CPC Exam Questions With Verified Answers

Abstractor - Answer hospital employee who converts documented procedurs and diangoses into medical codes Abuse - Answer coding practices that lead to improper reimbursement by error because they do not meet medical necessity, ex. changing diagnosis to be covered by insurance Accreditation - Answer an examination process the healthcare facility goes through to evaluate the facilities policies, procedures, and performance to meet higher standards. Accredited - Answer Having seal of approval after being evaluated and demonstrating quality standards Act/ Law/ Statute - Answer Legislation passed through Congress and signed by President or passed over his veto Actual Charge - Answer The amount the provider charges for medical services or supplies. Not always paid in full. Additional Benefits - Answer Health care services not covered by Medicare and are offered through the Medicare Advantage Organization for no additional premium. The benefits must equal the ACR (Adjusted Community Rating) Adjudication - Answer Health Insurance Claims process at the insurance company Adjusted Average Per Capita Cost (AAPCC) - Answer Estimate of how much Medicare will spend in a year for an average beneficiary Administrative Code Sets - Answer Non medical code sets that characterize a general business situation rather than a medical condition. Administrative Costs - Answer Medicare, Medicaid, CMS refer to this as their expenses to have the program, operating expenses, program management, etc. Administrative Data - Answer Health insurance information stored in automated information system about enrollment, eligibility, claims, etc. Administrative Law Judge (ALJ) - Answer hearing officer who presides over appeal conflicts between providers or beneficiaries, and Medicare contractors (MAC's) Administrative Simplification - Answer Part of HIPAA authorizing HHS (Health and Human Services) to 1. adopt standards for transactions & code sets; 2. adopt standard identifiers for health plans; 3. adopt standards to protect security & privacy of personally identifiable health information. Administrative Simplification Act - Answer Signed 12/17/01 allows HHS (Health & Human Services) to exclude providers from Medicare for HIPAA non-compliance of electronic claims and prohibit paper claims except in certain situations Admission Date - Answer The date the patient was admitted for inpatient care, outpatient, or start of care.For hospice, enter effective date of election of hospice benefits. Admitting Diagnosis - Answer Diagnosis code indicating patient's diagnosis at admission Admitting Physician - Answer The doctor responsible for admitting a patient to the hospital or other inpatient health facility Advance Beneficiary Notification (ABN) - Answer A notice from provider to patient that Medicare may deny payment. Patient must sign before services are provider, otherwise patient is not responsible if Medicare does not cover. Advanced Directive - Answer Statement written by patient on how they want medical decisions to be made. May include a Living Will or Durable Power of Attorney for healthcare. Allowed Charge - Answer Individual charge determination by carrier for a covered service or supply. Ambulatory Care - Answer All types of health services that do not require an overnight stay. Ambulatory Care Sensitive Conditions (ACSC) - Answer Medical condtions that if treated immediatly and managed properly should not require hospitalization. Ambulatory Payment Classification (APC) - Answer Medicare's outpatient prospective payment system in which services are grouped based on the resources needed and payment is fixed within each group Ambulatory Surgery Center (ASC) - Answer Outpatient surgery center not located in the hospital. Patient's may stay a few hours up to 1 night. American Hospital Association (AHA) - Answer Represents concerns of instituitional providers. They host the National Uniform Billing Committee (NUBC) which consults under HIPAA American Medical Association (AMA) - Answer Professional organization maintains CPT code sets, secretariat to National Uniform Claim Committee (NUCC) which consults under HIPAA. ASC payment group rate. ASHIM - Answer American Society of Health Informatics Managers, Inc. is a non-profit group of computer professionals that specialize in health information technology (HIT). They are certified through Certified Health Informatics System Professionals (CHISP) Ancillary Services - Answer Professional services by a hospital or inpatient facility. Xrays, drugs, labs, etc. Appeal - Answer Complaint by hospital or patient about a health care payment Approved Amount - Answer The fee Medicare sets as reasonable and pays to the provider. Assigned Claim - Answer Claim submittted by a provider who accepts Medicare Assignment - Answer Agreeing to acccept Medicare fees as payment in full Attending Physician - Answer Licensed physician who certifies the patient services via medical necessity and is primarily responsible for the patient's medical care and treatment. Automated Claim Review - Answer Claim review and etermination via system edits and don't require human intervention Basic Benefit - Answer Includes Medicare covered benefits (except hospice) and additional benefits Beneficiary - Answer The name of a person who has health care insurance through the insurance program Benefit Payment - Answer Amount paid by insurance after the deductible and coinsurance have been deducted Benefit Period - Answer Episode of care within hospitals & skilled nursing facilities (SNF). Begins on admission and ends 60 days after care has ended Benefits - Answer The money or services provided through an insurance policy Board Certified - Answer Doctor specializing in certain area of medicine and who passes an advanced exam. Primary care and specialists can both be board certified Business Associate - Answer Someone performs a function on behalf of a covered entity but is not part of the covered entity's workforce, outside business manager. Capitation - Answer Specified amount of money is paid to a health plan or doctor regardless of the services rendered in that period. One lump sum. Care Plan - Answer Written plan of services patient will receive to ensure the patient's best care physically, mentally & socially Caregiver - Answer Someone who cares for a patient who is ill, disabled, or aged. Can be relatives, friends or someone who is paid. Case Management - Answer Physician, nurse, or other person tracks use of facilities and resources of a patient to be sure they are receiving the care they need. Case Mix - Answer Distribution of patients into categories reflecting severity of illness or resource uses. Case Mix Index - Answer The average Diagnostic Related Groups (DRG) relative weight for all Medicare admissions