AAPC CPB ANSWERS AND QUESTIONS SET A+
✔✔The clinical Prior Authorization (PA) Program assists in the monitoring of - ✔✔drugs
not on Medicaid's formulary
✔✔Albert has purchased a Medigap policy to supplement his Medicare benefits, To
which entity will Albert pay his monthly premium - ✔✔Medigap insurance company
✔✔The total RVU is composed of which of the following components - ✔✔physician
work, practice expense and malpractice insurance
✔✔To determine the Medicare coverage and payment policy for a service or procedure,
which of the following resources will indicate if a service or procedure is payable,
noncovered, or bundled into another service - ✔✔status codes
✔✔Medicare A
Medicare B
Medicare C
Medicare D - ✔✔Inpatient hospital stays
Outpatient hospital care
Medicare Advantage
Prescription drugs
✔✔Medicare has four categories of items and services that are not covered under the
program, they are: - ✔✔1) Services and supplies that are not medically
reasonable and necessary;
2) Non-covered items and services;
3) Services and supplies denied as bundled or included
in the basic allowance of another service; and
4) Items and services reimbursable by other
organizations or furnished without charge.
✔✔Explain incident to services and who they are preformed by - ✔✔Once the initial
physician relationship has been established, incident-to services can be billed even
,when there is not a physician in the room. He or she must only be on the premises and
immediately available to assist the non-physician providers (nurse practitioners,
physician assistants, certified nurse midwives and clinical nurse specialists) provider
rendering the services
✔✔An NPI doesn't ensure - ✔✔a provider is licensed or credentialed
guarantee payment by a health plan
enroll a provider in a health plan
turn the provider into a covered provider
require a provider to conduct HIPPA transactions
✔✔Medicare was passed into law under the title XVIII of what Act - ✔✔social security
act
✔✔The federal False Claim Act allows for claims to be reviewed for how many years
after an incident - ✔✔seven years
✔✔A practice agrees to pay $250,000.00 to settle a lawsuit alleging that the practice
used x-rays of one patient to justify services on multiple other patients' claims. The
office manager brought the civil suit. What type of case is this? - ✔✔Qui Tam
✔✔In which of the following circumstances may PHI not be disclosed without the
patient's authorization or permission? - ✔✔An office receives a call from the patient's
husband asking for information about his wife's recent office visit.
✔✔According to the Privacy Rule, what must a Business Associate and a Covered
Entity have in order to do business? - ✔✔A contract
✔✔HMO plans require the enrollee to: - ✔✔To have referrals to see a specialist that is
generated by the patient's primary care provider.
✔✔Which of the following is NOT a component of the PPO payer model? - ✔✔Require
the enrollee to maintain a Primary Care Provider.
✔✔Under the Privacy Rule a health plan, clearinghouses, and any entity transmitting
health information is considered? - ✔✔Covered entity
✔✔A request for medical records is received for a specific date of service from a
patient's insurance company with regards to a submitted claim. No authorization for
release of information is provided. What action should be taken? - ✔✔Release the
requested records to the insurance company.
✔✔Which of the following situations allows the release of PHI without authorization from
the patient? - ✔✔Workers' Compensation
,✔✔HIPAA mandated what entity to adopt national standards for electronic transactions
and code sets? - ✔✔HHS
✔✔What is the standard time frame established for record retention? - ✔✔There is no
single standard for record retention; it varies by state and federal regulations.
✔✔CMS defines _______ as billing for a lower level of care than is supported in
documentation, making false statements to obtain undeserved benefits or payment from
a federal healthcare program, or billing for a service that was not performed. - ✔✔Fraud
✔✔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
✔✔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
✔✔Which of the following actions is considered under the False Claims Act? - ✔✔Up-
coding or unbundling services
✔✔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
✔✔Medicare was passed into law under the title XVIII of what Act? - ✔✔Social Security
Act
✔✔Which of the following statements are true regarding healthcare regulations? -
✔✔Healthcare regulations may vary by state and by payer
✔✔A physician office (covered entity) discovers that the billing company (business
associate) is in breach of their contract. What is the first step to be taken? - ✔✔Take
steps to correct the problem and end the violation
✔✔OIG, CMS, and the Department of Justice are the government agencies enforcing
______? - ✔✔Federal fraud and abuse laws
✔✔Fraud and Abuse penalties do NOT include: - ✔✔Ability to re-file claims in question
✔✔A biller at a medical practice notices that all claims contain CPT code 81002. She
questions the nurse who tells her that because they are an OB/GYN office they bill
every patient for a urinalysis. What does this violate? - ✔✔False Claims Act
, ✔✔Individuals have the right to review and obtain copies of the PHI. What is excluded
from the right of access? - ✔✔Psychotherapy notes
✔✔Medical Records are requested for a patient for a specific date of service. When
records are copied, multiple dates of service are copied and sent in reply to the request.
