CPPM/AAPC EXAM QUESTIONS AND ANSWERS LATEST UPDATE (GRADED A+)

CPPM/AAPC EXAM QUESTIONS AND ANSWERS LATEST UPDATE (GRADED A+) Health Care Reform - Part 1 The American Recovery & Reinvestment Act of 2009 (ARRA) -created an economic stimulus package enacted by Congress to help stimulate economy & consumer spending during recession. Resulting from ARRA - key pieces of legislature aimed at transforming US health care used technology. HITECH Act - allocates $36 billion in incentive payments for providers to adopt the use of electronic records (EMR)- late/non-adopters reduce Medicare reimbursements starting 2015 & fully phased in by 2017. -Gov't grants & funding for development of HIEs -Introduction of National Broadband Plan; FCC introduced country's 1st national broadband plan in Mar 2010 Health Care Reform - Part 2 Core Provisions of the Bill -key provisions of the new health reform law under the Health Care and Education Reconciliation Act (HCERA) and Patient Protection and Affordable Care Act (PPACA) - Health Insurance Mandate (no coverage - tax penalty) -State based Health Insurance Exchange ( American Health Benefit Exchange; Indiv. & Small Business Health Options Program (SHOP) -Insurance Market Reform: prohibition -denying coverage for pre-existing conditions; children on family policy until 26; insurers coverage (1st $$ of preventative care) - Employer Requirements - no reqs to offer insurance if 25 or less EEs & wages less than $50k receive tax credit Health Care Reform - Part 3 Focus on Prevention - eliminate cost sharing for Medicare covered preventative svcs. -waive deductible for colorectal cancer screening - cover prevention plan svcs; provide 10% bonus to PCP from practicing health professional shortage areas. -Mental health svcs receive 5% increase payments 2010 Payment Reform- PQRS; Medicare no longer pays for certain preventable hospital readmissions -Hospital value based purchasing program -Establish Medicare pilot program; Home demonstrations ACO- allow hospitals & Drs (team) be accountable for patient's care if achieved ACO eligible to keep portion of achieved Medicare savings Cost of Health Care Reform - CBO - provide economic data to Congress Quality in Health Care - Part 1 Quality Improvement Plan (QI) Ex. medical documentation Goals of quality improvement include svcs safe; effective, patient centered, timely, efficient, equitable Reasons quality metrics may have not been done effectively; quality taken for granted; emphasis placed on day to day ops; emphasis on on production vs. fee & svcs payments - not quality outcomes; complexities measuring quality w/variables: socio economic status, compliance w/treatment plans; genetics, age & associated co-morbitities & risk factors; related cost of measuring quality; lack of resources experienced in quality improvement Quality in Health Care - Part 2 Bench Marking - process of measuring & comparing data to internal or external results Internal Benchmarking - compare measurements acquired from internal processes overtime. External Benchmarking - compare measurements to other orgs or industries. Exs. MGMA, QIOs, JC (in healthcare) Exs. Disney, Nordstrom, Ritz Carlton (customer svcs outside healthcare) -Hospitals are required to have quality efforts in place to meet the requirements of the Joint Commission (JC) Steps to Initiate Effective BenchMarking Efforts - Identify what you what to measure & improve and how you will obtain measurements - Measure the performance of the process you have selected - Identifying what benchmark you are going to compare your measurements to - Comparing your measurements to that of your identified benchmark - Identifying the difference b/t your measurements & that of your benchmark - Deciphering reason for the differences - Deciding what improvements can be made to improve your processes - Implementing new processes or policies to accomplish improved measurements - Repeating process to identify if goals are accomplished to identify continual opps for improvement Quality in Health Care - Part 3 Plan-Do-Check Act (PDCA) - a quality cycle and QI Method that systematically affects a process or system challenges - transfer of knowledge & incorporating process improvements into the quality life cycle review. PDCA method imposes a formal approach to QI than can result in significant benefits Principles should be implemented to ensure the quality improvement initiative is charted, progressing and reviewed. Each step plays an important part for PDCA to be a success. Plan - To plan for change-need a benchmark so team understands the goal for improvement. Do- Put plan in action on small scale will help team test whether the plan is going to work. Check - Checking to see if a plan is working will help determine if the plan needs to be revised or possibly even aborted & a new plan created. Act - When the Plan, Do, Check cycle has proven successful, the plan is implemented throughout the practice & becomes part of the regular business process. Quality in Health Care - Part 4 (HIT) Health Information