Inspector General

115 of 155 Definition

supplies digestive enzymes

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Skipped

Correct answer

Which of the following is a function of the pancreas? * supplies digestive enzymes manufactures melatonin * stimulates growth * secretes vasopressin

116 of 155 Term

Appendix B

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Skipped

Correct answer Deleted 10/1/2004 - contained Glossary of Mental Disorders.

117 of 155 Term

If an NCD doesn't exist for a particular item, its up to the ____ to determine coverage.

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Skipped

Correct answer MAC

118 of 155 Term

A healthcare clearing house is a

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Skipped

Correct answer entity that processes nonstandard health information they receive from another entity into a standard format

119 of 155 Term

NP

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Skipped

Correct answer Nurse Practitioner

120 of 155 Term

As a part of Health Care Reform, the Affordable Care Act of 2010 amended the definition of fraud to remove the _______ requirement

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Skipped

Correct answer intent

121 of 155

Term

The ABN form is entitled

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Skipped

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

122 of 155 Term

HIPAA stands for

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Skipped

Correct answer

Health Insurance Portability and Accountability Act of 1996

123 of 155 Term

includes

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Skipped

Correct answer appears immediately after a three-digit code title to further define or clarify the category

124 of 155 Definition

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.

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Skipped

Correct answer Work RVUs reflect

125 of 155 Term

The tunica vaginalis is part of which system?

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Skipped

Correct answer male reproductive

126 of 155 Term

Published conversion factor for CY 2011

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Skipped

Correct answer $33.9764

127 of 155 Definition

[(Work RVU Work GPCI) + (Transitioned Non-Facility PE RVU PE GPCI) + (MP RVU MP GPCI)] (CF)

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Correct answer Formula for Non-Facility Pricing Amount

128 of 155 Definition

yes

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Correct answer Does Medicare Part B generally require a yearly deductable and copayment?

129 of 155 Term

What is the result of a ureteral blockage?

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

130 of 155 Term

CPT

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Correct answer Current Procedural Terminology

131 of 155 Term

In order for a V code to be listed first,

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Correct answer

it must meet the definition of a principle or first-listed diagnosis code

132 of 155 Term

Section I of the official guidelines includes

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Correct answer conventions, general coding guidelines, and chapter specific guidelines

133 of 155 Term

PLI

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Correct answer Professional Liability Insurance

134 of 155 Term

slanted brackets

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Correct answer indicate multiple codes are required

135 of 155 Term

Medicaid is a

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Correct answer a health insurance assistance program for some low-income people

136 of 155 Term

Appendix C

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Correct answer Classification of Drugs by American Hospital Formulary Service List Number and Their ICD-9-CM equivalents

137 of 155 Term

:

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Correct answer colon is used in Volume I (tabular list) after an incomplete term requiring one or more of the descriptions that follow to make it assignable to a given category

138 of 155 Term

Sebacious glands are a part of which anatomic system?

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Correct answer Integumentary

139 of 155 Term

A medically necessary service is the

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Correct answer least radical service/procedure that allows for effective treatment of the patients' complaint or condition

140 of 155 Term

MS-DRG

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Correct answer

Medical Severity-Diagnosis Related Group

141 of 155 Definition

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

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Correct answer fraud

142 of 155 Term

CMS-R-131

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Correct answer ABN form or Advance Beneficiary Notice which explains to the patient why Medicare may deny the particular service or procedure.

143 of 155 Term

The first step in 3rd party reimbursement is

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Correct answer establishing medical necessity

144 of 155 Definition

* 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

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Correct answer LCDs give guidance when

145 of 155 Term

The myocardium is thickest around which chamber of the heart?

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Correct answer left ventricle

146 of 155 Definition

* found in some non-Medicare health plan contracts * prohibits billing to patient for anything beyond deductibles and co-pays.

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Correct answer "hold harmless clause"

147 of 155 Term

HMO

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Correct answer

Health Maintenence Organization

148 of 155 Term

examples of common reasons to report V codes:

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Correct answer screening tests routine physicals personal or family history of a disease or disorder

149 of 155 Term

ASC

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Correct answer Ambulatory Surgical Centers

150 of 155 Term

Medicare Part D is a

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Correct answer prescription drug coverage program

151 of 155 Definition

1. knowledge of the emergent nature or severity of the patient's complaint or condition

2. All signs, symptoms, complaints, or background facts describing the reason for care, such as required follow-up care.

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Correct answer Information required by payers to determine the need for care

152 of 155 Term

PE

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Correct answer Physician Expense

153 of 155 Definition

* 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

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

154 of 155 Term

HHS

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Correct answer Department of Health and Human Services

155 of 155 Term

Which of the following is a renal calculus? * Pyelectasia * Hydroureter * Nephrolithiasis * Pyonephrosis

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Correct answer Nephrolithiasis