What standard does this violate? - ✔✔Minimum Necessary
✔✔Patient has questions and concerns regarding the Privacy Practices in the clinic
should be addressed by what party? - ✔✔Privacy Official
✔✔What standard transactions are NOT included in EDI and adopted under HIPAA? -
✔✔Waiver of liability
✔✔The Federal False Claim Act allows for claims to be reviewed for how many years
after an incident? - ✔✔Seven years
✔✔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 is that action considered? - ✔✔Fraud
✔✔What penalties can be imposed for Fraud and/or Abuse related to the United States
Code? - ✔✔a. Monetary penalties ranging from $10,000 to $50,000 for each item or
service
b. Imprisonment
c. Exclusion from Federal Healthcare Programs
(d.) All of the above
✔✔Medicare overpayments should be returned within ____ days after the overpayment
has been identified? - ✔✔60 days
✔✔What entities are exempt from HIPAA and not considered to be covered entities? -
✔✔Workers Compensation
✔✔A private practice hires a consultant to come in and audit some medical records.
Under the Privacy Rule, what is this consultant considered? - ✔✔A business associate
✔✔A hospital records transported is moving medical records from the hospital to an off-
site building. During the transport, a chart falls from the box onto 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? - ✔✔A breach
✔✔When a practice sends an electronic claim to a commercial health plan for payment,
what is this considered? - ✔✔A transaction
✔✔The clinical Prior Authorization (PA) Program assists in the monitoring of - ✔✔drugs
not on Medicaid's formulary
✔✔Albert has purchased a Medigap policy to supplement his Medicare benefits, To
which entity will Albert pay his monthly premium - ✔✔Medigap insurance company
✔✔The total RVU is composed of which of the following components - ✔✔physician
work, practice expense and malpractice insurance
✔✔To determine the Medicare coverage and payment policy for a service or procedure,
which of the following resources will indicate if a service or procedure is payable,
noncovered, or bundled into another service - ✔✔status codes
✔✔Medicare A
Medicare B
Medicare C
Medicare D - ✔✔Inpatient hospital stays
Outpatient hospital care
Medicare Advantage
Prescription drugs
✔✔Medicare has four categories of items and services that are not covered under the
program, they are: - ✔✔1) Services and supplies that are not medically
reasonable and necessary;
2) Non-covered items and services;
3) Services and supplies denied as bundled or included
in the basic allowance of another service; and
4) Items and services reimbursable by other
organizations or furnished without charge.
✔✔Explain incident to services and who they are preformed by - ✔✔Once the initial
physician relationship has been established, incident-to services can be billed even
,when there is not a physician in the room. He or she must only be on the premises and
immediately available to assist the non-physician providers (nurse practitioners,
physician assistants, certified nurse midwives and clinical nurse specialists) provider
rendering the services
✔✔An NPI doesn't ensure - ✔✔a provider is licensed or credentialed
guarantee payment by a health plan
enroll a provider in a health plan
turn the provider into a covered provider
require a provider to conduct HIPPA transactions
✔✔Medicare was passed into law under the title XVIII of what Act - ✔✔social security
act
✔✔The federal False Claim Act allows for claims to be reviewed for how many years
after an incident - ✔✔seven years
✔✔A practice agrees to pay $250,000.00 to settle a lawsuit alleging that the practice
used x-rays of one patient to justify services on multiple other patients' claims. The
office manager brought the civil suit. What type of case is this? - ✔✔Qui Tam
✔✔In which of the following circumstances may PHI not be disclosed without the
patient's authorization or permission? - ✔✔An office receives a call from the patient's
husband asking for information about his wife's recent office visit.