Technology (CPOE) Computerized Provider Order Entry Physician Quality Reporting 2006 Tax Relief & Health Care Act authorized CMS to establish a physician quality reporting system. CMS named the system Physician Quality Reporting Initiative (PQRI) - now the Physician Quality Reporting Systems (PQRS) program implemented in 2007 & included incentive payment to qualified physicians who voluntarily chose to report quality measures furnished to Medicare Part B beneficiaries (including RRB & Medicare Secondary Payer) - Incentive payments and to Eligible Professionals (EPs) - Listing of all EPs on CMS Website Annual PQR measure codes: Manual - Also instructs how to report Quality Data Codes (QDCs) Medical Office Accounting Strategic & Operational Planning - need year to year plan & 5 yr plan - drives all aspects of org with who you partner; how you do business and how accounting & finances will be set up Chart of Accounts - listing of potential accounts for financial info will be gathered (i.e. revenue, payer reimbursements, supply expenses, staff payroll expenses, rent, utilities, supplies, etc.) - varies in levels of complexities 1st step (identifying chart of accts) - identify financial info important to track & report; info used for managing your business & for tax purposes consulting - accountant is advisable More detailed tracked (increased # of chart of accts -> increase ability to mine data for ops & budgeting exercises allows for better tracking of exps Ex. Quickbooks provides list of potential accts grouped in optional classifications for tracking All revenue sources are listed on income statement (IS) - 1st followed by expenses. This way all expenses can be deduced from all revenue. Revenue categories -> income collections, from professional office svcs; income from research efforts, outside income (ex. speaking engagements, call coverage income, other income from other business associations) Medical Office Accounting - Part 2 Expenses - HR exps, supplies, rent/utilities, contract labor & svcs, marketing, professional insurance, state licensing fees Under each classification are sub classifications Ex. HR Expenses -> Physician salary, staff salary Accounting methods - 2 main methods Cash based Actual based cash based - most widely used by smaller practices b/c thought of as more simple & easy to underst and; also, method most reputable source (ex. MGMA, AMA) report surveys; easier to compare and benchmark cash based recognizes revenues only when cash collected and recognizes expenses only when cash is paid. Accrual Method - records revenues when they are earned and expenses when they have been incurred. Revenues recorded when billed to patients, insurance companies, and other 3rd party payers. Expenses recorded when incurred & obligation to pay. Benefit for accrual method - More accurate reflection of financial position b/c you record income on the books when it is actually earned & expenses when actually incurred. Medical Office Accounting - Part 3 Most clinics use acctg system different than practice management (billing) system. Billing system shows all charges to accounts as they occur & then are received. Cash based system - info from billing system will not be entered into acctg system until payment is actually received b/c revenue entered when received/little reconciling to be done. Accrual based system - charge entered into billing system at same time as acctg system. There will be write offs made to acctg system when payment received on accts in billing system. Medical Office Accounting - Part 4 Activity Based Costing (ABC Accounting) -define costs in terms of an org's process or activities - all expenses associated with a particular activity with intent to identify how much each activity costs Extra detail needed for ABC Acctg can be time consuming & difficult. Income Statement (IS) - provides a picture of the revenues, expenses & net income of the group and is a valuable document in assessing the financial condition, as well as useful report for creating a good budget. The IS records all revenues & expenses associated with business for the specified time. Expense portion of IS has increased items than revenue position. IS can be effective management tool & used in different ways. Expense tracking - Regular use of IS to track flow of expenses. Periods of time compared & monitoring of staff & supplies Break even point - IS used to identify the break even point for a business (pg. 63-65) Season projections - business in health care will fluctuate from season to season for some specialties. Use IS to compare periods. Tax Planning - Keeping good financials will help for annual tax planning; depending on corporate structure, there can be substantial tax savings by managing business expenses & planning ahead. Budgeting - Effective tool for practice manager to translate through practice's goals & objectives in $$$. Based on IS, formal budget should include projected or budgeted amounts for each item. Manager decides if budget is made yrly or monthly Create a Budget -build