AAPC CPB Final Exam 2025 Graded A+

Health plan, clearinghouses, and any entity transmitting health information is considered by the Privacy Rule to be a: Correct Answer: covered entity Which of the following is not a covered entity in the Privacy Rule Correct Answer: healthcare consulting firm A request for medical records is received for a specific date of service from patient's insurance company with regards to a submitted claim. No authorization for release of information is provided. What action should be taken? Correct Answer: release reqt to ins co How many national priority purposes under the Privacy Rules for disclosure of specific PHI without an individual's authorization or permission? Correct Answer: 12 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? Correct Answer: no 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? Correct Answer: Truth in Lending Act Which of the following situations allows release of PHI without authorization from the patient? Correct Answer: workers comp misusing any information on the claim, charging excessively for services or supplies, billing for services not medically necessary, failure to maintain adequate medical or financial records, improper billing practices, or billing Medicare patients at a higher fee scale that non-Medicare patients. Correct Answer: abuse A claim is submitted for a patient on Medicare with a higher fee than a patient on Insurance ABC. What is this considered by CMS? Correct Answer: abuse According to the Privacy Rule, what health information may not be de-identified? Correct Answer: phys provider number making false statements or misrepresenting facts to obtain an undeserved benefit or payment from a federal healthcare program Correct Answer: fraud All the following are considered Fraud, EXCEPT: Correct Answer: inadequate med recd 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 to 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? Correct Answer: breach impermissible release or disclosure of information is discovered Correct Answer: breach What standard transactions is NOT included in EDI and adopted under HIPAA? Correct Answer: waiver of liability The Federal False Claim Act allows for claims to be reviewed for a standard of how many years after an incident? Correct Answer: 7 A new radiology company opens in town. The manager calls your practice and offers to pay $20 for every Medicare patient you send to them for radiology services. What does this offer violate? Correct Answer: anti kickback laws A private practice hires a consultant to come in and audit some medical records. Under the Privacy Rule, what is this consultant considered? Correct Answer: biz associate Medicare overpayments should be returned within days after the overpayment has been identified Correct Answer: 60 HIPAA mandated what entity to adopt national standards for electronic transactions and code sets? Correct Answer: HHS Entities that have been identified as having improper billing practices is defined by CMS as a violation of what standard? Correct Answer: abuse In addition to the standardization of the codes (ICD-10, CPT, HCPCS, and NDC) used to request payment for medical services, what must be used on all transactions for employers and providers? Correct Answer: unique id A person that files a claim for a Medicare beneficiary knowing that the service is not correctly reported is in violation of what statute? Correct Answer: False Claims Act Medicare was passed into law under the title XVIII of what Act? Correct Answer: SS Act While working in a large practice, Medicare overpayments 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? Correct Answer: fraud A practice agrees to pay $250,000 to settle a lawsuit alleging that the practice used X-rays of one patient to justify services on multiple other patients' claims. The manager of the office brought the civil suit. What type of case is this? Correct Answer: qui tam OIG, CMS, and Department of Justice are the government agencies enforcing . Correct Answer: fed abuse and fraud laws 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? Correct Answer: TILA An insurance plan that provides a gatekeeper to manage the patient's health care is known as a/an Correct Answer: HMO a corporate umbrella for management of diversified healthcare delivery systems Correct Answer: IPO An employee has signed up for a program through her employer. It allows her to put pre-tax money away from her paycheck in order to pay for out-of-pocket healthcare expenses. She may contribute up to $2650 (2018) per year. If she does not use all of the money during the current year, she forfeits it. What is this? Correct Answer: FSA Which option is not considered an MCO? Correct Answer: HSA A Medicare patient presents after slipping and falling in a neighbor's walkway. The cement had a large crack, which caused the pavement to raise and be unsteady. The neighbor has contacted his homeowner's insurance and they are accepting liability and have initiated a claim. How should the visit be billed? Correct Answer: Homeowners, then Medicare Insurance coverage provided by an organization that is not an employer (such as a membership organization or credit card company that offer benefits to its members) is what kind of group insurance? Correct Answer: association group office bills Medicare, but the patient receives the payment and the office must collect their fee from the patient. The office, by state law, can charge the patient a limiting charge that is 10 percent above the Medicare fee schedule amount. What type of Medicare provider is this physician? Correct Answer: non par A patient presenting for care does not have an insurance card and is billed CPT 99213 for $100. The patient pays $100 to the provider. A week later, the patient presents verification of coverage through Medicaid for this date of service. What process should be followed? Correct Answer: file a claim to Medicaid w EOB Medicare part without a monthly charge if worked for 10+ years Correct Answer: A Managed Care Organizations (MCOs) place the physician at financial risk for the care of the patient and are reimbursed by Correct Answer: capitation Which of the following is NOT evaluated in the credentialing process? Correct Answer: phys req for priviledges HSA is to employees Correct Answer: tax free income What type of plan allows an insurer to administer straight indemnity insurance, an HMO, or a PPO insurance plans to its members? Correct Answer: triple option A healthcare organization with 2 hospitals, 20 clinics, and 3 urgent care centers belongs to an ACO program. They have been in the shared savings program for two years and are now eligible