CPC Exam
Each time an individual receives healthcare a record is - Answer-- Maintained of the resulting
observations
- Medical or surgical interventions
- Diagnostic test and studies
- Treatment outcomes
Coding is performed by - Answer-Physician or coder
Outpatient coders will focus on learning - Answer-CPT, HCPCS Level II, and ICD-10-CM
Outpatient facility coders work with - Answer-Ambulatory Payment Classifications (APCs)
APCs - Answer-Ambulatory Payment Classifications
Hospital Inpatient coding focuses on - Answer-ICD-10-CM & ICD-10-PCS ( also assign medical severity
diagnosis related groups (MS-DRGs))
MS-DRGs - Answer-Medical Severity-Diagnosis Related Groups
,NPPs - Answer-Non-physician providers ( mid-level providers or physician extenders)
Example: Physician assistants (PA) & Nurse Practioners ( NP)
*reimbursed at lower rates and require physician oversight
Two primary types of insurers - Answer-commercial and government
Commercial Carriers offer - Answer-Group and individual plans
- contracts provided = hospitalization, basic, & major medical coverage
Blue Cross/Blue Shield - Answer-Private payer (commercial payer)
Government Insurer - Answer-Medicare (federal health insurance program)
CMS - Answer-Centers for Medicare and Medicaid Services (administered Medicare)
* determines coding regulations for Medicare and Non-Medicare providers
Medicare - Answer-Coverage for 65 year olds, blind, disabled, permanent kidney disease or End-Stage
Renal Disease (ESRD)
Medicare Part A - Answer-Inpatient services
Medicare Part B - Answer-Outpatient services/preventive services
* optional benefit that patient must pay premium for
* requires yearly deductible and co-insurance
,Medicare Part C (Medicare Advantage) - Answer-Combines Medicare A, B, and sometimes D
* can charge different co-pays, coinsurance, and deductibles
Medicaid - Answer-Assistance program for low-income people (especially children and pregnant
women) sponsored by state and federal government
Resource-Based Relative Value Scale (RBRVS) - Answer-relative value scale for establishing Medicare
charges
- physician work 52%
- practice expenses 44%
- resource-based professional liability insurance (PLI) 4%
PLI - Answer-Professional liability insurance
NCD - Answer-National Coverage Determination - explain when Medicare will pay for items or services.
MAC - Answer-Medicare Administrator Contractor - responsible for interpreting national policies into
regional policies
LCD - Answer-Local Coverage Determination - national policies converted to regional policies
ABN - Answer-Advanced Beneficiary Notice - explains to patient why Medicare may deny the service or
procedure
"Hold Harmless" Clause - Answer-Prohibits the billing to the patient for anything other than co-pays or
deductibles
, HIPAA - Answer-Health Insurance Portability and Accountability Act of 1996
* provides federal protection for protected health information
Healthcare clearinghouse - Answer-the entity that processes electronic claims for healthcare providers
Minimum Necessary Requirement - Answer-Minimum necessary protected health information should
be shared to satisfy a certain purpose
PHI - Answer-Protected Health Information
HITECH - Answer-Health Information Technology for Economic and Clinical Health Act
* was enacted as part of the American Recovery and Reinvestment Act of 2009
* strengthens HIPAA's rules by addressing privacy/security concerns related to electronic transmission
HITECH requires - Answer-That an individual is notified if there is an unauthorized disclosure or use of
their health information
ARRA - Answer-American Recovery and Reinvestment Act of 2009
OIG - Answer-Office of Inspector General
* mandated by public law to test efficiency and economy of government programs suspected of
fraud/abuse.
Fraud is - Answer-Purposely bill for services that were never provided or bill for a service that has a
higher reimbursement
Each time an individual receives healthcare a record is - Answer-- Maintained of the resulting
observations
- Medical or surgical interventions
- Diagnostic test and studies
- Treatment outcomes
Coding is performed by - Answer-Physician or coder
Outpatient coders will focus on learning - Answer-CPT, HCPCS Level II, and ICD-10-CM
Outpatient facility coders work with - Answer-Ambulatory Payment Classifications (APCs)
APCs - Answer-Ambulatory Payment Classifications
Hospital Inpatient coding focuses on - Answer-ICD-10-CM & ICD-10-PCS ( also assign medical severity
diagnosis related groups (MS-DRGs))
MS-DRGs - Answer-Medical Severity-Diagnosis Related Groups
,NPPs - Answer-Non-physician providers ( mid-level providers or physician extenders)
Example: Physician assistants (PA) & Nurse Practioners ( NP)
*reimbursed at lower rates and require physician oversight
Two primary types of insurers - Answer-commercial and government
Commercial Carriers offer - Answer-Group and individual plans
- contracts provided = hospitalization, basic, & major medical coverage
Blue Cross/Blue Shield - Answer-Private payer (commercial payer)
Government Insurer - Answer-Medicare (federal health insurance program)
CMS - Answer-Centers for Medicare and Medicaid Services (administered Medicare)
* determines coding regulations for Medicare and Non-Medicare providers
Medicare - Answer-Coverage for 65 year olds, blind, disabled, permanent kidney disease or End-Stage
Renal Disease (ESRD)
Medicare Part A - Answer-Inpatient services
Medicare Part B - Answer-Outpatient services/preventive services
* optional benefit that patient must pay premium for
* requires yearly deductible and co-insurance
,Medicare Part C (Medicare Advantage) - Answer-Combines Medicare A, B, and sometimes D
* can charge different co-pays, coinsurance, and deductibles
Medicaid - Answer-Assistance program for low-income people (especially children and pregnant
women) sponsored by state and federal government
Resource-Based Relative Value Scale (RBRVS) - Answer-relative value scale for establishing Medicare
charges
- physician work 52%
- practice expenses 44%
- resource-based professional liability insurance (PLI) 4%
PLI - Answer-Professional liability insurance
NCD - Answer-National Coverage Determination - explain when Medicare will pay for items or services.
MAC - Answer-Medicare Administrator Contractor - responsible for interpreting national policies into
regional policies
LCD - Answer-Local Coverage Determination - national policies converted to regional policies
ABN - Answer-Advanced Beneficiary Notice - explains to patient why Medicare may deny the service or
procedure
"Hold Harmless" Clause - Answer-Prohibits the billing to the patient for anything other than co-pays or
deductibles
, HIPAA - Answer-Health Insurance Portability and Accountability Act of 1996
* provides federal protection for protected health information
Healthcare clearinghouse - Answer-the entity that processes electronic claims for healthcare providers
Minimum Necessary Requirement - Answer-Minimum necessary protected health information should
be shared to satisfy a certain purpose
PHI - Answer-Protected Health Information
HITECH - Answer-Health Information Technology for Economic and Clinical Health Act
* was enacted as part of the American Recovery and Reinvestment Act of 2009
* strengthens HIPAA's rules by addressing privacy/security concerns related to electronic transmission
HITECH requires - Answer-That an individual is notified if there is an unauthorized disclosure or use of
their health information
ARRA - Answer-American Recovery and Reinvestment Act of 2009
OIG - Answer-Office of Inspector General
* mandated by public law to test efficiency and economy of government programs suspected of
fraud/abuse.
Fraud is - Answer-Purposely bill for services that were never provided or bill for a service that has a
higher reimbursement
