HCCA CHC COMPREHENSIVE EXAM UPDATED
QUESTIONS AND ANSWERS GUARANTEE A+
✔✔HCPCS - ✔✔Healthcare Common Procedure Coding System: Codes used for
outpatient services and supplies (Medicare)
✔✔Diagnosis-related groups (DRGs) - ✔✔System that categorizes into payment groups
patients who are medically related with respect to diagnosis and treatment and
statistically similar with regard to length of stay (diagnosis 1, 2, sex, age, etc.)
✔✔Medicare Appeals Process - ✔✔5 steps:
1) re determination by MAC
2) reconsideration by Independent Contractor
3) Administrative law judge hearing
4) Medicare appeals council
5) Federal Court judicial review
✔✔Medicare Administrative Contractor (MAC) - ✔✔Independent insurance that
processes Medicare Parts A and B claims from hospitals, physicians, and other
providers.
✔✔Local Coverage Determination (LCD) - ✔✔decisions by MACs about the coding and
medical necessity of a service
✔✔National Coverage Determination (NCD) - ✔✔Rules developed by CMS that specify
under what clinical circumstances a service or procedure is covered (including clinical
circumstances considered reasonable and necessary) and correctly coded; Medicare
administrative contractors create edits for NCD rules, called local coverage
determinations (LCDs).
✔✔Common Causes of Improper Billing - ✔✔o Administrative / documentation errors
o Medically unnecessary services
o Diagnosis coding errors
✔✔Advanced Beneficiary Notice (ABN) - ✔✔A form provided to the patient when the
provider believes Medicare will probably not pay for services received
✔✔Cost Report (Medicare) - ✔✔An annual report required of facility contractors
participating in the Medicare program. The report details the cost and charges the
provider incurred in rendering services to all patients and the Medicare payments
received during a specific reporting period. Cost and reporting procedures are defined
by the Medicare program. Used to determine reimbursement.
, ✔✔Perspective Payment System - ✔✔Code/numbers that label a patients condition or
diagnosis that also indicates how much the organization will be reimbursed for their care
prior to service
✔✔CMS-1500 form - ✔✔Standard insurance form used by all government and most
commercial insurance payers. Non-institutaional
✔✔CMS-1450 (UB-04) - ✔✔A revised version of the UB-92, a federal directive requiring
a hospital to follow specific billing procedures, itemizing all services included and billed
for on each invoice. Institutional
✔✔Evaluation and management Codes - ✔✔Most common CPT codes used and
represent the office visit/time spent codes. Category I. Require history, exam (review of
symptoms), and medical decision making.
✔✔Medicare Part A - ✔✔hospital insurance
✔✔Medicare Part B - ✔✔medical insurance
✔✔Medicare Part C - ✔✔Medicare Advantage
✔✔Medicare Part D - ✔✔Prescription drug coverage
✔✔ Stark or Physician Self-Referral Law - ✔✔The Omnibus Budget Reconciliation Act
bans physicians from referring patients to receive "designated health services" to any
entity with which the physician has a financial relationship. Designated health services
include lab testing, imaging services, physical or occupational therapy, etc. (civil only,
medicare/medicaid only, strict liability)
✔✔Anti-Kickback Statute (AKS) - ✔✔Prohibits the solicitation, receiving, offering, or
paying any remuneration directly or indirectly in cash or in kind in exchange. Essentially
it prohibits the exchange of anything of value in exchange for or in an effort to gain the
referral of business reimbursable by federal healthcare programs. (intent, any federal
program, civil or criminal)
✔✔Physician Payments Sunshine Act (PPSA) - ✔✔Requires that detailed information
about payments or other "transfers of value" worth over $10 from manufacturers of
drugs, medical devices and biologics to physicians and teaching hospitals be made
available to the public. (Open payment data).
✔✔Deficit Reduction Act - ✔✔A Federal law that grants states the ability to modify their
Medicaid programs. This allows individual states to reform their Medicaid programs to fit
with the present health care environment while maintaining federal guidelines.