based on prior yr's expenses with mods to represent changes - identify % of total revenue to keep specific exps at & apply % to revenue budget monthly - fixed expenses should be entered monthly - create budget based on calculations of what you can accomplish for each category Medical Office Accounting - Part 5 Effective Use of Budget - maintain focus on goals for clinic - assess productivity of practice by comparing budgeted goals to actual results - foster accountability in dept. mgrs - analyze variances in production or costs of running practice -make timely changes to operations to keep on track for qtrly goals manage growth opps while sustaining current business Control Overhead Expenses - business increase net income by 2 ways increase revenue or decrease costs - reduce practice costs; evaluate malpractice insurance discounts, get bids for supplies, participate in GPOs (group purchasing orgs), review phone & data plans, evaluate purchased svcs, consolidate & efficiently use bldg/office space Balance Sheet - snapshot of a business' financial condition at a specific time. Run at end of an acctg cycle (i.e. monthly, qtrly, yrly) -includes values for assets, liabilities & stockholders' equity Medical Office Accounting - Part 6 Statement of Cash Flows -tells how much cash went into & out of practice during a specific time. Cash Management - process is essential to ensure money paid to the office Reports forming the basis of an effective revenue management process include: 1. Bank deposits and accounting entries 2. Daily receipts and Adjustments Posted 3. Gross Receipts Reports 4. Internal Controls 5. Implement Policy for External Accounting Audits 6. Cash, Check or Credit Cards (debit cards, direct deposit) Accounts Payable - refers to the amount a business owes to its suppliers or customers and has not yet paid. Paying AP on time and according to specified terms of the vendor can affect business and employee relationships. Medical Office Accounting - Part 7 Options for Financing New Equipment - advantages for leasing equipment (allows clinic to acquire equipment with little up front expenditure) - disadvantages for leasing equipment (lack of ownership and more expensive overall) - advantages for purchasing (ownership and tax breaks) - disadvantages for purchasing (initial cash outlay; depreciation) Maintain good relationships with bankers, accountants, life insurance professionals. Different Corporate Structures 3 types of corporate entities Sole Proprietorship Professional Business Corporation (PCs) - C corporations, S corporations, LLCs Electronic Medical Records (EMRs) - Part 1 National Alliance for Health Information Technology (NAHIT) defined EMR - electronic record of health related information on an individual created, gathered, managed, and consulted by licensed clinicians and staff from single org who are involved in the individual's health and care EHR- aggregate electronic record of health related information on an individual created and gathered cumulatively across more than one health care org and is managed and consulted by licensed clinicians and staff involved in individual's health and care. EHR is an EMR with interoperatability MU - meaningful use Selecting EMR is important decision for most small - mid size physician practices. Most small - mid size groups do not have their own IT staff or internal expertise. ROI- return on investment AHRQ - Agency for Healthcare Research and Quality - encourage practices to conduct workflow analysis to address start-up concerns such as: quality improvement, readiness assessment, staffing , feasibility analysis and strategies for financing health IT. HITECH Act - incentive program designed to promote nationwide adoption of technology to improve patient care Out of Pocket expenses for EMR implementation include costs associated with purchasing hardware to host the software, the purchase of software, training to implement EMR, hardware needed to use EMR throughout clinic, ongoing support and software upgrade costs Back in Pocket - savings realized with use of EMR that will offset out-of-pocket expenses EMR system will save cost in charting materials --estimated $5 per patient/yr; EMR replace need to call in prescriptions - saves patients $0.50/patient. Smaller practices better option - rather than own computer servers, web-based "cloud" installations aka SaaS (Software as a Service) delivered by ASP (Application Service Provider) gives best benefit. Electronic Medical Records (EMRs) - Part 2 Implementing EMR - ideas to consider - work flow analysis - facility design and hardware - templates - communication - scanning - interfaces Before being part of EMR selection process, practice manager must understand HIS (Health Information System) consists of electronic health records, secure email, coding/billing software, patient scheduling software, etc. HITECH Act is part of ARRA. Phased approach to EHR Stage 1 - focus heavily on establishing functionalitis in certified EHR technology Stage 2 - encourage use of health IT for continuous quality improvement such as CPOE Stage 3 - meaningful use criteria Meaningful Use (MU) - 3 separate elements. THe Final Rule specifies "An EP or eligible hospital shall be consider a meaningful EHR user for an EHR reporting period for a payment year if: 1. Demonstrate use of certified EHR technology in a meaningful manner. 