AAPC CPB CORE TEST ANSWERS AND QUESTIONS
SET A+
✔✔HIPAA mandated what entity to adopt national standards for electronic transactions
and code sets? - ✔✔HHS
✔✔What is the standard time frame established for record retention? - ✔✔There is no
single standard record retention time frame. It varies by state and federal regulation.
✔✔CMS defines ______ as billing for a lower level of care than is supported in
documentation, making false statements to obtain undeserved benefits or payment from
a federal healthcare program, or billing for services that were not performed. - ✔✔Fraud
✔✔A claim is submitted for a patient on medicare with a higher fee schedule that a
patient on Insurance ABC. What is this considered under CMS? - ✔✔Abuse
✔✔A person that files a claim for a Medicare beneficiary knowing that the service is not
correctly reported is in violation of what statue? - ✔✔FCA (False claims act)
✔✔What act is "upcoding or unbundling services" considered under? - ✔✔The false
claims act
✔✔A practice sets up a payment plan with a patient. If more than four installments are
extended to the patient, what regulation is the practice subject to that makes the
practice a creditor? - ✔✔TILA (truth in lending act)
✔✔A patient is seen in your clinic. Her husband calls later in the day to ask for
information about the visit. The practice pulls the patients privacy authorization to see if
they can speak to the husband. What act does this action fall under? - ✔✔HIPAA
✔✔Medicare was passed into law under what Act? - ✔✔SSA
,✔✔Are healthcare regulations the same in each state? - ✔✔No, they will vary from state
to state.
✔✔A physician's office (covered entity) discovers that the billing company (Business
associate) is in breach of their contract. What is the first steps to be taken. - ✔✔Take
steps to correct the problem and end the violation.
✔✔OIG, CMS, and the DOJ are the government agencies enforcing what laws? -
✔✔Federal fraud and abuse laws
✔✔Do fraud and abuse penalties include the ability to refile claims in question? - ✔✔No
✔✔A biller at a medical practice notices that all claims contain CPT code 81002. She
questions the nurse who tells her that because they are an OB/Gyn office, they bull
every patient for a urinalysis. What does this violate? - ✔✔FCA
✔✔Medical records are requested for a patient for a specific date of service. When
records are copied, multiple dates of service are copied and sent in reply to the request.
What standard does this violate? - ✔✔Minimum necessary
✔✔Individuals have the right to review and obtain copies of the PHI. What is excluded
from rights of access? - ✔✔- Psychotherapy notes
- Certain lab results
- Information involved in research studies
- Information related to legal proceedings
✔✔Patient questions and concerns regarding the Privacy Practices in the clinic should
be addressed by what party? - ✔✔The Privacy official
✔✔How many standard EDI transactions were adopted under HIPAA? - ✔✔8
✔✔What are the standard EDI transactions adopted under HIPAA? - ✔✔1. Claims and
encounter info
2. Payment and remittance advice
3. Claim status
4. Eligibility for a health plan
5. Enroll / Dis-enrollment in a health plan
6. Referrals and authorizations
7. COB
8. Premium payments
✔✔In addition to the standardization of the codes what other identifier is used on all
claims? - ✔✔A unique identifier for employers and providers
,✔✔The federal false claims act allows for claims to be reviewed for how many years
after an incident? - ✔✔Seven years
✔✔Entities that have been identified as having improper billing practices are defined by
CMS as a violation of what standard? - ✔✔Abuse
✔✔What penalties can be imposed for Fraud and / or abuse related to the US code? -
✔✔Monetary penalties ranging from $10k to $50k (before inflation) for each item or
service, imprisonment, and exclusion from federal healthcare programs.
✔✔How long after being identified should a practice return medicare over payments?
(days) - ✔✔60 days
✔✔A private practice hires a consultant to come in and audit some medical records.
Under the Privacy Rule, what is this consultant considered? - ✔✔A covered entity
✔✔According to the privacy rule, what health information *may not* be de-identified? -
✔✔The physician provider number
✔✔A hospital records transporter is moving medical records from the hospital to an off-
site building. During the transport, a chart falls from the box on the street. It is
discovered when the transporter arrives at the off-site building and the number of charts
is not correct. What type of violation is this? - ✔✔A breach
✔✔A practice allows patients to pay large balances over a six month time period with a
finance charge applied. The patient receives a statement every month that only shows
the unpaid balance. What does this violate? - ✔✔TILA
✔✔When a practice sends an electronic claim to a commercial health plan for payment,
what is this considered? - ✔✔A transaction
✔✔While working in a large practice, medicare over-payments are found in several
patient accounts. The manager states that the practice will keep the money until
medicare asks for it back. What does this action constitute? - ✔✔Fraud
✔✔What were the eight standard EDI transactions adopted under? - ✔✔HIPAA
✔✔A practice agrees to pay $250k to settle a lawsuit alleging that the practice used x-
rays of one patient to justify services on multiple other patient's claims. That manager of
the office brought the civil suit. What type of case is this? - ✔✔Qui Tam
✔✔A health plan sends a request for medical records in order to adjudicate a claim.