QUESTIONS AND ANSWERS GUARANTEE A+
✔✔HCPCS - ✔✔Healthcare Common Procedure Coding System: Codes used for
outpatient services and supplies (Medicare)
✔✔Diagnosis-related groups (DRGs) - ✔✔System that categorizes into payment groups
patients who are medically related with respect to diagnosis and treatment and
statistically similar with regard to length of stay (diagnosis 1, 2, sex, age, etc.)
✔✔Medicare Appeals Process - ✔✔5 steps:
1) re determination by MAC
2) reconsideration by Independent Contractor
3) Administrative law judge hearing
4) Medicare appeals council
5) Federal Court judicial review
✔✔Medicare Administrative Contractor (MAC) - ✔✔Independent insurance that
processes Medicare Parts A and B claims from hospitals, physicians, and other
providers.
✔✔Local Coverage Determination (LCD) - ✔✔decisions by MACs about the coding and
medical necessity of a service
✔✔National Coverage Determination (NCD) - ✔✔Rules developed by CMS that specify
under what clinical circumstances a service or procedure is covered (including clinical
circumstances considered reasonable and necessary) and correctly coded; Medicare
administrative contractors create edits for NCD rules, called local coverage
determinations (LCDs).
✔✔Common Causes of Improper Billing - ✔✔o Administrative / documentation errors
o Medically unnecessary services
o Diagnosis coding errors
✔✔Advanced Beneficiary Notice (ABN) - ✔✔A form provided to the patient when the
provider believes Medicare will probably not pay for services received
✔✔Cost Report (Medicare) - ✔✔An annual report required of facility contractors
participating in the Medicare program. The report details the cost and charges the
provider incurred in rendering services to all patients and the Medicare payments
received during a specific reporting period. Cost and reporting procedures are defined
by the Medicare program. Used to determine reimbursement.
, ✔✔Perspective Payment System - ✔✔Code/numbers that label a patients condition or
diagnosis that also indicates how much the organization will be reimbursed for their care
prior to service
✔✔CMS-1500 form - ✔✔Standard insurance form used by all government and most
commercial insurance payers. Non-institutaional
✔✔CMS-1450 (UB-04) - ✔✔A revised version of the UB-92, a federal directive requiring
a hospital to follow specific billing procedures, itemizing all services included and billed
for on each invoice. Institutional
✔✔Evaluation and management Codes - ✔✔Most common CPT codes used and
represent the office visit/time spent codes. Category I. Require history, exam (review of
symptoms), and medical decision making.
✔✔Medicare Part A - ✔✔hospital insurance
✔✔Medicare Part B - ✔✔medical insurance
✔✔Medicare Part C - ✔✔Medicare Advantage
✔✔Medicare Part D - ✔✔Prescription drug coverage
✔✔ Stark or Physician Self-Referral Law - ✔✔The Omnibus Budget Reconciliation Act
bans physicians from referring patients to receive "designated health services" to any
entity with which the physician has a financial relationship. Designated health services
include lab testing, imaging services, physical or occupational therapy, etc. (civil only,
medicare/medicaid only, strict liability)
✔✔Anti-Kickback Statute (AKS) - ✔✔Prohibits the solicitation, receiving, offering, or
paying any remuneration directly or indirectly in cash or in kind in exchange. Essentially
it prohibits the exchange of anything of value in exchange for or in an effort to gain the
referral of business reimbursable by federal healthcare programs. (intent, any federal
program, civil or criminal)
✔✔Physician Payments Sunshine Act (PPSA) - ✔✔Requires that detailed information
about payments or other "transfers of value" worth over $10 from manufacturers of
drugs, medical devices and biologics to physicians and teaching hospitals be made
available to the public. (Open payment data).
✔✔Deficit Reduction Act - ✔✔A Federal law that grants states the ability to modify their
Medicaid programs. This allows individual states to reform their Medicaid programs to fit
with the present health care environment while maintaining federal guidelines.