2. Demonstrate to satisfaction of Secretary of HHS that certified EHR technology is connected in manner that provides for electronic exchange of health information. 3. Using certified EHR technology, submit to Secretary of HHS, in a form and manner specified by the Secretary, information on clinical quality measures. Stage 1 Requirements: EP must meet or exceed objectives from 4 categories: EP must meet 20 objectives/measures to be a "meaningful user" of EHR and qualify for incentive payments. 15 "core" objectives/measurements/required % of patient encounters 5 "menu set" objectives/measures per required % of patient encounters (as selected by provider form this list of 10) An EP must meet 6 Clinical Quality Measures (CQMs) to be a "meaningful user" of EHR and qualify for incentive payments. -3 required "core" CQMs - 3 additional "menu set" CQMs Starting Jan. 1st, 2015, physicians "not meaningful" EHR user will see 1% reduction in payments; 2016- 2% reduction; 2017 - 3% reduction; payments continue to fall by !% per year not more than 5% overall. Modern Health IT and Interoperability Important part of objective (HITECH Act/ARRA) is CPOE (Computerized Physician Order Entry) Use certified EHR including E-prescribing CDS (Clinical Decision Support) tools provide health care providers with patient specific information t help prevent errors Telehealth & Telemedicine - process which medical care can be provided remotely through electronic media that doe snot include having a care provider physically present during evaluation Popular apps: Epocrates; 5 min clinical consult; Diagnosauras DDx; Stat ICD-9; Voxie Pro Recorder; Quest Diagnostics Core360 Mobile; MedScope Structured data required to enable querying and reporting; key component of health IT Basic terms ICD-9-CM; Vol 1 SNOMED CT July 2009 ICD-9-CM, Vol 2 CPt HCPCS Level II Enterprise architecture (EA) - strategic business planning; used by org to align business and IT goals Enterprise Master Patient Index (EMPI) Health Information Exchange (HIE) Protected Health Information (PHI) Health Information Orgs( HIO) manage HIEs Cooperative HIE is consortium of regional providers and hospitals who have come together to mutually benefit from the exchange. Basic components of HIE: -governance - image and data repository -EMPI -Security -credentialing process HIOs refer to themselves as: Health Information Exchange Clinical Information Exchange Health Information Organization Regional Health Information Organization Health Information Network Health Insurance Portability and Accountability Act (HIPAA) and Patient Data Security - Part 1 HIPAA (Kennedy-Kassebaum Bill) 1996 -creates national standards to protect individuals' health information - called Protected Health Information (PHI) -orgs required to follow the law are "covered entities" - the privacy rule protects all "individually identifiable health information" held or transmitted by covered entity - PHI - individual's past, present or future physical or mental health or condition; provision of health care to the individual or past present or future payment for the provision of health care to the individual - privacy rule excludes from PHI employment records that a covered entity maintains in its capacity as an employer and education and certain other records subject to Family Educational Rights and Privacy Act Under HIPAA, covered entities and business associates are allowed to disclose PHI w/o signed authorization for treatment, payment or haealth care operation (TPO) reasons. Exs. Drs & hospitals may share with one another for treatment reasons; patients information may be released to insurance companies to receive payment for svcs provided; "Minimum Necessary" - covered entity must make reasonable efforts to use, disclose and request only the minimum amt of of PHI needed to accomplish intended purpose. Covered entity must develop & implement policies and procedures to reasonably limit uses and disclosures to the minimum necessary. Health care providers required to have "Notice of Privacy Practices" available for patients to read. Patients have right under HIPAA to request restriction on certain types of uses and disclosures of their PHI. Incidental disclosures permitted under privacy rule. Authorizations required for use and disclosure that fall outside of TPO. HIPPA - Part 2 Administrative requirements of HIPAA - any business associate who performs a function, activity or service on behalf of a covered entity or organized health care arrangement involving use or disclosure of PHI must sign a Business Associate Agreement (BAA). Ex. of business associate - billing svcs; copy svcs; consultants; transcriptionists and software vendors BAA must include proper