✔✔According to the Privacy Rule, what must a Business Associate and a Covered
Entity have in order to do business? - ✔✔A contract
✔✔HMO plans require the enrollee to: - ✔✔To have referrals to see a specialist that is
generated by the patient's primary care provider.
✔✔Which of the following is NOT a component of the PPO payer model? - ✔✔Require
the enrollee to maintain a Primary Care Provider.
✔✔Under the Privacy Rule a health plan, clearinghouses, and any entity transmitting
health information is considered? - ✔✔Covered entity
✔✔A request for medical records is received for a specific date of service from a
patient's insurance company with regards to a submitted claim. No authorization for
release of information is provided. What action should be taken? - ✔✔Release the
requested records to the insurance company.
✔✔Which of the following situations allows the release of PHI without authorization from
the patient? - ✔✔Workers' Compensation
,✔✔HIPAA mandated what entity to adopt national standards for electronic transactions
and code sets? - ✔✔HHS
✔✔What is the standard time frame established for record retention? - ✔✔There is no
single standard for record retention; it varies by state and federal regulations.
✔✔CMS defines _______ as billing for a lower level of care than is supported in
documentation, making false statements to obtain undeserved benefits or payment from
a federal healthcare program, or billing for a service that was not performed. - ✔✔Fraud
✔✔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
✔✔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
✔✔Which of the following actions is considered under the False Claims Act? - ✔✔Up-
coding or unbundling services
✔✔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
✔✔Medicare was passed into law under the title XVIII of what Act? - ✔✔Social Security
Act
✔✔Which of the following statements are true regarding healthcare regulations? -
✔✔Healthcare regulations may vary by state and by payer
✔✔A physician office (covered entity) discovers that the billing company (business
associate) is in breach of their contract. What is the first step to be taken? - ✔✔Take
steps to correct the problem and end the violation
✔✔OIG, CMS, and the Department of Justice are the government agencies enforcing
______? - ✔✔Federal fraud and abuse laws
✔✔Fraud and Abuse penalties do NOT include: - ✔✔Ability to re-file claims in question
✔✔A biller at a medical practice notices that all claims contain CPT code 81002. She
questions the nurse who tells her that because they are an OB/GYN office they bill
every patient for a urinalysis. What does this violate? - ✔✔False Claims Act
, ✔✔Individuals have the right to review and obtain copies of the PHI. What is excluded
from the right of access? - ✔✔Psychotherapy notes
✔✔Medical Records are requested for a patient for a specific date of service. When
records are copied, multiple dates of service are copied and sent in reply to the request.
What standard does this violate? - ✔✔Minimum Necessary
✔✔Patient has questions and concerns regarding the Privacy Practices in the clinic
should be addressed by what party? - ✔✔Privacy Official
✔✔What standard transactions are NOT included in EDI and adopted under HIPAA? -
✔✔Waiver of liability
✔✔The Federal False Claim Act allows for claims to be reviewed for how many years
after an incident? - ✔✔Seven years
✔✔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 is that action considered? - ✔✔Fraud
✔✔What penalties can be imposed for Fraud and/or Abuse related to the United States
Code? - ✔✔a. Monetary penalties ranging from $10,000 to $50,000 for each item or
service
b. Imprisonment
c. Exclusion from Federal Healthcare Programs
(d.) All of the above
✔✔Medicare overpayments should be returned within ____ days after the overpayment
has been identified? - ✔✔60 days
✔✔What entities are exempt from HIPAA and not considered to be covered entities? -
✔✔Workers Compensation
✔✔A private practice hires a consultant to come in and audit some medical records.
Under the Privacy Rule, what is this consultant considered? - ✔✔A business associate
✔✔A hospital records transported is moving medical records from the hospital to an off-
site building. During the transport, a chart falls from the box onto 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? - ✔✔A breach
✔✔When a practice sends an electronic claim to a commercial health plan for payment,
what is this considered? - ✔✔A transaction