Does the office have to notify the patient or have them sign a release to send the
, information? - ✔✔No, since the information is used for payment activities it is not
necessary to notify or obtain authorization (reference: TPO)
✔✔Fraud or Abuse: A clinic fails to maintain adequate medical records - ✔✔Abuse
✔✔Fraud or Abuse: A clinic bills every new patient at the highest level E/M visit no
matter what - ✔✔Fraud
✔✔Fraud or Abuse: A clinic is found to be falsifying documentation to support a service
that was billed to receive payment - ✔✔Fraud
✔✔Fraud or Abuse: Reporting a diagnosis code that the patient does not have, but is
payable by medicare. - ✔✔Fraud
✔✔According to the privacy rule, what must a business associate and covered entity
have in order to do business? - ✔✔A contract
✔✔If a provider is excluded from federal health plans, what does that mean? - ✔✔They
many not participate in Medicare, Medicaid, VA programs, or Tricare and They cannot
bill for services or provide services, order services, or prescribe medication to any
beneficiary of a federal plan.
✔✔What is the purpose of the privacy rule? - ✔✔To protect patient privacy
✔✔A records request is received from a health plan for three dates of service in a chart
months apart. What should the biller do? - ✔✔Copy each date of service individually
and send to the health plan.
✔✔Is a healthcare consulting firm considered a covered entity? - ✔✔No
✔✔A new radiology company opens in town. The manager calls your practice and
offers to pay $20 for every medicare patient you send them for radiology services. What
does this offer violate? - ✔✔The Anti-kickback law
✔✔How many national priority purposes are under the Privacy rule to disclose PHI
without an individuals authorization? - ✔✔12
✔✔What are the 12 national priority purposes under the privacy rule? - ✔✔1. Required
by law
2. Public health activities
3. Victims of abuse / neglect/ domestic violence
4. Health oversight activities
5. Judicial and administrative proceedings
SET A+
✔✔HIPAA mandated what entity to adopt national standards for electronic transactions
and code sets? - ✔✔HHS
✔✔What is the standard time frame established for record retention? - ✔✔There is no
single standard record retention time frame. It varies by state and federal regulation.
✔✔CMS defines ______ as billing for a lower level of care than is supported in
documentation, making false statements to obtain undeserved benefits or payment from
a federal healthcare program, or billing for services that were not performed. - ✔✔Fraud
✔✔A claim is submitted for a patient on medicare with a higher fee schedule that a
patient on Insurance ABC. What is this considered under CMS? - ✔✔Abuse
✔✔A person that files a claim for a Medicare beneficiary knowing that the service is not
correctly reported is in violation of what statue? - ✔✔FCA (False claims act)
✔✔What act is "upcoding or unbundling services" considered under? - ✔✔The false
claims act
✔✔A practice sets up a payment plan with a patient. If more than four installments are
extended to the patient, what regulation is the practice subject to that makes the
practice a creditor? - ✔✔TILA (truth in lending act)
✔✔A patient is seen in your clinic. Her husband calls later in the day to ask for
information about the visit. The practice pulls the patients privacy authorization to see if
they can speak to the husband. What act does this action fall under? - ✔✔HIPAA
✔✔Medicare was passed into law under what Act? - ✔✔SSA
,✔✔Are healthcare regulations the same in each state? - ✔✔No, they will vary from state
to state.
✔✔A physician's office (covered entity) discovers that the billing company (Business
associate) is in breach of their contract. What is the first steps to be taken. - ✔✔Take
steps to correct the problem and end the violation.
✔✔OIG, CMS, and the DOJ are the government agencies enforcing what laws? -
✔✔Federal fraud and abuse laws
✔✔Do fraud and abuse penalties include the ability to refile claims in question? - ✔✔No
✔✔A biller at a medical practice notices that all claims contain CPT code 81002. She
questions the nurse who tells her that because they are an OB/Gyn office, they bull
every patient for a urinalysis. What does this violate? - ✔✔FCA
✔✔Medical records are requested for a patient for a specific date of service. When
records are copied, multiple dates of service are copied and sent in reply to the request.