use and disclose PHI; develop safeguards to protect PHI; report use or disclosure of PHI that is not agreed to in BAA; agree that any agent or subcontractor of business associate will properly use/disclose PHI, etc. (page 127) Obligations of covered entity - notify business associate of any limitations in its notice of privacy practices or revocation of permission to use PHI; or restriction to use/disclosure of PHI Code Sets - HIPAA standands for code sets -ICD-9-CM -CDT -HCPCS -CPT Electronic Data Interchange (EDI) - ability to transmit and receive information electronically which includes health claims and associated attachments HIPAA - Part 3 Standards for Electronic Transactions Jan. 16, 2009 HHS published X12 Version 5010 and NCPDP Version D.0 for HIPAA transactions -HIPAA X12 version 5010 and NCPDP version D.0 -new sets of standards that regulate the electronic transmission of specific health care transactions, including eligibility, claim status, referrals, claims and remittances. Transactions specified in HIPAA 5010 standards 270/271 - Health Care Eligibility Benefit Inquiry and Response 276/277 - Health Care Claim Status Request/Response 278 - Health Care Svcs - Request for Review/Response; Health Care Svcs Notification & Acknowledgement 820-Payroll Deducted and other Group Premium Payment for Ins products 834- Benefit Enrollment & Maintenance 835- Health Care Claim Payment/Advice 837-Health Care Claim (Professional, Institutional, and Dental) includ. coordination of benefits (COB) and subrogation claims NCPDP D.0 - Pharmacy Claims HIPAA security regulation adopts administrative, technical and physical safeguards required to prevent unauthorized access to PHI. Standards designed to protect confidentiality, integrity and availability of e-PHI a covered entity causes to create, receive, maintain or transmit. Security rule defines "confidentiality" to mean e-PHI is not available or disclosed to unauthorized persons HIPAA security rule if comprised of 3 levels 1. Administrative Safeguards - -security management process -security personnel -information access management -workforce training and management -evaluation 2. Physical Safeguards -facility access and controls - workstation and device security 3. Technical Safeguards -access control -audit controls -integrity controls -transmission security Org Requirements - include business associate contracts and other arrangements where covered entity ad business partners are required contractually Policies, Procedures & Documentation Requirements - requires covered entities to implement reasonable and appropriate policies and procedures to comply w/standards. Identifiers - HIPAA requires providers and plans and employers to have standard national numbers to identify them. Exs. EIN issued by IRS National Provider Identifier (NPI) adopted as standard unique health identifier for health care providers to use in filing and processing health care claims and other transactions. HIPAA - HITECH Part of ARRA, HITECH makes significant changes to HIPAA privacy and security laws. Patient now has right to request disclosures for treatment, payment, and operations (TPO) for previous 3 years. Breach Notification - new rules, covered entities and business associates must comply with several notice requirements eff. Sept 23, 2009 -covered entities must notify individual when unsecured PHI has been breached. method of notice varies; notice must include - date of breach and discovery date -brief description of incident that led to breach - description of the unsecured PHI involved -suggested steps individuals should take to protect themselves against any problems stemming from breach -notice must be received w/in 60 days of breach - if more than 500 individuals information has been breached, you must notify HHS HITECH law changed so that business associates can be regulated by HHS Under HITECH, penalties for non-compliance are severe - Tier A violation, offender didn't realize he/she violated the Act and would have handled matter differently - $100 fine per violation and total imposed for violation cannot exceed $25K for calendar yr. - Tier B violation, reasonable cause but not "willful neglect", $1,000 fine for each violation and total imposed cannot exceed $100K for calendar yr. - Tier C violation, willful neglect that org corrected, $10K fine for each violation and total imposed cannot exceed $250K - Tier D violation, willful neglect and org did not correct; $50K fine for each violation and total imposed cannot exceed $1.5M Protecting data is increasing more important due to technology advancements. Computer networks - LAN, WAN Firewalls Authentication VPN Viruses, Trojan Horses, Worms Best Practices for Data Security - data secured both electronically & physically Individual Authentication of Users - Uniform User ID; no weak passwords; system generates random passwords; tokens; biometrics; telephone callback Access Controls Monitoring of Access Physical Security & Disaster Recovery Protection of Remote Access Points & Protection of External