CPC EXAM STUDY GUIDE
Abstractor - Answers :hospital employee who converts documented procedurs and
diangoses into medical codes
Abuse - Answers :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 - Answers :an examination process the healthcare facility goes through to
evaluate the facilities policies, procedures, and performance to meet higher standards.
Accredited - Answers :Having seal of approval after being evaluated and demonstrating
quality standards
Act/ Law/ Statute - Answers :Legislation passed through Congress and signed by
President or passed over his veto
Actual Charge - Answers :The amount the provider charges for medical services or
supplies. Not always paid in full.
Additional Benefits - Answers :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 - Answers :Health Insurance Claims process at the insurance company
Administrative Law Judge (ALJ) - Answers :hearing officer who presides over appeal
conflicts between providers or beneficiaries, and Medicare contractors (MAC's)
Administrative Simplification - Answers :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 - Answers :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 - Answers :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 - Answers :Diagnosis code indicating patient's diagnosis at
admission
, Admitting Physician - Answers :The doctor responsible for admitting a patient to the
hospital or other inpatient health facility
Advance Beneficiary Notification (ABN) - Answers :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 - Answers :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 - Answers :Individual charge determination by carrier for a covered
service or supply.
Adjusted Average Per Capita Cost (AAPCC) - Answers :Estimate of how much
Medicare will spend in a year for an average beneficiary
Administrative Code Sets - Answers :Non medical code sets that characterize a general
business situation rather than a medical condition.
Administrative Costs - Answers :Medicare, Medicaid, CMS refer to this as their
expenses to have the program, operating expenses, program management, etc.
Administrative Data - Answers :Health insurance information stored in automated
information system about enrollment, eligibility, claims, etc.
Ambulatory Care - Answers :All types of health services that do not require an overnight
stay.
Ambulatory Care Sensitive Conditions (ACSC) - Answers :Medical condtions that if
treated immediatly and managed properly should not require hospitalization.
Ambulatory Payment Classification (APC) - Answers :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) - Answers :Outpatient surgery center not located in
the hospital. Patient's may stay a few hours up to 1 night.
American Hospital Association (AHA) - Answers :Represents concerns of instituitional
providers. They host the National Uniform Billing Committee (NUBC) which consults
under HIPAA
Abstractor - Answers :hospital employee who converts documented procedurs and
diangoses into medical codes
Abuse - Answers :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 - Answers :an examination process the healthcare facility goes through to
evaluate the facilities policies, procedures, and performance to meet higher standards.
Accredited - Answers :Having seal of approval after being evaluated and demonstrating
quality standards
Act/ Law/ Statute - Answers :Legislation passed through Congress and signed by
President or passed over his veto
Actual Charge - Answers :The amount the provider charges for medical services or
supplies. Not always paid in full.
Additional Benefits - Answers :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 - Answers :Health Insurance Claims process at the insurance company
Administrative Law Judge (ALJ) - Answers :hearing officer who presides over appeal
conflicts between providers or beneficiaries, and Medicare contractors (MAC's)
Administrative Simplification - Answers :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 - Answers :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 - Answers :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 - Answers :Diagnosis code indicating patient's diagnosis at
admission
, Admitting Physician - Answers :The doctor responsible for admitting a patient to the
hospital or other inpatient health facility
Advance Beneficiary Notification (ABN) - Answers :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 - Answers :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 - Answers :Individual charge determination by carrier for a covered
service or supply.
Adjusted Average Per Capita Cost (AAPCC) - Answers :Estimate of how much
Medicare will spend in a year for an average beneficiary
Administrative Code Sets - Answers :Non medical code sets that characterize a general
business situation rather than a medical condition.
Administrative Costs - Answers :Medicare, Medicaid, CMS refer to this as their
expenses to have the program, operating expenses, program management, etc.
Administrative Data - Answers :Health insurance information stored in automated
information system about enrollment, eligibility, claims, etc.
Ambulatory Care - Answers :All types of health services that do not require an overnight
stay.
Ambulatory Care Sensitive Conditions (ACSC) - Answers :Medical condtions that if
treated immediatly and managed properly should not require hospitalization.
Ambulatory Payment Classification (APC) - Answers :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) - Answers :Outpatient surgery center not located in
the hospital. Patient's may stay a few hours up to 1 night.
American Hospital Association (AHA) - Answers :Represents concerns of instituitional
providers. They host the National Uniform Billing Committee (NUBC) which consults
under HIPAA
