AAPC CPC Chapter 1 Questions and Answers 100% Pass

AAPC CPC Chapter 1 Questions and Answers 100% Pass Medical coding process of translating a healthcare provider's documentation of a patient encounter into a series of numeric or alphanumeric codes Health information coders, medical record coders, coder/abstractors, coding specialists coders who specialize in coding inpatient hospital services MS-DRG Medical Severity-Diagnosis Related Groups MS-DRG are used to: determine the amount the hospital will be reimbursed if the patient is covered by Medicare or other insurance programs using the MS-DRG system Cancer (or tumor) registrars maintain facility, regional, and national databases of cancer patients EHR electronic health record Other roles coders can have: consultants, educators, medical auditors Outpatient coders use CPT, HCPCS Level II, and ICD-10-CM codes; work in provider offices, outpatient clinics, and facility outpatient departments; also use Ambulatory Payment Classifications (APCs); have more interaction with providers Inpatient coders use ICD-10-CM and ICD-10-PCS codes; also use MS-DRGs for reimbursement; have less interation directly with providers Remittance advice (RA) / Explanation of Benefits (EOB) explains the payer's determination in payment Scope of practice practice guidelines for each level of a provider individually dictated by states Mid-level Provider (MLP) include physician assistants (PA) and nurse practitioners (NP); aka physician extenders Physician Assistant (PA) Works under the supervision of physicians; PA program takes approximately 26 1/2 months to complete after completion of a bachelor's degree Nurse Practitioner (NP) have a master's degree in nursing Two types of payers: private insurance plans and government insurance plans Medicare primary government payer in the U.S.; provides coverage for people 65 and older, blind, disabled, and people with permanent kidney failure or end-stage renal disease (ESRD) Medicare Part A Inpatient coverage, home health, hospice, skilled nursing facilities; also defines limits of Medicare usage Medicare Part B The part of the Medicare program that pays medically necessary provider services, preventative services, durable medical equipment, and other services and supplies. Medicare Part C (Medicare Advantage Plans) combines benefits of Part A, B, and sometimes D; managed by private insurers approved by Medicare; may charge different copays, coinsurance, or deductibles CMS-HCC Centers for Medicare & Medicaid Services-Hierarchical Condition Category Medicare Part D Prescription drug coverage Medicaid health insurance assistance program sponsored by federal and state governments for low-income people Limiting charge set limits on what the patient can be charged SOAP subjective, objective, assessment, plan Subjective patient's statement about his or her health, includes symptoms Objective provider's examination and documentation of the patient's illness Assessment evaluation and conclusion made by the provider; where you find the diagnoses Plan course of action E/M Evaluation and Management Operative Report coding tips 1. Highlight unfamiliar words 2. Use post-operative Dx for coding; if pathology report available, use pathology report for Dx 3. Start with procedures listed 4. Look for key words 5. Read the body Medical Necessity the lease radical service/procedure that allows for effective treatment of the pt's complaint or condition National Coverage Determinations Manual describes whether specific medical items, services, treatment, procedures, or technologies can be paid for under Medicare National Coverage Determination (NCD) explain when Medicare will pay for items or services Medicare Administrative Contractor (MAC) responsible for interpreting national policies into regional policies Local Coverage Determination (LCD) decisions by MACs that define what codes are needed and when an item or service will be covered; have jurisdiction only within their region Advance Beneficiary Notice (ABN) a standardized form that explains to the pt why Medicare may deny the service or procedure; protects the provider's financial interest Common reasons Medicare denies a procedure or service: 1. Medicare doesn't pay for the procedure/service for the pt's condition 2. Medicare doesn't pay for the procedure/service as frequently as proposed 3. Medicare doesn't pay for experimental services Reasonable estimate on an ABN $100 or 25%, whichever is greater Non-Medicare payers may not recognize: ABN Health Insurance Portability and Accountability Act (HIPAA) provides federal protections for protection health information when held by covered entities; five part act Covered entity under HIPAA doctors, clinics, psychologists, dentists, chiropractors, nursing homes, pharmacies, health insurance companies, HMOs, company health plans, government programs, healthcare clearinghouse HCFAC Health Care Fraud and Abuse Control Program; designed to coordinate federal, state, and local law enforcement activities with respect to healthcare fraud and abuse HCPCS Healthcare Common Procedure Coding System CPT Current Procedural Terminology CDT Current Dental Terminology ICD-10-CM International Classification of Diseases, 10th Revision, Clinical Modification NDC National Drug Code Minimum necessary only the minimum necessary protected health information should be shared to satisfy a particular purpose PHI Protected Health Information HITECH Act of 2009 Health Information Technology for Economic and Clinical Health Act; made into a law to promote the adoption and meaningful use of health information technology MACRA Medicare Access and CHIP Reauthorization Act of 2015; repealed sustainable growth rate (SGR) formula for physician payment updates in Medicare, prevented scheduled reductions in physician payments, and provided 0.5% rate increases to Medicare Part B single conversion factor QPP Quality Payment Program MIPS Merit-based Incentive Payment System will be a budget neutral program successful reporters will earn incentive payments by unsuccessful reporters. CMS Centers for Medicare and Medicaid Services Promoting Interoperability (PI) promotes secure exchange of health information and the use of certified electronic health record technology for coordination of care CEHRT Certified Electronic Health Record Technology APMs Advanced Alternative Payment Models Office of the Inspector General (OIG) government agency tasked to protect the integrity of HHS programs, and the health and welfare ofthe beneficiaries of those programs; offers compliance program guidance OIG Compliance Program Guidance Seven key components: 1. conducting internal monitoring and auditing through periodic audits 2. implementing compliance and practice standards through development of written standards and procedures 3. designating a compliance officer or contact 4. conducting appropriate training and education 5. responding appropriately to detected violations 6. developing open lines of communication 7. enforcing disciplinary standards through well-publicized guidelines OIG Work Plan sets forth a plan outlining its priorities for the fiscal year and beyond AAPC American Academy of Professional Coders (founded 1988) AAPC Code of Ethics Integrity, respect, commitment, competence, fairness, responsibility HHS Department of Health and Human Services PPACA Patient Protection and Affordable Care Act of 2010 TPO Treatment, payment, and healthcare operations