AAPC CPB - Practice Exam B with complete solution

What is the term for the total amount of covered medical expenses a policyholder must pay each year out-of-pocket before the health insurance company begins to pay any benefits? A. Copayment B. Deductible C. Secondary Payment D. Coinsurance - Answer- B. Deductible Which type of insurance covers physicians and other healthcare professionals for liability as to claims arising from patient treatment? A. Business liability B. Bonding C. Medical malpractice D. Workers' compensation - Answer- C. Medical malpractice Which of the following does NOT fall under group policy insurance? I. The premium is paid for by the employee. II. The premium is paid for (or partially paid for) by an employer. III. The employer selects the plan(s) to offer to employees. IV. Physical exams and medical history questionnaires are a mandatory part of the application process. V. Employee can make changes to the policy. VI. The employee's spouse and children are not eligible for coverage. A. III, IV, and V B. II, III, and VI C. II, IV, and V D. I, IV, V, and VI - Answer- D. I, IV, V, and VI Dr. Wallace is in a capitation contract with Belleview Managed Care Health Plan. He received $25,000 from the health plan to provide services for the 175 enrollees on the health plan. The services provided by Dr. Wallace to the enrollees cost $23,000. Based on the information, what must be done? A. Dr. Wallace can keep the $2,000 profit under the terms of the capitated plan. B. Dr. Wallace experienced a loss under the capitated plan and will need to pay $2,000 to the health plan. C. Dr. Wallace will need to payout the $2,000 to the 175 enrollees. D. Dr. Wallace is required to put the $2,000 in a mutual fund. - Answer- A. Dr. Wallace can keep the $2,000 profit under the terms of the capitated plan. What is the deadline for filing a Medicare claim? A. One year from the date of service B. 30 days from the date of service C. 90 days from the date of service D. Two years from the date of service - Answer- A. One year from the date of service A provider sees a patient who has TRICARE Select. The provider is not contracted with TRICARE but is certified by the regional TRICARE Managed Care Support Contractor (MCSC). The provider charges $200 for the office visit. TRICARE allows $160 and pays $140. How much can the provider bill the patient for? A. $0.00 B. $20.00 C. $60.00 D. $160.00 - Answer- C. $60.00 What organization is responsible in evaluating the medical necessity, appropriateness, and efficiency of the use of healthcare services and procedures? A. Utilization Review Organization B. External Quality Review Organization C. Quality Assurance Organization D. Managed Care Organization - Answer- A. Utilization Review Organization Medicaid providers are forbidden by law to: A. Refer patients to specialists B. Bill patients for non-covered services C. Balance bill patients D. Accept co-payments - Answer- C. Balance bill patients Which statement is FALSE about Local Coverage Determinations (LCDs)? A. LCDs list covered codes, but do not include coding guidelines. B. If a Medicare Administrative Contractor (MAC) develops an LCD, it applies only within the area serviced by that contractor. C. National Coverage Determination (NCD) takes precedence when an NCD and LCD exist for the same procedure. D. CMS develops LCDs when there is no National Coverage Determination - Answer- D. CMS develops LCDs when there is no National Coverage Determination When a minor procedure is performed on a Medicare patient, what is the global period and what time frame is covered? A. 90-day global period - the day of the procedure and 90 days following the procedure. B. 10-day global period - the day before the procedure and 10 days following the procedure. C. 90-day global period - the day before the procedure and 90 days following the procedure. D. 10-day global period - the day of the procedure and 10 days following the procedure. - Answer- D. 10-day global period - the day of the procedure and 10 days following the procedure. If add-on procedure code 11103 is performed twice during an office visit, how is it indicated on the CMS-1500 claim form? A. Code 11103 is reported with a modifier 50 B. Code 11103 is reported twice C. Code 11103 is reported once with the number 2 in box 24G D. Code 11103 is reported twice with the number 2 in box 24G - Answer- C. Code 11103 is reported once with the number 2 in box 24G Which set of documentation guidelines can be used for E/M services submitted to Medicare for a physician assistant (PA)? A. Physician assistants cannot report E/M services B. Only the 1995 CMS documentation guidelines C. Only the 1997 CMS documentation guidelines D. Either 1995 or 1997 CM