Electronic Communications Software & System Maintenance Reassess Your Security Practices in a Health IT Environment (manual on pg. 136) Human Resource Management - Part 1 Principle responsibilities of HR management include recruiting and retaining effective work force that has the abilities, skills and knowledge to carry out the mission and goals of the org. Hiring - identifying the EEs who have right skill set and personality to fit in with culture of company. Effective tactics for finding right EE: Job Description - identify right person for the right job by identifying the responsibilities and skills required to perform job. Recruiting - outside posting (org's website, job posting, i.e. Monster, Career Builder, temp agencies, search firms Effective Interview Questions - be aware of federal, state and local laws that govern interview and hiring process Ok ?s: ever worked under diff. name? ever convicted of a crime? US citizen? education level? relatives employed by org? prior employment? Restricted ?s: age? sex? race? religion? national origin? disability? Qualities of effective interview questions -open ended questions - what skills do you bring? -case based questions or tests -behavioral questions - what kind of decision have you made where you had responsibility but not authority to implement a project? Assessment Tests - aptitude, proficiency and personality/psychological tests Background Checks/Criminal Checks and References - verify credentials and perform background check; obtain signed release from candidate when conducting background check Introductory/Probationary Period - time to evaluate for proper fit with org; monitor performance of EE Discipline & Termination - EEs performance not meeting expectations, schedule time to review the concerns and determine a PIP (performance improvement plan); adhere to all labor laws when terminating EE; detailed documentation shouldbe kept with EE's personnel file; if RIF employer should thoroughly document the process and document selection criteria for layoff; EE Evaluations- performance evaluation provide mgr with opp to provide feedback on what EE is doing well and where are opps for improvement. Use evaluations to show strengths and weaknesses Keeping EEs motivated is important part of retention, production and maintaining quality svc. Reward and recognition programs can be elaborate or simple; expensive or low cost. To maintain equity with EEs give careful thought to any formal recognition plan. Exs of effective & inexpensive recognition: verbal "thank you"; certificates of achievement; cards or letters celebrating birthdays, work anniversaries; small gift certificates. Other important factors: -feeling their employers listens and values their opinion -understanding mission of company and how their role can affect it. -believing their employer is interested in their personal and professional development -trusting employer will follow through and not mislead them - having opportunity to serve the patient; most people choose to work in healhcare b/c of svc component Human Resource Management - Part 2 Record Keeping Each EE has own personnel file: -copy of signed application -tax filing status -certifications or professional licenses -employment contracts -performance reviews, awards, recognition, disciplinary actions -anecdotal conversations with EE -job description -promotion and reason for promotion -background check/reference check -I-9 -RIF documentation Policies should be kept up to date and field so that current version can be pulled at any time. - Forms that should be kept in separate file -ADA/reasonable accommodations -workers' compensation -OSHA -FMLA Total compensation - usually salary, benefits, paid and unpaid time off. Goal of good compensation plan should be to achieve perceived equity by EEs. EEs feel they are compensated fairly for the the work they do. Basic points to remember - identify a pay range for each job classification - compare pay ranges (benchmark) to similar positions - identify how you will administer adjustments for things such as yrs of svc, special training, certifications, performance evals. -figure in benefits to total compensation package - identify the potential for yrly increases for cost of inflation Physician Compensation - physicians can be paid on salary basis, on a production basis or by a combination of both. Simplest model is to compensate a physician with a set salary. Contention can arise with this model; when physician's production starts to fall to levels unsustainable and yet a salary expectation remains. Compensation models with production component are more prevalent in independent clinics. Relative Value Unit (RVU) consists of calculating total RVU values for each physician and then paying a fixed $$ amount per RVU to calculate the compensation amount. 3 components make up total value of RVU: work RVU + malpractice RVU + practice expense RVU. Many RVU models will focus on the work component of that RVU (wRVU) b/c this value focuses on the work value of each code. (pg. 156)