to move large payments to a population-based model as they have been successful in keeping costs down and have met all the CMS benchmarks set for them. What type of ACO is this? Correct Answer: Pioneer What is the largest health program in the United States? Correct Answer: Medicare a unique 10-digit identification number required by HIPAA Correct Answer: NPI Medicaid plans provide for low-income families. Which statement regarding Medicaid is NOT correct? Correct Answer: All plans offer HMOs A new physician comes in to the practice that is just out of medical school. He will need to be able to see patients in the office and at the hospital. What process will he need to undergo in order to be able to participate with Medicare and other health plans? Correct Answer: credentialling NPI numbers have two types of entities - identify the two types: Correct Answer: group and sole proprietor NPI Correct Answer: National Provider Identifier Which of the following services is NOT covered under Medicare Part B? Correct Answer: Home Health ACOs are formed with lives Correct Answer: 5000 HMOs are formed with lives Correct Answer: 100,000 + When insurance coverage is being verified, which of the following is NOT a method on which to rely? Correct Answer: patient When a fee ticket (encounter form) is not completed, what procedure would NOT be acceptable? Correct Answer: no charge Information about deductibles, copays, eligibility dates, and benefit plans is completed during what step? Correct Answer: verify benefits determine primary and secondary coverage Correct Answer: birthday rule Which of the following is NOT considered a part of the authorized process when the patient signs the consent for payment? Correct Answer: auth for treatment Patient types help to classify the patients based on Correct Answer: payer, ins type Life Cycle of a Claim Correct Answer: submission processing adjudication payment/denial What authorizes information to be sent to the insurance payer so payment of medical benefits can be processed? Correct Answer: consent for payment Amount of expenses that must be paid before any payment is made by the insurance company Correct Answer: deductible BCBS member #: Correct Answer: 3 letters then 9 numbers When charges are entered and all required components are verified by the claims editing system, what would this be considered as? Correct Answer: clean claim When does the processing of an insurance claim for a patient begin? Correct Answer: when appt scheduled When a patient is seen for evaluation and the decision is made for a minor procedure that is performed on the same day, which modifier is appended to the claim to allow reimbursement for the E/M and the procedure? Correct Answer: 25 A 68-year-old Medicare patient presented for an annual examination and had no complaints. Her claim, billed as 99387, was denied. Was this billed correctly? If not, how is this encounter correctly billed? Correct Answer: it depends on doc If a procedure is performed on a 72-year-old Medicare patient which code category is preferred for reporting? Correct Answer: G code HCPCS The NCCI policy manual is updated: Correct Answer: annually The part of National Correct Coding Initiative (NCCI) that places frequency limitations on codes that can be billed on a single date of service by a single provider is called: Correct Answer: MUE provide limitations of frequency on codes that can be billed in a single day by a single provider for a beneficiary. Correct Answer: MUE NCCI edits are updated by CMS and released Correct Answer: quarterly When using the Practitioner PTP Edits table, an NCCI tool, the modifier indicator of 0 (zero) tells the user: Correct Answer: mod not allowed Indicates specific CPT code pairs that can be reported on the same day for the same beneficiary by the same provider. Correct Answer: NCCI file The Medicaid NCCI program consists of six methodologies. Each methodology is composed of components Correct Answer: 4 Medicare states that reporting bundled codes in addition to the major procedural code is considered to be unbundling, and if repeated with frequency it is considered to be: Correct Answer: fraud When looking at the NCCI Edit tables, Column 1 codes are indicated as payable. Column 2 codes contain the codes that are: Correct Answer: not payable without mod What modifier is required when a procedure is performed on the same day as an E/M service and both should be paid and not considered bundled? Correct Answer: 25 What modifier is used to indicate two procedures are performed on the same day and should not be bundled? Correct Answer: 59 NCDs are released by which of the following entities: Correct Answer: CMS Reporting a service based on an LCD requires the CPB to look at coverage guidance for the procedure being performed. Coverage guidance would NOT include: Correct Answer: experimental procedures Which of the following modifiers are not used to bypass NCCI edits? Correct Answer: 76, 77 Services that are performed for treatment or diagnosis of an injury, illness, or disease in accordance with generally accepted standards of medical practice defines: Correct Answer: medical necessity Codes that are considered to be bundled are based on Centers for Medicare & Medicaid (CMS) standards called: Correct Answer: NCCI An E/M service that is performed during a post-operative period, but is not related to the surgical procedure that was performed, can be billed with which modifier? Correct Answer: 24 Medicare provides a list of questions to ask beneficiaries that helps determine if Medicare is primary or secondary. Where can this information be found? Correct Answer: MSP Manual What type of code reports the event(s) related to the billing period on the UB-04 claim form? Correct Answer: occurrence codes What is the purpose of the standard CMS-1500 claim form? Correct Answer: pro services for phys FL 35 and FL 36 are used on the UB-04 claim form to identify occurrence span code and dates. When is this section completed? Correct Answer: inpt services When entering the patient's name on the CMS-1500 claim form, what punctuation should be used? Correct Answer: comma A is used to indicate an inpatient service is reported on an outpatient claim. Correct Answer: condition code The UB-04 claim form is also called: Correct Answer: CMS 1450 Determination of the insurer's payment amount after the member's insurance benefits have been applied. Correct Answer: adjudication provider with overall responsibility for the patient's medical care during hospitalization. Correct Answer: attending Identify the correct format to enter the date of birth on a paper CMS-1500 claim form Correct Answer: MMDDCCYY