What standard does this violate? - ✔✔Minimum necessary
✔✔Individuals have the right to review and obtain copies of the PHI. What is excluded
from rights of access? - ✔✔- Psychotherapy notes
- Certain lab results
- Information involved in research studies
- Information related to legal proceedings
✔✔Patient questions and concerns regarding the Privacy Practices in the clinic should
be addressed by what party? - ✔✔The Privacy official
✔✔How many standard EDI transactions were adopted under HIPAA? - ✔✔8
✔✔What are the standard EDI transactions adopted under HIPAA? - ✔✔1. Claims and
encounter info
2. Payment and remittance advice
3. Claim status
4. Eligibility for a health plan
5. Enroll / Dis-enrollment in a health plan
6. Referrals and authorizations
7. COB
8. Premium payments
✔✔In addition to the standardization of the codes what other identifier is used on all
claims? - ✔✔A unique identifier for employers and providers
,✔✔The federal false claims act allows for claims to be reviewed for how many years
after an incident? - ✔✔Seven years
✔✔Entities that have been identified as having improper billing practices are defined by
CMS as a violation of what standard? - ✔✔Abuse
✔✔What penalties can be imposed for Fraud and / or abuse related to the US code? -
✔✔Monetary penalties ranging from $10k to $50k (before inflation) for each item or
service, imprisonment, and exclusion from federal healthcare programs.
✔✔How long after being identified should a practice return medicare over payments?
(days) - ✔✔60 days
✔✔A private practice hires a consultant to come in and audit some medical records.
Under the Privacy Rule, what is this consultant considered? - ✔✔A covered entity
✔✔According to the privacy rule, what health information *may not* be de-identified? -
✔✔The physician provider number
✔✔A hospital records transporter is moving medical records from the hospital to an off-
site building. During the transport, a chart falls from the box on the street. It is
discovered when the transporter arrives at the off-site building and the number of charts
is not correct. What type of violation is this? - ✔✔A breach
✔✔A practice allows patients to pay large balances over a six month time period with a
finance charge applied. The patient receives a statement every month that only shows
the unpaid balance. What does this violate? - ✔✔TILA
✔✔When a practice sends an electronic claim to a commercial health plan for payment,
what is this considered? - ✔✔A transaction
✔✔While working in a large practice, medicare over-payments are found in several
patient accounts. The manager states that the practice will keep the money until
medicare asks for it back. What does this action constitute? - ✔✔Fraud
✔✔What were the eight standard EDI transactions adopted under? - ✔✔HIPAA
✔✔A practice agrees to pay $250k to settle a lawsuit alleging that the practice used x-
rays of one patient to justify services on multiple other patient's claims. That manager of
the office brought the civil suit. What type of case is this? - ✔✔Qui Tam
✔✔A health plan sends a request for medical records in order to adjudicate a claim.
Does the office have to notify the patient or have them sign a release to send the
, information? - ✔✔No, since the information is used for payment activities it is not
necessary to notify or obtain authorization (reference: TPO)
✔✔Fraud or Abuse: A clinic fails to maintain adequate medical records - ✔✔Abuse
✔✔Fraud or Abuse: A clinic bills every new patient at the highest level E/M visit no
matter what - ✔✔Fraud
✔✔Fraud or Abuse: A clinic is found to be falsifying documentation to support a service
that was billed to receive payment - ✔✔Fraud
✔✔Fraud or Abuse: Reporting a diagnosis code that the patient does not have, but is
payable by medicare. - ✔✔Fraud
✔✔According to the privacy rule, what must a business associate and covered entity
have in order to do business? - ✔✔A contract
✔✔If a provider is excluded from federal health plans, what does that mean? - ✔✔They
many not participate in Medicare, Medicaid, VA programs, or Tricare and They cannot
bill for services or provide services, order services, or prescribe medication to any
beneficiary of a federal plan.
✔✔What is the purpose of the privacy rule? - ✔✔To protect patient privacy
✔✔A records request is received from a health plan for three dates of service in a chart
months apart. What should the biller do? - ✔✔Copy each date of service individually
and send to the health plan.
✔✔Is a healthcare consulting firm considered a covered entity? - ✔✔No
✔✔A new radiology company opens in town. The manager calls your practice and
offers to pay $20 for every medicare patient you send them for radiology services. What
does this offer violate? - ✔✔The Anti-kickback law
✔✔How many national priority purposes are under the Privacy rule to disclose PHI
without an individuals authorization? - ✔✔12
✔✔What are the 12 national priority purposes under the privacy rule? - ✔✔1. Required
by law
2. Public health activities
3. Victims of abuse / neglect/ domestic violence
4. Health oversight activities
5. Judicial and administrative proceedings
